Political, economic and social transition creates HIV risk environment: BMJ article

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Political, economic and social transition has created a risk environment for HIV transmission in eastern Europe and the western Balkans, according to an article published in the July 23rd edition of the British Medical Journal. The investigators, from Imperial College, London, argue that the HIV risk environment means “prevention strategies aimed at individual behaviour may…only partially reduce the risk of transmission.”

Transition in eastern Europe and the western Balkans since the early 1990s has disrupted individual and community levels of HIV risk reduction and weakened public health responses to the epidemic.

The abrupt and large scale political and social change in these regions has created a risk environment for HIV transmission independent of individual risk behaviour.

The risk environment

The physical, social, economic and policy environments also contribute to the wider risk environment on two levels. The micro-risk environment influences personal decision-making and community norms and practices. The macro-risk environment comprises structural factors, including laws, military action, economic conditions and wider cultural beliefs.

Eastern Europe



In discussions of consent for medical treatment, the ability of a person to make a decision for themselves and understand its implications. Young children, people who are unconscious and some people with mental health problems may lack capacity. In the context of health services, the staff and resources that are available for patient care.

risky behaviour

In HIV, refers to any behaviour or action that increases an individual’s probability of acquiring or transmitting HIV, such as having unprotected sex, having multiple partners or sharing drug injection equipment.

structural factors

Social forces which drive the HIV epidemic and create vulnerability to HIV infection. They include gender inequality and violence, economic and social inequality, and discriminatory legal environments.

HIV has spread rapidly, due to injecting drug use, in eastern Europe since 1995. “Current evidence suggests that transition has led to economic and social dislocation, creating an environment that allows illicit drug markets, drug injecting, and related HIV risk to thrive.”

Increased migration, poverty and the weakening of civil society have all contributed to the HIV risk environment, suggest the authors. They also note that public health infrastructures have weakened in the region and that the spread of HIV has coincided with generally declining standards of health, the re-emergence of communicable diseases such as tuberculosis, high levels of illness caused by alcohol and a high prevalence of sexually transmitted infections.

The investigators also observe “tensions exist between public health and law enforcement approaches…aggressive street policing has been shown to reduce opportunities for reducing risk among injecting drug users and increase sharing of syringes.”

Western Balkans

The western Balkans include Bosnia Herzegovina, Serbia Montenegro, Kosovo, Albania and Macedonia. Official HIV prevalence figures are low and the most case of the infection have been transmitted sexually (with the exception of Serbia, where drug use is the main mode of transmission).

The HIV risk environment in the Balkans is similar to that in eastern Europe, including widespread poverty and mass unemployment; social insecurity; trafficking of people, drugs and sex; migration, often associated with civil strife; and transition to market economies accompanied by major reductions in health and welfare provision and the development of new drug and sex markets.

There are large numbers of displaced persons in the region due to armed conflict and the investigators note that some refugee collection centres are “associated with sexual violence or abuse.”

Poverty, resulting from conflict in the region is also commented on by the investigators. “In 2002, the income of over half of the Serbian population was insufficient to meet basic needs.” Economic decline also resulted in health care professionals leaving the country.

Conflict in the region also lead to people having more sexual partners. The weakening of the labour market also led to an increase in sex work. During the conflicts in Bosnia and Croatia, it is estimated that 50,000 women were raped. The investigators highlight evidence suggesting that levels of drug use increased because of “psychological trauma and experiencing war and perceived loss of opportunity.”

Prejudice has increased in the region because of the conflicts, “feeding intolerance to social groups that do not meet a national ideal.” This includes men who have sex with men and individuals with HIV. In addition, the investigators note that “prejudice within medical communities towards men who have sex with men and people with HIV infection discourages them from seeking helps and limits capacity to prevent the spread of HIV.”

HIV has had to take second place to other health priorities in countries in the region and there are shortages of basic medical supplies, including HIV testing kits. Non-governmental agencies are embryonic and the procedures to track the evolution of the HIV epidemic in the region are poor .

The investigators conclude, “study of the HIV risk environment shows that prevention strategies need to support large scale community risk avoidance as well as change individual behaviour.”


Rhodes T et al. Transition and the HIV risk environment. BMJ 331: 220 – 223, 2005.