Since the first Estonian case of HIV was reported in 1988, more than 9000 cases have been reported. That makes Estonia the country in the EU with the highest number of people with HIV compared to population. This is mainly because of the country’s many drug users. For the past ten years, they have been successful in decreasing the numbers of new cases of HIV, but they still have a long way to go to reach their future goals.
Vova sits down, clamping his hands nervously. He is ready to tell about his life with HIV, a disease he has had since he was 25 years old. “In the beginning nothing changed. I ignored it. I had hepatitis B and then I got diagnosed with HIV, and that was just another disease”, says Vova who is now 38 years old. Vova is not his real name; the real name is known by the writers.
Vova is one of the about 8000 people in Estonia who is living with HIV. This is an estimation, because no exact numbers exist. The only official number that exists, is the total amount of 9492 reported cases. Even in that number lies an uncertainty because before 2008 some cases of HIV were reported twice due to anonymous testing.
The official 9492 reported cases make Estonia the country in the EU with the highest number of reported cases compared to population. Almost one percent of the population has HIV. That is almost twice as much as the neighbour country Latvia.
More drugs lead to the spread of HIV
Understanding the historical background of Estonia is the key to understand the current HIV-issue. Doctor Kristi Rüütel is an HIV-expert working at the National Institute for Health Development, and she says that Estonia’s independence from the Soviet Union has had a significant impact. “Once we became independent, there were all these new things available for us; including modern drugs”, says Dr Kristi Rüütel.
She explains that the drug use increased remarkably in the early 1990’s after the independence and that it is still one of the main social problems in Estonia. When a country has many drug users, it is more likely that the cases of HIV are high as well. For people who inject drugs, the risk is 100 times higher than people who do not.
The majority of people having HIV in Estonia got it from injecting drugs. Vova also got HIV from injecting drugs. He explains that sometimes he had to choose between not getting drugs or getting drugs in a used syringe. “Sometimes you buy drugs separately, but sometimes you buy it with a used syringe. Then you must decide whether you reject it or accept it. And of course, you accept it and use it. You need it and you paid for it.”
However, statistics from the National Institute for Health Development show that in the past years there was a decrease in number of new cases of HIV amongst people who inject drugs. The main part of new cases of HIV is because of heterosexual sex.
According to Dr Kristi Rüütel, one of the reasons why is because drug users are so well informed about how to protect themselves and prevent getting infected with HIV. She says that the older population is not aware of the risks of getting HIV, because some people do not think that HIV is an infection everyone gets.
Budget for treatment gets increased
The political effort to solve the HIV-issue has changed notably in the past 20 years. In late 1990’s the authorities were informed about a hepatitis B and C outbreak amongst drug users without doing anything. Dr Kristi Rüütel explains that if hepatitis B and C, which are two of the indicator diseases of HIV, spreads, HIV may also spread.
Today, the politicians are very much aware of the HIV-issue and last year they increased the annual budget for Anti-Retroviral Treatment (ART), the medicine that people with HIV take to control the virus, to 15 million euros instead of 10 million euros the year before. “15 million euros spent on HIV-treatment is a lot of money”, says Tiina Drell, adviser in the public health department of the Estonian Ministry of Social Affairs.
According to Tiina Drell, having a big budget for this treatment is necessary. To contain an epidemic, the medicine should be as available as possible; especially if one of the main affected groups are people who inject drugs. If the medicine would not be free of charge, they must weigh spending money on drugs or on treatment, and they will probably choose drugs due to their addiction, she explains. “It is a contagious disease with a very high spread, which we have seen in history in the early 2000’s with the HIV-epidemic. We do not want it to happen again.”
New goals expected to solve the issue
Estonia has 17,4 new cases of HIV per 100.000 inhabitants a year, that is three times more than the European medium of 5,7. But in the past decade they have been successful in decreasing the number of new cases. In 2007 there were 47,1 new cases and ten years later that number was reduced to the current 17,4 new cases. By 2020 the government tries to reduce the new infections even more, so they reach the European medium.
Next, they try to reach the 90-90-90 goals. The first 90 is 90 percent of people who are living with HIV have been diagnosed, but the government does not have exact numbers yet, so they do not know if they have already reached the goal.
The two other goals are to have 90 percent of HIV-infected people on treatment and 90 percent of these people having the virus under control. So far, those goals are only reached to 70-80 percent.
They know that this could be the key to solve the HIV-issue in Estonia, because they have seen other countries reaching the same goals and being successful in keeping down the numbers of new cases.
According to Tiina Drell, the problem is that not all people end up getting treatment, or that people quit their treatment. “Some people tend to quit treatment, even though you have to be very regular with it. It may be that drug users do not have regularity in their lives, so they quit treatment and then their viral load goes up again.”
HIV-patient Vova is one of the around 4100 people getting Anti-Retroviral Treatment. Even though he was diagnosed 13 years ago, it was only after eight years that he finally realised that he needed to have treatment for his HIV. “Information on HIV was a mess. People were afraid of HIV, but people did not know what to be afraid of. I did not understand the information”, says Vova.
Vova is happy about the treatment today because it is free, and it is good. A big part of his treatment is also the help he gets from the AIDS Information and Support Centre, AIDS-I, in Tallinn.
Half of 5000 drug users in Tallinn have HIV
Nelli Kalikova, leader of harm reduction projects at AIDS-I, has been with the NGO ever since the very beginning in 1996. “In the mid 1990’s drug users were the ones getting HIV. The hospitals said we were imagining all the problems but is was reality”, says Nelli Kalikova.
Nowadays AIDS-I is a well-known centre where around 200 people come by every day to get their dose of methadone. Methadone is a drug used as a substitute for heroin, so addicts can get off of their addiction. Next to the people that are provided with methadone, AIDS-I hands out 20.000 clean needles every month to the 5000 drug users in Tallinn. Half of them are diagnosed with HIV.
People in Estonia started using more drugs after the fall of the Soviet Union. Nelli Kalikova says that poor people started picking poppy flowers and dry the seeds to cook them afterwards. After drying and cooking the poppy seeds, you get a liquid which people injected as an opium. “But that was very dangerous and dirty”, says Nelli Kalikova.
Stigma on people with HIV is still strong
No one knows exactly why Estonia has such a high number of HIV cases, according to Nelli Kalikova. “Even the government does not know. All the government does is making reports, but they do not ask themselves why people get infected with HIV. And that is essential if you want to solve the issue”, she says.
In the general population there is a stigma related to how people get infected with HIV. “People think they have been using drugs or they have had sex with prostitutes. You feel sorry for people with diabetes, but you do not blame them. You do not even blame people having high blood pressure, yet we know that it has something to do with their lifestyle”, says Dr Kristi Rüütel.
There is a big difference between the regions in Estonia when it comes to stigma on people having HIV. According to Dr Kristi Rüütel, it is especially in the north-eastern part of Estonia where they are quite hostile to people with HIV. That is despite the fact that 25 percent of all cases reported is from that part of Estonia.
Fortunately, Vova has experienced more people accepting his disease than people who do not. However, having HIV still has enormous personal consequences for him. “I lost a lot of teeth because of drugs and HIV and it has had a significant impact on my life. I cannot smile, I cannot find a girlfriend, I cannot find good work”, says Vova.