Findings from an ongoing CHP/PCOR research project on HIV/AIDS in Russia provide clear and urgent policy guidance for officials there: Injection drug use is central to Russia's rapidly expanding HIV/AIDS epidemic, and if the country continues with its current approach - largely failing to treat HIV-positive drug users with antiretroviral medications - the epidemic will spread rapidly among the general public, as well as drug users.

The findings - which CHP/PCOR researchers presented at the 14th International Conference on AIDS, Cancer and Related Problems (May 23-27 in St. Petersburg, Russia) and in separate meetings with HIV/AIDS experts and organizations in St. Petersburg and Moscow - indicate that antiretroviral therapies should be given to as many of Russia's HIV-positive drug users as possible, preferably integrated with drug rehabilitation programs. In fact, the results indicate that devoting most of Russia's HIV/AIDS resources to treating injection drug users would do far more to limit infection rates among the general public than would efforts focused on non-drug users.

"Our research shows that if they don't treat injection drug users, they'll never get a handle on the AIDS epidemic, and it will spiral out of control," said CHP/PCOR core faculty member Douglas K. Owens, principal investigator for the research project, which is funded by the National Institute on Drug Abuse. "We hope these results will provide compelling scientific evidence to help influence policymakers in Russia to make needed changes," he added.

Although HIV/AIDS is a relatively new problem for Russia - the epidemic began to take hold there just 10 years ago - today the country has one of the fastest-growing HIV/AIDS populations in the world. While official registered figures show 311,400 HIV cases to date, international experts believe the actual number is closer to 1 million. Until recently, the majority of cases have been concentrated among injection drug users. However, the increasing number of cases among women, along with infections transmitted heterosexually and from mother to child, indicate that the epidemic is shifting from high-risk groups to the general population.

While several countries have taken steps to effectively address their HIV/AIDS epidemics (such as Uganda and Brazil), Russia has lagged behind. There, denial and stigmatization of HIV/AIDS are widespread, the government is reluctant to seek assistance from outside organizations, and the country has scarce resources for HIV/AIDS prevention and treatment. Only about 1,500 HIV-positive individuals in Russia are receiving highly active antiretroviral therapy (HAART) -- less than 5 percent of those who need the treatment. HAART is a powerful drug regimen that can add months or years to the lives of HIV-positive individuals.

"Going to Russia was sobering because they have a huge HIV/AIDS problem, a huge amount of denial, and very little resources to deal with it," said CHP/PCOR associate Margaret Brandeau, a member of the research team. The others are Cristina Galvin, Elisa Long, Gillian Sanders, Adam Schwartz, Swati Tole and Tatyana Vinichenko.

Russia has similarly failed to address the problem of injection drug use, which is believed to be responsible for transmission in more than half of the country's HIV/AIDS cases, through the sharing of HIV-contaminated needles as well as sexual contact. There are approximately 2-3 million injection drug users in Russia, and in the most heavily affected cities about a third of them are HIV-positive.

Few drug treatment programs exist in Russia, however, methadone clinics are illegal, and needle-exchange programs are discouraged. Injection drug users are instead regarded as criminals, and are often incarcerated. Those living with HIV/AIDS suffer double discrimination; confidentiality regarding HIV status is often breached in medical settings, and stigma is widespread. Owens said the combination of neglect and punishment "is a recipe for disaster" as it relates to the future of Russia's HIV/AIDS epidemic.

To provide guidance on how Russia could most effectively address the problem with its limited resources, the CHP/PCOR researchers developed decision models that evaluated the cost-effectiveness of different treatment strategies and predicted how each would affect the spread of HIV/AIDS in Russia. The model draws on data from St. Petersburg on HIV/AIDS infection rates, transmission rates and mortality rates among drug users and non-drug-users.

The researchers evaluated three treatment strategies: scenario 1, in which HAART is given to 80 percent of HIV-positive non-drug users but is not given to any drug users; scenario 2, in which HAART is given to 80 percent of HIV-positive drug users and 1 percent of non-drug users; and scenario 3, in which 50 percent of both groups receive therapy. They also evaluated the course of the epidemic if the current low level of treatment with HAART continues: in that case, by 2025 the prevalence of HIV in St. Petersburg would be 60 to 80 percent among drug users and 7 percent among the general population - a whopping 10-fold increase from the current 0.7 percent prevalence.

Under scenario 1 - providing HAART to 80 percent of non-drug users only - the researchers' model indicates that by 2025, HIV prevalence would reach 77.8 percent among drug users and 5.4 percent among the general population. Under scenario 2, however - providing HAART to 80 percent of drug users and 1 percent of non-drug users - the spread of HIV would be slowed significantly, with HIV prevalence reaching 69.3 percent among drug users and 3.2 percent among the general population. This analysis highlights how treating drug users with HAART would reduce the spread of HIV, among the general population as well as drug users.

While scenario 3 (providing HAART to 50 percent of both groups) would also significantly decrease the spread of HIV/AIDS over 20 years, the results are not as striking as for scenario 2; HIV prevalence by 2025 would reach 72 percent among drug users and 3.4 percent among the general population.

Regarding cost-effectiveness, the researchers' analysis found that treating 80 percent of drug users with HAART would prevent more than 100,000 infections over 20 years and would add millions of quality-adjusted life years (QALYs) to the population, at a cost of about $1000 per QALY gained, compared with current practice. Treating only non-drug users with HAART, however, would prevent fewer infections and would cost more per life-years gained. In the third scenario, about the same number of infections would be prevented as when only injection drug users are treated. All three strategies would be cost-effective as judged by guidelines from the World Health Organization.

"What's most striking about our results is that the greatest impact on the general population comes from treating drug users, not the general population," Owens said. "It underscores the fact that injection drug users seem to be the critical link in the spread of HIV to other groups in Russia." This is not to suggest that HAART should be given primarily to drug users, Owens explained; rather, it highlights the importance of treating drug users and non-drug users aggressively.

The CHP/PCOR researchers said these messages were well-received in the meetings they held with leaders of several organizations addressing HIV/AIDS in Russia, including the World Health Organization and UNAIDS. "The people we talked to were very supportive and interested in our results," said CHP/PCOR research associate Cristina Galvin. "They have a strong interest in making sure this information reaches high-level policymakers in Russia."

One point the researchers emphasized in their meetings was the need to provide adequate support services to injection drug users taking HAART - a factor that was incorporated into their decision model. Treating any population with HAART is a challenging task, Owens explained, given the number of different medications involved and the importance of taking them on schedule.

Treating injection drug users with HAART even more difficult, he added, because they tend to have inadequate healthcare access, high rates of Hepatitis C and other diseases, and conditions such as depression and homelessness - all factors that can reduce adherence to a medication regimen.

Still, Owens pointed out, studies have shown that HIV-positive drug users can adhere to a HAART regimen at rates similar to the general population if they have access to well-designed, supportive treatment programs, with features such as convenient hours and locations, HIV counseling, and protocols whereby staff members observe patients taking all doses of their medications.

"There are legitimate concerns about drug users' adherence to HAART," Owens said, "but if you gave them the services and support to help them take their medications, it could have a huge positive impact on the epidemic in Russia."