HIV INFECTION AMONG COMMERCIAL SEX WORKERS AND INJECTING DRUG USERS IN THE CZECH REPUBLIC

Since the first HIV infection was diagnosed in the Czech Republic in 1985,¹ the number of HIV cases has increased in the last decade.² The majority of HIV cases have been reported in the capital of Prague, and the dominant transmission has occurred mainly among homosexual/bisexual population.³ Because of the worsening economic situation in the Czech Republic, however, there has been a dramatic increase in the number of female (FCSWs) and male commercial sex workers (MCSWs), concentrated mainly in border areas with Austria and Germany,⁴ especially after the November 1989 Revolution.⁵ Only a few published studies have assessed the HIV status in this country; therefore, there is a lack of information on the epidemiology of HIV in most high-risk groups. We describe the epidemiology of HIV infection among three high-risk groups: FCSWs, MCSWs, and injecting drug users (IDUs) in four cities of the Czech Republic.

Three cross-sectional studies among FCSWs were conducted in the cities: Western Bohemia in the city of Cheb, Northern Bohemia, in the town of Usti nad Labem, and Moravia in the city of Ostrava (Figure 1). Among MCSWs, four cross-sectional studies were conducted in the three cities previously described (Western Bohemia, Northern Bohemia, and Moravia) and in the capital city of Prague. Among IDUs, four cross-sectional studies were performed in Western Bohemia, Northern Bohemia, Moravia, and Prague city. Participants were recruited by outreach workers in collaboration with three Czech Ministry of Health (MOH) Hygienic Stations (the Regional Hygienic Station of Northern Moravia, the Regional Hygienic Station of Northern Bohemia, and the District Hygienic Station of Western Bohemia) and through the Projekt Sance and Drop-In, two non-governmental organizations (NGOs).

Potential participants were defined as practicing commercial sex work if they reported receiving money or goods in exchange for sexual services, either regularly or occasionally, irrespective of whether they self-identified as sex workers, and provided that such activities resulted in generation of any type of income (UNAIDS definition).⁶ FCSWs were contacted at brothels, saunas, massage houses, parks, and streets. MCSWs were contacted at public and private venues and meeting locations (discotheques and bars) through the three hygienic stations and the Projekt Sance, an NGO that works with street people and whose main objective is to prevent sexually transmitted infections (STIs), including HIV. IDUs were recruited at street gathering locations and through direct referrals from staff/attendants at Drop-In, an NGO that works with IDUs in Prague using the following: 1) a walk-in counseling center in central Prague; 2) a core group of outreach workers who visit areas in Prague where IDUs congregate; and 3) a mobile van that takes outreach workers to areas outside of Prague. To obtain a representative sample of street-based IDUs in the study, clients of the walk-in counseling center were not enrolled. Outreach workers received pre-study enrollment and pre- and post-test counseling training by the National AIDS Program staff.

Individuals 18 years of age or older who provided informed consent and who were available for at least 2 weeks after providing the initial sample were enrolled. Confidential face-to-face interviews were conducted on-site using a confidential questionnaire that queried for each subject’s demographic and risk factor information. During these encounters, the study was explained, and subjects were invited to participate on a voluntary basis. All participants received free pre- and post-test counseling for HIV and other STIs as well as psychological and social counseling by outreach workers. Individuals found to be HIV positive were referred to the Regional AIDS Clinical Center to ensure they received additional medical follow-up and care for HIV-related conditions in accordance with national treatment guidelines. In addition, medical counseling was also provided, which addressed potential risk of transmission of HIV to other persons or contacts and personal protective measures. No mandatory, compulsory reporting of HIV-positive persons was in effect by public health authorities to protect patient’s confidentiality.

During the initial screening, a saliva sample was collected and tested for HIV antibodies by Wellcozyme HIV 1 and 2 GACELISA kit (Abbot-Lurex laboratories, Wiesbaden, Germany; sensitivity, 99–100%). A serum sample was collected from all those participants who were HIV reactive on the initial (saliva) sample and was tested by a third-generation ELISA (ELISA-2; Abbott Laboratories, North Chicago, IL), and repeatedly reactive samples were subjected to Western blot confirmation by PEPTI-LAV 1–2 (Sanofi Pasteur Diagnostics, Marnes-La-Coquette, France).

A total of 1,277 subjects were enrolled from June 1999 to August 2000. Of these, 585 (45.8%) were FCSWs, 230 (18.0%) were MCSWs, and 462 (36.2%) were IDUs. Among FCSWs, the mean age of participants was 24.8 years (range: 18–48 years), 60% were Czechs, and 83% were single. Only a small proportion (10%) of FCSWs self-identified as sex workers; a majority (59%) stated another “official” occupation (such as waitress, dressmaker, barmaid, and others). In addition, 10% self-reported being bisexual, 48% reported a previous history of sexual contact with foreigners, and 10% reported a previous IDU history (Table 1). Among the 230 MCSWs, the mean age of participants was 22.9 years (range: 18–54 years). Almost one third (29%) self-identified as sex workers, 35% self-reported being heterosexual, 38% reported sexual contact with foreigners, and 38% reported previous IDU history. Among IDUs, > 60% were young adults (18–22 years old), 74% were unemployed, 92% reported being heterosexual, and 17% gave a history of past sexual contact with foreigners.

The HIV prevalence was 0.7% (4 of 585; 95% CI: 0.2–1.7%), 0.9% (2 of 230; 95% CI: 0.1–3.1%), and 0.2% (1 of 462; 95% CI: 0.01–1.2%) among FCSWs, MCSWs, and IDUs, respectively (Table 2). Of the four HIV-infected FCSWs, two of them were foreigners from Ukraine and one was from Moldova; three of four HIV-infected FCSWs were older than 20 years of age. All HIV-infected MCSWs and IDUs were Czechs.

Prostitution has grown exponentially in the Czech Republic in the past few years, especially along the German border areas, one of the main destinations for migration of prostitutes within Europe.⁵ It has been estimated that there are ~10,200 FCSWs in the Czech Republic; the majority coming from the Russian Federation, the Ukraine, Slovakia, Bulgaria, Romania, and Albania.⁷ In our study, ~40% of FCSW participants were foreigners, mostly from the Ukraine (54%), the Russian Federation (14%), and Bulgaria (5%). Although the HIV prevalence among FCSWs in this study was higher, it did not vary in a significant way (P = 0.200 by Fisher exact test) compared with a previous study conducted in the German border in 1997, where an HIV prevalence of 0.2% was documented among 561 FCSWs. Recent increases in STI rates have taken place in the Czech Republic, especially for syphilis and gonorrhea, where their incidence rates have been estimated at ~10.2 and 9.5 per 100,000, respectively, in 2001.⁸ High-risk behaviors, such as unsafe sexual practices, may contribute to the rapid transmission of HIV in this high-risk group.⁹

As in other European countries, the risk of HIV has been previously associated with a history of homosexual/bisexual behavior, which is estimated to constitute the predominant risk category. In the Czech Republic, the majority of recorded HIV-infected persons are from the city of Prague, principally among homosexuals/bisexuals.³ Concomitantly, in this study, the two HIV-infected individuals in the MCSW group reported bisexual/homosexual risk behaviors. Given that homosexuals/bisexuals constitute an important “bridge” for HIV transmission to other populations such as heterosexually active women, changes in their risk behaviors might significantly increase the incidence of new HIV infections.^10,11

There has been a radical shift in the transmission of HIV infection observed among IDUs from 1996 to 2001 in Central and Eastern Europe, mainly in the countries of the Russian Federation, the Ukraine, and the Baltic States.³ A low HIV prevalence (0.2%) has been previously reported among young IDUs in the city of Prague in 1998.⁹ The one HIV-infected subject among IDUs found in our study was a young, 20-year-old Czech heterosexual from the city of Prague, who reported using heroine and pervitin (a variety of metham-phetamine, also called “Czecho”). This suggests that the HIV epidemic situation in the Czech Republic seems to be stable and low among IDUs for now. However, recent trends reflecting increased consumption of injecting opiates by teenagers may rapidly fuel the spread of HIV in the Czech Republic.¹² During the period when this study was conducted, prevention programs were in place for this high-risk group; needle exchange programs were also available in other locations (e.g., settings accessible to drug users and street workers). This may explain the effectiveness of this program, which has resulted in the continuing low incidence of HIV infection.

In countries such as the Czech Republic, Poland, Hungary, and Slovenia, where well-designed national HIV/AIDS programs are now in operation, the general population’s prevalence of HIV continues to remain at a low level.³ Recent increases in STI rates among FCSWs, as well as increased risky sexual and drug-using behaviors among MCSWs, seem to perpetuate the ongoing low-level transmission of HIV.

Trends analysis (1996–2001) of the HIV epidemic in eastern Europe suggests that this region will soon face a major AIDS epidemic and that this will depend on the size of so-called bridging populations that link high-risk groups, mainly IDUs, with the general population.¹³ Recent UNAIDS data indicated that the number of adults (15–49 years old) living with HIV has increased from 2,100 in 2001 to 2,500 in 2003 to upward of 3,000 in 2005 in the Czech Republic.¹⁴ Notwithstanding the HIV prevalence detected, ongoing sentinel surveillance studies, which address modifiable behavioral and biologic risk factors among high-risk groups, are necessary to guide prevention strategies, which in turn may stem the tide of the epidemic in this region.

Sites for HIV studies.

Citation: The American Journal of Tropical Medicine and Hygiene Am J Trop Med Hyg 75, 5; 10.4269/ajtmh.2006.75.1017

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Sites for HIV studies.

Citation: The American Journal of Tropical Medicine and Hygiene Am J Trop Med Hyg 75, 5; 10.4269/ajtmh.2006.75.1017

• Download Figure
• Download figure as PowerPoint slide

Sites for HIV studies.

Citation: The American Journal of Tropical Medicine and Hygiene Am J Trop Med Hyg 75, 5; 10.4269/ajtmh.2006.75.1017

• Download Figure
• Download figure as PowerPoint slide