The neighbouring Baltic states of Estonia and Latvia offer starkly contrasting examples of how different public health approaches affect HIV epidemics among people who inject drugs. In the early 2000s, the two countries had among the highest rates of HIV diagnosis in Europe. As was the case for many European countries at that time, the sharing of non-sterile injecting equipment among drug users was fuelling their HIV epidemics.
The two epidemics began to diverge in the mid-2000s. According to the HERMETIC study, new HIV infections in Estonia declined by 61% countrywide and by 97% among men who inject drugs between 2007 and 2016.
Latvia’s HIV epidemic followed a different trajectory. The HERMETIC study highlights that, between 2007 and 2016, new HIV infections increased by 72% overall. By 2016, overall HIV incidence in Latvia was almost double that in Estonia (35 cases per 100 000 people versus 19 cases per 100 000).
Both epidemics centred largely on the sharing of injecting equipment by people who inject drugs, and probably on unprotected sex between people who inject drugs and their sexual partners. The HERMETIC study concludes that the main difference between the two epidemics lay in the availability of harm reduction services.
Needle–syringe programmes had been operating in Latvia since 1997, but on a very limited scale. As late as 2016, Latvia was distributing about 93 needle–syringes per drug user per year; neighbouring Estonia was distributing 230 per user per year. Both countries expanded access to opioid substitution therapy, which is proven to reduce drug injecting and HIV transmission, and improved HIV testing and antiretroviral therapy services for people who inject drugs. Although access to opioid substitution therapy remained limited in both countries, it was higher in Estonia than in Latvia.
The HERMETIC study’s results indicate that by 2016, about half the people who inject drugs in Estonia were taking HIV tests in a 12-month period—and three quarters of those who tested HIV-positive were on antiretroviral therapy. In Latvia, meanwhile, about 10% of people who inject drugs took an HIV test in any given year between 2007 and 2016, and only 27% of those living with HIV were on antiretroviral therapy. Slow adoption of international HIV treatment guidelines contributed to the low treatment coverage in Latvia.
