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HIV Cascade: Eastern Europe
Cascade of HIV Care in Eastern Europe

Released: December 03, 2021

Expiration: December 02, 2022

Milosz Parczewski
Milosz Parczewski, MD, PhD
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Several interesting studies reported data from the Central and Eastern European region at the European AIDS Conference 2021 in London. The first study I’d like to discuss with you was presented by Fursa and colleagues on the cascade of HIV care in Eastern Europe.

The CARE East Cohort
The CARE East Cohort from Russia, Ukraine, and Georgia included 3814 people with HIV (PWH), 59% of whom acquired HIV through heterosexual transmission, which makes this group different from typical cohorts from Western Europe.

The Georgia subgroup achieved the highest rate of PWH aware of their status receiving antiretroviral therapy (ART) at 99.6%, and 91% of them were virologically suppressed. The cohort therefore met 2 important UNAIDS 90-90-90 targets.

The Ukraine subgroup achieved the on ART target with nearly all their cohort (98.6%) on ART, and they almost achieved the virologic suppression target (86.4%).

The Russia subgroup did not meet either target (86.6% on ART and 65.4% virologically suppressed). Almost one third of Russian patients started ART <6 months before enrollment in the CARE East Cohort.

Older age and not participating in injection drug use were factors associated with greater likelihood of virologic suppression; this may be reflected in better treatment uptake and adherence among these subgroups. Among the Russian subgroup, recent HIV diagnosis and hepatitis C virus coinfection were associated with lower likelihood of virologic suppression. These results highlight the importance of focusing on improving treatment uptake and linkage to care in certain populations and regions of Eastern Europe as a targeted strategy to prevent HIV morbidity and transmission and to achieve regional and global HIV elimination goals.

Delays in Diagnosis and TB and HIV Mortality
A study by Kraef and colleagues reported on delays in diagnosis of tuberculosis (TB) in Eastern Europe, and the effects of delayed diagnosis on mortality in patients with HIV and TB. Patients in this prospective, observational cohort were enrolled from 21 HIV and TB clinics in Belarus, Estonia, Georgia, Latvia, Lithuania, Poland, Romania, Russia, and Ukraine. In this study, delayed diagnosis was defined as self-reported onset of TB symptoms at least 1 month before diagnosis of TB.

The authors reported that among 740 patients with HIV and TB, 65% had delayed TB diagnosis. Delayed TB diagnosis conferred a 36% increased risk of death (HR: 1.36; 95% CI: 1.04-1.08) before adjustment. Even after adjustment for concomitant risk factors, including sex, CD4+ cell count, earlier AIDS diagnosis, alcoholism, clinical presentation, and others, the risk of death was 27% higher (HR: 1.27; 95% CI: 0.95-1.70) among those with delayed diagnosis.

The authors also identified factors associated with delayed diagnosis, including older age, injection drug use, being naive to ART, and having disseminated TB or weight loss.

These 2 studies—on the CARE East cohort and on delays in TB diagnosis—show that among PWH, those who also inject drugs are less likely to be virally suppressed and more likely to experience delays in TB diagnosis. We should remember that, as in many lower-resource settings, TB is the most common opportunistic infection in this region. 

Addressing Systemic Factors in Care Disparity
How can we explain the regional differences seen in the CARE East Cohort study? And how can we improve linkage to care where gaps persist?

Georgia has made great strides in recent years with the rollout of national testing and treatment programs with strong support from nongovernmental organizations (NGOs) and harm-reduction networks. Georgia has been able to increase the number of PWH aware of their HIV status by linking hepatitis C virus testing with HIV testing. Ukraine is also making headway in collaboration with NGOs by expanding testing programs and implementing HIV pre-exposure prophylaxis. Russia has the biggest challenges because of its large landmass and large population, both of which make rollout and implementation of testing and treatment programs much more difficult.

A significant problem in the Eastern Europe region is the stigma of an HIV diagnosis, which tends to get worse the farther east one goes—particularly against men who have sex with men. Some individuals will avoid testing sites to avoid intake questions about sexual behaviors. At-home HIV testing can help people become aware of their HIV status in private, and in some countries such as Poland, the confirmatory laboratory testing is inexpensive and readily available. Availability and costs of at-home HIV tests vary, but some NGOs are distributing tests to patients at reduced cost or without cost. Along with community- and healthcare-based testing facilities, home-based testing will help us close the diagnosis and linkage to care gaps in Eastern Europe.

Your Thoughts?
What are the successes and shortcomings of timely testing and treatment in your location? Join the conversation by posting a comment below and/or answering the polling question. For more details on this and other key HIV issues from EACS 2021, review more CCO Conference Coverage, including Capsule Summary slidesets, video recaps with expert faculty, and other ClinicalThought commentaries highlighting US and global perspectives.

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