Assessing and Responding to the AIDS Threat in Central Asia
Jay Dobkin, M.D.
College of Physicians and Surgeons of Columbia University

Mostly off the AIDS radar screen the threat of an explosive epidemic in Central Asia looms increasingly large. Several factors have converged there to create an environment that is primed for HIV. When and whether there will be a massive outbreak or a low-level smoldering one cannot be predicted with any certainty. What is clear is that to the extent that a large outbreak is preventable, now is the time for aggressive efforts. As a consultant to the Open Society Institute I have had the opportunity in the last three years to visit several countries in the region and to observe the work of government and public health officials as well as patients and medical care providers who are grappling with the AIDS threat. My observations are presented in the constext of 20 years experience working with AIDS in the USA.

Features of both geography and history contribute to the present AIDS risk in Central Asia. As detailed in the papers by Dr. Vassilenko and Mr. Mikkelsen, Central Asia is the corridor through which much of the world’s hard drug trade is conducted, inevitably involving more of the local population as couriers, local distributors and users. The collapse of the Soviet Union hit this region especially hard, both economically and medically. Unemployment pushed many people into involvement with the drug trade and into commercial sex work. Opening of borders and loosening travel restrictions along with economic and political pressures have created a much more mobile population with a greater capacity to spread infectious diseases like HIV. At the same time the ability of the public health system to trace, diagnose and treat patients with infections like sexually transmitted diseases has deteriorated. The rising rate of congenital syphyllis in Kazakhstan is an illustration. These untreated STD’s serve as key co-factors for transmission of HIV.

As Dr. Vassilenko points out there is a long history of psycho-active substance abuse in the region but there appear to be significant changes underway. The use of home-prepared partially purified opium extracts in the past is being replaced by purified heroin due in part to proximity to large scale narcotics enterprises. As economic and social stresses push more young people in the direction of injection drug use, access to more potent drugs is becoming easier and cheaper.

The example of the city of Temirtau in the north central Karaganda region of Kazakhstan illustrates several of these points. It is the site of a massive steel mill that, together with related mines and other facilities (known as KARMET), employed 65,000 people and was a major producer in Soviet times. With the end of the USSR management changed several times before KARMET shut down entirely in the mid-90’s. On-site observers have commented on the massive disruption of social and family life as the economic bottom fell out of this classic ‘company town’. Drug and alcohol abuse became rampant, families fell apart and coincidentally or not the first major outbreak of HIV in Central Asia began there in 1996. Though the plant reopened, layoffs contributed to ongoing social turmoil.

As of November 2000 official reports in Kazakhstan indicated 237 new HIV+ cases for the year for a cumulative total of 1227 (121 of the new cases and 954 of the total were from the Karaganda oblast, mostly from the city of Temirtau).

The response to the AIDS outbreak in the Karaganda region has taken several forms. Both UNAIDS and OSI have established needle exchange programs in the area. The Republican AIDS Center has offered some care and services for AIDS patients but is severely hampered by a lack of resources. Standard measures such as antibiotics to prevent the opportunistic infectious complications of AIDS are not available and donated anti-HIV drugs have been used for only a few pregnant patients to try to prevent HIV infection of the newborn. Laboratory facilities to perform the standard assessments of level of viral infection and degree of immune system damage are also unavailable. As a result of the unavailability of HIV-related medical care as well as the suspicion drug users have for government agencies it appears that many of those who have tested positive for HIV lose touch with the HIV agencies once they have left the criminal justice system, a lost opportunity for further efforts to reduce transmission. In addition it appears that the lack of treatment and other resources has limited the extent of partner notification or other efforts to reach individuals who may have been exposed via needle sharing or sexual contact with known positive cases. Instead many of the newly identified HIV cases are found through required testing that occurs in the prison system or in other institutional settings such as tuberculosis hospitals. On a recent visit one prison health official estimated that about half of the inmates in the HIV unit had been newly diagnosed upon incarceration.

Will HIV smolder or explode in Central Asia? No one can tell. Since the start of the AIDS epidemic the pattern of spread among drug users in various areas of the world has been hardest to understand. In some cities HIV has spread rapidly to infect the large majority of injectors while in other, apparently comparable settings, only a small fraction of injection drug users (IDU) has been involved. Instability in the pattern of drug use may be important in promoting spread of HIV. An influx of new injectors from a high HIV prevalence area might set off an outbreak (several people in Temirtau felt that drug users arriving from Ukraine in the mid 90’s had brought HIV with them). A change in the drugs used is another example. The arrival of cheap cocaine for injection in the US in the early 80’s seems to have contributed to very rapid spread of HIV among IDUs in places like New York for several reasons: the frequency of injection tends to increase dramatically when cocaine is added to or substituted for heroin; changes in sexual or other behaviors may also contribute and previously stable or closed networks of IDUs may open to new or transient members. Although cocaine has not made an appearance in Central Asia, the social and economic turmoil, mobility and rise in transmission cofactors like STDs suggest to me that a large HIV outbreak among drug injectors is more likely in this region than in some others.

What can be done to prevent or limit the extent of HIV in Central Asia? What will it cost and what priority should it receive? These are also largely rhetorical questions. Improving the economic and social status of the region would probably have the greatest long term impact. More targeted efforts at drug abuse treatment and prevention as well as harm reduction strategies directed at active users are all obviously critical as detailed in the other papers. The additional points I would like to make have to do with the role of medical treatment in containing the epidemic. The effective (and expensive) anti-HIV therapy available in Western countries certainly cuts down on HIV transmission. Beyond this however there is an important substantial and symbolic role for direct care in enhancing prevention efforts. Offering treatment services once someone tests HIV positive provides an incentive to further contact and adds to the potential for education, counseling and behavior change. Initially care for HIV infected patients need not be complicated or expensive: diagnosis and treatment of STDs, preventive therapy for tuberculosis and antibiotic prophylaxis for AIDS-related opportunistic infections can be done with little equipment and quite inexpensive drugs. These interventions don’t alter the eventual course of HIV infection but substantially extend disease-free survival. Anti-retroviral therapy is certainly more complex and expensive but with the drive to allow generic production of these agents the cost should drop greatly.

Where should treatment of HIV infection be ranked in countries struggling to provide elementary medical care such as childhood immunizations and to control contagious diseases such as TB? In a superficial cost-benefit calculation in a region with a large HIV epidemic and other critical needs the balance would certainly tilt away from AIDS. But in Central Asia, at an early stage of what threatens to be a major outbreak a realistic opportunity seems to exist to attempt aggressive steps, including the use of AIDS medical treatment, to try to contain the further spread of the disease.

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Posted March 1, 2001 © Eurasianet
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