The cascade of HIV care in Russia, 2011-2013.

INTRODUCTION: The cascade of HIV care is one of the main tools to assess the individual and public health benefits of antiretroviral therapy (ART) and identify barriers of treatment as prevention (TasP) concept realization. We aimed to characterize the changes in engagement of HIV-positive persons in care in Russia during three years (2011-2013). METHODS: We defined seven steps in the cascade of care framework: HIV infected (estimation data), HIV diagnosed, linked to HIV care, retained in HIV care, need ART, on ART and viral suppressed (VL < 1000 copies/mL during 12 month ART). Information was extracted from the Federal AIDS Centre database and from the national monitoring forms of Rospotrebnadzor from the beginning of 2011 to 31 December 2013. RESULTS: Nearly 668,032 HIV-diagnosed Russian residents were alive by the end of 2013, which consisted 49% of the estimated 1,363,330 people living with HIV. Among the alive HIV-diagnosed patients, 516,403 (77%) were linked to care and 481,783 (72%) were retained. Of 163,822 (25% of HIV diagnosed) patients who were eligible for ART, 156,858 (96%) were on treatment while 127,054 (81%) had viral suppression. However, only 19% of HIV-diagnosed patients achieved viral suppression which is necessary to prevent viral transmission. We noted substantial improvements over time in the proportion of individuals on ART. The proportion of patients who received ART increased from 24% in 2011 to 34% in 2013. The most significant leakages of patients during three years were on steps: "HIV infected → HIV diagnosed" (loss -55% in 2011, -53% in 2012, and -51% in 2013), "HIV diagnosed → Linked to care" (-23% yearly) and "Retained in care → Need ART" (-76%, -70%, and -66%, respectively). CONCLUSION: The stages of HIV diagnosis and estimation of ART eligibility were the most vulnerable to leakage. Encouraging HIV testing and earlier ART initiation are needed to maximize the effects of TasP interventions and to contain the spread of HIV in Russia.

Characterization of an emerging heterosexual HIV epidemic in Russia.

BACKGROUND: The Russian Federation is currently experiencing one of the fastest growing HIV epidemics worldwide. The objective was to identify sexual risk factors for recent heterosexually-acquired HIV infections. METHODS: A case-control study of recent HIV infection was conducted in the regions of Altaiskiy Krai, Krasnoyarskiy Krai, Saratov Oblast, and Tverskaya Oblast. Data from 166 participants who did not report recent injection drug use were analyzed (19 male cases, 22 male controls, 67 female cases, 58 female controls). Independent risk factors for HIV infection are reported as adjusted odds ratios (AOR) with 95% confidence intervals (CI). RESULTS: Risk factors were unprotected sex with an HIV-positive/status unknown regular partner (among women only: AOR 5.4, 95% CI 2.1-13); a regular sexual partner who was an injection drug user (AOR 3.6, 95% CI 1.5-8.5); 5 or more sexual partners (among men only: AOR 2.7, 95% CI 0.66-11); unprotected sex with a partner who had a diagnosed sexually transmitted infection (STI) or signs/symptoms of an STI (AOR 6.4, 95% CI 1.1-38); and undiagnosed signs/symptoms of an STI (AOR 3.4, 95% CI 1.5-7.6). CONCLUSIONS: These data provide evidence of bridging between the injecting and noninjecting populations. Concomitant STI seem to have a major role in fueling the Russian HIV epidemic.

Temporal trends in the HIV-1 epidemic in Russia: predominance of subtype A.

During the period 1996-1997, three highly homogeneous variants of HIV-1 were identified, circulating among injecting drug users (IDUs) in the former Soviet Union republics. One of these belonged to HIV-1 genetic subtype A (IDU-A), another belonged to HIV-1 genetic subtype B (IDU-B) and the third was a recombinant between the first two variants (CRF03_AB). However, since 1997, the HIV-1 epidemic has affected an increasing number of geographic regions in Russia. This study was undertaken to survey the prevailing genetic variants and to estimate the current proportions of these three HIV-1 genetic subtypes in Russia. Blood samples were taken in 1999-2003 from 1090 HIV-infected individuals and analysed by gag/env HMA. The IDU-A variant was found to be the majority variant (89.7-100%) in 44 of 45 regions of the Russian Federation studied. The IDU-A variant was also found to spreading rapidly through heterosexual transmission in 1999-2003 (30/34, 88%). CRF03_AB predominates in the Kaliningrad region only (28/29, 96.6%). The IDU-B variant is currently of minor importance in the IDU epidemic but other European subtype B variants predominate among men having sex with men (18/18, 100%). Sequence analysis of the env V3 encoding regions derived from HIV-1 infected individuals in Yekaterinburg (the main centre of the HIV-1 epidemic in Russia in 2002-2003) showed that the IDU-A variant is still highly homogeneous. The mean pairwise nucleotide distance (n = 9) was 2.89 +/- 1.14 (range 1.36-6.14). However, the mean genetic distance between each sequence within the samples collected from the Yekaterinburg IDU-A variant subset and the IDU-A consensus is 2.51 +/- 1.06 (range 1.36-4.66) and considerably higher than in South Russia in 1996 (0.79 +/- 0.51, range 0.38-1.90). The current HIV-1 epidemic in Russia is almost entirely caused by a highly homogeneous A-subtype strain, which will influence vaccine development strategies and must be taken into account in the quality control of molecular tests for the diagnosis of HIV-1.