Anneli Uusküla

Seroepidemiological study of herpes simplex virus types 1 and 2 in Brazil, Estonia, India, Morocco, and Sri Lanka

Background: The association between herpes simplex virus type 2 (HSV-2) and human immunodeficiency virus (HIV) and the development of HSV vaccines have increased interest in the study of HSV epidemiology. Objectives: To estimate the age and sex specific seroprevalence of HSV-1 and HSV-2 infections in selected populations in Brazil, Estonia, India, Morocco, and Sri Lanka. Methods: Serum samples were collected from various populations including children, antenatal clinic attenders, blood donors, hospital inpatients, and HIV sentinel surveillance groups. STD clinic attenders were enrolled in Sri Lanka, male military personnel in Morocco. Sera were tested using a common algorithm by type specific HSV-1 and HSV-2 antibody assay. Results: 13 986 samples were tested, 45.0% from adult females, 32.7% from adult males, and 22.3% from children. The prevalence of HSV-1 varied by site ranging from 78.5%–93.6% in adult males and from 75.5%–97.8% in adult females. In all countries HSV-1 seroprevalence increased significantly with age (p<0.001) in both men and women. The prevalence of HSV-2 infection varied between sites. Brazil had the highest age specific rates of infection for both men and women, followed by Sri Lanka for men and Estonia for women, the lowest rates being found in Estonia for men and India for women. In all countries, HSV-2 seroprevalence increased significantly with age (p<0.01) and adult females had higher rates of infection than adult males by age of infection. Conclusions: HSV-1 and HSV-2 seroprevalence was consistently higher in women than men, particularly for HSV-2. Population based data on HSV-1 and HSV-2 will be useful for designing potential HSV-2 vaccination strategies and for focusing prevention efforts for HSV-1 and HSV-2 infection.

Genital mycoplasmas, including Mycoplasma genitalium, as sexually transmitted agents

Mycoplasmas are the smallest free-living organisms, widespread in nature. Several mycoplasma species have been isolated from humans. For 6 of them: Mycoplasma hominis, Ureaplasma urealyticum, M. primatum, M. genitalium, M. spermatophilum and M. penetrans, the genital tract is the main site of colonization. This review is concentrated on the role of mycoplasmas as sexually transmitted agents, with the emphasis to M. genitalium infections. M. hominis and U. urealyticum are isolated from the genital tract of healthy men and women with considerable frequency. The biological features (attachment properties, possible intracellular location) and experimental inoculation studies of M. genitalium indicate that this mycoplasma has pathogenic potential. Data from case-control studies, looking at men with non-gonococcal urethritis and women with cervicitis, have revealed that M. genitalium behave similarly to Chlamydia trachomatis and have revealed that carriage of M. genitalium and C. trachomatis is usually independent of one another. M. genitalium could be considered as a potential cause of sexually transmitted urethritis in men, including men with persistent or recurrent urethritis. More studies are expected to ascertain the role of M. genitalium in the female genital tract. Evidence-based data are needed to decide whether current non-gonococcal infection treatment principles are applicable or not for M. genitalium infections.

High Hiv prevalence among injecting drug users in Estonia: implications for understanding the risk environment

We found a high prevalence of HIV among injecting drug users (IDU) 54% in Tallinn and 90% in Kohtla Jarve, Estonia. Risk factors for HIV in Tallinn included use of the drug ‘china white’, being registered as an IDU at a drug treatment clinic, and sharing injecting equipment with sex partners. Differences existed in risk behaviour between the cities. An urgent scale-up of HIV prevention is needed. It is also important to explore how local ‘risk environments’ mediate the risk of HIV transmission.

High-prevalence and high-estimated incidence of HIV infection among new injecting drug users in Estonia: Need for large scale prevention programs.

OBJECTIVE To examine HIV risk behavior and HIV infection among new injectors in Tallinn, Estonia. Design and methods Data from two cross-sectional surveys of injecting drug users (IDUs) recruited from a syringe exchange program (N = 162, Study 1) or using respondent driven sampling (N = 350, Study 2). Behavioral surveys were administered; serum samples were collected for HIV testing. Subjects were categorized into new injectors (injecting < or = 3 years) and long-term injectors (injecting > 3 years). RESULTS Twenty-eight of 161 (17%, Study 1) and 73/350 (21%, Study 2) of the study subjects were new injectors. HIV infection was substantial among the newer injectors: HIV prevalence was 50% (Study 1) and 34% (Study 2), and estimated HIV incidence 31/100 PY and 21/100 PY, respectively. In Study 2, new injectors were more likely to be female and ethnic Estonian and less likely to be injecting daily compared with long-term injectors. No significant difference was found among two groups on sharing injecting equipment or reported number of sexual partners. CONCLUSIONS A continuing HIV epidemic among new injectors is of critical public health concern. Interventions to prevent initiation into injecting drug use and scaling up HIV prevention programs for IDUs in Estonia are of utmost importance.

High prevalence of blood-borne virus infections and high-risk behaviour among injecting drug users in Tallinn, Estonia.

The HIV epidemic in Estonia is rapidly expanding, and injection drug users (IDUs) are the major risk group contributing to the expansion. A convenience sample of 159 IDUs visiting syringe-exchange programmes (SEPs) was selected to quantify the association of HIV-risk behaviours and blood-borne infections. A high prevalence of HIV, hepatitis B core antibody (HBVcore), hepatitis B surface antigen (HbsAg) and hepatitis C virus antibodies (56, 85.1, 21.3, and 96.2%, respectively) was associated with high-risk injections, unsafe sexual behaviour and alcohol abuse. These findings emphasize the importance of evidence-based secondary prevention among the HIV-infected, especially given the uncertain sustainability of antiretroviral and substance abuse treatments.

The HIV Epidemic in Eastern Europe and Central Asia

Eastern Europe and Central Asia represent one of the few regions globally where there is a continued increase in the incidence of HIV infection. For example, in Eastern Europe the rate of diagnosed cases of HIV infection per 100 000 population has increased from 11.7 in 2004 to 22.5 in 2011. Initially propelled by injection drug use, heterosexual transmission has now become a major driver of new infections in the region. Nonetheless substance use remains an important factor, with its control limited by challenges in scaling up harm reduction efforts. While most countries have implemented opioid substitution therapy programs, their scale remains very limited. Similarly, coverage of needles syringe programs across the region is variable. Complicating the control of HIV has been the emergence of non-injection drugs and inadequate access to antiretroviral therapy. In addition, structural barriers and stigma toward HIV infected people may contribute to the high proportion of late presentations for HIV care. Finally in the wake of the HIV epidemic, high rates of hepatitis C infection and tuberculosis have been noted.

Estimating injection drug use prevalence using state wide administrative data sources: Estonia, 2004

Estonia has rapidly expanding injection drug use (IDU) driven HIV/AIDS epidemic with the highest reported incidence rate and prevalence (1.3%) of HIV in the European region. To evaluate the feasibility of IDU prevalence estimations based on routine nationwide data sources using capture-recapture methodology, and provide estimates of IDU prevalence. IDUs were identified from the Police, Health insurance fund, State HIV reference laboratory data sources. Poisson regression models were fitted to the observed data, with interactions between data sources fitted to replicate ‘dependencies’ between the data sources. There were 13,886 (95% CI 8132–34,443) IDUs in Estonia in 2004, which translates into a prevalence of 2.4% (95% CI 1.4–5.9%) among people aged 15–44 years. The estimate is in line with the estimate provided by the panel of experts and estimates from the neighbouring countries experiencing similar societal and economic challenges.

The role of injection drug use in the emergence of human immunodeficiency virus infection in Estonia

OBJECTIVE This article reviews the marked increase in human immunodeficiency virus (HIV) among injection drug users (IDU) in Estonia, a former Soviet Union republic bordering the Baltic Sea. HIV infection associated with injecting drug use has been reported worldwide. In Eastern Europe large-scale HIV epidemics have been observed from 1995 onward, after injection drug use (IDU) communities became infected. MATERIALS AND METHODS In Estonia, surveillance of HIV infection is based on the mandatory universal notification of newly identified cases, with the same reporting principles in use throughout the last decades. By legal regulations every sample sent for HIV testing has to be coded (on the testing form) to identify the transmission category it belongs to. HIV testing was introduced in Estonia in 1987; by now over 2 million HIV tests have been performed. RESULTS To date since 1987, 1305 cases of HIV have reported in Estonia. The incidence of HIV infections remained very low until recently, even when a considerable rise occurred in the incidence of sexually transmitted diseases, especially syphilis. Through 1999, only 96 cases of HIV had been reported nationally. Since then however, a dramatic increase has occurred. The cumulative data, including the information recorded on HIV testing forms and clinical records suggest that IDU was a factor in nearly 90% of the new HIV cases reported in year 2000. CONCLUSIONS HIV infection appeared in Estonia much later than in many other parts of the world, so the experience from other countries that have confronted with the challenges of HIV could be of great help and importance for Estonia. The IDU related HIV infection epidemic in Estonia emphasizes an urgent need for preventive measures for IDUs as the target group.

A study on HIV and hepatitis C virus among commercial sex workers in Tallinn

Introduction: Estonia is confronted by a dramatic expansion of the initially injection drug use-driven HIV epidemic. Little is known about HIV occurrence in population groups at high risk other than injection drug users. Objective: To obtain data on the prevalence of HIV and hepatitis C virus (HCV) among female sex workers (FSW) in Tallinn. Design: An unlinked, anonymous, cross-sectional survey of FSW recruited in Tallinn from October 2005 to May 2006. Methods: 227 FSW were recruited for the survey and biological sample collection (HIV, HCV antibodies detection) using a combination of time-location, community and respondent-driven sampling. Results: Among 227 women the HIV and HCV prevalences were 7.6% (95% CI 4.6% to 12.5%) and 7.9% (95% CI 4.5% to 12.6%), respectively. HIV prevalence was higher among FSW working in the street (odds ratio (OR) 6.4; 95% CI 1.1 to 35.6) and at the brothels and apartments supervised by the organised sex industry (OR 5.0; 95% CI 1.3 to 18.4). The duration of sex work was negatively associated with HIV prevalence (OR 0.78; 95% CI 0.63 to 0.97). Conclusions: Prevention needs of FSW in this area include increasing rates of HIV testing and putting in place effective programmes that can help extend HIV prevention behaviours across a range of sexual and drug use risk behaviours.

Trends in the epidemiology of bacterial sexually transmitted infections in eastern Europe, 1995–2005

Background Sexually transmitted infections (STI) are a significant public health problem both worldwide and in Europe. This article reviews trends in the epidemiology of the major bacterial STI in eastern European countries, their key determinants, as well as challenges and opportunities for enhancing STI control in the region. Search strategy Publications were sought through computerised searches in PubMed from 1995 to 2008 using using free text and relevant medical subject headings with no language restrictions. Conference abstracts and other unpublished manuscripts were excluded. Results The reported rates of STI in many eastern European countries have either decreased (syphilis and gonorrhoea in the eastern/Russian regions, gonorrhoea throughout eastern Europe) or been relatively stable (syphilis in the southeastern region, chlamydia throughout eastern Europe), in the past decade, but are still significantly higher than in western Europe. There is a significant east–west geopolitical gradient in reported STI rates throughout eastern Europe (STI rates: Russia/eastern region>>southeastern region>central region). Challenges for STI control include: the need to strengthen public health components of control; improvements in surveillance and improvement, as well as quality assurance, in diagnostic strategies. Gains in STI control may be achieved through greater collaboration and harmonisation of practicss at the European level.