New Old screening

Vasiliy V Vlassov, MD Russian branch of the Nordic Cochrane Centre,

B. Denisov

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We believe that thorough analysis must go before the decisions, but in case when analysis[1] support the decision it give a relief. This modeling study rise two questions – both addressed in the discussion – how reliable are estimates of the prevalence and was the old approach to screening for HIV right.

Russia still enjoys a rather low prevalence of HIV, but Russian HIV epidemic is the fastest all over the world, -- it is a common and widespread belief: that there are 940 000 [560 000 - 1 600 000] persons living with HIV/AIDS according to UNAIDS[2]. Although the registered (one could say: evidence based) number of HIV+ in Russia is 347 222 [3]. Two natural questions stem from huge difference between the data and estimate(s): (1) where the estimate(s) came from, and (2) what are their prospects, for instance, reconsiderations and reasons for up/downgrades. We suppose that the basis for neglecting data is low reputation of Russia or charm of a genre of Russian thriller. These estimates supported from within Russia itself ironically by the major official authority in this area Dr. V. Pokrovski, head of the national HIV/AIDS center, a special service to control and combat the epidemic. Pokrovski many times declared that true number of HIV+ persons in Russia is 2-5 higher than registered one. Although neither Pokrovski himself nor his aides in Russia and supporters abroad ever provided rational reasons for these estimates.

Recently published UNAIDS technique to estimate unknown HIV+ population from known populations of drug users, sex workers, and gays[4] seems too approximate to improve the data in Russia. This estimate relies on the other estimates (1) of prevalence in risk groups, and (2) of their sizes. Although the populations’s size of sex workers, gay/lesbian people, intravenous drug users is hardly known in Russia and elsewhere.

Meanwhile, Russia inherited from the USSR the system of extensive testing of citizens without a barrier of consent: blood donors, pregnant women, all inpatients etc. It is reasonable to suppose that no other big country does such testing. More likely Russian HIV prevalence data are more reliable than in other countries[5]. Although the projects aimed on estimating the completeness of the Russian registration failed in fundraising, the support to common sense is appearing from unexpected sides. The efficacy of Russian case reporting system was de-facto recognized by the U.S. Centers for Disease Control and Prevention recommendations calling for routine HIV testing without specific consent in all doctors' offices, clinics, and hospitals, unless patients explicitly refuse or "opt out.", what is mimicking the Russian style[6]. The WHO recently is also supporting the Russian style system by its recommendation of provider-initiated testing[7].

Until recently Russian government paid little attention to AIDS, and it seems like an adequate behavior first years – keeping in mind that incidence was low for the long time. The government relied on erected at the end of Soviet era surveillance system; keeps it and averted to destroy it in spite of appeals of international advisers who claim that system is ineffective and violates human rights. Two events moved HIV/AIDS upward the agenda list: (1) rising prevalence of HIV+, and (2) introduction of antiretrovirals. The latter made the system of registration sensible, and gave good reason for the optimism of its designers and builders, who are yet alive and deserve great esteem and respect.

B. Denisov, Senior Researcher, Lab of Population Economics and Demography, Moscow University

V. Vlassov, Director, Russian Branch of the Nordic Cochrane Centre

Reference List

(1) Paltiel AD, Walensky RP, Schackman BR, Seage GR, III, Mercincavage LM, Weinstein MC et al. Expanded HIV Screening in the United States: Effect on Clinical Outcomes, HIV Transmission, and Costs. Ann Intern Med 2006; 145(11):797-806.

(2) UNAIDS. Russian Federation: Indicators, Estimates and Country Assessment). Accessed Dec 6, 2006. Available from: URL:http://www.unaids.org/en/Regions_Countries/Countries/russian_federation.asp

(3) Russian Federal AIDS Centre. Officially Registered HIV Cases in the Russian Federation 1 January 1987 through 30 June 2006. Accessed Dec 6, 2006. 2006 Available from: URL:http://www.afew.org/english/statistics/HIVdata-RF.htm

(4) Walker N, Grassly NC, Garnett GP, Stanecki KA, Ghys PD. Estimating the global burden of HIV/AIDS: what do we really know about the HIV pandemic? Lancet 2004; 363(9427):2180-2185.

(5) The Russian HIV/AIDS Case Reporting System. European Population Conference, 21-24 June 2006, Liverpool, UK. Accessed Dec 6, 2006.

(6) CDC. Advancing HIV Prevention. New Strategies for a Changing Epidemic. Accessed Dec 6 2006. 2006 Available from: URL:http://www.cdc.gov/hiv/topics/prev_prog/AHP/default.htm

(7) WHO. WHO and UNAIDS Secretariat Statement on HIV testing and counseling, Aug 14, 2006. Accessed Dec 06 2006. Available from: URL:http://www.who.int/hiv/toronto2006/WHO- UNAIDSstatement_TC_081406_dh.pdf

Conflict of Interest:

None declared

Written in responce to:

Expanded HIV Screening in the United States: Effect on Clinical Outcomes, HIV Transmission, and Costs

Annals of Internal Medicine: 5 December 2006 | Volume 145 Issue 11 | Pages 797-806