The HIV epidemics in eastern Europe are particularly hard to
tackle because so many of those infected are injecting drug users and, partly because of this, a high proportion are co-infected with TB and/or
hepatitis C. Professor Alexander Panteleev of St Petersburg State Medical
University gave a sobering account of care for HIV/TB co-infected
patients in the city.

In global terms, Russian TB prevalence is not especially high. Though TB is ten times more common than in western Europe, its prevalence of 60 people with
active TB per 100,000 population is ten times lower than the prevalence in South Africa or the Philippines (TB is endemic in south-east Asia).

Additionally,
TB prevalence in eastern Europe and central Asia has fallen in almost all
countries in the last decade – by 44%, in Russia’s case. And
although the prevalence of TB/HIV co-infection has risen, from 15 per 100,000 in
2010 to 24 per 100,000 in 2017, this is largely because of the increase in HIV
cases, and is now starting to level off.

But that is not the challenge Russia is facing. The health emergency St Petersburg is dealing with is caused
by the intersection of two factors – an ageing population with HIV who, in the
absence of ART, are now increasingly unwell, and the fact that two-thirds
are or were injecting drug users, with all that implies about reaching out to a criminalised,
suspicious and sometimes chaotic patient group.

Although there are 17,500 people on ART in St
Petersburg now, compared with 1800 a decade ago, 35.5% of the diagnosed are now living
with an AIDS-defining illness compared with 11% in 2010. In 2002, at the
peak of incidence in people who inject drugs, just 10% of those had a CD4 count
below 200. That figure is now 64% and 46% have an AIDS-defining illness, more often than
not TB.

The degree to which the Russian HIV/TB crisis is all about
linkage to care is shown by the fact that 85% of people with HIV and TB in St
Petersburg have known their status for 7-10 years, yet are not in care. TB care
is also complicated by the fact that severely immune-compromised people often
have the disseminated, systemic form of the disease rather than the pulmonary one,
and standard approaches to
early detection of tuberculosis do not work in patients with advanced HIV
infection.

Another terrible legacy of lack of care, or rather of
intermittent care and loss to follow-up, is the proportion of people who have
TB that is multi-drug resistant (MDR-TB). Here the data are truly startling.

The World Health Organization defines MDR-TB as TB resistant
to the two most powerful first-line drugs, isoniazid and rifampicin. It
estimates that globally, 4% new and 19% of previously treated TB cases are of MDR-TB. MDR-TB is a significant cause of mortality.
Globally, in 2014 54% of people treated for MDR-TB were cured while 18% died
and 8% were left with continuing active TB.

In St Petersburg, the proportion of people with HIV and TB
who had MDR rose from about 40% before
2011 to 70% since 2013. Nearly a quarter of people with HIV and MDR-TB live
less than a year and half die within three years. And Russia’s mortality
rate is not the worst: 7.3 out of 100,000 people die of AIDS-defining TB; compared to 8.7 in Ukraine and Azerbaijan and 9.9 in Turkmenistan.

Professor Panteleev said that there were three factors that
had combined to produce something for which for once the phrase ‘perfect storm’
feels appropriate.

Firstly, the lack of social care for injecting drug users
and people with HIV meant they dropped out of whatever systems there were, and
they were very hard to find. Secondly, there was a problem with medical staff who
were “intolerant to socially-deviant forms of behaviour”, and who lacked the training
to work with active drug users. Thirdly, low levels of knowledge and education among patients and a pervasive distrust of healthcare workers and treatments meant that people avoided
seeking treatment. In Russia, despair has led to a secondary epidemic of
HIV denialism, with tens of thousands of people reading HIV denialist websites
and subscribing to their beliefs, in an echo of the situation in South Africa nearly
two decades ago.

How does one begin to tackle such an epidemic? Panteleev
laid emphasis on something that became a theme during the Standard of Care
meeting: although education and skilling of healthcare staff was vital, as was better
social support for injecting drug users and others with HIV, there is no substitute
for peer support. Russia’s co-infected drug users desperately need the national, regional and local authorities to recognise the value of local NGOs who
can support and train peer navigators to assist their fellows on the hard journey
back towards health.