Epidemiology of socially significant infectious diseases (TB, HIV-infection, viral hepatitis C and B) in Russia Olga Nechaeva Expert of the Expert Group “TB, HIV-infection and Associated Infections” of NDPHS PhD, professor, Head of the Federal Monitoring Center for Counteraction to Tuberculosis Spread in the Russian Federation, Federal Research Institute for Health Organization and Informatics, Moscow, Russia 07-08.11.2018 - Riga

Tubersulosis and HIV infection in Russia HIV infection exceeds TB: prevalence since 2008 notification since 2014 mortality rate since 2015 TB screening coverage (%): TB: 2005 – 57,9% 2016 – 69,3% 2017 – 71,3%. HIV antibodies screening coverage: 2005 – 13,6% 2016 – 21,9% 2017 – 23,8% HIV cases detected per 1000 examined: 2005 – 0,20% 2016 – 0,38% 2017 – 0,30%

Tuberсulosis and HIV infection The proportion of HIV-infection in mortality from certained infectious and parasitic diseasesis is changing. 2017 год: TB: total – 27,4% male – 31,2% Female – 19,3% HIV-infection: total – 57,2% male – 56,1% female – 59,5% In the age group 18-44 most frequent the causes of death are: External – 38,2% Circulatory system – 18,7% Digestive system – 9,0% Respiratory – 3,3% Cancer – 8,2% Infectious and parasitic diseases– 13,3%

2017: Every fifth (20,9%) new TB patient taken on records was HIV-positive; out of those on records with TB at the end of the year 18,5% were HIV-positive. 693 120 HIV-positive patients were on records during 2017, out of those 22,3% with late stages (in 2005 – 2,8%). During this period the number of patients with late stages increased 23,7 times - from 6 505 to 154 357 persons. TB rate in non-HIV-positive residents (33,4 per 100K) lower than in 1991, when HIV-infection did not influence TB prevalence (34,0 per 100K). TB mortality rate, which practically does not include those with HIV-infection (6,5 per 100K) is lower than lowest level observed in (7,4 per 100K). 2018: TB: TB notification and mortality continue to decline (circa 10% from 2017). HIV-infection: notification of new HIV a/b positive cases and HIV mortality increased 5% as compared with 2017.

between patients who don’t receive ART — 4.6 years and Infection rates of tuberculosis among HIV-infected patients are highly influenced by overall regional epidemiological situation with tuberculosis, incidence rate of tuberculosis, incidence rate of mycobacterium tuberculosis infection. Medium age of HIV antibodies revealing in 2016 in Russia was 35.3 years including 35.7 years for men and 34.7 years for women. Medium of patients died of HIV-infection was 37.5 years, including 37.9 years for men and 36.6 for women. Because of HIV related mortality 606552 years of life were not lived. HIV infected women live less than man despite medium data of life duration (generally in Russia women live 10 years longer than men). In Sverdlovsk region since 2010 till 2016 cases of HIV-infection were revealing 5.1 years later; patients died from HIV 4.7 years later, from other reasons 5.0 years later. Life duration from registration of HIV-infection till HIV-related death in 2016 was 6.5 years; till death not related to HIV was 6,4 years. Among known cases of HIV-Among known cases of HIV-related death this parameter was 5,9 years and it differs between patients who don’t receive ART — 4.6 years and patients who receive ART and have undetectable viral load — 7.5 years. Between died patients only 7.2% were getting ART and having undetectable viral load. Among patients who died from HIV-infection as older patients were at the time of revealing HIV as more frequent CD4 count less than 200 cells/ml was detected. Time from HIV diagnosis till establishing of diagnosis HIV-infection + tuberculosis in 2016 was 5.4 years; medium CD4 count before establishing of diagnosis «tuberculosis» among HIV-infected patients was 225.7 cells/ml; mycobacterial infection dominates in structure of HIV-related death. At the same time prevalence of this reason of death started to decrease (2012 — 43.1%; 2016 — 38.7%).

Long-term state health policy includes the following components: President Decree dated 31.12.2015 г. № 683 «On Strategy of National Security in the Russian Federation»: «National threats in public health are epidemic and pandic, mass prevalence of oncological, cardio-vascular, endocrinological, HIV-infection and TB, drug addiction and alcoholism, trauma and poisoning, availability of psychoactive and psychotropic drugs for illegal use». Long-term state health policy includes the following components: Strategy on cancer control; Strategy on cardio-vascular diseases control; Strategy on endocrine disease control; Strategy on TB Control; Strategy on HIV control; etc. Strategy – is a general, non-detailed plan of action, covering a long period of time and is a method to attain a complex problem. The aim of TB Control Strategy is sustainable decrease in TB incidence and mortality. The strategy target is to decrease TB incidence and mortality 2 times during 10 years. In the view of TB decline – it is necessary to develop a strategy on future of TB facilities.

HIV-infection and hepatitis С in Russia Number of new cases of viral hepatitis in 2017 – 86987 on records during 2017 – 892 689 on records on 31.12.2017 – 750 480 Deaths from viral hepatitis in 2017 - 2124 (Rosstat): acute hepatitis – 21; acute hepatitis C – 12; chronic hepatitis В – 223 cases; chronic hepatitis С – 1564; other hepatitis – 304. If HIV-infected patient dies from TB or hepatitis – the cause of death registered as HIV-infection Acute infection hepatitis C: spontaneous cure (15%-45%), chronic hepatitis C (55%-85%). Viral hepatitis monitoring reference center of Rospotrevnadzor (2014) – 57444 new cases of HCV Large scale representative surveys: 2,5% general populations hepatitis C a/b positive (3,6 mln persons), of which 60% have active morphological forms – chronic hepatitis C have 2,2 mln persons (I.G.Nikitin and AG Kravchenko estimations) Large scale vaccination lead to decrease acute hepatitis B notification, but the number of chronic hepatitis B presently is 2,8 – 3,0 mln. Only 10% patients with chronic hepatitis C receive treatment. Natural development of chronic HCV – liver cirrhosis – 15-30%; risk of hepatocellular carcinoma Up to 45% patients on waiting list for liver transplantation are patients with chronic HCV. HCV disease decreases survival before and after transplantation.

Source of financing to be determined. Estimated annual cost of treatment based on current market costs of antiviral drugs in Russia (I.G. Nikitin): Chronic HCV (2,4 M patients) - 1,3 trillion rubles = 17 billion euro; Chronic HBV (1,0 M patients) - 53,3 million rubles = 0,7 million euro. Not feasible to provide care to all eligible patients with chronic viral hepatitis due to current economic situation and health system capacity. Source of financing to be determined. List of patients with F3-F4 fibrosis (20-25%) should be formed - to be treated during next 3 years by direct anti-viral drugs. First priority list (100 K patients) – total cost of treatment 5 billion rubles: F4 fibrosis and genotype 1, 2, 3 F0-F3 fibrosis and genotype 2, 3. Genotype 1 and no fibrosis – patients co-payment? Direct antiviral agents (DAAs) costs reduction – India case - not on agenda.

Impact of HIV-infection on severity of chronic HCV disease: 30-40% HIV-infected have HCV; 2–8 higher HCV RNA concentration in serum – lower rate of spontaneous cure; more severe forms of hepatitis; 2 – 5 times more frequent and faster (in 10 – 20 yrs) liver cirrhosis; higher risk of decompensation of liver cirrhosis; higher lethality due to liver diseases; higher sexual transmission(up to 3%), vertical mother-to-child (up to 20%) . Treatment strategy for HIV/HCV co-infected patients: All HCV RNA positive HIV-infected patients are eligible for HCV treatment; All HIV-infected and HCV are eligible ART therapy; if СD4 >500 cells to start HCV treatment and then ART; otherwise start ART and then add HCV treatment. Liver cirrhosis in HIV/HCV – during 10 years, i.e. earlier than mono HCV (on average 20 years). Since majority of patients contracted HIV-infection (and most likely acquired HCV) during 2000-2005 – the rise in HIV-deaths due to liver cirrhosis is anticipated. Параллельные эпидемии, ссылки

Thank you for attention !