Search

Men who have sex with men (MSM) face negative health outcomes such as sexually transmitted infections (STIs) at disproportionate rates. Nonetheless, infections may be underestimated due to limited uptake in testing. To increase testing, screening interventions have been utilized in the past; however, some have resulted in limitations such as poor recruitment. To increase recruitment for screening of MSM in Estonia, two different recruitment strategies were examined. Recruitment was separated into two promotional periods: passive and active. Passive consisted of banners on gay-related sites, while active also placed banners on websites to the general public such as Facebook linked to specific thematic pages and users self-identifying as men. More men were recruited during the active period of five weeks (n = 134) than the passive period of 46 weeks (n = 126). Active promotion was so successful in that the number of home sampling kit orders far exceeded what was projected, forcing promotion to the general public to be closed after 13 days. Recruiting MSM through a combination of general public and gay-related websites and applications has the ability to quickly recruit for testing interventions. This method can recruit a large number in a short amount of time; therefore, a budget must be planned accordingly to support testing for all that participate. [ABSTRACT FROM AUTHOR]

To assess the efficacy of an education- and strengths-based counselling programme to promote antiretroviral therapy (ART) adherence in a cohort of HIV-infected individuals with high prevalence of injection drug use in Estonia. Parallel-group randomized (1:1) controlled trial (RCT). Adults receiving ART in two clinics were followed for 12 months. The trial compared: (i) an intervention (three sessions) incorporated into routine clinic visits, providing education about HIV, ART, the role of adherence, and tailoring regimen to daily routines using problem-solving skills to address adherence barriers versus (ii) usual care (control). Primary and secondary outcomes were self-reported ART adherence (3-day recall) and viral load (respectively). 519 patients were randomized and 82% completed the study. Recent optimal ART adherence (3-day recall ≥95%) was reported by 75.6% in the intervention group and 72.9% of controls at baseline and 76.7% and 67.5%, respectively, at 12 months (RR 1.14, 95% CI 1.00-1.28; adjusted RR 1.13, 95% CI 1.00-1.27). There was no difference in the proportion of patients with undetectable viral load. At 12 months the intervention group reported significantly higher perceptions of ART necessity versus ART concerns [mean ART necessity-concerns differential: intervention group 1.32 (SD 1.22) vs control group 1.08 (SD 1.12); p = 0.048]. All-cause mortality among study participants was 27.7 per 1000 person years (95% CI 15.6-44.8). A brief, clinic-based adherence intervention alone may assist with adherence but lacks impact on viral load at 12 months. [ABSTRACT FROM AUTHOR]

Many studies over the last decade provide strong evidence of elevated rates of suicidality among lesbian, gay, bisexual, and transgender populations compared to heterosexual populations. The aim of the current study was to investigate suicidal ideation and attempts and related factors among men who have sex with men (MSM) in Estonia. We conducted a nationwide Internet-based study among MSM with 265 eligible participants. Our results reveal high rates of self-reported suicidal ideation (lifetime prevalence 45%) and attempts (lifetime prevalence 11%) as well as a high rate of problem drinking (33%) and depressive symptoms (32%) among MSM. Recent suicidal ideation (14% had thought about suicide in the last 12 months) was related to depressive symptoms and lower socioeconomic situation. There is a need to develop specific interventions to address these issues among MSM and to provide gay-friendly mental health services. [ABSTRACT FROM PUBLISHER]

People living with HIV (PLHIV) have higher rates of suicidal behavior than the general population. This study assessed suicidal behavior (ideation and/or attempts, ever and in the past 12 months) among PLHIV receiving outpatient HIV medical care in Estonia and associations between suicidal behavior and psychological treatment. The cross-sectional study collected data from January to November 2013 using a self-report questionnaire. Eight hundred PLHIV participated, 39 % (n = 306) of whom had been suicidal. Lifetime prevalence was 36 % for suicidal ideation and 20 % for attempts. Younger age, incarceration, having ever abused alcohol and also injected drugs, having lived with HIV for more than 10 years, and being depressed were associated with lifetime suicidal behavior. Suicidal behavior within the past 12 months was reported by 20 % (n = 156) of respondents. Of these, 27 % received psychological treatment (counseling and/or psychotherapy), 20 % had taken antidepressants, and 49 % sedatives. Individuals perceiving a need for treatment were significantly more likely to receive psychological treatment when experiencing suicidal behavior (OR 25.65, 95 % CI 2.92-225.47). In conclusion, suicidal behavior is frequent among PLHIV but psychological treatment is not often received. One of the barriers to treatment is patients' lack of perceived need for help. [ABSTRACT FROM AUTHOR]

Objectives: Our study assessed sexually transmitted infections (STI) occurrence and risk behaviours from a sample of the defence forces of Estonia. Previous research on military personnel yields various results on the prevalence of STIs and high risk behaviours. The increasing recognition of high risk behaviours among military personnel is evident given increased programmes that focus on education of drug use and risky sexual behaviours. Many militaries conduct routine, periodic screening for diseases such as HIV and viral hepatitis at entry and pre-foreign deployment. Protecting deployed forces from secondary infections is important as persons with chronic viral infections are living longer, healthier lives and are more frequently serving in military forces.Methods: A cross sectional study used convenient sampling among professional defence forces. Participation was both voluntary and anonymous.Results: Of 186 participants accounting for 7.3% of all forces (86.6% male, mean age 30 years) at selected bases, there were four cases of chlamydia. No cases of gonorrhea, trichomoniasis, hepatitis C, hepatitis B, or HIV were found. One person reported ever injecting drugs.Conclusions: These findings indicate a lower STI occurrence among professional defence forces in Estonia compared with the non-military population. While these rates were lower than expected, as a voluntary study, people suspicious of having an STI might opt not to participate, limiting generalizability to the remainder of the military. Militaries without regular screening programmes could consider regular scheduled testing for STIs, HIV and blood borne pathogens, even if voluntary, especially prior to foreign deployment. Consistent testing would align across many militaries who deploy international peace keepers. [ABSTRACT FROM AUTHOR]

HIV and sexually transmitted infections (STI) testing rates among men who have sex with men (MSM) in Estonia are low. We collected data from 265 MSM in a national, online survey. Lifetime HIV testing was related to risky sexual behaviors and contacts with health care services, while lifetime STI testing was related only to contacts with health care services. In addition, some personal values were significant predictors of testing. For example, high achievement (personal success through demonstrating competence according to social standards) had a negative impact on lifetime HIV testing, and high interpersonal conformity (avoiding upsetting others) had a negative impact on lifetime STI testing. The results demonstrate the need to develop gay-friendly health services and to recognize the role of personal values and individual differences in values when designing attractive interventions to increase HIV/STI testing rates among MSM. [ABSTRACT FROM AUTHOR]

Men who have sex with men (MSM) continue to be at higher risk for negative health outcomes including HIV, STIs, depression, substance use, suicidality, and anxiety. Associative relationships between homonegativity (internal and external) and these outcomes are used to explain the observed disproportionate impact. The current study assessed associations between internalized homonegativity and high-risk behaviours, markers of substance use and symptoms of mental illness as well as openness and level of same sex attraction. A 2013 Internet-based survey was conducted among MSM, collecting data on socio-demographics, sexuality, drug and alcohol use, mental health, suicidality, and internalized homonegativity. The sample (n = 265) had a median age of 31 years, with 85 % employed at least part-time; at least a college-level education in 43 %; and 87 % lived in an urban setting. Sexual orientation was reported as: gay, 72 %; bisexual 23 %; other 5 %. Almost all men (97 %) reported ever having sex with a man, with more than one-third (36 %) having a steady male partner. Statistically significant higher homonegativity scores were detected among men reporting any level of opposite sex attraction compared to men attracted to only men; mostly men ( p = 0.001), men and women equally ( p = 0.002), and mostly women ( p = 0.004), as well as less openness of same sex attraction to family and friends; >50 % family ( p = 0.032), no family knowing ( p = 0.042), and few friends knowing ( p = 0.011). Anxiety risk and increased homonegativity also had a statistically significant increasing relationship. The identified associations between homonegativity and opposite sex attraction among MSM warrants further exploration as well as the relationship with increased anxiety risk. [ABSTRACT FROM AUTHOR]

Limited research exists on sexually transmitted infection (STI) and risk behaviour among military personnel. Published research on condom use and types of contraceptives used yield mixed results, yet, the perception that military members are at higher risk for STIs remains. The objectives of this cross-sectional study were to measure factors such as condom use, contraceptive methods, and risky behaviours (i.e. drug use and sex with commercial sex workers) and investigate differences between ethnic groups, where culture could influence behaviour. Data were collected from a recruited population of 584 male, military conscripts in northeastern Europe. Using multinomial logistic regression models, statistically significant findings include an interaction between the use of contraceptive methods of Russians with casual partners and ethnicity, with higher odds of effective methods used among Estonians with regular partners (OR = 8.13) or casual partners (OR = 11.58) and Russians with regular partners (OR = 4.98). Effective contraceptive methods used less frequently with casual partners by ethnic Russians is important in providing education and risk reduction services to young, male conscripts. These findings may be used as a baseline to inform health education and STI prevention programmes tailored to military members in Eastern Europe in the absence of other published studies. [ABSTRACT FROM AUTHOR]

Risk taking behavior and sexually transmitted infections (STIs) research outcomes vary among militaries. A common theme indicates STI prevalence and risk taking among military personnel is higher than the general population. Alcohol and drug misuse is well documented. From these behaviors, high-risk sexual encounters increase. Exploring STI prevalence, knowledge, and risk behaviors among conscripted military forces, we recruited 584 conscripts from a defense force in Eastern Europe. The observed STI prevalence in the young, male conscripts was equal or less than their non-conscripted counterparts. Military entry screenings could reduce STIs, creating a healthier population. However, these findings remain informative as the notion of high STI rates among military forces is not supported. As this study was one of the first of its type in the region, it demonstrates the ability of a nation to secure their defense forces against HIV/STIs even in the face of increased prevalence within that nation. [ABSTRACT FROM AUTHOR]

Abstract: Background: Illegal drug use and HIV are independent risk factors for tuberculosis (TB) among injecting drug users (IDU). Estonia and Latvia have experienced high rates of TB as well as IDU and HIV outbreaks. There is a lack of knowledge about TB among IDUs in these countries. The purpose of the current study was to estimate the prevalence and risk factors of Mycobacterium tuberculosis (MTB) infection among IDUs in Estonia and Latvia. Methods: Participants for this cross-sectional study were recruited from syringe exchange programmes using respondent-driven sampling. For assessing infection with MTB interferon-gamma release assay (IGRA) was used. Results: The study included 375 participants from Estonia and 313 from Latvia. The prevalence of IGRA-positivity among IDUs was 7.7% in Estonia and 25.6% in Latvia. HIV-prevalence was 62% in Estonia and 23% in Latvia. In both countries, IGRA-positivity rates did not differ between HIV-positive and HIV-negative participants. IGRA-positivity was independently associated with a prior diagnosis of TB in Estonia and with imprisonment (ever within a lifetime) and preceding contact with a TB patient in Latvia. Conclusion: Our findings indicate there is an urgent need for a more vigorous approach in providing IDUs with TB screening services. [Copyright &y& Elsevier]

Background: The purpose of the current study was to describe tuberculosis (TB) knowledge, beliefs, and experience with TB services among injecting drug users. Methods: Participants for this anonymous, cross-sectional study were recruited from a community based syringe exchange programme in Tallinn, Estonia. A structured questionnaire was completed and included information on socio-demographics, health history, drug use, and knowledge about TB and HIV. Results: The study included 407 people (79% male, mean age 27.9 years, mean injection drug use 9.4 years). 32.9% of participants reported HIV infection and 1.7% lifetime history of TB. 26.4% participants (n=106) reported symptoms suggestive of TB. 93% of participants recognized correctly that TB is air-borne infection and 91% that HIV is a risk factor for TB. Only 40% of the participants knew that TB diagnostics and treatment in Estonia are free of charge for everybody and 58% reported they knew where to get health care services in case they suspected that they had TB. TB transmission and treatment adherence knowledge was better among those in contact with either health care or harm reduction services, e.g thecommunity based syringe exchange programme. Conclusion: Similar to HIV services, TB prevention and education should be integrated into harm reduction and drug treatment programmes to facilitate early diagnosis and treatment of TB among injecting drug users. [ABSTRACT FROM AUTHOR]

Background: In the European Union it is estimated that up to 30% of HIV-infected people are not aware of their status. Community-based testing (CBT) models are implemented to increase the uptake of HIV testing. Aims: The aim of this project was to assess the feasibility and acceptance of HIV rapid testing in CBT settings in Estonia to identify non-clinical recruitment venues for people more likely to engage in high-risk behaviours. Methods: Participants for this anonymous, cross-sectional study were recruited from a syringe exchange programme and gay-oriented locations using convenience sampling. Socio-demographic and HIV testing preferences data were collected using a semi-structured questionnaire. HIV rapid testing was performed using Determine HIV-1/2 (Abbott) rapid test system. Results: With a participation rate of 88.3%, this project enrolled 308 persons and identified 58 preliminary positive cases. Out of them, 52 reported injecting drug use in last 12 months and 30 reported no previous HIV test. Approximately 45% of all participants preferred rapid testing while 25% reported a preference for a full blood test. Conclusions: This project demonstrates that HIV rapid testing in community-based settings in Eastern Europe can be an effective approach for reaching people who engage in high-risk behaviours and increasing the number of HIV-infected people who are aware of their status. [ABSTRACT FROM PUBLISHER]

The special norms in testing for HIV infection are not typical of testing or screening for other diseases. In four European countries, we studied health professionals’ views on HIV testing This study is based on cross-sectional surveys of two groups of health professionals: presidents of selected health professional societies and head physicians and nurses of selected hospital clinics in Belgium, Estonia, Finland, and Portugal in 2008. A common structured semi-anonymous questionnaire was used in the four countries. The number of societies responding varied from five to 10 and for hospital clinics from six to 18; the response rates were from 32% to 100% and 41% to 100%, respectively. Opinions on whether HIV testing is like any other test and on the value of specific approaches in HIV testing varied both within and between countries. Some professionals thought that HIV testing is different from the testing of other infectious diseases; others thought that such an exceptional approach may be a disservice to people and to the health system. Many professionals thought that HIV testing should not be thought of only from the point of view of the individual to be tested, but also from that of other people (potential patients). Obligatory testing was considered appropriate in certain circumstances. Generally, more HIV testing in health care was called for. Normalization of HIV testing, i.e., considering it like any other diagnostic test, is unlikely to meet much opposition from health professionals. Larger surveys are needed to confirm the results. [ABSTRACT FROM PUBLISHER]

Background: Estonia has experienced an HIV epidemic among intravenous drug users (IDUs) with the highest per capita HIV prevalence in Eastern Europe. We assessed the effects of expanded syringe exchange programs (SEP) in the capital city, Tallinn, which has an estimated 10,000 IDUs. Methods: SEP implementation was monitored with data from the Estonian National Institute for Health Development. Respondent driven sampling (RDS) interview surveys with HIV testing were conducted in Tallinn in 2005, 2007 and 2009 (involving 350, 350 and 327 IDUs respectively). HIV incidence among new injectors (those injecting for < = 3 years) was estimated by assuming (1) new injectors were HIV seronegative when they began injecting, and (2) HIV infection occurred at the midpoint between first injection and time of interview. Results: SEP increased from 230,000 syringes exchanged in 2005 to 440,000 in 2007 and 770,000 in 2009. In all three surveys, IDUs were predominantly male (80%), ethnic Russians (>80%), and young adults (mean ages 24 to 27 years). The proportion of new injectors decreased significantly over the years (from 21% in 2005 to 12% in 2009, p = 0.005). HIV prevalence among all respondents stabilized at slightly over 50% (54% in 2005, 55% in 2007, 51% in 2009), and decreased among new injectors (34% in 2005, 16% in 2009, p = 0.046). Estimated HIV incidence among new injectors decreased significantly from 18/100 person-years in 2005 and 21/100 person-years in 2007 to 9/100 person-years in 2009 (p = 0.026). Conclusions: In Estonia, a transitional country, a decrease in the HIV prevalence among new injectors and in the numbers of people initiating injection drug use coincided with implementation of large-scale SEPs. Further reductions in HIV transmission among IDUs are still required. Provision of 70 or more syringes per IDU per year may be needed before significant reductions in HIV incidence occur. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to determine the associations between the level of HIV knowledge, HIV-related risk behaviours, and HIV status among persons receiving voluntary counselling and testing services in Tallinn, Estonia. Design: A cross-sectional study design was used. Methods: A total of 772 subjects completed a 47-item questionnaire gathering information on demographics, HIV-related risk behaviours, and HIV-related knowledge. Participant’s HIV status was determined by an anonymous rapid test. Only incident HIV cases were included in regression analyses. An analysis of covariance (ANCOVA) modelling evaluated associations between HIV knowledge and high-risk behaviours while multivariable logistic regression assessed association between HIV status and HIV knowledge. Results: The final ANCOVA model indicates that HIV risk behaviours are significantly associated with HIV knowledge (p = 0.01). Compared to participants with no identified high-risk behaviour, the adjusted mean score of HIV knowledge was higher among persons sharing injection equipment (p = 0.05), and persons engaging in unprotected heterosexual intercourse (p = 0.03); there was no statistical difference observed among men engaging in unprotected sex with other men. Women had higher mean scores than men (p = 0.01) and persons of ‘‘other’’ ethnicities had a higher mean knowledge score than ethnic Estonians (p = 0.01) and Russians (p < 0.01). Logistic regression indicated that mean knowledge was higher among participants who tested HIV positive (OR = 1.42; 95% CI = 1.12—1.87). Conclusions: In this sample, higher knowledge scores were not associated with lower infection rates. These results indicate the importance of targeting all high-risk groups in HIV prevention and education programmes. [ABSTRACT FROM PUBLISHER]

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. [ABSTRACT FROM AUTHOR]

This article describes current trends of HIV/AIDS and related conditions in Estonia, with the aim of highlighting key determinants in transmission dynamics and risk groups, problems and barriers of combating HIV/AIDS, and possible implications for prevention and control. Throughout the transition period Estonia has experienced major changes in political, economic, and social structure which all have contributed to increased violence, high-risk sexual behaviour, and substance abuse. Incidences of hepatitis B, C and sexually transmitted infections (STIs) increased in the early 1990s. HIV outbreaks were first detected among injecting drug users (IDUs) in 2000 and are still concentrated among this population group. High rates of sexual risk behaviour and inadequate knowledge regarding prevention of disease transmission in Estonia emphasizes the threat of a sex-related and STI facilitated driven HIV epidemic. To prevent further spread of HIV it is necessary to implement harm reduction interventions among IDUs. However, without effective management of socioeconomic and administrative barriers to health care and other services, an explicit policy on drugs will not reach marginalized groups and will not be able to prevent a further spread of these interrelated epidemics. [ABSTRACT FROM AUTHOR]

Background Evidence supports that gay, lesbian, and transgender populations are at increased risk for mental health problems. The current study was conducted to estimate the prevalence of anxiety and depressive symptoms and related factors among men who have sex with men (MSM) in Estonia. This is the only known study of its type in the Eastern European region. Methods In 2013, an Internet-based survey was conducted among men who have sex with men, collecting data on socio-demographics, sexuality, drug and alcohol use, mental health, suicidality, and internalized homonegativity. Results 265 MSM completed the questionnaire (median age 31 years, 90% Estonian, 71% from the capital; 73% employed full-time, 42% with at least college education; 44% in a steady relationship; 72% gay, 23% bisexual; 23% reported illegal drug use in the last 12 months). One third met criteria for problem drinking and depressive symptoms with one quarter for anxiety symptoms. Suicidality was 44% reported lifetime suicidal thoughts and 11% with at least one suicide attempt. Limitations The study instruments, EST-Q and CAGE, only measure symptoms and are not diagnostic tests. A non-random sample which could possibly include persons with easier internet access. Self-reported data and cross-sectional study design are prone to issues with recall bias and temporality. Conclusions With demonstrated high rates of anxiety, depression, drinking, and drug use among MSM which is consistent with similar studies in Western countries, further research could help determine effective MSM focused interventions to address the broad spectrum of issues among MSM. [ABSTRACT FROM AUTHOR]

Abstract: Aim: To explore socio-demographic factors, health risks and harms associated with early initiation of injecting (before age 16) among injecting drug users (IDUs) in Tallinn, Estonia. Methods: IDUs were recruited using respondent driven sampling methods for two cross-sectional interviewer-administered surveys (in 2007 and 2009). Bivariate and multivariate logistic regression analysis was used to identify factors associated with early initiation versus later initiation. Results: A total of 672 current IDUs reported the age when they started to inject drugs; the mean was 18 years, and about a quarter of the sample (n =156) reported early initiation into injecting drugs. Factors significantly associated in multivariate analysis with early initiation were being female, having a lower educational level, being unemployed, shorter time between first drug use and injecting, high-risk injecting (sharing syringes and paraphernalia, injecting more than once a day), involvement in syringe exchange attendance and getting syringes from outreach workers, and two-fold higher risk of HIV seropositivity. Conclusions: Our results document significant adverse health consequences (including higher risk behaviour and HIV seropositivity) associated with early initiation into drug injecting and emphasize the need for comprehensive prevention programs and early intervention efforts targeting youth at risk. Our findings suggest that interventions designed to delay the age of starting drug use, including injecting drug use, can contribute to reducing risk behaviour and HIV prevalence among IDUs. [Copyright &y& Elsevier]

Abstract: Background: Following a heroin shortage, fentanyl and 3-methylfentanyl, known as “China White” and “White Persian”, have become the most widely used drugs, along with amphetamine, among injecting drug users (IDUs) in Tallinn, Estonia. Methods: In order to assess the relationships between the injection of fentanyl and amphetamine, and levels of HIV prevalence and risk behaviour, 350 current IDUs were recruited using respondent-driven sampling for an interviewer-administered unlinked cross-sectional survey and HIV testing. IDUs were categorised into groups based on self-report of the main drug used within the last 28 days. Results: 77% (256/331) of participants reported fentanyl and 23% (75/331) amphetamine as their main drug of injection. HIV prevalence was 27% (95% confidence interval [CI]: 18.45–35.51) and 62% (95% CI: 56.97–67.03) among amphetamine and fentanyl injectors, respectively. After adjustment, fentanyl injectors had three times the odds of being HIV positive (adjusted odds ratio [AOR]=2.89; 95% CI: 1.55–5.39). They also had higher odds for injecting in the street with a previously used needle/syringe (AOR=2.39; 95% CI: 1.14–5.04) and sharing a needle/syringe with somebody known to have HIV (AOR=3.00, 95% CI: 1.33–6.79). Fentanyl injectors also had higher odds for lifetime overdose (AOR=3.02, 95% CI: 1.65–5.54). Conclusion: The injection of fentanyl is associated with elevated injecting risk behaviour derived from injection practice and situational risk factors, and needs urgently targeted interventions. [Copyright &y& Elsevier]

IntroductionObtaining epidemiological data on chronic hepatitis C virus (HCV) infection is essential to monitor progress towards the hepatitis C elimination targets.AimWe aimed to estimate the prevalence of chronic HCV and the seroprevalence of HCV in the adult general population in Estonia.MethodsThis cross-sectional study, conducted between 12 July and 6 December 2022, included anonymised residual sera collected prospectively from patients 18 years and older visiting a general practitioner in all counties of Estonia. Specimens were considered HCV-seropositive if they tested positive for HCV antibodies by enzyme-linked immunoassay, confirmed by line-immunoblot assay. Chronic HCV infection was determined by positive RT-qPCR.ResultsWe tested a total of 4,217 specimens. The estimated HCV seroprevalence and prevalence of chronic HCV infection were 1.8% (95% CI: 1.4-2.2) and 0.8% (95% CI: 0.5-1.1), respectively, with ca 8,100 persons estimated to have chronic HCV infection in the general adult population of Estonia. No statistically significant differences in the prevalence of chronic HCV infection were observed between sexes, counties or age groups, with the highest prevalence rates observed in men (sex ratio: 1.7), Ida-Virumaa County (1.8%; 95% CI: 0.8-3.6) and the age group 40-49 years (1.7%; 95% CI: 0.9-2.9).ConclusionThis study found an overall low prevalence of chronic HCV infection in Estonia. Continued efforts should be made for the targeted screening, diagnosis and treatment of individuals with chronic HCV infection to achieve hepatitis elimination targets.

Objectives: In Eastern Europe, HIV-1 transmitted drug resistance (TDR) data, especially in the integrase (IN) region, are limited. In Estonia, INSTI (integrase strand transfer inhibitors) TDR has been studied only prior to the INSTI scale-up in late 2010s. The current study aimed to determine the levels of protease (PR), reverse transcriptase (RT) and IN surveillance drug resistance mutations (SDRMs) among newly diagnosed patients in Estonia in 2017., Methods: The study included 216 newly diagnosed HIV-1 individuals from 1 January until 31 December 2017 in Estonia. Demographic and clinical data were obtained from the Estonian Health Board, the Estonian HIV Cohort Study (E-HIV) and clinical laboratories' databases. The PR-RT and IN regions were sequenced and analysed for SDRMs and subtype determination., Results: Seventy-one percent (151/213) of available HIV-positive samples were successfully sequenced. The overall level of TDR was 7.9% (12/151; 95% CI 4.4%-13.8%); no dual or triple class resistance was detected. No major INSTI mutations were found. The distribution of SDRMs for NNRTI, NRTI and PI was 5.9% (9/151), 1.3% (2/151) and 0.7% (1/151), respectively. The predominant NNRTI mutation was K103N. CRF06&#95;cpx was the predominant variant (59%) in the Estonian HIV-1 population, followed by subtype A (9%) and subtype B (8%)., Conclusion: Although no major INSTI mutations were found, close monitoring of INSTI SDRMs is needed considering the extensive use of the first- and second-generation INSTIs. PR-RT TDR is slowly rising in Estonia, indicating the need for continuous surveillance in the future. Low genetic barrier NNRTIs should be avoided in the treatment regimens., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objectives: In the early 2000s, Estonia and Latvia experienced a rapidly growing HIV epidemic among people who inject drugs (PWID), and had, with Russia, the highest diagnosis rates in Europe. Understanding epidemic dynamics in both countries and how responses to HIV impacted them is essential to ending injection-driven epidemics., Design: Statistical modeling, programmatic data collection, and triangulation., Methods: Data on newly diagnosed HIV cases were used in a back-calculation model to estimate, for each country, trends in HIV incidence, time to diagnosis, and undiagnosed infections. Modeled estimates were then triangulated with programmatic data on harm reduction services, HIV testing, and ART., Results: From 2007 to 2016, HIV incidence decreased in Estonia by 61% overall, for all exposure groups, and particularly for male PWID (97%), except men who have sex with men, where it increased by 418%. In Latvia, it increased by 72% overall. Median time to diagnosis decreased for male PWID in Estonia, from 3.5 to 2.6 years, but not in Latvia. In 2016, most new and undiagnosed infections, ∼50% in Latvia and ∼75% in Estonia, affected individuals reporting heterosexual transmission, showing a gradual shift toward heterosexual route as the main reported exposure mode. Coverage of services had been higher in Estonia; for example, by 2016, for PWID, there were >200 needles and syringes distributed per PWID annually, and HIV testing and ART coverage reached ∼50% and 76%, respectively, in Estonia, against respectively less than 100%, 10% and 27% in Latvia., Conclusions: Estonia has turned the tide of its epidemic - large scale-up of prevention and care programs probably contributed to it - whereas in Latvia it remains very active., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Studies of missed opportunities for earlier diagnosis of HIV have shown that patients with undiagnosed HIV often present to healthcare settings numerous times before eventually receiving their diagnosis., Aim: The aim of the study was to assess missed opportunities for HIV testing among people newly diagnosed with HIV., Methods: In this observational retrospective study, we collected data from the Estonian Health Board on new HIV cases in people aged 16–49 years diagnosed in 2014–15 and from the Estonian Health Insurance Fund database for treatment invoices on their contacts with healthcare services in the 2 years preceding diagnosis. Diagnoses on treatment invoices were categorised as HIV indicator conditions using ICD-10 codes., Results: Of 538 newly diagnosed HIV cases (62.5%; 336 men), 82% had visited healthcare services at least once during the 2 years before HIV diagnosis; the mean number of visits was 9.1. Of these, 16% had been tested for HIV and 31% had at least one ICD-10 code for an HIV indicator condition on at least one of their treatment invoices. In 390 cases of HIV indicator conditions, only 5% were tested for HIV. Of all new HIV cases aged 20–49 years from high-incidence regions (defined as priority groups in national testing guidance), 18% had been tested., Conclusions: The HIV testing rate in the 2 years before an HIV diagnosis was very low, even in the presence of an HIV indicator condition. This emphasises the importance of implementing the Estonian HIV testing guidelines.

Objective: The role of CC chemokine receptor 5 (CCR5) and its ligand CCL5 on the pathogenesis of HIV infection has been well studied but not for HCV infection. Here, we investigated whether CCL5 haplotypes influence HIV and HCV seropositivity among 373 Caucasian people who inject drugs (PWID) from Estonia., Methods: Study included 373 PWID; 56% were HIV seropositive, 44% HCV seropositive and 47% co-infected. Four CCL5 haplotypes (A-D) were derived from three CCL5 polymorphisms (rs2107538/rs2280788/rs2280789) typed by Taqman allelic discrimination assays. The data of CCR5 haplotypes were used from our previous study. The association between CCL5 haplotypes with HIV and/or HCV seropositivity was determined using logistic regression analysis., Results: Possessing CCL5 haplotype D (defined by rs2107538A/rs2280788G/rs2280789C) decreased the odds of HCV seropositivity compared to those not possessing it (OR = 0.19; 95% CI 0.09-0.40), which remained significant after adjustment to co-variates (OR = 0.08; 95% CI 0.02-0.29). An association of this haplotype with HIV seropositivity was not found. In step-wise logistic regression with backward elimination CCL5 haplotype D and CCR5 HHG*1 had reduced odds for HCV seropositivity (OR = 0.28 95% CI 0.09-0.92; OR = 0.23 95% CI 0.08-0.68, respectively) compared to those who did not possess these haplotypes, respectively., Conclusions: Our results suggest that among PWID CCL5 haplotype D and CCR5 HHG*1 independently protects against HCV. Our findings highlight the importance of CCL5 genetic variability and CCL5-CCR5 axis on the susceptibility to HCV.

Background: This study seeks to identify the prevalence of, and risk factors associated with, non-fatal overdose among people currently injecting drugs (PWID) in St. Petersburg (Russia) and in Kohtla-Järve (Estonia)., Methods: Five hundred eighty-eight study participants in Kohtla-Järve (in 2012) and 811 in St. Petersburg (in 2012-2013) were recruited using respondent driven sampling for interviewing and HIV testing., Results: Three-quarters (76%) of the current PWID were male. Participants from St. Petersburg were older (mean age 32.1 vs. 29.6 years, p < 0.0001) and reported a longer average duration of injecting drugs (mean duration: 13.3 vs. 10.9 years, p < 0.0001). Main drugs injected were opioids (fentanyl in Kohtla-Järve, heroin in St Petersburg). HIV prevalence was 63% (95% CI 59-67%) in Kohtla-Järve and 56% (95% CI 52-59%) in St. Petersburg. Two thirds of the PWID in Kohtla-Järve and St. Petersburg reported ever having experienced a drug overdose involving loss of consciousness or stopping breathing. In Kohtla-Järve, 28% (95% CI 24-31%) of participants and, in St Petersburg, 16% (95% CI 14-19%) of participants reported an overdose within the previous 12 months. Characteristics of injection drug use practice (longer duration of injection drug use, main drug injected), correlates of high-risk injection behaviour (higher injecting frequency, sharing), and problem alcohol use were associated with the risk of overdose within the previous 12 months. The significant factors effects did not differ between the sites., Conclusions: PWID are at high risk for overdose. Effective overdose prevention efforts at the public health scale are therefore warranted.

Background: The influence of the diversity of CCR5 on HIV susceptibility and disease progression has been clearly demonstrated but how the variability of this gene influences the HIV tropism is poorly understood. We investigated whether CCR5 haplotypes are associated with HIV tropism in a Caucasian population., Methods: We evaluated 161 HIV-positive subjects in a cross-sectional study. CCR5 haplotypes were derived after genotyping 9 CCR2-CCR5 polymorphisms. The HIV subtype was determined by phylogenetic analysis using the maximum likelihood method and viral tropism by the genotypic tropism assay (geno2pheno). Associations between CCR5 haplotypes and viral tropism were determined using logistic regression analyses. Samples from 500 blood donors were used to evaluate the representativeness of HIV-positives in terms of CCR5 haplotype distribution., Results: The distribution of CCR5 haplotypes was similar in HIV-positive subjects and blood donors. The majority of viruses (93.8%) belonged to HIV-1 CRF06&#95;cpx; 7.5% were X4, and the remaining were R5 tropic. X4 tropic viruses were over represented among people with CCR5 human haplotype E (HHE) compared with those without this haplotype (13.0% vs 1.4%; P = 0.006). People possessing CCR5 HHE had 11 times increased odds (odds ratio = 11.00; 95% confidence interval: 1.38 to 87.38) of having X4 tropic viruses than those with non-HHE. After adjusting for antiretroviral (ARV) therapy, neither the presence of HHE nor the use of ARV was associated with X4 tropic viruses., Conclusions: Our results suggest that CCR5 HHE and ARV treatment might be associated with the presence of HIV-1 X4 tropic viruses.

Background: Up to 90% HIV-1 positive intravenous drug users (IDUs) are co-infected with HCV. Although best recognized for its function as a major co-receptor for cell entry of HIV, CC chemokine receptor 5 (CCR5) has also been implicated in the pathogenesis of HCV infection. Here, we investigated whether CCR5 haplotypes influence HIV-1 and HCV seropositivity among 373 Caucasian IDUs from Estonia., Methods: Of these IDUs, 56% and 44% were HIV and HCV seropositive, respectively, and 47% were coinfected. 500 blood donors seronegative for HIV and HCV were also evaluated. CCR5 haplotypes (HHA to HHG*2) were derived after genotyping nine CCR2-CCR5 polymorphisms. The association between CCR5 haplotypes with HIV and/or HCV seropositivity was determined using logistic regression analysis. Co-variates included in the models were length of intravenous drug use, HBV serostatus and copy number of CCL3L1, the gene encoding the most potent HIV-suppressive chemokine and ligand for CCR5., Results: Compared to IDUs seronegative for both HCV and HIV (HCV-/HIV-), IDUs who were HCV+/HIV- and HCV+/HIV+were 92% and 82%, respectively, less likely to possess the CCR5-HHG*1 haplotype, after controlling for co-variates (P(adjusted) = 1.89 × 10(-4) and 0.003, respectively). This association was mostly due to subjects bearing the CCR5 HHE and HHG*1 haplotype pairs. Approximately 25% and<10% of HCV-/HIV- IDUs and HCV-/HIV- blood donors, respectively, possessed the HHE/HHG*1 genotype., Conclusions: Our findings suggest that HHG*1-bearing CCR5 genotypes influence HCV seropositivity in a group of Caucasian IDUs.

This study assesses relationships between drug administration routes and HIV serostatus, drug use, and sexual behaviors among current injecting drug users (IDUs) in Tallinn, Estonia. We recruited 350 IDUs for a cross-sectional risk behavior survey. Adjusted odds ratios (AORs) were calculated to explore injection risk behavior, sexual behavior, and HIV serostatus associated with multiple route use. Focus groups explored reasons why injectors might use non-injecting routes of administration. Those reporting multiple drug administration routes were less likely to be HIV seropositive (AOR = 0.49, 95% confidence interval [CI] = 0.25-0.97) and had almost twice the odds of having more than one sexual partner (AOR = 1.90, 95% CI = 1.01-3.60) and of reporting having sexually transmitted diseases (AOR = 2.38, 95% CI = 1.02-5.59). IDUs who engage in noninjecting drug use may be reducing their risk of acquiring HIV though sharing injection equipment, but if infected may be a critical group for sexual transmission of HIV to people who do not inject drugs., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Estonia has the second highest adult HIV prevalence in Europe of 1.3%. The primary transmission is among injecting drug users (IDU), who account for 56-90% of HIV infections (Report on the Global AIDS Epidemic: UNAIDS/WHO, July 2008 and Platt et al. AIDS 20(16):2120-2123, 2006). Of those persons newly diagnosed, 50.4% reported injecting drugs in the last 12 months, 16.3% of these reported IDU as the sole risk factor and 31.2% reported IDU among other risk factors. In this sample (n = 790) 170 persons reported a high risk behavior and 51 persons received a positive result through rapid testing. The largest proportion (35.29%) was among persons reporting high risk heterosexual intercourse and second (33.33%) among persons sharing injecting equipment. Covariates in a logistic regression model indicate that male sex (OR = 2.57, 95% CI 1.00-6.59), non-Estonian ethnicity (OR = 2.68, 95% CI 1.46-4.93), higher education (OR = 0.56, 95% CI 0.40-0.80), and high risk heterosexual intercourse (OR = 2.68, 95% CI 1.19-6.02) are statistically significant in predicting a positive HIV status.

Background: A high copy number of CCL3L1, the most potent human immunodeficiency virus (HIV)-suppressive chemokine, associates with reduced HIV susceptibility. Whether CCL3L1 influences acquisition of multiple blood-borne infections (eg, hepatitis C virus [HCV], HIV, and hepatitis B virus [HBV] infections), which occur commonly among injection drug users (IDUs), is unknown., Methods: We determined CCL3L1 copy number by real-time polymerase chain reaction among 374 Caucasian IDUs from Estonia; 285 were HCV positive, 208 were HIV positive, 177 were HCV and HIV positive, and 57 were HCV and HIV negative., Results: In univariate and multivariate analyses, HCV and HBV seropositivity and duration of IDU each strongly predicted HIV seropositivity. A high CCL3L1 copy number (>2) was associated with an 80% reduced risk of acquiring HIV infection after adjusting for age, sex, HCV and HBV status, CCR5-Delta32 polymorphism, and IDU duration (odds ratio, 0.20; 95% confidence interval, 0.09-0.45). By contrast, CCL3L1 gene dose did not influence HCV seropositivity. Among HCV-positive IDUs, there was a 3.5-fold overrepresentation and 65% underrepresentation of a high CCL3L1 copy number among HCV-positive, HIV-negative subjects and HCV-positive, HIV-positive subjects, respectively., Conclusion: Among IDUs with extensive exposure to HCV and HIV, CCL3L1 copy number is a major determinant of HIV seropositivity but not of HCV seropositivity. The contrasting distribution of a protective high CCL3L1 copy number among HCV-positive, HIV-negative IDUs versus HCV-positive, HIV-positive IDUs may reflect that HIV preferentially selects for subjects with a low CCL3L1 gene dose.

The assessment of quality of life is central to understanding how people's lives are affected by HIV infection. Estonia--the smallest of three Baltic countries--has experienced massive outbreak of HIV infection. Yet, little is known about the quality of life of HIV infected people in Estonia. The purposes of the present study were to adapt the World Health Organization's Quality of life HIV instrument (WHOQoL-HIV) into Estonian setting and to assess the quality of life in a sample of HIV-infected persons in Estonia.

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.

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.