On Russia’s AIDS front

On a cool evening early last October, half a dozen graduate students of psychology and sociology began knocking on doors in a college dormitory in St. Petersburg, Russia, to ask the residents a simple question: “Whom do you talk to most?” As a reward for writing down the names of five people, each respondent received a chocolate bar.

Several hundred students live in the five-story dormitory at the Ioffe Physico-Technical Institute, which grants degrees in engineering, marketing and economics and boasts a Nobel laureate on its faculty. Yet despite the institute’s prestige, the residence halls have no lights in the stairwells and only dim fluorescent bulbs to illuminate the hallways. A few students have quarters to themselves but most double or triple up, cooking on electric hotplates in their rooms or on gas stoves in the kitchens on each hallway.

The simple question about social contacts lies at the heart of a plan to reduce the spread of HIV/AIDS in St. Petersburg. The strategy is to use social networks within the dorms to raise awareness of the disease and the means of avoiding it. “There is a lot of risk in terms of sexually transmitted disease and HIV,” says Alla V. Shaboltas, Ph.D., an associate professor of psychology at Saint-Petersburg State University who is supervising the graduate students in their survey. Indeed, the group’s initial findings indicate that 15 percent of dormitory residents carry a sexually transmitted disease and almost 1 percent are HIV-positive, suggesting high rates of unprotected sex.

And this is what worries Russian health officials. Until now, intravenous drug use has driven the AIDS epidemic throughout Russia. About 90 percent of those infected are drug users, and 80 percent of infections occur in people younger than 29, according to a recent report by UNAIDS, the arm of the United Nations charged with developing AIDS prevention, research and treatment strategies.

Now the virus is poised to spread through sexual contact. By virtue of their age, dorm-dwellers are at the highest risk of infection in one of the countries at the heart of the world’s fastest-growing HIV/AIDS epidemic. Government figures show that St. Petersburg, with a population of 5 million, has 16,000 HIV/AIDS cases. The real number is probably closer to 100,000, according to UNAIDS.

At the end of 1998, the number of HIV infections for all of Russia stood at slightly under 11,000, UNAIDS says. Halfway through 2002, federal health officials pegged the number at more than 200,000, an 18-fold increase that many believe severely underestimates the spread of the disease. Unofficial estimates run as high as 800,000 to 1.2 million.

Although the government and non-governmental organizations have gotten a few harm reduction and prevention programs off the ground in the last two years, UNAIDS believes they need to be expanded, that access to sterile needles and syringes should be increased and that stronger efforts should be made to reduce the risk of sexual transmission from drug users to their partners.

The survey, undertaken in collaboration with Yale’s Center for Interdisciplinary Research on AIDS (CIRA) and the Medical College of Wisconsin’s Center for AIDS Intervention Research (CAIR), is funded by the National Institute of Mental Health. It is one component of an international study taking place not only in Russian college dormitories but also in marketplaces in China, slums in Peru and communities in India and Zimbabwe. Roman Dyatlov, Ph.D., an assistant professor of biology and soil science at Saint-Petersburg State University, is the project manager in St. Petersburg; the principal investigator is Wisconsin professor Jeffrey A. Kelly, Ph.D., who originally developed the intervention model being evaluated in the study. CAIR scientists have shown its efficacy in reducing high-risk sexual behavior among various populations in the United States. Shaboltas, who heads the intervention group in St. Petersburg, is applying skills and knowledge she gained as part of the first wave of Russian psychologists, physicians and scientists to train at Yale’s School of Public Health under a grant from the National Institutes of Health’s Fogarty International Center.

International approach to a global threat

Since 1999, the Fogarty program has sent scientists from Saint-Petersburg State University and the Biomedical Center in St. Petersburg to train and study at Yale and the Medical College of Wisconsin. Thirty Russians have come to Yale and Wisconsin to learn epidemiological techniques and interventions. Four Yale scientists have gone to St. Petersburg to study the epidemic and implement research projects with Russian colleagues who have completed their training. Now researchers from both sides of the Atlantic are working together on public health projects, conducting and evaluating HIV prevention programs, providing case management of tuberculosis in Russian prisons and assessing the risk of contracting sexually transmitted diseases among drug users.

Yale public health faculty working at CIRA and scientists from CAIR first approached colleagues in St. Petersburg in 1997. “Our initial interest stemmed from the belief that Russia and other newly emerging democracies in Eastern Europe would soon confront a major HIV epidemic driven by injected-drug use and that HIV prevention research would be essential to ensure effective control efforts,” says Michael H. Merson, M.D., dean of the School of Public Health, who before coming to Yale was director of the Global Programme on AIDS at the World Health Organization. “We were alarmed that the epidemic in Russia was going to explode.” In St. Petersburg, and throughout Russia, health officials were already taking steps to contain the epidemic: St. Petersburg had a city AIDS center and a needle exchange similar to the one launched in New Haven in 1990. The concern was that the programs weren’t reaching all who might need them and that more was required to make people aware of the risks they faced.

In 1997 Merson began talking with Andrei P. Kozlov, Ph.D., a Russian microbiologist who had studied with Robert Gallo, M.D., one of the scientists credited with discovering HIV. Kozlov had also founded the Biomedical Center, a nonprofit research institute in St. Petersburg. In 1999, the first four Russian researchers came to Yale and Wisconsin.

Kovloz says he was interested in working with Yale because the collaboration would open the door to international funding for HIV/AIDS prevention work in Russia. Other programs would surely follow, he felt. And it would give Russian public health workers access to Yale’s faculty and resources. “We needed the international expertise,” Kozlov says. “We decided to think big and include people from different disciplines—biology, medicine, sociology, psychology, management, international relations and statistics. We trained an excellent group of people who are now leading the grants.”

A migration of knowledge

The early trainees have returned to St. Petersburg and are beginning their own intervention and treatment studies. Russian scientists continue to travel to New Haven for training, and Merson is leading an effort by Yale with the support of several public health schools in the United States to implement the first university-based public health master’s-level program in Russia (See sidebars).

Natalia A. Khaldeeva, M.D., Ph.D., the only physician in the initial group of four to study at Yale, is in a unique position to trace the path of the epidemic in St. Petersburg. Originally trained in infectious diseases, she was one of the first doctors to treat AIDS patients in St. Petersburg in the late 1980s. “I can remember the first patients with AIDS,” recalls Khaldeeva, noting that they numbered fewer than 100. “We knew them all by face.”

Most of those early patients had become infected through sexual contact. By the mid-1990s, however, the demographics had changed. “We had more and more and more patients,” says Khaldeeva, who after a year and a half at Yale returned to St. Petersburg to a new job as clinical director at the Biomedical Center. “Most new cases were detected among drug users. We started to count HIV patients in the hundreds and thousands. Before, we counted by tens.”

While at Yale, Khaldeeva studied epidemiology and worked at the Yale AIDS Program, learning to apply anti-retroviral therapies that remain scarce and costly in Russia. She returned to St. Petersburg in May 2001, and by October of last year, she had moved into her office at the Biomedical Center. For her re-entry grant, she had recently collected data for a study of 250 drug users newly diagnosed as HIV-positive. Her objective was to describe their clinical characteristics in order to improve their medical care and plan therapeutic and prophylactic measures. Her study also looked at differences in clinical manifestations related to age, sex, duration of drug abuse and immunologic status.

“Who are the newly infected?” she asks. “What clinical manifestations and comorbidities are present? We have to be prepared to plan for the future.”

Khaldeeva is also playing a role in the center’s efforts to find a vaccine against HIV/AIDS. She is examining differences in the functioning of the immune system in drug users and non-drug users. “We have to know those differences,” Khaldeeva says, adding that investigators need to know how a vaccine will affect an immune system compromised by drug use. “The purpose of this study is to describe the clinical and immunological factors of the injecting drug user population. It is important because it is the population at highest risk.”

Kozlov, who is leading the vaccine study, is well aware that an effective vaccine has so far eluded scientists. The virus’s ability to mutate into new forms has been hard to overcome. But, he says, a vaccine must be pursued, along with other prevention and treatment efforts. Looking back to smallpox for a historical parallel, he cautioned that a quick fix is unlikely. A smallpox vaccine first became available in the late 1700s, but it took almost two centuries to eradicate the disease. “If tomorrow we had a 100-percent-effective vaccine,” Kozlov says, “it would take us about 100 years to contain and eradicate the epidemic.”

A crisis from abroad

Both drug use and AIDS were rare in Russia until the fall of the Soviet Union in 1991. Several factors coincided to bring about an epidemic first of drug addiction, then of HIV. Over the past 10 years world heroin production increased fourfold, according to UNAIDS, largely as a result of civil war in nearby Afghanistan. When warlords turned to opium production to finance their fighting, supplies of heroin traveled along new smuggling routes through Central Asia to Russia and Eastern Europe. The drug found fertile ground in a society that was struggling to reinvent itself after the collapse of the Soviet system, which had ruled for more than 70 years. Since the mid-1990s inflation has jumped from 7 to 22 percent and the percentage of those living below the poverty level has increased from 25 percent to about 40 percent. Almost 9 percent of the people are unemployed, according to the CIA’s World Factbook 2002. Underemployment is rampant and many young people are disaffected by the poor economy and lack of jobs.

At first, according to Kozlov, there was official as well as societal denial that there could be a health crisis. “There could be no AIDS because Russian people had no sex,” he says with more than a little irony. And the initial low infection rates and slow progression of the epidemic lulled health officials into a false sense of security. “It was so slow that it was not important.” Stigma also played a role—AIDS was seen as affecting only people on the margins of society—drug addicts, prostitutes and homosexuals.

Now, there are two figures that bear watching, Kozlov says. One shows that 0.74 percent of college dormitory residents have HIV/AIDS. “That is very big for us. Among sexually active young people, almost 1 percent have HIV,” he says. “The other figure from our studies shows that 37 percent of drug users have HIV.”

Kozlov believes these figures show a need for greater awareness of the risks of AIDS and says Russia has begun mobilizing resources to prevent its transmission. “We are studying scientifically based interventions, we are training teams of researchers and social workers and we are working on federal programs which will involve the whole educational system from higher education to elementary education. This is our idea—to bring preventive messages to people,” he says.

Behavior and prevention are on Shaboltas’ mind as she applies techniques first developed for advertising in her survey of dormitory residents. “This idea is not new,” she says. The model for her survey and the intervention that will follow were first used as marketing tools to encourage consumers to accept new products. Here they will be employed to nudge people into healthy lifestyles. Shaboltas’ target is risky sexual behavior. “Our goal is to increase condom use and reduce unprotected sex with both casual and steady partners,” she says.

Looking for leaders

Shaboltas’ experiment on this fall night is more than a mere popularity contest. Her graduate students have spread out through the top two floors of the five-story building, asking students to put the name of a good friend on each of five cards. After a couple of hours of knocking on doors, Shaboltas is pleased with the results. Her students have collected more than 100 cards and found the dormitory residents generally receptive to the survey, despite those who write in Vladimir Putin.

Shaboltas’ next task is to sort through the cards for the names that crop up most often. These are the students who will be designated, in the jargon of the survey, as popular opinion leaders. Shaboltas will then attempt to recruit them to a subtle program for increasing HIV/AIDS awareness. “We will go to these people and say, ‘Would you like to do something for your community in HIV prevention and participate in training?’ ” she says. The training—five sessions of up to two hours—provides basic information on HIV and its transmission as well as advice on how to provide prevention messages in conversations with friends and neighbors.

To be effective, the opinion leaders need only be themselves. “They should behave naturally,” Shaboltas says. “They should put prevention messages into everyday conversations, using a lot of their own experiences. They could say they have their own risk for HIV. They should not behave as experts. They should just talk.”

Shaboltas and Dyatlov, working with CAIR’s Anton Somlai, Ed.D., plan to repeat the program at 20 dormitories, where 2,000 students are expected to participate in the study. Ten dorms will serve as controls, while the other 10 will undergo this intervention. Rather than rely on self-reported data to gauge results, the investigators have turned to hard science to determine whether behaviors have changed. Laboratory techniques including ELISA, PCR and Western blot will determine the presence of sexually transmitted pathogens.

Nadia Abdala, D.V.M., Ph.D., an associate research scientist at Yale, is working with the laboratory at the Biomedical Center to analyze blood samples donated by volunteer participants in the survey—one at the start of the intervention and a second one a year later. “That is where we want to see a drop in risky behavior,” says Abdala. “Studies in St. Petersburg have shown that people can be very misinformed about how HIV is transmitted, or they might have a negative attitude toward condoms or not know how to use condoms safely.”

Such a marriage of the basic and social sciences, microbiology and psychology, is one of the main lessons Shaboltas brought back to St. Petersburg from Yale. “For us that was a new area,” she says. “I had never been involved in collaborative work with specialists from other sciences. AIDS, because of its nature, is a multidisciplinary problem.”

With Russian physicians and social scientists beginning to work together, Kozlov believes all these efforts are essential to fight the epidemic. “We must contain it,” he says. “We have no choice.” YM