1. U.S. Civilian Research & Development Foundation Peace and prosperity through science collaboration Estonia: overlaping epidemics of IDU and HIV Anneli Uusküla MD, MS, PhD Department of Public Health Department of Dermatology University of Tartu Estonia

2. EPIDEMIC OUTLOOK Several overlapping epidemics  Drug Use  HIV/AIDS  Other infectious diseases (tuberculosis, HBV, HCV)  [Sexual risk behavior?] Epidemic drivers act regionally and can best be addressed at regional level  Economic and political migration  Trafficking in drugs and people  Sex Work  Prisons Adapted from: Novotny T, 2004

3. U.S. Civilian Research & Development Foundation Peace and prosperity through science collaboration An estimated 1.1% of the young adult population (aged 15- 49) in Estonia are living with HIV infection (UNAIDS, 2003) Heterosexual transmission: High rates of sex risk behavior and inadequate knowledge regarding prevention of disease transmission (Wilson T, 2002) may indicate a risk for an impending sexually and STI driven HIV epidemic. Majority of HIV incidences are related to injection drug use (IDU) Adapted from: Lowndes CM, 2003

4. U.S. Civilian Research & Development Foundation Peace and prosperity through science collaboration WOMEN AMONG NEW HIV + CASES http://www.ltkh.ee/?id=1070

5. U.S. Civilian Research & Development Foundation Peace and prosperity through science collaboration MOLECULAR EPIDEMIOLOGY The Estonian HIV outbreak was found to be caused by simultaneous introduction of two strains: –minor subtype: A strain very similar to the Eastern European subtype A strain (~ 8% of cases), –major strain: CRF06-cpx strain (77% of cases), most closely related to the previously described only from African countries The variability in the two clusters was very low, suggesting point source introductions (Zetterberg V, 2004; Adojaan M, 2005)

6. U.S. Civilian Research & Development Foundation Peace and prosperity through science collaboration OVERLAPPING EPIDEMICS Injection drug use

7. U.S. Civilian Research & Development Foundation Peace and prosperity through science collaboration [INJECTION] DRUG USE Police. State agency of statistics

8. U.S. Civilian Research & Development Foundation Peace and prosperity through science collaboration Capture–recapture method: administrative data sources – State HIV reference laboratory IDU definition = HIV positive test results under category 102: user of illicit drugs – Police IDU definition = individuals arrested for the possession of illegal drugs in small quantities – Estonian health insurance fund (EHIF) drug overdose data IDU definition = life threatening non-fatal drug overdose, ICD-10: T40 T40.0, T40.1, T40.2, F11.0 – EHIF drug treatment data IDU definition = drug treatment, ICD-10 F11.1-F11.9 Uusküla A. 2006 IDU PREVALENCE

9. U.S. Civilian Research & Development Foundation Peace and prosperity through science collaboration CRC estimates [Estonia, 2004] Uusküla A. 2006

10. U.S. Civilian Research & Development Foundation Peace and prosperity through science collaboration OVERLAPPING EPIDEMICS HIV

11. U.S. Civilian Research & Development Foundation Peace and prosperity through science collaboration By July 2006 the cumulative number of HIV+ cases was 5420 0.8% of the adult population (15-49) Incidence of 550 new infections per million population in 2005

12. U.S. Civilian Research & Development Foundation Peace and prosperity through science collaboration IDU / HIV STUDIES [Estonia] YearTeamsDesignSamplingSample size 2003 Univ of Tartu SUNY RCTConvenience sample HIV / drug Rx settings 262 2004 Univ of Tartu SUNY Univ of Yale Cross sectional Convenience sample SEPs 162 2005 Univ of Tartu ICL London NIHD Cross sectional Respondent driven sampling 450 * ETF Estonian Science Foundation

13. U.S. Civilian Research & Development Foundation Peace and prosperity through science collaboration IDU / HIV STUDIES [cont.] Year Age (mean, range) Gender (M %) Ethnicity (EST / RUS) SharingMain drugs used 200323 (16-45) 88%15% 79% 51% 1 Heroin 79% MAK 3 29% 200422 (18-49) 88%4% 77% 32% 1 Heroin 59% Amfetamine 30% 200524 (15-43) 83%12% 82% 29% 2 Fentanyl 59% MAK 3 20% Amfetamine 19% 1 Last 90 days; 2 Last 28 days; 3 MAK= liquid derivate of opium poppy straw

14. U.S. Civilian Research & Development Foundation Peace and prosperity through science collaboration IDU / HIV STUDIES [cont.] YearPrevious HIV testing HIV + (EIA) HIV incidence (estim. 1 ) 200365%43%NA 200449%56%18.3/100 person- years at risk 200590% Tallinn 54% Kohtla-Järve 90% 21.1/100 person- years at risk 1 HIV incidence estimation assumptions among persons who recently began injecting drugs 1) all of them were HIV seronegative when they began injecting, 2) the HIV seropositives became infected at the midpoint between beginning to inject and the time of blood sample collection, and 3) no HIV seropositives are lost to AIDS or other causes among the new injectors

15. U.S. Civilian Research & Development Foundation Peace and prosperity through science collaboration CRDF FUNDED RESEARCH August 2004: ESXO-1057-TR-04 “Collaborative response to tackle HIV epidemic in Baltics: international and multidisciplinary workshop to prioritize areas and methods of research”

16. U.S. Civilian Research & Development Foundation Peace and prosperity through science collaboration CRDF FUNDED RESEARCH July 2006: Project agreement ESXO-2722-TA-06 –US PI: Louise-Anne McNutt, SUNY at Albany Jack Dehovitz, SUNY Downstate Tracey Wilson, SUNY Downstate –Eurasian PI: Anneli Uuskula, University of Tartu, Estonia Ave Talu, National institute for health development Krista Fischer, University of Tartu Igor Sobolev, NGO Convictus, Tallinn Aleksander Laanemann, NGO MAS, Kohtla-Jarve

17. U.S. Civilian Research & Development Foundation Peace and prosperity through science collaboration CRDF FUNDED RESEARCH July 2006: ESXO-2722-TA-06 Sex partners of IDUs both non-/IDU are at substantial risk for HIV, particularly if they engage in sexual intercourse without using condoms, and / or share needles with sexual partners. The objectives of the study: to describe IDUs HIV-risk (injecting, sexual) behavior with sex partners (primary and other); to assess HIV prevalence among IDUs and their sexual partners; to conduct a short educational intervention with pre and post test.

18. U.S. Civilian Research & Development Foundation Peace and prosperity through science collaboration CRDF FUNDED RESEARCH July 2006: ESXO-2722-TA-06 Study design: (1) Rapid assessment (2) Quantiative study 2.1. Cross/sectional study 2.2 Recruitment: IDUs (index cases) will be recruited using respondent driven sampling, and will thereafter requested to bring in their sexual partners. 2.3 Measurements: (i) risk (IDU, sexual) behavior survey; (ii) biological sample collection (HIV ab testing); (iii) post intervention test.

19. U.S. Civilian Research & Development Foundation Peace and prosperity through science collaboration Thank you