1. HIV/AIDS in Eastern Europe Setting the Stage for Prevention HIV/AIDS in Eastern Europe Setting the Stage for Prevention Thomas E. Novotny, MD, MPH April 16, 2004

2. HIV/AIDS in Eastern Europe Background Most rapid rate of increase in new HIV infections among all regions of the world; Transition and economic disruption may lead to increased risk behavior (IDU, trafficking) and reduced prevention and treatment services; Prevention opportunities based on lessons learned in the region and from outside.

3. Adult prevalence rate 15.0% – 36.0% 5.0a% – 15.0% 1.0% – 5.0% 0.5% – 1.0% 0.1% – 0.5% 0.0% – 0.1% not available + 1 300% +60% + 160% + 100% + 30% + 40% + 20% Global HIV: Change in Prevalence Rates 1996–2001

6. Causing or Aggravating Poverty Loss of income Catastrophic cost of care Increased dependency ratio Loss of productivity (companies) Loss of social capital (countries) Reduced national income? CONTRIBUTORS TO POVERTY HIV Infection AIDS

7. Impacts for Generalized Epidemic of HIV/AIDS 0.5-1.0 percentage point decline in economic growth 50-100% increase in health expenditures –Impact private sector development –Aggravate informalization of economy Change in dependency ratio, straining social systems Change in HH size and composition (single parents, orphans, elderly caring for children Negative intergenerational effects: Poverty trap

8. Transmission Groups and Risk Main mode is heterosexual: IDU (80%) Little MTCT Romania: Nosocomial and now heterosexual (n=8,000) MSM underreported Structural factors in ECA: social disruption, open borders, economic crisis Mobility and globalization Increases in STIs Youth most at risk (age 20-30 years)

9. Mobile Populations Example: SE Europe Merchant marines, truckers (37% have unsafe sex while traveling) Peacekeepers Roma and other ethnic minorities (8 mil.) Trafficked women (and children) Commercial Sex Workers (CSW) Tourists

10. Effective Interventions CSW: 100% condom use, STI treatment, client education, peer education and outreach IDU: demand reduction, condom social marketing, needle exchange and cleaning education, treatment Youth: school reproductive health education and peer support Contacts: tracing, voluntary testing and counseling, referral STI surveillance, syndromic treatment

11. Harm Reduction Needle exchange CSW outreach, reproductive health services Drug abuse treatment (Methadone) Condom distribution Decriminalization of drugs and prostitution

12. Challenges in Low Prevalence Countries of ECA Lack of recognition of future potential High levels of stigmatization (HIV+, IDU, CSW, ethnic minorities) Lack of government ownership of harm reduction (HR) approaches Lack of sentinel surveillance among most vulnerable populations Most funds go to treatment and not prevention programs Lack of evaluation on HR and other prevention interventions Increase in sexual risk behavior

13. Conclusions: HIV/AIDS in Low Prevalence Countries Opportunity for prevention is now Cross-border externalities important in addressing most vulnerable groups Future burden on health systems and economic productivity may be enormous Need sentinel surveillance in high risk groups and vulnerable populations Harm reduction, harm reduction, harm reduction Public information and professional education are essential

14. IGH/CAPS Activities ICOHRTA Supplement with Croatia (NIDA) Regional training in the Balkans Eastern Europe/Central Asia Working Group Research and writing for World Bank publications (Central Asia, Balkan, ECA) Modeling epidemic and economic impact in the Baltics