俄羅斯:歐洲愛滋病疫情最嚴重的地區其省份之間存在巨大差異
自 2000 年以來愛滋病死亡人數大幅增加
Gus Cairns/2023 年 1 月 11 日/aidsmap
俄羅斯各省的愛滋病毒盛行率。 圖片來自 tochno.st/problems/hiv
儘管世界衛生組織 (WHO) 歐洲地區(包括西伯利亞和中亞)一半以上的新愛滋病毒病例發生在俄羅斯,但令人驚訝的是,在全國範圍內我們對該國的流行病知之甚少。
這部分是由於俄羅斯當局故意缺乏透明度,但也與這樣一個事實有關,即愛滋病毒病例通報、死亡通報和愛滋病毒盛行率數據都是由不同的當局收集而未經整理的。 此外,由於俄羅斯對主要受影響人群的污名化文化,以及沒有收集關於可能傳播途徑的全面統計數據。
現在,在參考文獻作者所說的「探索性和描述性研究」中,來自不同機構的數據匯集在一起,描繪了這個幅員遼闊國家的愛滋病毒情況。
倫敦經濟學院的 Zlatko Nikoloski 博士及其同事進行的分析發現,俄羅斯不同省份之間的 HIV 死亡人數和 HIV 盛行率間存在巨大差異,整個大陸之 HIV 盛行率最高的地區緊臨於一些最低的盛行率地區。
地區內與愛滋病毒相關的死亡人數和愛滋病毒盛行率有高度相關,這顯示當有可用數據時,它們會相互印證。
它還發現,愛滋病病毒盛行率和死亡率都與抗反轉錄病毒療法 (ART) 的提供呈負相關。 在一個提供良好 ART 的國家,人們會期望在盛行率較高的地區使用更高水平的 ART,但俄羅斯的情況恰恰相反——令人震驚的低水平 ART 提供,直接繼續地推動仍在擴大的流行病。
俄羅斯現在確實每年向歐洲疾病預防控制中心提供新的愛滋病毒診斷數字,該中心的最新報告顯示,2021 年有 58,340 例新的愛滋病毒診斷,而整個世衛組織歐洲區域的其他地區則超過 48,000 例。 這實際上比六年前的情況有所改善,當時俄羅斯的愛滋病例幾佔歐洲區署的近三分之二。
但由於俄羅斯的人口僅佔世衛組織區域人口的 18%,這相當於該地區其他地區人均新診斷率的近六倍,是歐盟新診斷率的十倍多。 2021 年,每 2,475 名俄羅斯人中就有 1 人被診斷出感染愛滋病毒,而該區域其他地區的此一比例為 15,536 人。
研究
Nikoloski 博士從另外四個來源獲取數據,試圖更好地了解該國的流行病。且均提供省(州)級數據。
• 由俄羅斯生育率和死亡率數據庫通報由愛滋病毒引起的死亡中取得。
• 愛滋病盛行率——愛滋病毒感染者的比例——由俄羅斯聯邦愛滋病中心收集。
• 由非政府組織主導的該國愛滋病毒指標計畫,評估不同地區抗反轉錄病毒治療覆蓋率之估計中取得。
• 關於愛滋病毒知識的數據來自聯邦國家統計局在 2018 年進行的一項大型一般人口調查。除了有關其他健康問題的問題外,受訪者還被問及他們是否知道保險套可以降低感染愛滋病毒的風險,是否知道在哪裡可以獲得愛滋病毒測試以及他們是否相信 HIV 可以透過共用食物器具傳播。
• 最後,結果還與各省的人口結構、經濟產出和醫療資源等指標相關。
死亡率、盛行率和 ART
全國死亡率數據(以每年每 10 萬人因愛滋病毒死亡的人數表示)顯示,與愛滋病毒相關的死亡率已從 2000 年的每 10 萬人 0.2 人死亡,幾乎全部為男性,增加到 2018 年的每 10 萬人 18.5 人死亡。 (每 5,405 名男性中有 1 人死亡),每 100,000 名女性中有 8.7 人死亡(每 11,494 女性中有 1 人死亡)。這可以與同年英國每 66,850 人中有1例 HIV 相關死亡相提並論。
但死亡率顯示出很大的地區間差異。 最高的 HIV 死亡率是西伯利亞東南部和中南部一些省份的五倍以上,這些省份從烏拉爾山脈的斯維爾德洛夫斯克一直延伸到與貝加爾湖接壤的伊爾庫茨克,再往東將近 3,500 公里(超過 2,000 英里)。
克麥羅沃的死亡率為每 100,000 人 88.9 人,即每年每 1,125 人中有 1 人死於 HIV。 伊爾庫茨克、新西伯利亞(西伯利亞最大城市所在地)和斯維爾德洛夫斯克的死亡率分別為每 1,767 人、1,871 人和 1,976 人每年一人。
「令人震驚的低水平抗反轉錄病毒藥物供應,繼續地驅動著仍在擴大的流行病」。
相較之下,一些地區的死亡人數甚至低於英國。 其中兩個實際上與伊爾庫茨克接壤——圖瓦,夾在伊爾庫茨克和蒙古之間,以及廣闊的薩哈共和國,西伯利亞東部的一大片以寒冷的城市雅庫茨克為中心。 這兩個地區的人口密度都非常低,城市化工業也很少。 但與烏克蘭接壤的別爾哥羅德省的情況並非如此,該省在 2018 年每 77,000 人中只有一人死於愛滋病毒。
愛滋病毒盛行與愛滋病毒死亡密切相關。 在伊爾庫茨克,每 100,000 名成年人中有近 2,000 人感染愛滋病毒(每 50 人中就有一個),而克麥羅沃和斯維爾德洛夫斯克的感染率幾乎相同。 不過,感染率最高的記錄發生在斯維爾德洛夫斯克以南的車里雅賓斯克省,那裡 3% 的人口(每 33 人中就有一人)感染了 HIV。
這可以與英國大約每 400 人中有 1 人的比率相提並論,盛行率最低的省份的比率也是如此:圖瓦每 1,812 人中有 1 人,俄羅斯在車臣旁邊裡海邊界的兩個歐洲省份卡爾米基亞和達吉斯坦不到 1,000 人中有 1 人。
愛滋病毒死亡與愛滋病毒盛行率之間的相關性為 0.84,非常高。
俄羅斯的 ART 供應仍然有限,全國平均有 45% 的 HIV 感染者接受 ART。 比率與 HIV 死亡率和盛行率呈中度負相關 (–0.45)——即接受 ART 的 HIV 感染者比例越低,死亡率和盛行率越高。 例如,在西伯利亞中南部和車里雅賓斯克的高流行省份,30% 至 35% 的愛滋病毒感染者接受抗反轉錄病毒治療。
在烏拉爾以西的歐洲俄羅斯,獲得 ART 的機會普遍較高,但表現出廣泛的異質性。一些最低的 ART 提供率——在 25% 到 35% 之間——令人驚訝地出現在一些人口最密集和城市化程度最高的地區:在諾夫哥羅德和彼爾姆,甚至在聖彼得堡和莫斯科,這兩個地區都有ART 之供應水平低於周邊省份。接受 ART 治療的 HIV 感染者比例最高的省份緊隨其後,包括普斯科夫(聖彼得堡和愛沙尼亞之間)和基洛夫(與彼爾姆接壤)。 這兩個省份的盛行率也都非常低,基洛夫的盛行率幾乎與達吉斯坦的一樣低。
其他一些省份的 ART 供應量也很低,但盛行率也很低,特別是薩哈、卡累利阿、摩爾曼斯克和涅涅茨耶,但這些省份屬於北極地區,人口稀少。
是什麼導致了愛滋病毒的高盛行?
研究人員還研究了在知識和社會經濟指標方面與 HIV 高盛行率相關的其他因素。 具有統計顯著性的某些因素是較少的人報告他們知道保險套可有效降低感染愛滋病毒的風險,登記為注射吸毒者的人口比例更高,和更高的人均地區生產總值 ( gross regional product , GRP )。
與吸毒的關係並不奇怪,因為俄羅斯的流行最初是由共用針具驅動的,而且在一定程度上現在仍然如此。 然而,在 2016 年,歸因於男女性行為的感染比例 (48%) 與注射吸毒相關的比例持平,並且此後有所上升。 然而,重要的是要強調,俄羅斯 55% 的 HIV 病例立沒有通報任何感染途徑,並且歸因於男性之間性行為的病例比例為 1.5%,儘管男性 HIV 診斷率並非如此,報告非因注射吸毒的比例遠高於女性。早在 2011 年,聯合國愛滋病規劃署就報告稱,俄羅斯和烏克蘭男同性戀者的愛滋病毒感染率為 8%。
「這些城市吸引了農民工,隨之而來的是更高比例的女性性工作、性交易和毒癮」。
但注射吸毒仍然很重要。俄羅斯因不允許注射吸毒者使用阿片類藥物替代療法 (OST) 而臭名昭彰,而且自從俄羅斯脫離全球基金後,獲得針頭和注射器交換計畫的機會也急劇減少。先前在鄂木斯克和葉卡捷琳堡等高盛行城市的流行病模型估計,啟動 OST 和針具交換計畫、擴大 ART 以及整合式藥物和 HIV 治療計畫將導致新診斷率在十年內下降一半。
關於保險套基本知識的調查結果顯示需要開展教育和預防計畫。 然而,政治家和教會不鼓勵討論這些話題(尤其是對性少數群體),而俄羅斯沒有政府贊助的保險套供應。
與經濟產出的關聯很有趣。西伯利亞和北極的某些地區儘管相對偏遠,但在俄羅斯的 GRP 最高。這是因為這些地區之所以有城市,是因為它們通常圍繞石油和天然氣開採而建,尤其是採礦業在烏拉爾和北極。這些城市吸引了移民工人,隨之而來的是更高比例的女性性工作、性交易(通常是來自海洛因生產國的移民)和毒品依賴。
官僚主義和未整合的系統是缺乏 ART 供應的另一個原因,這助長了流行病。例如,莫斯科和聖彼得堡的 ART涵蓋率較低的原因之一,可能是因為搬到城市尋找工作的國內移民在新地點註冊醫療保健時面臨官僚障礙。
結論
之前還有其他關於俄羅斯愛滋病流行的分析,但大多數都集中在特定的城市和地區。這組作者說,這項研究是研究人員第一次嘗試透過使用可用的原始數據來關聯這個廣闊而分布不同國家的愛滋病毒趨勢,儘管它是不完整的。
作者以悲觀的方式結束,指出俄羅斯的社會和宗教態度限制了對注射吸毒者、性少數和其他邊緣化社區的有效介入。他們說:「俄羅斯正在進行的社會和政治變革很可能會給應對愛滋病流行帶來嚴峻挑戰」。
參考文獻:
Nikolosi Z et al. 俄羅斯聯邦的人類免疫缺陷病毒:死亡率、盛行率、危險因素和目前對性傳播的了解。 《後天免疫缺陷病毒》期刊,印刷前線上發表,2022 年 12 月 7 日。
www.doi.org/10.1097/QAD.0000000000003441
完整圖片之來源:俄羅斯各省的愛滋病毒盛行率。 圖片來自 tochno.st/problems/hiv
Russia: huge differences between provinces in Europe’s worst HIV epidemic
Large increase in HIV deaths since 2000
Gus Cairns/11 January 2023/aidsmap
HIV prevalence by province in Russia. Image from tochno.st/problems/hiv
Although well over half of new cases of HIV in the World Health Organization (WHO) European region (which includes Siberia and Central Asia) occur in Russia, there is surprisingly little we know on a nationwide level about the country’s epidemic.
This is partly due to deliberate lack of transparency by Russian authorities but it also to do with the fact that notifications of HIV cases, notifications of deaths and figures for HIV prevalence are all collected by different authorities and not collated. In addition, owing to Russia’s culture of stigma against key affected populations, comprehensive statistics on the likely route of transmission are not collected.
Now, in what its authors describe as an “exploratory and descriptive study”, figures from different agencies have been pulled together to paint a picture of HIV in this vast country.
The analysis, by Dr Zlatko Nikoloski from the London School of Economics and colleagues has found huge differences in HIV deaths and HIV prevalence between different provinces in Russia, with areas with the highest HIV prevalence in the whole continent next door to areas with some of the lowest prevalence.
Figures for HIV-related deaths and HIV prevalence within regions were highly correlated, showing that when figures are available, they corroborate each other.
It also found that both HIV prevalence and deaths were correlated negatively with the provision of antiretroviral therapy (ART). Whereas in a country with good ART provision, one would expect higher levels of ART usage in areas with higher prevalence, the reverse is the case in Russia – appallingly low levels of ART provision continue to directly drive an epidemic which is still expanding.
Russia does now supply new HIV diagnosis numbers every year to the European Centre for Disease Prevention and Control, whose latest report shows that there were 58,340 new HIV diagnoses in 2021 compared with over 48,000 in the whole of the rest of the WHO European region. This is actually an improvement from the situation six years ago, when Russia had nearly two thirds of the HIV cases in Europe.
But because Russia only has 18% of the WHO region’s population, this amounts to nearly six times as many new diagnoses per head of population as in the rest of the region, and well over ten times the new diagnosis rate in the European Union. One in every 2475 Russians was diagnosed with HIV in 2021, compared with one in 15,536 people in the rest of the region.
The study
Dr Nikoloski took data from four additional sources to try to better understand the country’s epidemic. All provide data at the provincial (oblast) level.
•Deaths caused by HIV are reported to the Russian Fertility and Mortality database.
•HIV prevalence – the proportion of people living with HIV – is collected by the Russian Federal AIDS Centre.
•Estimated ART coverage in different regions was assessed by an NGO-led project on HIV indicators in the country.
•Data on HIV knowledge came from a large general population survey conducted by the Federal State Statistics Service in 2018. Alongside questions on other health issues, respondents were asked whether they were aware that condoms reduce the risk of HIV, knew where to get an HIV test and if they believed HIV could be passed on by sharing food utensils.
•Finally, results were also related to indicators of each province’s population structure, economic output and healthcare resources.
Mortality, prevalence and ART
The national mortality data, expressed in the annual number of deaths due to HIV per 100,000 people, showed that HIV-related mortality had increased from 0.2 deaths per 100,000 in the year 2000, almost all in men, to 18.5 per 100,000 in 2018 in men (one death per 5405 men) and 8.7 per 100,000 in women (one death in 11,494). This can be compared with one HIV-related death per 66,850 people in the UK in the same year.
But the death rate shows big inter-regional disparities. The highest HIV death rates were over five times this rate in a band of provinces in south-east and south-central Siberia, stretching from Sverdlovsk in the Ural mountains to Irkutsk which borders Lake Baikal nearly 3500km (over 2000 miles) further east.
Mortality in Kemerovo was 88.9 per 100,000 people, or one death due to HIV per year in every 1125 people. Death rates in Irkutsk, Novosibirsk (home to Siberia’s biggest city) and Sverdlovsk were one per year in every 1767, 1871 and 1976 people respectively.
“Appallingly low levels of ART provision continue to drive an epidemic which is still expanding.”
In contrast, deaths in some regions were lower than even in the UK. Two of these actually border Irkutsk – Tuva, sandwiched between it and Mongolia, and the vast Sakha Republic, a huge swathe of eastern Siberia centred on the freezing city of Yakutsk. These are both areas with very low population densities and little urbanised industry. But that isn’t the case for Belgorod, a province bordering Ukraine, where only one HIV-related death per 77,000 people was recorded in 2018.
HIV prevalence is closely correlated with HIV deaths. In Irkutsk, nearly 2000 per 100,000 adults are living with HIV (one in 50) and the rates in Kemerovo and Sverdlovsk are almost identical. The highest prevalence, though, was recorded in Chelyabinsk, a province just south of Sverdlovsk, where 3% of the population – one in 33 people – has HIV.
This can be compared with the UK rate of about one in 400 people, as can the rates on the lowest-prevalence provinces: one in 1812 people in Tuva, and less than one in 1000 in two European Russian provinces, Kalmikia and Dagestan, both on the borders of the Caspian Sea next to Chechnya.
The correlation between HIV deaths and HIV prevalence was 0.84, which is extremely high.
Russia still has limited provision of ART, with a national average of 45% of people with HIV on ART. Rates had a moderate negative correlation (–0.45) with HIV mortality and prevalence – i.e. the lower the proportion of people with HIV taking ART, the higher the mortality and prevalence. For example, in the high prevalence provinces of south-central Siberia, and also in Chelyabinsk, between 30% and 35% of people with HIV are on ART.
Access to ART is generally higher in European Russia west of the Urals but shows wide heterogeneity. Some of the lowest rates of ART provision – between 25% and 35% – are, surprisingly, in some of the most highly-populated and urbanised areas: in Novgorod and Perm, and even in St Petersburg and Moscow, both of which have levels of ART provision lower than their surrounding provinces. Provinces with the highest proportion of people with HIV on ART are right next to them, including Pskov (between St Petersburg and Estonia) and Kirov (which has a border with Perm). Both of these provinces also have notably low prevalence, with Kirov’s nearly as low as Dagestan’s.
Some other provinces have very low ART provision but with low prevalence, notably Sakha, Karelia, Murmansk and Nenetsiye, but these are Arctic regions with sparse population.
What’s driving high HIV prevalence?
The researchers also looked at what other factors, both in terms of knowledge and socioeconomic indicators, correlated with high HIV prevalence. The only factors that reached statistical significance were fewer people reporting that they knew condoms were effective in reducing the risk of HIV, a higher proportion of the population registered as injecting drug users and a higher gross regional product (GRP) per capita.
The relationship with drug use is not surprising as Russia’s epidemic was originally driven by needle-sharing, and to a certain extent still is. In 2016, however, the proportion of infections attributed to sex between men and women (48%) equalled the proportion linked to injecting drug use and has risen since. It is important, however, to emphasise that 55% of cases of HIV in Russia do not have any route of infection reported, and that the proportion of cases ascribed to sex between men is 1.5%, despite the rate of HIV diagnoses in men not reporting injecting drug use being considerably higher than the rate in women. As far back as 2011, UNAIDS reported that HIV prevalence in gay men in both Russia and Ukraine was 8%.
“These cities attract migrant workers and, with them, higher rates of female sex work, sex trafficking, and drug dependency.”
But injecting drug use remains important. Russia is notorious for not allowing opioid substitute therapy (OST) for people who inject drugs, and since Russia disengaged from the Global Fund access to needle and syringe exchange programmes also decreased abruptly. Previous modelling of the epidemic in the high-prevalence cities of Omsk and Ekaterinburg estimated that starting OST and needle-exchange programmes, scaling up ART and integrating drug and HIV treatment programmes would result in the rate of new diagnoses dropping by half within ten years.
The finding on basic condom knowledge shows the need for education and prevention programmes. However politicians and the church discourage discussion of these topics (especially for sexual minorities), while Russia has no government-sponsored condom provision.
The association with economic output is interesting. Some parts of Siberia and the Arctic have the highest GRPs in Russia, despite relative remoteness. This is because the reason there are cities at all in these areas is because they were often built around oil and gas extraction and, especially in the Urals and the Arctic, mining. These cities attract migrant workers and, with them, higher rates of female sex work, sex trafficking (often of migrants from heroin-producing countries), and drug dependency.
Bureaucracy and unintegrated systems are another reason for the lack of ART provision, which fuels the epidemic. One reason ART rates are lower in Moscow and St Petersburg, for instance, may be because internal migrants who move to the cities find work face bureaucratic barriers to registering for medical care in their new location.
Conclusion
There have been other analyses of the Russian HIV epidemic before, but most have concentrated on specific cities and regions. This study, according to the authors, is the first time researchers have attempted to correlate HIV trends in this vast and disparate country by going to the available raw data, incomplete though it is.
The authors end on a pessimistic note, noting the social and religious attitudes in Russia that curtail effective interventions for injecting drug users, sexual minorities and other marginalised communities. “The social and political transformations underway in Russia will most likely present serious challenges in addressing the HIV epidemic,” they say.
References
Nikolosi Z et al. Human immunodeficiency virus in the Russian Federation: mortality, prevalence, risk factors, and current understanding of sexual transmission. AIDS, online ahead of print, 7 December 2022.
www.doi.org/10.1097/QAD.0000000000003441
Full image credit: HIV prevalence by province in Russia. Image from tochno.st/problems/hiv