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The explosive increase in the number of people infected with tuberculosis (TB), multi drug resistant tuberculosis (MDRTB), and injecting drug users (IDU) HIV/AIDS has become a serious public health challenge in Russia. The World Health Organization is recommending policies including simultaneous use of highly active antiretroviral therapy (HAART) to treat HIV/AIDS and second line drugs to treat MDRTB. We developed a System Dynamics simulation model to represent the dynamic transmission of TB, MDRTB and human immunodeficiency virus (HIV). The model simulated scenarios regarding MDRTB cure rate and HAART coverage, that is the HIV/AIDS population covered by HAART. The results over a 20-year period indicate that reduction in TB and HIV-associated TB deaths would be negligible for HAART coverage up to 50%. The reduction is only significant for HAART coverage of 70% and above. Similarly, high MDRTB cure rate reduces significantly deaths from TB and MDRTB and this reduction is more important as the HAART coverage is increased. [ABSTRACT FROM AUTHOR]

Few studies have examined the personal and social consequences of stigma associated with HIV infection in Russia, a country with one of the most rapidly advancing HIV epidemics globally. By May 2005, Samara Oblast, Russia had 24,022 notified seropositive individuals. Focus-group discussions with randomly sampled seropositive and seronegative individuals, matched by age, gender and education were selected from the general population and used to provide an informal forum for discussion of attitudes to HIV and potentially stigmatizing behavior. The results demonstrated that the perception that HIV was associated with immoral behaviour underpinned stigma. Discriminating attitudes are strongly associated with misperceptions regarding transmission and frequent over-estimation of risks from casual contact. The general population was unforgiving to those who had become infected sexually or through drug use. Infection through a medical procedure or from an assault was perceived as a likely route of infection. Knowledge of population attitudes and perceptions, as well as those who are HIV-positive, is critical for successful interventions and to encourage people to come forward for HIV testing. This research offers insights into the distance that needs to be traveled if stigma is to be addressed in wider efforts to control HIV in Russia. [ABSTRACT FROM AUTHOR]

Background: The World Health Organisation (WHO) defines Russia as one of the 22 highest-burden countries for tuberculosis (TB). The WHO Directly Observed Treatment Short Course (DOTS) strategy employing a standardised treatment for 6 months produces the highest cure rates for drug sensitive TB. The Russian TB service traditionally employed individualised treatment. The purpose of this study was to implement a DOTS programme in the civilian and prison sectors of Samara Region of Russia, describe the clinical features and outcomes of recruited patients, determine the proportion of individuals in the cohorts who were infected with drug resistant TB, the degree to which resistance was attributed to the Beijing TB strain family and establish risk factors for drug resistance. Methods: prospective study Results: 2,099 patients were recruited overall. Treatment outcomes were analysed for patients recruited up to the third quarter of 2003 (n = 920). 75.3% of patients were successfully treated. Unsuccessful outcomes occurred in 7.3% of cases; 3.6% of patients died during treatment, with a significantly higher proportion of smear-positive cases dying compared to smear-negative cases. 14.0% were lost and transferred out. A high proportion of new cases (948 sequential culture-proven TB cases) had tuberculosis that was resistant to first-line drugs; (24.9% isoniazid resistant; 20.3% rifampicin resistant; 17.3% multidrug resistant tuberculosis). Molecular epidemiological analysis demonstrated that half of all isolated strains (50.7%; 375/740) belonged to the Beijing family. Drug resistance including MDR TB was strongly associated with infection with the Beijing strain (for MDR TB, 35.2% in Beijing strains versus 9.5% in non-Beijing strains, OR-5.2. Risk factors for multidrug resistant tuberculosis were: being a prisoner (OR 4.4), having a relapse of tuberculosis (OR 3.5), being infected with a Beijing family TB strain (OR 6.5) and having an unsuccessful outcome from treatment (OR 5.0). Conclusion: The implementation of DOTS in Samara, Russia, was feasible and successful. Drug resistant tuberculosis rates in new cases were high and challenge successful outcomes from a conventional DOTS programme alone. [ABSTRACT FROM AUTHOR]

Background: Clinical management of tuberculosis in Russia involves lengthy hospitalizations, in contrast to the recommended strategy advocated by the World Health Organization. Methods: We used Fourier transform, spectral analysis and Student's t-test to analyse periodic and seasonal variations in admission and discharge rates for tuberculosis hospitalizations in 1999-2002, using routinely captured data from the Samara Region, Russia. Results: Hospital admissions in colder months were significantly higher than in warmer months. The mean monthly adjusted number of admissions in colder and warmer months for all adults was 413 and 372 (P < 0.01), for unemployed adults 218 and 198 (P < 0.02) and for pensioners 104 and 82 (P < 0.05). Hospital discharges varied seasonally. Maximum differences between admissions and discharges occurred in colder months and minimum differences were observed in warmer months. Conclusions: As hospitalizations of tuberculosis patients in colder months fulfil an important social need, shifts to ambulatory care must be carefully managed. [ABSTRACT FROM AUTHOR]

In April, 2003 the World Bank approved a long-awaited $150 million loan to the Russian Federation to support tuberculosis (TB) and AIDS control. Although the Russian Federation accounts for a relatively small fraction of the global TB case-load the proportion of cases which are drug-resistant and particularly multidrug-resistant is very high in some regions. HIV incidence, principally associated with intravenous drug abuse, has also increased dramatically and this will impact upon TB control efforts. Federation-wide data are limited but a focus on one region shows something of the confluence of the epidemics of HIV and TB. Approaching 200 cases of HIV-associated TB have occurred in the past two years, and the age structure of the HIV-infected population and that with high rates of TB shows sizeable overlap. The region has high rates of multidrug-resistant TB which are likely to impact considerably on efforts to meet this emerging and complex public health challenge. Insights gained through the examination of this one region can tell us something of the magnitude of the challenge now faced by both the international community and Russia. [ABSTRACT FROM AUTHOR]

Objective. The aim of this study was to describe health system challenges faced by tuberculosis (TB) treatment facilities in Russia through an analysis of format institutional dietary provisions to patients in an inpatient facility that provides care for poor patients. Methods. Analysis of formal dietary provisions by institutions and financing data from TB hospitals in Samara Oblast, Russia. Results. Formal dietary provision for inpatients with TB has fallen substantially in recent years. In a hospital providing inpatient care for the poorest patients with fewest social support networks, this has been very pronounced. The likely reason for this is that financial support for other budget lines, principally salaries, has required protection. Conclusion. Formal institutional nutritional support in institutions providing care for the poorest patients with TB is unlikely to be enhancing the speed of recovery, or reducing the duration of infectiousness. Furthermore, the role that hospital may have played in the past in enabling patients to regain weight lost before admission may have been limited by reductions in formal financing. Reductions in state provision of food for patients may serve as an important illustration of wider TB control system frailties in the Russian Federation. [ABSTRACT FROM AUTHOR]

Background: Russia faces a worsening IDU/HIV epidemic. This paper examines the social and economic characteristics of injecting drug users in two cities in Russia and compares this with the general population to explore their social and economic needs and the wider implications of the epidemic for the economy and society., Methods: A cross sectional survey of 711 IDUs in two Russian cities (Volgograd and Barnaul) recruited by a modified chain referral sampling method. Respondents were asked about their education, work, living conditions, expenditure on goods and services and livelihoods. Their characteristics were compared with a random sample of the general population., Results: There are a number of characteristics, in which IDUs do not differ systematically from the general population. They have general education; live in the towns where they were born; and their monthly income is comparable with the Russian average. However, IDUs are more likely to have a vocational qualification than a university degree; less likely to have a permanent job; and those employed are skilled manual rather than professional workers. IDUs are less likely to be officially married and more likely to be living with their parents or on their own. The majority rely on financial help from relatives or friends; and much of their income is from illegal or semi-legal activities., Conclusion: IDUs are not atypical or marginal to the Russian economy and society. However, their drug-dependency and related life-style make them particularly vulnerable to the impact of poverty, violence and social insecurity. A failure to effectively control the dual IDU/HIV epidemic can have a significant negative impact on the Russian labour force, health and social costs and overall economy., (Copyright © 2010 Elsevier B.V. All rights reserved.)

Introduction: Studies on the relevance of stronger health systems to the success of vertical programmes has focused mainly on developing countries with fragile infrastructures and limited human resources. Research in middle-income, and particularly post-Soviet, settings has been scarce. This article examines the relationships between health system characteristics and the HIV response in Russia, the country which towards the end of the Soviet period had the world's highest ratios of doctors and hospital beds to population and yet struggled to address the growing threat of HIV/AIDS., Methods: The study is based on semi-structured qualitative interviews with policy-makers and senior health care managers in two Russian regions, and a review of published and unpublished sources on health systems and HIV in Russia., Findings: We identified a number of factors associated with the system's failure to address the epidemic. We argue that these factors are not unique to HIV/AIDS. The features of the wider health system within which the HIV response was set up influenced the structure and capacities of the programme, particularly its regulatory and clinical orientation; the discrepancy between formal commitments and implementation; the focus on screening services; and problems with scaling up interventions targeting high-risk groups., Discussion: The system-programme interplay is as important in middle-income countries as in poorer settings. An advanced health care infrastructure cannot protect health systems from potential failures in the delivery of vertical programmes. The HIV response cannot be effective, efficient and responsive to the needs of the population if the broader health system does not adhere to the same principles. Strengthening HIV responses in post-Soviet societies will require improvements in their wider health systems, namely advocacy of prevention for high-risk populations, reallocation of resources from curative towards preventive services, building decision-making capacities at the local level, and developing better working environments for health care staff.

Long-established Medico-Social Expert Commissions (MSECs) play a pivotal role in the Russian mental health system. They act as gatekeepers to pensions, rehabilitation, and employment services. This column describes their role in encouraging or impeding the social inclusion of people with mental illness, drawing on findings of a three-year project in Sverdlovsk Oblast. In Russia the emphasis remains on medical aspects of treatment, without adequate consideration of social and occupational rehabilitation. Links with local employment services are weak. To promote social inclusion, steps must be taken to encourage and facilitate cooperation and collaboration between the MSECs, employment services, and medical services.

Objectives: to examine attitudes of Russian policy-makers and HIV stakeholders towards harm reduction (HR) scale up, focusing on the factors constraining the scale-up process., Methods: Semi-structured interviews with representatives of 58 government and non-governmental organisations involved in HIV policies and programmes in Volgograd Region, Russian Federation., Results: We found a considerable diversity of opinion on HR scale-up and suggest that Russia is experiencing the situation of power parity between HR supporters and opponents with many stakeholders being indecisive or cautious to express their views. We identified six main factors which constrain policy decisions in favour of HR scale-up: insufficient financial resources; lack of information on HR effectiveness; perception of HR as being culturally unacceptable; reluctance of IDUs to use the services; opposition from law enforcement agencies and the Russian Church; and unclear legal regulations. We demonstrate a complex interplay between these factors, policy-makers' attitudes and their choices on HR scale-up., Conclusions: A number of actions are needed to achieve a successful scale-up of HR programmes in Russia and similar political contexts: (i) a strategic approach to HR advocacy, targeting neutral and indecisive stakeholders; (ii) more systematic evidence on HR effectiveness and cost-effectiveness in the local context; (iii) HR advocacy targeting law enforcement agencies and the Russian Church; and (iv) aligning best international HR practices with the objectives of local policy-makers, practitioners and service-users.

Objective: To evaluate how the regulatory environment and health system organisation, financing and provider payment systems influence the delivery of mental health services in the Sverdlovsk region of the Russian Federation., Methods: A multi-methods study was conducted including analysis of routine data and key informant interviews supplemented by analysis of published literature, legal and regulatory documents, ministerial orders and reports., Results: Mental health care services are still largely provided in hospitals, although the need for more community-based and rehabilitation services is widely recognised. Resource allocation and provider payment systems remain largely unchanged from Soviet times and favour large inpatient institutions, creating incentives for hospitals to maintain a large number of beds and staff. Community-based social services and human resources remain limited, especially in the areas of social work, housing support and vocational rehabilitation, but co-operation across sectors at local level is growing., Conclusion: In Russia, the pace of reform in the mental health system will be helped if financial resource allocation mechanisms and provider payment systems are also reformed, so that resources follow individuals regardless of where they are treated. Such major health system shifts can only be achieved through changes at the Federal level and require major political will. Additional transitional funding is also required to help develop the necessary alternative community-based services. The nature of mental health disorders mean that this is not a problem faced within the health system alone, greater attention needs to be placed also on how to maximise the cross sector benefits especially with the social protection and employment sectors.

We analysed costs and outcomes of tuberculosis care for patients in a traditional Russian tuberculosis control system, using 3-year retrospective cohort data. Of 1749 cases at 3 years of follow-up, 65% were cured, 11.3% (198/1749) still had 'active' or 'chronic' disease, 10.3% had transferred out of the local civilian health care system and 12.7% had died. The mean cost of managing one case over 3 years was 886 US dollars: 1,078 US dollars for bacteriologically confirmed (BK+) cases and 718 US dollars for bacteriologically unconfirmed (BK-) cases. Approximately 60% of treatment costs were incurred in the first 12 months and 40% incurred in the remaining 2 years. Around 60% of the total cost was accounted for by hospital inpatient care. The cost, treatment and outcome of BK+ and BK- cases differed substantially. The cost of treating BK+ cases was 50% higher than treating BK- cases due to higher hospitalization rates and the additional cost of managing BK+ cases that become 'chronic'. While BK+ cases accounted for 55% of total health expenditure on tuberculosis, the share of BK- cases was 45% of the total - due to hospitalization and lengthy periods of follow up. The costs of treating tuberculosis in the Russian tuberculosis control system are very high compared with other high-burden countries due to hospitalization policies and lengthy case management periods. Much of this expenditure can be avoided if the WHO-recommended DOTS strategy is implemented. In particular, the proportion of expenditure for BK- cases is surprisingly high and can be avoided as most of these patients do not need hospitalizing or lengthy periods of follow-up.

The Russian Federation has witnessed a marked rise in rates of tuberculosis (TB) over the past decade. Public health TB control institutions remain broadly modelled along pre-1990 lines despite substantial programmes of investment and advocacy in implementing the World Health Organization's 'Directly Observed Treatment--short course' (DOTS) strategy. In 2002, we undertook a qualitative study to explore health care providers' perceptions of existing barriers to access to TB services in Samara Oblast in Russia. Six focus group discussions were conducted with physicians and nurses from facilities in urban and rural areas. Data were analyzed using a framework approach for applied policy research. Barriers to access to care were identified in interconnected areas: barriers associated with the health care system, care process barriers, barriers related to wider contextual issues, and barriers associated with patients' personal characteristics and behaviour. In the health care system, insufficient funding was identified as an underlying problem resulting in a decrease in screening coverage, low salaries, staff shortages, irregularities in drug supplies and outdated infrastructure. Suboptimal collaboration with general health services and social services limits opportunities for care and social support to patients. Worsening socioeconomic conditions were seen both as a cause of TB and a major obstacle to access to care. Behavioural characteristics were identified as an important barrier to effective care and treatment, and health staff favoured compulsory treatment for 'noncompliant' patients and involvement of the police in defaulter tracing. TB was profoundly associated with stigma and this resulted in delays in accessing care and barriers to ensuring treatment success.

Objectives: To determine risk factors for pulmonary tuberculosis in Russia., Design: Case-control study of exposure to a variety of risk factors before and during the development of pulmonary tuberculosis., Setting: Large city in Russia., Participants: Cases were 334 consecutive adults diagnosed as having culture confirmed pulmonary tuberculosis between 1 January 2003 and 31 December 2003. Controls were 334 individuals sampled from a validated population registry, matched for age and sex to the patients with tuberculosis. A questionnaire collected information on potential risk factors., Main Outcome Measures: Risk factors associated with the development of tuberculosis., Results: The main risk factors for tuberculosis were low accumulated wealth (univariate odds ratio 16.70), financial insecurity (5.67), consumption of unpasteurised milk (3.58), diabetes (2.66), living with a relative with tuberculosis (2.94), being unemployed (6.10), living in overcrowded conditions (2.99), illicit drug use (8.74), and a history of incarceration in both pretrial detention centres (5.70) and prison (12.50)., Conclusions: When prevalence of exposure is taken into account the most important factors in the development of pulmonary tuberculosis in Russia are exposure to raw milk and unemployment.

Objective: To establish whether admissions, discharges and hospital utilisation for tuberculosis (TB) in Russia are independent of sex, age, disability and employment status., Study Population and Methods: Analysis of hospital admissions, discharges and in-patient utilisation using routinely collected data in Samara Region of the Russian Federation., Results: Male, unemployed and disabled adults were significantly more likely to be hospitalised (P < 0.001). The unemployed and pensioners were more likely to have multiple admissions. Unemployed adults were more likely to have longer average lengths of stay per admission (P < 0.001), with a cumulative length of stay for unemployed and disabled adults significantly greater than for employed adults and adults with no disability. Interruption of hospital care was significantly more frequent in male, disabled and unemployed patients (P < 0.001)., Conclusions: Socio-economic factors influence hospital admission patterns and the length of stay for patients when hospitalised, as the providers of TB services attempt to mitigate the lack of social care provision for patients. For the WHO DOTS strategy to be effectively implemented and sustained in the Russian Federation health system, social sector linkage issues need to be addressed.

The Russian Federation has the eleventh highest tuberculosis burden in the world in terms of the total estimated number of new cases that occur each year. In 2003, 26% of the population was covered by the internationally recommended control strategy known as directly observed treatment (DOT) compared to an overall average of 61% among the 22 countries with the highest burden of tuberculosis. The Director-General of WHO has identified two necessary starting points for the scaling-up of interventions to control emerging infectious diseases. These are a comprehensive engagement with the health system and a strengthening of the health system. The success of programmes aimed at controlling infectious diseases is often determined by constraints posed by the health system. We analyse and evaluate the impact of the arrangements for delivering tuberculosis services in the Russian Federation, drawing on detailed analyses of barriers and incentives created by the organizational structures, and financing and provider-payment systems. We demonstrate that the systems offer few incentives to improve the efficiency of services or the effectiveness of tuberculosis control. Instead, the system encourages prolonged supervision through specialized outpatient departments in hospitals (known as dispensaries), multiple admissions to hospital and lengthy hospitalization. The implementation, and expansion and sustainability of WHO-approved methods of tuberculosis control in the Russian Federation are unlikely to be realized under the prevailing system of service delivery. This is because implementation does not take into account the wider context of the health system. In order for the control programme to be sustainable, the health system will need to be changed to enable services to be reconfigured so that incentives are created to reward improvements in efficiency and outcomes.

Setting: Samara Oblast, Russia., Objective: To compare the rates of tuberculosis (TB) in health care workers (HCWs) working in TB services, general health services (GHS) and the general population in a region of the Russian Federation., Design: Analysis of notification rates of TB among HCWs, GHS workers and the general population during the 9-year period from 1994 to 2002., Results: During 1994-2002, TB incidence among staff employed at the TB services in Samara Oblast was ten times higher than among the general population, reaching 741.6/100 000 person years at risk. Staff working at in-patient TB facilities were found to be at highest risk, with an incidence rate ratio of 17.7 (95% CI 11.6-27.0) compared to HCWs at the GHS., Conclusions: HCWs at TB services in the Russian Federation are at substantially increased risk for TB, suggesting significant risks from nosocomial transmission. Control of institutional spread of TB in the Russian Federation is an area that requires urgent attention, especially given the epidemic of human immunodeficiency virus that Russia is currently witnessing.

Background: Inappropriate antibiotic prescribing exposes patients to the risk of side effects and encourages the development of drug resistance across antimicrobial groups used for respiratory infections including tuberculosis (TB)., Aim: Determine among Russian general practitioners and specialists: (1) sources of antimicrobial prescribing information; (2) patterns of antimicrobial prescribing for common respiratory diseases and differences between primary and specialist physicians; (3) whether drug resistance in TB might be linked to over-prescribing of anti-TB drugs for respiratory conditions., Methods: Point-prevalence cross-sectional survey involving all 28 primary care, general medicine and TB treatment institutions in Samara City, Russian Federation. In this two-stage study, a questionnaire was used to examine doctors' antimicrobial (including TB drugs) prescribing habits, sources of prescribing information, management of respiratory infections and a case scenario ('common cold'). This was followed by a case note review of actual prescribing for consecutive patients with respiratory diseases at three institutions., Results: Initial questionnaires were completed by 81.3% (425/523) of physicians with 78.4% working in primary care. Most doctors used standard textbooks to guide their antimicrobial practice but 80% made extensive use of pharmaceutical company information. A minority of 1.7% would have inappropriately prescribed antibiotics for the case and 0.8-1.8% of respondents would have definitely prescribed TB drugs for non-TB conditions. Of the 495 respiratory cases, 25% of doctors prescribed an antibiotic for a simple upper respiratory tract infection and of 8 patients with a clinical diagnosis of TB, 4 received rifampicin monotherapy alone. Ciprofloxacin was widely but inappropriately used., Conclusion: Doctors rely on information provided by pharmaceutical companies; there was inappropriate antibiotic prescribing.

Setting: Tuberculosis control programme in Samara Oblast, Russia, funded in part by the government of the United Kingdom., Objective: To identify and evaluate institutional and regulatory influences as well as incentives and disincentives that might be amenable to change in the promotion of the DOTS strategy., Design: Multidisciplinary situational analysis through in-depth interviews of stakeholders and review of official federal and oblast documents., Results: Interpretation of traditional notification data is complex because classification and reporting systems differ from World Health Organization principles. Regulations governing financing encourage lengthy hospitalisations and interventions, and provide few incentives to shift policy to ambulatory care., Conclusion: Accurate comparability of epidemiological trends and programmatic successes requires equivalent classification and reporting systems. If the DOTS strategy is to be sustainable, changes to financing systems will be needed.