Epidemiology, social, cultural and political
The impact of social, economic and political forces on emerging HIV epidemics
Gorbach, Pamina M.1,3; Ryan, Caroline2; Saphonn, Vonthanak1; Detels, Roger1
1University of California, Los Angeles, CA, USA
2Centers for Disease Control and Prevention, Atlanta, GA, USA.
3Correspondence to Dr. Pamina M. Gorbach, Department of Epidemiology, School of Public Health, Box 951772, University of California, Los Angeles, Los Angeles, CA 900095-1772. Tel: 310-267-2805; fax: 310-206-6039; e-mail: email@example.com
More than twenty years has past since the recognition of the first HIV epidemics. The spread of this disease worldwide has left in its wake tremendous social devastation and a legacy of important lessons in epidemiology and disease control. A new wave of epidemics is now emerging in countries that have not yet needed these lessons, but are fortunate to have an opportunity to do so to avert transitions into generalized epidemics. Russia, China and Vietnam are among the countries with emerging HIV epidemics. All three are large countries in the midst of conversions to market-driven economies forcing loosening governmental control and greater social openness. Financial support newly available from multi-national organizations such as the World Bank and The Global Fund to Fight AIDS, Tuberculosis & Malaria, technical assistance from agencies such as the World Health Organization (WHO), and the last decade's vast programmatic experience with HIV prevention and control represent some of the greatly expanded resources that new epidemics can now be confronted with. Much improved epidemiological data on HIV is also widely available and systematically collected through well established HIV surveillance systems introduced by WHO in 1988 . Surveillance guidelines were recently updated as second-generation surveillance and now include behavioral surveillance . By 2001 out of 167 countries analyzed, 98 had initiated sero-surveillance systems that were either fully implemented or had most of the attributes of quality sero-surveillance systems . Russia, China and Vietnam were among those with fully implemented HIV sero-surveillance systems and that are introducing surveillance of sexual and injection risk behaviors. Thus, new epidemics can be confronted more efficiently than in the past.
The considerable international support levied for proactive HIV/AIDS control includes The World Bank's US$1.7 billion available through loans to developing countries. In fiscal year 2001 US$744 million was committed for new HIV/AIDS prevention and control efforts . The United Nations created a global fund with a target of $10 billion a year to fight HIV/AIDS; to date US$2.1 billion have been pledged to The Global Fund from developed and developing country governments, private corporations and foundations, and individuals  of this $616 million has been awarded in grants from the first round of proposals and the second are due to be awarded January, 2003. In addition, in 2002 the World Bank committed over $300 million for new lending operations .
Positive examples from the last decade's experience with HIV/AIDS interventions now abound. Structural interventions involving policy changes such as the mandate for 100 percent condom use in commercial sex establishments in Thailand were shown to effectively control an HIV epidemic by reducing sexually transmitted infections (STIs) among men , lowering HIV incidence among military [8,9], and reducing HIV prevalence among female sex workers (FSWs) . Integrating behavior change with treatment of STIs for members of high prevalence or ‘core groups’ such as FSWs reduced HIV incidence in Abidjan, Ivory Coast , and lowered HIV prevalence over time in Thailand  and Cotonou, Benin . Provision of STI treatment services for FSWs also has reduced incidence and prevalence of STIs both among FSWs and the surrounding community in a South African mining community  and STI treatment at the community level reduced HIV incidence in Mwanza, Tanzania . Finally, a community mobilization approach such as a Popular Opinion Leader Model that reduced risk behavior among men who have sex with men (MSM) in the USA  may be promising for other groups in other countries.
Beyond resources, data, and empirical evidence of effective interventions other elements required for an effective national response to control an HIV epidemic are concentrated around social and governmental policy. For example, political will and commitment, unified national planning, and a public environment conducive to the social inclusion of people with HIV and those most at risk are essential . Other crucial elements include activism to maintain government spending and keep public health issues at the political forefront, shown to be effective through the achievements of organizations in the US such as ACT UP. Government acknowledgement of the severity of the epidemic was very effective in Thailand and Brazil. A clear national commitment to prevention worked in Uganda and Thailand, as did rapid implementation of prevention methods again in Thailand but also in Cambodia. A change in how resources for public health are determined and a broad reinterpretation of the national and international laws that govern the use of resources for public health is being implemented in India regarding drug patents and prices . Finally, early involvement of NGOs and government leadership aside from donor-driven resources has also been attributed to the success of Thailand's HIV/AIDS control program . Given that Russia, China and Vietnam are countries that had communist political systems until recently, many elements listed above will be a challenge.
The above examples demonstrate that HIV can be contained in specific communities, occupational groups, or countries and that data sources, resources, and intervention models now exist on how to do so. Yet countries in the midst of social and political transitions are particularly vulnerable such situations cascade through multiple levels that end in increased incidence of HIV and STIs (Fig. 1). The first of these levels involves increases for the worse in social values, conflict situations, rural-urban migration, poverty, gender inequality, and health system restructuring, which in turn lead to the second level: a decrease in social control, increase in instability of sexual partneships, increase in commercial sex work, decrease in access to health care, increase in drug trade, increase in stigmatization of HIV positive people and increase in individual depression that all contributed to the third level that consists of increases in risk behaviors such as IV drug and alcohol use and increased numbers of sex partners as well as an overall decrease in health status. A consideration of the emerging epidemics in Russia, China and Vietnam will consider their specific social, economic and political challenges and how these have resulted in the changes at different levels listed above and ultimately their emerging HIV epidemics.
Russia: Political Transitions, Social and Economic Pressures and Health Status
The new HIV epidemic in the Russian Federation is one of the fastest growing in the world and is emerging in the midst of transitioning economic and political systems, a deteriorating health care system, and rapidly changing moral norms and values. There are now 195 000 registered cases of HIV in Russia and UNAIDS estimates that up to 1.2 million people may have the virus  (Fig. 2). There were more than 75 000 reported new infections in Russia by early November 2001, a 15-fold increase in just three years . The epidemic is mostly concentrated in socially vulnerable populations of intravenous drug users (IVDU) and commercial sex workers.
The Russian Federation has a population of 147.9 million people , 72.9% living in urban areas, and is enormously diverse with 75 distinct nationalities, numerous ethnic groups, languages and religions.  The transition from a centrally planned to market based economy began in the early 1990s and has been marked by an overall decline in national income; over 50 million Russians are living below the official poverty line. Social and economic conditions in Russia during the past decade — increasing poverty, high unemployment, labor migration, inadequate health care and a lack of preventive health education — provided fertile ground for the rise in injecting drug use and commercial sex work and facilitated the spread of HIV .
After the first documented case of AIDS was reported in 1986, a system of regional AIDS Centers throughout the USSR was set up to carry out testing and limited prevention activities. Fewer than 1100 HIV cases were registered from 1987 until the end of 1995. These HIV cases were mostly among MSM and urban FSWs.  From 1996 to 1998, however, Russia experienced sharp increases in HIV infection among IDUs. 
Initially, government policy emphasized using HIV anti-body testing on a wide scale to identify HIV-positive people.  Screening targets included low risk (e.g. pregnant women, blood donors, occupational groups) and vulnerable populations (drug users, prisoners, STD patients). Testing policies for low risk populations have become less stringent since the mid 1990's. Officially, most HIV tests are now voluntary, except for blood donors and foreigners. Reporting of HIV/AIDS cases is required by law and Ministry of Health regulations. Registration includes the recording of all results and the referral of positive results to an AIDS center for confirmation, history taking, official registration, and treatment (when available and then only to official residents). Classification into transmission category is based on clinical interview; therefore reliability is questionable because of stigmatization and potentially serious consequences for people who disclose drug use, homosexuality or commercial sex.
Drug use rapidly increased in the 1990s. many Russians who were hard hit by unemployment and poverty turned to growing and selling drugs as a way to survive in the 1990s while others became consumers of drugs, seeking escape from hardship, disillusionment, and social dislocation. In some groups, drugs are substituting or supplementing traditional patterns of heavy alcohol consumption.  Additionally, the spread of HIV in the region is influenced by current drug production and distribution patterns. The world production of heroin quadrupled in the last decade, creating new markets in the production areas as well as along transport routes. Free market economies and open borders facilitated the exchange and transport of drugs. Self-produced opioids and amphetamines are also prepared for injection. The social context of drug injecting, especially the ubiquitous practice of preparing and using drugs in groups, may well be responsible to a large extent for the rapid diffusion of HIV among the IDU population . Intravenous drug users in Russia are younger than their counterparts elsewhere, most are among 18 to 25 years old, and estimates of the numbers range from 600 000 to 2.5 million .
There is growing evidence that in addition to drug users, the number of people working in the sex industry increased dramatically during the 1990s and also has contributed to the growth of the HIV epidemic. For many Russian women, sex work is their only means of survival. However, there is substantial overlap between sex workers and IDU; the number of female IDUs involved in sex work ranges from 10 to 30 percent [24,25]. Sexual transmission of HIV is growing in areas of Russia where the drug use and HIV epidemics have existed for a number of years. Moscow is particularly vulnerable since it has the region's largest sex worker population, with estimates of up to 70 000 sex workers [22,26]. In Kaliningrad, sexual transmission has increased from an estimated 5–15 percent of newly detected cases in 1996 to 30–35 percent in 2000 . At the same time, large epidemics of STIs have been reported. Between 200 000 and 400 000 new cases of syphilis are reported annually. This increases the potential for a major heterosexual epidemic.
In the last decade organized, visible and legal gay community venues have emerged and MSM who frequent these venues have been found to be mostly young, highly sexually active, often sell sex and practice high risk behaviors such as anal intercourse without consistent condom use . Moreover, in one study in St. Petersburg many MSM at these venues reported both male and female partners in the past three months, therefore acting as sexual bridges between networks of MSM and women.
Health care organization and health system financing have been profoundly affected by the break-up of the former Soviet Union. Health expenditure as a share of GDP has fallen over the last ten years to 4.8% in 1994 down from 9.1% in 1987 and 12.3% in 1970.  The former highly centralized organization and funding has been replaced by an increasingly loose grouping of autonomous states. Local governments vary the degree of support they make available to the health sector and increasing inequalities are entering the system, such as health care services that are available only to official residents of the territory . The structure of the health system makes a coordinated approach difficult and key policy makers outside the health system are not engaged. There is a great deal of variation in the way regions are tackling the problem, with some increasingly open to reform. There is a need for policy direction at the federal level so that best practice can be developed and disseminated effectively, and so that there is a consistent approach across the country. The emergence of the non-governmental sector has been hampered by the tax status of non-governmental organizations (NGOs), which restrict the extent to which charitable organizations have been able to function .
The Russian Federal Government and regional administrations are committing budgetary resources to HIV/AIDS programs. However, presently the Ministry of Health is being criticized for spending the bulk of its meager $5 million annual budget on treatment rather than on prevention . A harm reduction movement, usually at the local level, is under way. Needle/syringe exchange programs are currently operating with the tacit permission of local authorities even though the national government has not officially endorsed such policies. Several groups, including the Soros Foundation, Department for International Development (UK), Médecins sans Frontières, UNAIDS and UNDP, are working to organize, fund and sustain harm reduction projects. Even though the number of organizations involved continues to increase, the need for viable harm reduction programs is rising even faster as injecting drug use surges.
Epidemics of the type in Russia are particularly sensitive to early and focused prevention efforts. Because the epidemic is concentrated in a limited number of smaller populations, efforts that work with the communities of IDU and with sex workers and their clients to reduce both their injecting and sexual risk can be particularly effective in slowing the spread of HIV to the general population. The present epidemiological situation calls for an urgent coordinated response, before the window of opportunity to prevent a further spread from drug users and sex workers into the general population closes.
China has the largest population in the world, currently 1.3 billion people, 24% of the world's population. Of these 1.3 billion, 720 million are 15–49 years old, the period of greatest sexual activity and drug use. This is a huge population of sexually active persons potentially at risk for sexually transmitted infections, including HIV. Thus, a major epidemic of HIV in China would dwarf the current global epidemic in terms of the number infected even if the epidemic does not reach the proportions observed in sub-Saharan Africa.
In the last decade China's transformation from a state-controlled to a market-oriented economy has been accompanied by dramatic changes in the social milieu. Sex before and outside of marriage is now more socially acceptable, especially to young people. This change in attitude, plus the increasing disparity between rich and poor, has stimulated a rapid rise in sex establishments and commerical sex, especially in the wealthy east coast cities . Commensurate with the increased sexual freedom, STI rates have risen at a rate of 30% or more per year over the last decade . China also became involved in the epidemic of injection drug use, which began in the late 1980s in the golden triangle area of Southeast Asia, which includes southern Yunnan Province . Finally, the change to a market-oriented economy has created large industries, particularly in the larger urban centers and the coastal cities that demand cheap labor spurring a rapid increase in the migrant population currently estimated to be as high as 200 million persons. Thus, China has the key ingredients for a major HIV/AIDS epidemic: a large mobile population, a society undergoing rapid economic change, widespread commercial sex and increasing sexual permissiveness and promiscuity.
The first cases of HIV/AIDS were reported in Beijing in 1985 but the HIV epidemic became established in Chian in 1989 among IDUs in southern Yunnan Province as part of the broader IDU epidemic in Thailand, Myanmar and northeast India fueled by an increasing production of opium. By 1994 the HIV epidemic among drug users had spread to many of the other provinces of China, particularly Xinjiang, Guangxi and Guangdong. In 2002, it is estimated that 69% of all HIV infections are due to injection drug use . Concurrently, the demand for blood and blood products could not be met in China through donations from volunteers requiring paid blood/plasma donors. The high profit margin resulted in the growth of illegal blood and plasma centers not regulated by the government; consequently blood and plasma-collecting apparatus was often not sterilized between donors resulting in transmission of infections, including HIV [33,34]. In some of these illegal plasma centers blood may have been pooled before separation of cells that were then returned to the donor  with the rationale that this would enable them to donate plasma more frequently. A deteriorating economic situation in the rural areas after the change to a market economy, especially in central China, forced farmers to supplement their income and donation of plasma was an easy way to increase their income especially if it could be done frequently if their cells were returned to them. Controlling the frequency of donation by individuals was thwarted when they donated to several different centers, which did not have coordinated records. Although plasma donors are estimated to represent only 7% of HIV infections in 2002, in parts of Henan the proportion of plasma donors infected with HIV has been reported to be over 40% .
The origins of the HIV epidemic among rural drug users and plasma/blood donors in rural areas probably explains the unusual epidemiology of HIV in China, where the majority of HIV infections in China are currently in the rural areas with low rates in urban areas. Therefore, concern is growing about the large ‘floating’ population, which migrates from the rural areas to the urban industrial areas who may have many sexual partners and engage in commercial sex . Further, most of the new wealth in China is concentrated in cities, stimulating the establishment of sex venues, which, in addition to attracting wealthy clients, also attract young women from the rural areas trying to escape poverty. Over 600 000 commercial sex workers have been identified in China but the true number is estimated to be 5–10 times higher. Although condom use is reported to be very low among FSWs, the HIV infection rate was estimated to be 1.32% in 2000 but is now likely considerably higher .
The government of China estimates that in 2002 there are 850 000 HIV infected persons (Fig 3.). UNAIDS, however, estimates that the actual number of infected individuals is closer to 1.5 million. Males currently represent 89% of infections and individuals 20–39 years of age represent 81% of infections. Sixty-nine percent of cases currently are estimated to be injection durg users, 7% to be blood or plasma donors and 7% to be heterosexuals. However, the source of infection is unknown for 17% of those infected .
China has responded to the epidemic vigorously. A national sentinel surveillance program was established in 1995, which included sex workers, drug users, long distance truck drivers, pregnant women and blood donors. The government has banned illegal blood and plasma donation centers. They have a vigorous anti-commercial sex worker program, which, unfortunately, has been largely ineffective and may be counter productive. They developed both a mid-term and a long-term plan for HIV/AIDS prevention and control from 1998–2010 and a containment, prevention and control of HIV/AIDS action plan for 2001–2005. They have mounted a public education program targeting the general population, injection drug users, persons who have multiple sexual partners and blood donors. The Ministry of Health has established a National Center for AIDS/STD Control and Prevention, which is conducting many research projects to evaluate different intervention strategies. There is a need for an even greater political commitment, which involves all the relevant sectors of the government. The surveillance system needs to be standardized across provinces and improved. Community mobilization has proved to be very effective in mounting national programs in the past in China and should be used to combat the spread of HIV, to reduce the incidence of injection drug users, and to promote condom use. China is confronting a very serious threat to its future growth and development. Recent history suggests that China can respond to the threat, but must establish the necessary political commitment to mobilize the population to implement intervention and prevention strategies.
Like Russia and China, Vietnam embarked upon the transition to a market economy in the late 1980s that was accompanied by an expansion in social openness. Unfortunate consequences have been a resurgence of commercial sex in the big cities and increasing drug use in specific communities. HIV was first identified in Vietnam in 1990; as of April 2002 the cumulative number of HIV infections in Vietnam was 48 762 (including 7148 AIDS cases and 3871 AIDS deaths) . In the year 2000, Vietnam's HIV sentinel surveillance program reported nationally HIV prevalence in specific groups of 20% among IDUs, over 4% among FSWs, and about 2% among STD patients . In 1990, the Government created the National AIDS Committee (NAC) that is mirrored on the local level by 61 Provincial AIDS Committees and mass organization focal points that deliver AIDS services and HIV control. For the first half of the 1990s HIV infections were largely confined to IDUs in Ho Chi Minh and several other cities of southern Vietnam. Most of these drug users were older men. In 1998, however, there was an explosive increase in the prevalence of young injecting drug users and of HIV infection among drug users in several of the provinces of northern Vietnam including Quang Ninh and the major cities of the north . The infected drug users in the north tended to be younger and were sexually active . As a result, infection rates among FSWs rapidly rose to 10–15% in areas such as Hanoi and Haiphong, some of whom injected drugs. Therefore, the epidemic in Vietnam has grown rapidly among at least one core group (IDUs) and is spreading to at least one other core group (FSWs) and certainly has the potential to spread to the broader population.
Nationwide, between 63–81% of IDUs reported sharing needles and syringes [43,44]. This sharing occurs despite the fact that disposable needles and syringes are legally available for sale in pharmacies and clinics at very low prices. Given these estimates the deputy head of Vietnam's National AIDS Committee estimated that the real number of HIV infections in Vietnam reached 140 000–165 000 by the end of 2001 . Sentinel surveillance covering 30 provinces found the median HIV seroprevalence among IDUs to be 13%, but recent studies indicate that rates in Hanoi and Haiphong cities and Quang Ninh Province are as high as 65–74% among injecting drug users [46–48]. A dramatic recent increase in HIV infections associated with IDU was reported in 14 of 21 sentinel provinces during 1996 to 1999 but primarily in the northeastern corner of Vietnam bordering China . The rapid surge in young injectors and HIV infection among drug users in northeast Vietnam parallels what is being observed in China's Guangxi Province just north of Quang Ninh Province and may represent a cross-border epidemic across the porous border between Vietnam and China.
Although currently much less frequent than drug-related transmission, the second most common risk factor (accounting for at least 10.9% of cases) remains sexual transmission, principally heterosexual transmission. Of all infections reported through 1999, 5.0% of cases with risk information were FSWs; an additional 3.6% of cases were patients being seen clinically for an STI (for whom sexual risk is assumed to be the source of transmission), and another 2.3% were workers in the entertainment industry or others thought to be at increased sexual risk . HIV prevalence among FSWs especially increased significantly in 6 of 21 provinces since 1998. Preliminary results from the first round of behavioral surveillance suggest there may be sexual link-ages between the commercial sex and IDU networks that may result in further spread of HIV across and outside of these core groups .
Sentinel groups representing the population at large (pregnant women, military recruits, blood donors) continue, in general, to experience a relatively slow increase of HIV prevalence suggesting that transmission from IDUs and FSWs to the general population is still relatively low. For example, there was no statistically significant change in HIV prevalence among pregnant women in any individual province from 1996 though 1999, despite the significant increases for IDUs and FSWs in the same provinces. For military recruits, among approximately 800 tested per province, the overall rate in 1999 was 0.61%, significantly higher than the rates in 1996 (0.04%), 1997 (0.13%), and 1998 (0.20%) . HIV among blood donors remains infrequent, but has shown a small but statistically significant increase in the late 1990s.
Vietnam's government is struggling to address HIV control within a tradition of a hard line approach to social problems that has included a punitive response to commercial sex and drug use involving arrest and isolation for reeduction. Efforts to control HIV/AIDS have been closely linked to the government's ‘social evils’ campaign launched in 1993 to wipe out prostitution and drug use, although recently the Vietnamese government is making an effort to separate this campaign from HIV prevention programs. Upgrading of the surveillance system and plans to utilize peer education strategies amongst IDUs are planned for the near future but a broader response will be required to avert generalization of the epidemic. Like Russia, non-governmental organizations are relatively new to Vietnam, most establishing offices since the lifting of the US embargo in 1994. While these agencies have grown rapidly, they are still in infancy stages and have limited capacity to tackle large-scale prevention efforts.
The epidemics in Russia, China and Vietnam have emerged only recently, well after the epidemics in the U.S., Africa and Thailand. Perhaps because of the profound and rapid social and economic changes occurring in them, these three countries have failed to heed the early warning signs of the epidemics in their countries — relatively high prevalence rates in injection drug users and other risk groups. Now that the epidemic is well established in several risk groups in each of them control will be more difficult. Because of the changing political/social situations in these countries the public health and social sectors have not received priority and are struggling with often insufficient direction and shrinking resources to change from central government dominated control to local control. For example, health care is no longer free in these countries, which complicates implementing broad public health approaches.
Although their epidemics are now well established in one or more of the risk groups they have not yet spread to the general population. Thus, there is time to implement the lessons learned from previous epidemics, but the window of opportunity is short. These countries have demonstrated that they can implement broad effective programs through community mobilization. Two examples in China are the success of the one child campaign and the effective response to severe flooding .
Some essential components for HIV epidemic control for these countries are now well-established including resources, epidemiological data and programmatic experience. The need for political will and a national commitment remain primary and are not as uniformly apparent. China now has the political will, but Vietnam and Russia could benefit from a stronger national commitment to control the epidemic. Concurrent with this political will must be allocation of resources and strengthening of the public health sector. More effective sentinel surveillance will assist these countries in identifying where the epidemic is, how fast it is spreading and what interventions are most likely to be effective. Another component is mobilization of the community to recognize the magnitude of the problem and to support effective intervention programs. Yet Russia, China and Vietnam have little experience with non-governmental organizations, social activism was historically repressed, and open public discussion of socially sensitive behaviors such as sex and drug consumption discouraged. The socially conservative societies of China and Vietnam need to recognize the need to discuss sexual and other sensitive issues, which promote the spread of HIV. Interventions targeting core groups such as the 100% condom campaign in Thailand and Cambodia need to be implemented to prevent the spread of HIV from the affected high-risk groups to the general population. These intervention strategies need to be implemented in a culturally sensitive and acceptable manner. Given the epidemics are largely concentrated in segments of their societies that practice behaviors outside of social norms such as commercial sex, drug use and same sex activity, an effort to reduce the stigma associated with such behaviors and to remove the threat of punitive response to the admission of such behaviors will be necessary.
Russia, China and Vietnam still have an opportunity to learn from successes of countries affected early in the epidemic and to implement programs that have proven to be successful elsewhere. If acting rapidly and decisively, they can avert their epidemics transitioning into generalized epidemics. They must now do so if they are to avert the disaster, which accompanies a large scale HIV/AIDS epidemic.
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