Monitoring anonymous HIV testing in Estonia from 2005 to 2015.

OBJECTIVES: In Estonia, a network of anonymous and free of charge HIV testing sites has been operating since 1988. Services are provided by health care organizations and financed by the National Institute for Health Development from the state budget. The objective of this analysis was to assess anonymous HIV testing in Estonia from 2005 to 2015. METHODS: We used data collected from the National Institute for Health Development's annual reports, Health Board and Estonian Health Insurance Fund. RESULTS: In Estonia, more than 200 000 HIV-tests are performed annually, and of these approximately 5-6% are within anonymous HIV testing sites. The percentage tested with rapid tests in anonymous testing sites has increased from 15% in 2010 to 53% in 2015. Furthermore, up to 65% of all newly diagnosed HIV-cases have been detected in these sites. The proportion of HIV-positive tests has decreased from 3.8% to 0.5% in anonymous testing sites and from 0.3% to 0.1% in general health care. Simultaneously, the cost of detecting one new HIV case has increased almost six times. CONCLUSIONS: This analysis reveals that anonymous HIV testing services are well accepted by the general population as well as vulnerable populations. The positivity rate among those tested in anonymous testing sites remains higher than among all people tested, showing that the sites reach more of those who are at higher risk of HIV. In the light of decreasing positivity rate, more attention should be paid to people with higher HIV risk and increasing access to testing in community based settings.

Monitoring HIV-indicator condition guided HIV testing in Estonia.

OBJECTIVES: The aim of the study was to assess indicator condition (IC) guided HIV testing in Estonia from 2012-2015. METHODS: We used Estonian Health Insurance Fund (EHIF) data. EHIF is the core purchaser of health care services in Estonia, covering health care costs for insured people (94% of the total population). After health care services' provision, the provider sends an invoice to EHIF, which includes patient information (e.g. age, gender, diagnoses based on ICD-10) and services provided (e.g. what tests were performed). RESULTS: Among the ICs analysed, the highest proportion of patients tested was among those presenting with infectious mononucleosis-like illness (27-33% of patients) and viral hepatitis (28-32%), the lowest proportion of patients tested was among those presenting with herpes zoster (4-5%) and pneumonia (4-8%). Women were tested somewhat less than men, especially in cases of sexually transmitted infections (9-13% and 18-21%, respectively). CONCLUSIONS: Our data shows that IC-guided HIV testing rates are low in Estonia. Therefore, it is critical to follow Estonian HIV testing guidelines, which recommend IC-guided testing. In general, health insurance data can be used to monitor IC-guided HIV testing.

HIV continuum of care in Europe and Central Asia.

OBJECTIVES: The European Centre for Disease Prevention and Control (ECDC) supports countries to monitor progress in their response to the HIV epidemic. In line with these monitoring responsibilities, we assess how, and to what extent, the continuum of care is being measured across countries. METHODS: The ECDC sent out questionnaires to 55 countries in Europe and Central Asia in 2014. Nominated country representatives were questioned on how they defined and measured six elements of the continuum. We present our results using three previously described frameworks [breakpoints; Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets; diagnosis and treatment quadrant]. RESULTS: Forty countries provided data for at least one element of the continuum. Countries reported most frequently on the number of people diagnosed with HIV infection (37; 93%), and on the number in receipt of antiretroviral therapy (ART) (35; 88%). There was little consensus across countries in their approach to defining linkage to, and retention in, care. The most common breakpoint (>19% reduction between two adjacent elements) related to the estimated number of people living with HIV who were diagnosed (18 of 23; 78%). CONCLUSIONS: We present continuum data from multiple countries that provide both a snapshot of care provision and a baseline against which changes over time in care provision across Europe and Central Asia may be measured. To better inform HIV testing and treatment programmes, standard data collection approaches and definitions across the HIV continuum of care are needed. If countries wish to ensure an unbroken HIV continuum of care, people living with HIV need to be diagnosed promptly, and ART needs to be offered to all those diagnosed.

Internet-based recruitment system for HIV and STI screening for men who have sex with men in Estonia, 2013: analysis of preliminary outcomes.

The aim of the current project was to develop an Internet-based recruitment system for HIV and sexually transmitted infection (STI) screening for men who have sex with men (MSM) in Estonia in order to collect biological samples during behavioural studies. In 2013, an Internet-based HIV risk-behaviour survey was conducted among MSM living in Estonia. After completing the questionnaire, all participants were offered anonymous and free-of-charge STI testing. They could either order a urine sample kit by post to screen for chlamydia infections (including lymphogranuloma venereum (LGV)), trichomoniasis, gonorrhoea and Mycoplasma genitalium infections, or visit a laboratory for HIV, hepatitis A virus, hepatitis B virus,hepatitis C virus and syphilis screening. Of 301 participants who completed the questionnaire, 265 (88%),reported that they were MSM. Of these 265 MSM,68 (26%) underwent various types of testing. In the multiple regression analysis, Russian as the first language,previous HIV testing and living in a city or town increased the odds of testing during the study. Linking Internet-based behavioural data collection with biological sample collection is a promising approach. As there are no specific STI services for MSM in Estonia,this system could also be used as an additional option for anonymous and free-of-charge STI screening.

Risk for Heterosexual HIV Transmission Among Non-Injecting Female Partners of Injection Drug Users in Estonia.

The HIV epidemic in Estonia, as with other eastern European countries, is currently concentrated among injection drug users (IDUs). Non-IDUs who have IDU sex partners could serve as a potential bridge in an expanding epidemic. We applied HIV transmission modelling to data collected from non-IDU/IDU heterosexual couples in Kohtla-Järve, Estonia to estimate HIV risk from IDUs to their sex partners based on self-reported sexual behaviors shared by the couple. IDUs and their current main non-injecting sex partners were recruited for an interviewer-administered survey and HIV testing. Bernoulli modelling techniques were applied to estimate the risk of HIV transmission (incidence) among HIV negative non-injecting female partners of male IDUs. The estimated HIV incidence in this population of non-injecting women with only main sexual partners in the last 6 months ranged from 3.24 to 4.94 HIV seroconversions per 100 person years depending on the value used in the models for the per act transmission rate during acute stage infection. Non-IDUs who have IDU sex partners are at high risk for HIV and could serve as a potential bridge to a more generalized epidemic. Whether this might lead to an expansion of the HIV epidemic beyond core groups in Estonia or other Eastern European countries warrants closer study.

Emergent properties of HIV risk among injection drug users in Tallinn, Estonia: synthesis of individual and neighbourhood-level factors.

OBJECTIVES: HIV/AIDS risk is embodied within multiple levels including structural and social levels. The aim of this study was to assess the effects of neighbourhood characteristics on HIV prevalence among injection drug users (IDU) residing in the area of Tallinn, Estonia in 2007. METHODS: A cross-sectional, multilevel design collecting individual-level data--a behaviour survey including data on self-reported residency and HIV antibody testing among 350 IDU and neighbourhood-level data--aggregate measures on socio-demo-economic residential characteristics from the 2000 Estonian census. Geocoding and multilevel modelling analysis was employed. RESULTS: Among the 350 IDU recruited, earlier age at first injection, fentanyl as the main injection drug, receptive syringe sharing, main income source other than legal employment and ever attended a syringe exchange programme remained significantly associated with increased odds of anti-HIV positivity in the multivariable analysis involving individual effects with no predictors at the neighbourhood level. In the multilevel model, individual (earlier at IDU initiation AOR 1.86, 95% CI 1.01 to 3.44; injecting opioids AOR 4.43, 95% CI 2.74 to 7.18; receptive syringe sharing AOR 2.51, 95% CI 1.86 to 3.37; main income source other than work AOR 2.04, 95% CI 1.32 to 3.14; ever attended a syringe exchange programme AOR 2.58, 95% CI 1.83 to 3.61) and neighbourhood level (higher unemployment rate AOR 5.95, 95% CI 2.47 to 14.31; greater residential change AOR 1.89, 95% CI 1.09 to 3.26) emerged as significant predictors of individual HIV-positive status. CONCLUSIONS: Our results indicate that both individual-level and emergent neighbourhood-level factors contribute to HIV risk among IDU and are amenable for preventive interventions.

HIV risk behaviour knowledge, substance use and unprotected sex in men who have sex with men in Tallinn, Estonia.

This study examines HIV risk behaviour knowledge, substance use and unprotected sex in a sample of 79 men who have sex with men (MSM) in Tallinn, Estonia. Median age of the study population was 30 years (range 18-62 years); 35 were bisexual; 56 answered correctly to at least 10 out of 13 questions about HIV risk behaviours; 23 consumed more than seven alcoholic drinks in the week before the survey; nearly half (n=34) of the participants reported some illicit drug use in the past 12 months; 40 did not use a condom regularly in the 12 months preceding the survey, and 41 did not use a condom during their last sexual intercourse. Alcohol consumption in the week before the survey was negatively associated with condom use during last intercourse (RR 0.48; 95% CI 0.41-0.56). Use of illicit drugs varied significantly by ethnicity (p-value = 0.02). Multivariable analysis showed that higher consumption of alcohol in the week before the survey could be predicted by education, age group and sexual orientation. In conclusion, socio-demographic factors such as education, age, ethnicity and sexual orientation may affect HIV risk behaviour knowledge, sexual behavior and substance use among MSM in Estonia, and need to be taken into consideration for targeted HIV prevention.

Knowledge of HIV serostatus and risk behaviour among injecting drug users in Estonia.

We used the findings from two, cross-sectional studies of HIV serostatus and risk behaviours to assess the effects of knowledge of HIV serostatus and risk behaviours (relating to sex and injection drug use) among injecting drug users (IDUs). Respondent-driven sampling was used simultaneously at two sites in Estonia (the capital Tallinn, and the second-largest city of Ida-Virumaa County, Kohtla-Jarve). The research tool was an interviewer-administered survey. Biological samples were collected for HIV testing. Participants were categorised into three groups based on HIV testing results and self-report on HIV serostatus: HIV-negative (n=133); HIV-positive unaware of their serostatus (n=75); and HIV-positive aware of their serostatus (n=168). In total, 65% of the participants tested positive for HIV. Of those 69% were aware of their positive serostatus. HIV-positive IDUs aware of their serostatus exhibited more risk behaviours than their HIV-positive counterparts unaware of their serostatus or HIV-negative IDUs. Effective prevention of HIV among IDUs should therefore, include programmes to reduce high-risk sexual and drug use behaviours at the public health scale and enhanced prevention efforts focusing on HIV-infected individuals.