This joint Swedish-Russian project in St. Petersburg originated in 1998. At that time the number of known HIV-infected persons in Russia was not great. The total number of notified cases was about 6 500. In St. Petersburg, a big city with five million inhabitants, the total number of notified cases was approximately 250 (1). However, there were ominous signs. The use of intravenous drugs was exploding in Russia. In St. Petersburg the number of intravenous drug users was estimated to be between 60 000 and 120 000 and HIV was introduced to this population. In Kaliningrad there were already approximately 2 000 HIV cases among intravenous drug users (1). Thus it was easy to foresee a rapidly evolving HIV epidemic in many places in Russia, primarily among drug users, but with the potential to spread to the population at large through sexual transmission.
Two things seemed very important. One was to inform the population in general and especially the youth about the dangers of HIV infection (and other STIs prevalent in Russia as well) and intravenous drugs. The other, and even more urgent, was to try and prevent the spread of HIV infection among drug users. The Swedish organisation LAFA (Stockholm County Prevents AIDS) had already started projects aiming at creating youth centres in St. Petersburg. Sweden had good experience with centres for the promotion of a healthy life style among the youth, including prevention of HIV, other STIs and abortions. Our project aimed at preventing the spread of HIV infection among drug users. Such a project, initiated by the organisation ”Doctors of the World”, was already established in St. Petersburg, but considering the extent of the problem the actions taken against HIV infection among drug users seemed too limited. The objective of our project was to reduce the spread of HIV infection and, in a pilot project, to give an example of one way to deal with the problem.
A project aiming at the prevention of HIV infection among drug users was established at the end of the 1980s at the Department of Infectious Diseases, Malmö University Hospital, in Malmö in southern Sweden. This project provides information concerning HIV and how to avoid infection, syringe exchange, regular testing for HIV and other bloodborne infections, medical care including gynecological care for women, distribution of condoms and links to medical and social services for treatment and rehabilitation of drug users. The project seems to have been effective in preventing HIV infection, since only very few new cases have been detected among drug users in the Malmö region during the time period the project has been running. Several leading international organisations including WHO are also in favour of such programmes as a means to limit the spread of HIV infection. Thus it was decided to use the Malmö project as a model for a project in St. Petersburg.
The project plan was written in 1998 and in May 1999 a Russian project group made a one-week study visit to the Malmö project. The Russian project group included a professor of infectious diseases (team leader and adviser in matters concerning infectious diseases to the Health Committee of the City of St. Petersburg), a physician from the infectious diseases control authority (Sanepidnadzor) in St. Petersburg and two infectious diseases nurses. The group visited the Department of Infectious Diseases and the Detoxification Unit of the Malmö University Hospital and several rehabilitation centres for drug users in the city.
The Russian group returned to St. Petersburg to set up the project. It was decided to tie the project to the infectious disease hospital number 10 not far from the centre of the city. The project came to consist of two parts. One was a bus which could move around the city, but was often placed near one of the main squares. The bus was staffed with a driver, two nurses and sometimes a physician. It was active from Mondays through Thursdays between 16 and 23. Drug users were given advice and information materials, received clean syringes and needles in exchange for used ones, condoms and were offered testing for HIV, hepatitis B and C and syphilis. The other part of the project was a policlinic, the ”Drop-in Center”, now located in a building at the entrance to the hospital. Here the same kind of activities took place as in the bus, but the possibilities to access medical aid were greater. The drug users could be referred to a psychologist and to narcologic services (psychiatric services specializing in problems of drug addiction). They also received information about nongovernmental organizations that engage in providing rehabilitation. Lately, they have also been offered simple food.
For laboratory diagnosis of HIV infection ELISA and Western Blot were used. For laboratory diagnosis of hepatitis B and C ELISA was used.
One interesting part of the project was the distribution of questionnaires to the drug users with the purpose of getting a better understanding of their situation and attitudes. A further step in this direction was the creation of focus groups for more detailed discussions.
On the World AIDS day December 1, 1999 the project started with a demonstration of the activities and the participation of the mass media on the Nevskij Prospekt, the main street of St. Petersburg.
During 2000 and 2001 representatives from the Department of Infectious Diseases in Malmö visited the project in St. Petersburg, and in the summer of 2001 the Russian group again spent a week in Malmö.
During the period December 1, 1999 to December 31, 2002 a total of 2 796 intravenous drug users made 16 508 visits to the bus. All except 20 gave a blood sample at the first visit. At the first visit 326 of the drug users (12%) were already infected with HIV whereas 939 (34%) were infected with hepatitis B and 2 253 (81%) were or had been infected with hepatitis C (Table 1).
Table 1. Number of drug users positive for hepatitis B, hepatitis C and HIV at first testing at the bus
During the same time period the policlinic “Drop-in Center” had 5 398 visitors. 822 of the drug users (15%) were HIV infected at the first visit and 4 366 (80%) were or had been infected with hepatitis B and/or C (table 2).
Table 2. Number of drug users positive for hepatitis B and/or hepatitis C and HIV at first testing in the Drop-in Center
987 HIV-negative visitors to the bus were tested for HIV more than once. Excluding the initial test, 1 393 HIV tests were performed among the visitors. 686 were tested twice, 216 three times, 70 four times and 15 5 times or more. A total of 130 persons underwent repeated testing in the year 2000, 389 in 2001 and 468 in 2002. Among these 987 persons 30 new HIV infections were detected during the project period.
Approximately 210 000 needles and syringes were distributed during the project period and 207 000 used needles and syringes were returned. Furthermore, approximately 168 000 condoms were distributed.
The mean age of the 2 796 drug users was 23.9 years and 2 141 (77%) were males. The questionnaires gave some interesting information regarding drug use. The mean age for starting intravenous drug use was 19.4 years. The 14 youngest were 12 years old at the time they started using intravenous drugs. The frequency of drug injection is shown in table 3.
Table 3. Frequency of drug use for visitors to the bus and Drop-in Centre
87.5% of the drug users used heroin. 36% had used drugs for 4 years or more. 379 bus visitors have been referred to a narcologist and 363 to detoxification treatment. 331 have received at least one dose of hepatitis B vaccine.
The main purpose of the project was to limit the spread of HIV infection among drug users. Of the 987 visitors to the bus who were tested for HIV more than once 30 (3%) seroconverted. It is difficult to interpret this result because there was no control group. But it is necessary to keep in mind that the project was conducted in the midst of the explosion of HIV infection among drug users in St. Petersburg. The HIV notification rate in the city seems to have peaked in 2001. More than 10 000 new cases were detected in that year, primarily among the user population estimated to be between 60 000 and 120 000 persons (2). The prevalence of HIV infection at first testing among the visitors to the bus was 12% and 15% among the visitors to the Drop-in Center. These figures are comparable with the results from two other studies of drug users in St. Petersburg showing prevalence rates of 12% for HIV (3) and 10,9% for HIV, 78,2% for hepatitis C and 15,8% for hepatitis B (4) in blood from syringes. The participants in the project seem to be relatively heavy drug users, with one third of the bus visitors injecting at least once daily and a similar proportion having used drugs for at least four years. Thus our seroconversion rate of 3% during the three-year project suggests a positive effect of the project on the drug users participating. Due to the limited scope of the project, it may not have had a very great influence on the situation as a whole in St. Petersburg but, rather, may be considered a pilot project. To our knowledge there are no similar data from other cohorts of drug users in St. Petersburg. An important result of the project is the creation of a valuable contact surface and better relations between health care personnel and drug users in St. Petersburg.
There were substantial challenges associated with the initiation of the project including to secure permission to drive the bus in the city and to exchange needles and syringes. The aim to regularly test every participant in the project for HIV infection has not been achieved, although the number of re-tested persons has grown through the years. The links to narcology and rehabilitation services need to be adequately developed. These aspects should be improved in the future.
After the completion of the Swedish-Russian project in December 2002, the City of St. Petersburg continues to support the Drop-in Center but to date not the bus. Furthermore, the City has started three new policlinics similar to the Drop-in Center. One is attached to the infectious disease hospital number 30, Botkin, one to a narcology dispensary and one to a venerology dispensary.
1. VITJ-infektsija v Severo-zapadnom regione Rossii. Informatsionnyj bjulleten za 1997 god. Sankt-Peterburgskij nautcno-issledovatelskij institut epidemiologii i mikrobiologii im. Pastera. Sankt Petersburg, 1998.
2. City AIDS Center St. Petersburg. Personal communication.
3. Smolyskaya T, Khodakevich L, Kobyshcha Yet al. An HIV prevalence study by means of sentinel epidemiological surveillance among injection narcotic abusers in Saint Petersburg. Zh Mikrobiol Epidemiol Immunol 2000; Jul-Aug(4):31-3.
4. Abdala N, Carney J, Durante A et al. Estimating the prevalence of syringe-borne and sexually transmitted diseases among injection drug users in St. Petersburg, Russia. Int J STD AIDS 2003; Oct 14(10):697-703.