Trends of HIV infection in the border zone of the Russian Federation on the example of the Belgorod region

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Introduction

The Belgorod Region is one of the most promising border regions of the Russian Federation: it is part of the Central Federal District and borders the Voronezh and Kursk Regions, as well as Ukraine in the southwest. The Belgorod Region also has a mild climate with relatively warm winters and long summers¹. The main sectors of the economy are metallurgy, agriculture, and construction [1].

This geographical location and characteristics can create favorable conditions for both external and internal migration flows. Previous studies have characterized the Belgorod region as one of the most attractive regions in Russia for migration from the north [2]. There is also a steady flow of refugees from the neighboring Ukraine [3]. Currently, migration and tourist flows continue to play a significant role among the main factors in the spread of infectious diseases, and in most countries, migrants are identified as a separate and key risk group, along with injecting drug users (IDUs), men who have sex with men (MSM), and commercial sex workers [4]. However, the impact of migration on the spread of HIV infection in host countries is ambiguous and depends on a number of factors, including territorial, social, and temporal ones. For example, Russia, as a host country, has close migration ties with the former republics of the USSR (Ukraine, Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan) [5]. The influx of migrant workers to Russia from these countries consists mainly of young men, which, from an epidemiological point of view, places them in a high-risk group for HIV infection and subsequent transmission of the virus to the population. This fact is due to the behavioral and social environment characteristics typical of this demographic group [4].

Molecular genetic analysis methods have made a significant contribution to understanding the ways in which HIV infection spreads. In Russia, there has been a decrease in the proportion of the A6 HIV-1 genetic variant characteristic of Russia and the former Soviet Union, along with an increase in the proportion of non-A subtypes, including those of Asian and African origin [6]. Also, given the current unstable political situation in Europe, there has been an increase in the number of HIV infections caused by the sub-subtype A6 virus, due to migration flows from Ukraine [7].

Thus, the circumstances listed above may significantly affect the epidemiological and clinical characteristics of HIV infection in border regions.

The main task of healthcare in the Belgorod region is to improve the quality of life and ensure sustainable population growth².

For 40 years, HIV infection has been a global public health problem, with solutions in Russia regulated at the state level³ [8]. Currently, in Russia, it is possible to get tested for HIV at any medical facility, and the practice of prescribing antiretroviral therapy (ART) immediately after diagnosis of HIV/AIDS, which has been in place in Russia since 2017, allows for a rapid reduction in viral load (VL), as well as restore and maintain immunity, which significantly improves the quality and duration of life of people living with HIV (PLHIV) and prevents further transmission of HIV infection⁴ [9, 10]. At the same time, the necessity for lifelong ART poses new challenges: patient adherence to treatment, the toxicity of antiretroviral drugs (ARVs), and the emergence and spread of HIV-1 drug resistance [11–14]. Furthermore, it is well known that the biological age of PLHIV exceeds their chronological age, which leads to an increased risk of developing chronic diseases, including cardiovascular and oncological diseases [15, 16]. All of the above indicates the necessity for careful regular monitoring of trends in HIV infection and necessitates increased attention to PLHIV.

HIV infection trends vary across different regions of the Russian Federation due to their specific characteristics. Previous studies have noted differences in HIV infection trends across different federal districts of Russia [17], with individual regions having their own distinctive features.

The aim of this study was to analyze HIV infection trends in the border region using the example of the Belgorod region in 2016–2024.

Materials and methods

Key epidemiological characteristics of people living with HIV in the Belgorod Region

The following data sources were used:

1. Federal statistical observation form No. 61 “Information on HIV infection”;
2. Federal State Statistics Service of the Russian Federation (Rosstat) (population data)⁵;
3. report on the causes of death among HIV-infected individuals (for 2020–2024) from the Unified State Health Care System of the Belgorod Region; available only to medical workers in the Belgorod Region at: https://report.zdrav31.ru/login/index?ReturnUrl=%2f (28.03.2025);
4. report on the provision of ART to HIV-infected individuals (2020–2024); available at: https://report.zdrav31.ru/login/index?ReturnUrl=%2f (March 28, 2025). The study was carried out exclusively with aggregated and initially anonymized data from government statistics forms, which do not contain personal identifiers in their format. The data were obtained between 2016 and 2024. The study was approved by the Biomedical Ethics Committee of the N.F. Gamaleya National Research Center for Epidemiology and Microbiology (protocol No. 85 of December 18, 2024).

Based on data from these first two sources, the following indicators were calculated using the according formulas (1)–(7).

The trend in mortality dynamics (2016–2024) and the trend in long-term dynamics of morbidity, prevalence, and mortality were determined using linear regression (least squares method) [18]. The severity of the trends was calculated as described earlier [17]. The quality of the approximation was assessed using the coefficient of determination (R²). To identify differences between specific years of the study, the χ² criterion was used with a Bonferroni correction for multiplicity.

$Incidence=\frac{NumberofnewHIVcases-infectionsperyear}{Population}\times 100 000.$ (1)

$Prevalence=\frac{NumberofPLHIVregisteredattheendoftheyear}{Population}\times 100 000.$ (2)

$Mortality=\frac{NumberofPLHIVremovedfromtheregistryduetodeath}{Population}\times 100 000.$ (3)

$Lethality=\frac{NumberofPLHIVremovedfromtheregistryduetodeath}{NumberofPLHIVperyear}\times 100 000.$ (4)

$Testcoverage=\frac{NumberofpeopletestedforHIV-1}{Population}\times 100.$ (5)

$\%ofPLHIVreceivingART=\frac{NumberofPLHIVreceivingART}{NumberofPLHIVregisteredattheendoftheyear}\times 100.$ (6)

$\%ofPLHIVonARTwithsuppressedVL=\frac{AmountofpatientswithsuppressedVL}{NumberofPLHIVreceivingART}\times 100.$ (7)

Confidence intervals (95%) were calculated using the formula:

$\frac{p+\frac{{\mathrm{1,96}}^2}{2N}\pm \mathrm{1,96}\sqrt{\frac{p(1-p)}{N}+\frac{{\mathrm{1,96}}^2}{4N^2}}}{1+\frac{{\mathrm{1,96}}^2}{N}},$ (8)

where p — percent of the parameter of interest; N — number of observations.

When analyzing the causes of death among PLHIV (data source No. 3), the causes were grouped as follows:

• AIDS;
• cardiovascular insufficiency;
• oncology;
• tragic circumstances (accident, suicide, drug overdose, violent death);
• decompensated cirrhosis of the liver;
• stroke;
• pneumonia (COVID-19, pneumonia, bilateral pneumonia);
• others.

When analyzing the composition of ART (data source No. 4), ARVs were divided into main groups: protease inhibitors (PIs), integrase inhibitors (IIs), nucleoside reverse transcriptase inhibitors (NRTIs), and non-nucleoside reverse transcriptase inhibitors (NNRTIs).

Statistical significance was assessed using Fisher's F-test and SPSS Statistics v. 27 (IBM). Correlation analysis was performed using Spearman's correlation coefficient.

HIV and tuberculosis co-infection

The source of data was the Federal Register of Persons with Tuberculosis (TB).

The dynamics of TB detection among PLHIV (2016–2024) was also determined using the least squares method (linear regression) [18].

Analysis of socio-demographic and clinical-epidemiological data of newly diagnosed patients with HIV infection

The following data sources were used:

1. Statistical Report No. 168 — Journal of patients included in the Federal Register of Persons Living with HIV;
2. Statistical Report No. 171 — Report on new cases of HIV infection;
3. Report on the socio-demographic characteristics of people living with HIV; available at: https://report.zdrav31.ru/login/index?ReturnUrl = %2f (28.03.2025).

The data analyzed included sociodemographic characteristics (gender, age) (data source No. 1) and clinical and epidemiological indicators (CD4 lymphocyte count (data source No. 2), route of infection (data source No. 1)) at the time of initial consultation (among newly diagnosed HIV-infected patients). The data from these sources were combined using the unique registration number of the patient record. The data were also checked for duplicates using this number. In total, the Federal Register of Persons Living with HIV contains records of 2,727 HIV-positive individuals in the Belgorod Region (96% of all registered cases as of early 2025 in the region), and for 1,630 (60%) of them, data on the results of CD4 lymphocyte count tests at the time of registration are available.

Furthermore, the social status in terms of employment among all PLHIV was analyzed, as well as indicators of HIV testing and detection among foreign citizens (data source No. 3).

All data were summarized in descriptive form and the proportions of components in each category for each year were calculated. The χ² test was used for statistical evaluation of significant differences between proportions. In the case of multiple comparisons, Bonferroni's correction for multiplicity was applied.

Quantitative data were tested for normality using the Kolmogorov–Smirnov test. Then, statistical differences were assessed using the appropriate criteria: the Mann–Whitney test for comparing two independent groups and the Kruskal–Wallis test for comparing more than two groups, followed by pairwise comparisons using the Mann–Whitney test with Bonferroni correction for multiple comparisons. A value of p < 0.05 was considered statistically significant.

The Python Software Foundation library (numpy, pandas, scipy, matplotlib, seaborn) was used for data analysis and graphical visualization.

Results

A significant pronounced downward trend in HIV infection incidence was identified (p = 0.008; R² = 0.651; average annual growth rate (AARG) = –7.42%), a significant pronounced upward trend in prevalence (p < 0.001; R² = 0.794; AARG = 5.95%), and a significant moderate trend toward an increase in mortality (p = 0.036; R² = 0.489; AARG = 4.51%; Fig. 1, a, b). The mortality rate remained stable (Fig. 1, c).

 

Fig. 1. Epidemiological indicators of HIV infection in the Belgorod Region for 2016–2024 (per 100,000 population).

a — incidence (1), mortality (2), and prevalence (3), persons per 100,000 population. The left y-axis shows incidence and mortality rates; the right y-axis shows prevalence rates;

b — trend lines for long-term dynamics of intensive epidemiological indicators of HIV infection in the Belgorod Region. The left axis shows incidence and mortality rates; the right axis shows HIV prevalence;

c — mortality among HIV-infected individuals.

 

When assessing the causes of death among PLHIV, it was found that the main causes were cardiovascular failure, tragic circumstances, and decompensated liver cirrhosis (Table 1).

 

Table 1. Causes of death among people living with HIV in the Belgorod Region in 2020–2024.

Cause of death		2020	2021	2022	2023	2024	p
All	abs.	97	124	165	198	148
AIDS	abs.	16	12	16	14	14	1
	%	16.49	9.68	9.70	7.07	9.46
Cardiovascular insufficiency	abs.	9	16	10	41	28	0.002
	%	9.28	12.90	6.06	20.71	18.92
Oncology	abs.	7	4	3	12	10	0.872
	%	7.22	3.23	1.82	6.06	6.76
Tragic circumstances	abs.	10	11	6	31	19	0.019
	%	10.31	8.87	3.64	15.66	12.84
Decompensated liver cirrhosis	abs.	13	18	14	26	22	1
	%	13.40	14.52	8.48	13.13	14.86
Stroke	abs.	7	5	2	4	8	0.362
	%	7.22	4.03	1.21	2.02	5.41
Pneumonia	abs.	1	14	22	4	2	0.004
	%	1.03	11.29	13.33	2.02	1.35
Others	abs.	34	44	92	66	45	0.004
	%	35.05	35.48	55.76	33.33	30.41

 

The proportion of PLHIV who died directly from AIDS and decompensated liver cirrhosis did not change significantly over the entire study period (p = 1.0). However, the proportion of deaths from cardiovascular failure increased sharply from 6.06% in 2022 to 20.71% in 2023 (p = 0.001 in posterior comparisons with 2022 using the χ² criterion adjusted for Bonferroni multiplicity). A sharp increase in the proportion of PLHIV who died in tragic circumstances was also observed in 2023 (15.66%) (p = 0.003 in a posteriori comparisons with 2022 using the χ² test with Bonferroni correction for multiple comparisons). It is also worth noting that spikes (p < 0.05 with Bonferroni multiple comparison correction in all pairwise comparisons between 2021 and 2022 from 2023 and 2024) in the proportion of deaths from pneumonia (caused by COVID-19) were identified in 2021–2022 (11.29% and 13.33%, respectively).

HIV testing coverage in the Belgorod region showed a significant (p < 0.001) and pronounced (AARG = 7.94%) upward trend (Fig. 2), despite a sharp and one-time decline in 2020 observed in the visual assessment. The proportion of individuals placed under dispensary observation after an HIV diagnosis increased significantly (p < 0.001) from 60.96% in 2016 to 87.78% in 2024 (Fig. 2).

 

Fig. 2. HIV testing data in the Belgorod Region for 2016–2024.

a — percentage of the population tested for HIV, %; b — proportion of people under dispensary observation, %; c — ART coverage indicators: proportion of PLHIV receiving ART, % (entire bar), and proportion (in %) of PLHIV with suppressed viral load (dark part of the bar). The solid red line indicates the 95% threshold for overall ART coverage. The dotted red line indicates the 95% threshold that must be achieved for the third indicator of the “95–95–95” strategy (undetectable viral load) for each year of observation; d — ART structure by main classes of ARVs used in the Belgorod Region in 2020–2024; e — ART structure by individual ARVs used in the Belgorod Region in 2020–2024. NVP — nevirapine; RPV — rilpivirine; ETR — etravirine; EFV — efavirenz; ESV — elsufavirine; DOR — doravirine

 

ART coverage in the Belgorod region also increased from 48% in 2026 to 95% in 2024. The proportion of PLHIV with suppressed viral load fluctuated over the years of observation and reached 89% in 2023 (Fig. 2, c). At the same time, there was an increase in the proportion of integrase inhibitors (IIs): raltegravir and dolutegravir in treatment regimens, as well as a decrease in the proportion of efavirenz and an increase in the proportion of elsufavir among NNRTIs (Fig. 2, d, e).

It was found that the overall coverage of TB testing among PLHIV was at least 82.24% for all years of observation, with a tendency toward an increase in TB testing coverage among HIV-infected individuals (Table 2, Fig. 3).

 

Table 2. TB testing coverage among PLHIV in the Belgorod Region for 2016–2024

Year	Number of PLHIV	Number of PLHIV tested for TB		Number of PLHIV with detected pathology
		abs.	%	abs.	%
2016	1737	1483	85.38	22	1.48
2017	2072	1704	82.24	27	1.58
2018	2246	1881	83.75	40	2.13
2019	2375	2031	85.52	17	0.84
2020	3102	3012	97.10	34	1.13
2021	2874	2596	90.33	18	0.69
2022	3053	2731	89.45	27	0.99
2023	2986	2624	87.88	40	1.52
2024	2850	2606	91.44	21	0.81
p		< 0.001		< 0.001

 

Fig. 3. TB detection rates among PLHIV in the Belgorod Region and in Russia as a whole for 2016–2023, %.

R² — coefficient of determination, necessary for assessing the quality of approximation.

 

At the same time, maximum testing coverage was achieved in 2020 (97.10%) and 2024 (91.44%).

Among PLHIV tested for TB, pathology was detected in 0.69–2.13% of cases, with an overall downward trend in TB detection rates among PLHIV tested both in the Belgorod region and in Russia as a whole.

The following characteristics were identified for the cohort of newly diagnosed HIV-infected patients:

1. a predominance of men (56–72% in different years of observation); the proportion of women in the cohort of newly diagnosed HIV-infected patients did not exceed 44% in all years of observation ( 4, a);

 

Fig. 4. Gender composition of newly diagnosed HIV-infected patients in the Belgorod Region in 2016–2024, %

 

2. the proportion of newly diagnosed HIV-infected patients aged 20–29 and 30–39 decreased significantly (p < 0.001), however, there was a significant trend toward an increase in the proportion of patients over 40 years of age (p < 0.05), indicating a gradual “aging” of the PLHIV population (Table 3);

 

Table 3. Age distribution of newly diagnosed HIV-infected patients in the Belgorod Region in 2016–2024, %

Age, years		2016	2017	2018	2019	2020	2021	2022	2023	2024	p*
0–14	abs.	0	1	2	1	0	0	1	0	0	1
	%	0.00	0.28	0.63	0.39	0.00	0.00	0.46	0.00	0.00
15–19	abs.	3	3	6	2	4	4	1	3	2	1
	%	0.90	0.85	1.90	0.77	2.05	2.26	0.46	1.57	1.11
20–29	abs.	85	67	53	36	25	27	21	14	14	0.004
	%	25.53	19.09	16.77	13.90	12.82	15.25	9.59	7.33	7.78
30–39	abs.	177	191	150	113	85	72	87	61	51	0.004
	%	53.15	54.42	47.47	43.63	43.59	40.68	39.73	31.94	28.33
40–49	abs.	53	72	83	75	60	48	66	86	74	0.004
	%	15.92	20.51	26.27	28.96	30.77	27.12	30.14	45.03	41.11
50–59	abs.	10	12	17	23	13	14	36	21	28	0.004
	%	3.00	3.42	5.38	8.88	6.67	7.91	16.44	10.99	15.56
60 and older	abs.	5	5	5	9	8	12	7	6	11	0.04
	%	1.50	1.42	1.58	3.47	4.10	6.78	3.20	3.14	6.11
Total		333	351	316	259	195	177	219	191	180

Note. *Statistically significant differences (Fisher's exact test with Bonferroni correction for multiple comparisons).

 

3. the median age increased (33–40 years; p < 0.001) of newly diagnosed HIV-infected patients in the Belgorod region (Table 4);

 

Table 4. Median age at the time of diagnosis of HIV infection among newly identified HIV-infected patients in the Belgorod Region in 2016–2024

Year	Age	Q1; Q3
2016	33	29.0; 38.0
2017	35	30.0; 39.0
2018	36	31.0; 42.0
2019	37	32.0; 43.0
2020	37	32.0; 43.0
2021	37	32.0; 43.0
2022	39	34.0; 47.0
2023	41	36.0; 46.0
2024	40	35.0; 48.0

 

Table 5. Structure of HIV transmission routes among newly diagnosed HIV-infected patients in the Belgorod Region in 2016–2024, %

Transmission route		2016	2017	2018	2019	2020	2021	2022	2023	2024	p*
Heterosexual	abs.	112	167	170	182	169	149	201	182	146	0.002*
	%	47.86	54.05	48.71	60.47	74.78	73.76	76.14	80.89	80.66
Homosexual	abs.	4	2	16	6	6	6	4	3	7	0.187
	%	1.71	0.65	4.58	1.99	2.65	2.97	1.52	1.33	3.87
Related to the use of narcotic substances	abs.	117	139	161	110	51	46	58	39	27	0.002*
	%	50.00	44.98	46.13	36.54	22.57	22.77	21.97	17.33	14.92
Vertical	abs.	1	1	1	2	0	1	1	1	1	1
	%	0.43	0.32	0.29	0.66	0	0.50	0.38	0.44	0.55
Others	abs	0	0	1	1	0	0	0	0	0	1
	%	0	0	0.29	0.33	0	0	0	0	0
Total		234	309	349	301	226	202	264	225	181

Note. *Statistically significant differences (Fisher's exact test with Bonferroni correction for multiple comparisons).

 

4. there was a predominance of heterosexual HIV transmission with a significant upward trend, as well as a significant downward trend in the proportion of cases of infection through intravenous drug use (p = 0.002), which requires attention in terms of the possible range of infection outside specific groups, such as IDUs (Table 4).

The highest proportion of CD4 lymphocytes (more than 500 cells/μL) was found in the group of patients aged 0–14 years (85.71%). In contrast, the lowest proportion (23.94%) of CD4 lymphocytes exceeding 500 cells/μL was found in the group of patients over 50 years of age; this age group also had the highest proportion of CD4 lymphocytes below 200 cells/μL (29.25%; Fig. 5).

 

Fig. 5. Ratio of CD4 lymphocyte counts in newly diagnosed HIV-infected patients of different ages in the Belgorod Region in 2016–2024.

 

There has been an increase in the median age of newly diagnosed HIV-infected patients (Fig. 5) and an increase (until 2020) in the proportion of patients with CD4 lymphocyte counts below 200 cells/μL.

In 2024, there was a decrease in the proportion of patients with CD4 lymphocyte counts below 200 cells to 12% (Fig. 6).

 

Fig. 6. CD4 lymphocyte counts among newly diagnosed HIV-infected patients in the Belgorod Region in 2016–2024.

 

At the same time, there was a significant decrease (p = 0.017) in the median baseline CD4 lymphocyte count among newly diagnosed HIV-infected patients, with minimum values in 2020 (Table 6). Starting in 2021, this indicator gradually increased. It should be noted that, despite the observed changes, the number of CD4 lymphocytes within the range of 350–499 cells/μL can be considered as a single group (with moderate immunodeficiency).

 

Table 6. Median baseline CD4 lymphocyte count in newly diagnosed HIV-infected men and women in the Belgorod Region in 2016–2024

Gender	2016	2017	2018	2019	2020	2021	2022	2023	2024
Total, Ме [Q1; Q3]	430 [294, 0; 618, 0]	427 [270, 0; 583, 0]	419 [284, 0; 596, 0]	390 [280, 75; 544, 25]	358 [258, 00; 489, 25]	395 [239, 5; 566, 0]	386 [201, 0; 563, 0]	415 [250, 75; 587, 00]	400 [355, 0; 545, 0]
Male	434	400	419	394	364	369	358	401	411
Female	422	440	430	380	356	410	422	437	383

 

No significant differences in the median baseline CD4 lymphocyte count were found among newly diagnosed HIV-infected men and women and among patients with different routes of infection (Table 7).

 

Table 7. Median baseline CD4 lymphocyte count in newly diagnosed HIV-infected men and women in the Belgorod Region in 2016–2024 with different routes of infection

Year	Infection through heterosexual contact	MSM	IDU
2016	404	586	437
2017	408	354	490
2018	385	432	476
2019	380	256	423
2020	35	295	372
2021	388	401	358
2022	386	288	420
2023	414	509	418
2024	396	404	389
р	0.179	0.298	0.279

 

However, in the homosexuals group (which includes MSM), the median baseline CD4 lymphocyte count was uneven, with periods of both sharp decline and sharp increase (Table 7).

The proportion of unemployed and temporarily employed persons (a form of employment relationship in which an employee is hired for a fixed term or to complete a specific project) among PLHIV decreased significantly from 58.26% in 2016 to 38.33% in 2024 (p < 0.001) and from 2.01% to 6.11% (p < 0.001), respectively. At the same time, the share of the employed population among PLHIV increased significantly: from 22.82% in 2016 to 45.56% in 2024 (p < 0.001) (Table 8).

 

Table 8. Status of employment among people living with HIV in the Belgorod Region for 2016–2024

Social status		2016	2017	2018	2019	2020	2021	2022	2023	2024	p
Employed	abs.	76	94	66	83	61	54	85	76	82	< 0,001*
	%	22.82	26.78	20.89	32.05	31.28	30.51	38.81	39.79	45.56
Unemployed	abs.	194	169	171	115	80	66	94	87	69	< 0,001*
	%	58.26	48.15	54.11	44.40	41.03	37.29	42.92	45.55	38.33
Temporarily employed	abs.	40	67	56	46	38	39	27	20	11	< 0,001*
	%	12.01	19.09	17.72	17.76	19.49	22.03	12.33	10.47	6.11
Retired	abs.	8	7	6	6	7	9	7	6	10	1
	%	2.40	1.99	1.90	2.32	3.59	5.08	3.20	3.14	5.56
Students	abs.	4	2	5	3	2	4	0	0	1	1
	%	1.20	0.57	1.58	1.16	1.03	2.26	0.00	0.00	0.56
Schoolchildren	abs.	0	0	0	0	0	0	1	0	0	1
	%	0.00	0.00	0.00	0.00	0.00	0.00	0.46	0.00	0.00
Children	abs.	0	1	3	1	0	0	0	0	0	1
	%	0.00	0.28	0.95	0.39	0.00	0.00	0.00	0.00	0.00
People with disabilities	abs.	11	11	9	5	7	5	5	2	7	1
	%	3.30	3.13	2.85	1.93	3.59	2.82	2.28	1.05	3.89
Total		333	351	316	259	195	177	219	191	180

Note. *Statistically significant differences are indicated (Fisher's exact test with Bonferroni correction for multiple comparisons).

 

The proportion of foreign nationals who underwent HIV testing correlated with the number of tests performed (r = 0.883; p = 0.002): the expansion of HIV-1 testing coverage among foreign nationals was accompanied by an increase in the proportion of detected HIV infections, which has been particularly noticeable since 2022 (Fig. 7). This peak is likely related to a sharp change in migration flows at the border between two countries (Russia and Ukraine), including an influx of refugees. Given that a significant correlation does not exclude the influence of unstudied parameters, it can be assumed that foreign citizens remain under-tested at present and the number of HIV-positive individuals may be somewhat underestimated.

 

Fig. 7. Indicators of HIV testing and detection among foreign citizens in the Belgorod Region for 2016–2024. The bar chart shows the total number of foreign citizens tested for HIV (on the right axis), while the red line shows the proportion of those with HIV-positive results (on the left axis).

 

Discussion

The current and long-term dynamics of key HIV infection indicators, such as incidence, prevalence, mortality, testing coverage, and ART coverage, in the Belgorod Region corresponded to national trends [17, 19, 20]. For the first time, the causes of death among PLHIV were additionally analyzed: the main ones were cardiovascular failure, tragic circumstances, and decompensated cirrhosis of the liver. The increase in the proportion of cardiovascular failure is explained by the fact that diseases of this type are one of the most significant problems both globally and in our country, and are the leading cause of mortality worldwide⁶ [21]. The sharp increase in the proportion of PLHIV who died in tragic circumstances in 2023–2024 may be linked to the unstable geopolitical situation and border tensions, but this cannot be stated with certainty. A similar sharp increase in the proportion of deaths from pneumonia in 2021–2022 is comparable to the COVID-19 pandemic, during which pneumonia was the main complication among those who fell ill (and died). The mortality rate remainеd stable, not exceeding 4.2% for all years of observation.

HIV testing coverage increased significantly, despite a one-time decline in 2020, which we attribute to the onset of the COVID-19 pandemic and the inability to conduct large-scale HIV testing events in the region under self-isolation conditions. At the same time, there was a statistically significant increase in the proportion of people under dispensary observation, reaching 87.78% in 2024, which may indicate an increase in the population's knowledge of HIV infection as a result of effective educational work by medical workers and the application of the following approaches: development, publication, and distribution of informational materials on HIV prevention; organization of training seminars, thematic meetings, round tables, lectures, and video screenings on HIV infection; holding events dedicated to UN Health Day, World AIDS Prevention Day and AIDS Victims Memorial Day; posting information on information stands about the possibility and procedure for HIV testing⁷⁸.

Since 2017, the Russian Ministry of Health has recommended prescribing ART to all HIV-infected individuals, regardless of their CD4 lymphocyte count and viral load⁹. ART coverage in the Belgorod region has also increased significantly, reaching 95% in 2024, which is in line with the requirements of the “95-95-95” strategy of the Joint United Nations Program on HIV/AIDS, according to which 95% of PLHIV should be provided with ART¹⁰. It is worth noting that such high indicators have been observed for the first time. For example, in a previous study conducted in the Republic of Crimea, testing coverage for all years of observation (2016–2023) has not yet exceeded 79% [22].

An analysis of the composition of therapy revealed that promising AI drugs are being actively introduced into clinical practice in the region. The NNRTI group remained the preferred choice for the third ARV in the ART regimen, in addition to the basic NRTIs. At the same time, this group saw a decrease in the proportion of efavirenz and an increase in the proportion of elsufavirine, which may indicate its high efficacy and/or lack of toxicity [23].

The coverage of HIV-infected individuals with TB testing has also increased significantly, but the proportion of HIV-infected individuals with TB has decreased, which may indicate the timeliness of testing and reflect the overall downward trend in TB incidence in Russia. This is facilitated by a comprehensive approach that includes preventive examinations, the consolidation and coordination of tuberculosis services, and the use of artificial intelligence for early detection of the disease. The World Health Organization (WHO) has officially notified the Minister of Health of the Russian Federation that the country has been removed from the list of 30 countries with a high TB burden and that its successes in reducing the TB burden in recent years have been recognized¹¹. As of 2021 (and currently), the WHO has excluded Russia from the list of “30 countries with a high burden of tuberculosis”; it is also not included in the list of “30 countries with a high burden of TB/HIV.”

Among the peculiarities of the HIV epidemic in Russia, it should be noted that the start and further widespread spread of HIV infection in Russia began with the introduction of the virus into the IDU cohort in the Russian–Ukrainian border area [24]. Given the border location of the Belgorod region, this could have had a direct impact on the socio-demographic characteristics of PLHIV and, as a result, on their clinical and laboratory indicators. Therefore, in the next stage of the study, these indicators were analyzed.

Despite similar trends across Russia as a whole (prevalence of men, “aging” of the HIV-infected population, and an increase in the proportion of heterosexual transmission), the initial (in 2016) proportions of transmission through “heterosexual contact” and “injection drug use” were practically equal, which is noted for the first time for a separate region of the country and may be due to the above-mentioned features of the spread of HIV infection, given the geographical location of the region. At the same time, a study analyzing HIV infection in the Voronezh region noted a sharp change in the nature of the epidemiological process, namely, a shift in the ratio of infection routes from sexual to parenteral through the use of psychoactive substances [25]. In the Kursk region, sexual transmission of HIV infection prevailed throughout 2014–2022 [26]. Similar results were obtained when assessing the structure of infection routes in the Republic of Crimea [22]. Thus, it is not possible to clearly assert that the identified ratio of transmission routes is a characteristic feature of the region under study, but a comparative analysis with the Voronezh region suggests the presence of an infection hotspot in the IDU cohort in the mid-2000s.

When assessing CD4 lymphocyte counts in different groups by gender and route of infection, certain characteristics were also identified. Thus, no significant differences in the median baseline CD4 lymphocyte count were found between men and women, with the indicators in both groups being higher than the Russian average, which may indicate timely diagnosis of HIV infection in the region. A previous study of these indicators in Samara also noted gender differences in CD4 lymphocyte counts: their level was higher in women [27].

Analysis of the median baseline CD4 lymphocyte count over time showed minimum values in 2020, which may be associated with HIV testing during hospitalization for suspected coronavirus infection rather than voluntary testing. In this case, the group tested for HIV may have included individuals with a long period of infection. The median baseline CD4 lymphocyte count has been increasing since 2021. Given the average age of newly diagnosed HIV-infected patients of different ages and the ratio of CD4 lymphocyte counts in newly diagnosed HIV-infected patients of different ages, it can be assumed that there is further active identification of long-term infected individuals. At the same time, the highest proportion of CD4 lymphocytes exceeding 500 cells/μL was found in the group of newly diagnosed HIV-infected patients aged 0–14 years, which may indicate high-quality dispensary observation of children [28]. Conversely, the highest proportion of CD4 lymphocytes below 200 cells/μl was found in the group of newly diagnosed HIV-infected patients over 50 years of age. The results obtained are consistent with the results of all-Russian studies, as well as with studies by foreign scientists, who note lower CD4 lymphocyte levels in elderly patients [29, 30]. A similar trend has been observed throughout Russia [19].

In contrast to the nationwide trend, the Belgorod region has seen fluctuations in the median baseline CD4 lymphocyte count in the MSM cohort, with periods of decline and increase. At the same time, the median baseline CD4 lymphocyte count in the IDU cohort was higher than in Russia as a whole. Taken together, this may indicate a “mixing” of transmission routes in the region and the relative close nature of the MSM cohort, as a result of which members of this group identify themselves as heterosexual or IDU when collecting medical history¹². This can be noted as a distinctive feature of the border industrial region, where blue-collar workers are prevalent, which may influence the closed nature of this group with regard to its status (MSM) when collecting epidemiological history. When analyzing the epidemiological process of HIV infection in the Kursk region in 2014–2022, the share of MSM in the overall structure of infection routes was 0.0%, which may also indicate that this group conceals its status. In contrast, studies devoted to this cohort of patients in the Moscow region noted its “openness” to doctors¹².

Additional analysis of social indicators such as social status in relation to employment among PLHIV showed an increase in the detection of HIV infection among the working population, which may be due to several factors: a decrease in overall unemployment, an increase in the retirement age, and improvements in medical examination procedures in the workplace¹³. At the same time, the increase in the detection rate of HIV infection among the working population justifies the importance of continuing and expanding these workplace testing programs.

The correlation between the number of HIV tests performed and the detection of HIV among foreign nationals since 2020 may be due to changes in testing procedures and the structure of the tested population in connection with migration processes and requires further monitoring.

Research limitations. The study has a number of limitations due to possible systematic errors inherent in retrospective official reporting data (incomplete information, coding errors), which may to some extent influence the choice of analysis methods and the results of the study. Thus, in this study, we analyzed CD4 lymphocyte content depending on various factors (gender, age, route of infection) separately, since the presence of various types of systematic errors or lack of data reduced the amount of data available for multivariate analysis, and the combined effect of all factors would explain only about 4% of the outcomes.

When analyzing trends, we used the least squares method (linear regression), so our analysis does not identify specific points of statistically significant trend changes, which may be the subject of future, more detailed studies.

It is important to note that significant differences in indicators are not always significant from an epidemiological and practical point of view, as we noted, for example, when analyzing the median CD4 lymphocyte count.

It is also important to note the potential impact on the dynamics of indicators of such mass events as the COVID-19 pandemic and changes in the geopolitical situation.

Conclusion

This study is a comprehensive research of the dynamics of HIV infection in the border region of Russia, using the Belgorod region as an example. The main trends in HIV infection were compared with those for Russia as a whole. A number of features were identified that had not previously been noted in Russia and some regions: high ART coverage, similarity in the median baseline CD4 lymphocyte count in male and female groups, and the relative closed nature of the MSM cohort. Overall, the results showed that the HIV epidemic in the region is under control: a significant downward trend in HIV infection rates was identified. At the same time, a significant trend towards an increase in the prevalence of HIV infection was identified, including due to the increase in the life expectancy of PLHIV in the Belgorod region. The identified moderate trend towards an increase in mortality, together with an analysis of the causes of death among PLHIV, indicates the necessity for interdisciplinary clinical monitoring of the ageing cohort of PLHIV.

 

¹ Ministry of Natural Resources of the Russian Federation. Interactive Maps. Belgorod Region. URL: https://www.mnr.gov.ru/activity/regions/belgorodskaya_oblast/?sphrase_id=509928 (date of access: March 30, 2025).

² Resolution of the Government of the Belgorod Region dated December 18, 2023 No. 733-pp "On Approval of the State Program of the Belgorod Region 'Development of Healthcare in the Belgorod Region'.

³ Order of the Government of the Russian Federation dated December 21, 2020 No. 3468-r "On Approval of the State Strategy to Counteract the Spread of HIV Infection in the Russian Federation through 2030".

⁴ Ministry of Health of the Russian Federation. Clinical Guidelines "HIV Infection in Adults." 2024 URL: https://cr.minzdrav.gov.ru/preview-cr/79_2?ysclid=maqpfdvdhg762593191

⁵ Federal State Statistics Service of the Russian Federation (Rosstat). Demography. URL: https://rosstat.gov.ru/folder/12781 (date of access: 30.03.2025).

⁶ World Health Organization. Fact sheets. Cardiovascular diseases (CVD). URL: https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds) (date of access: March 30, 2025).

⁷ Order of the Government of the Belgorod Region dated December 26, 2022 No. 1046-rp "On approval of the Action Plan of the Interdepartmental Program for the Prevention of HIV Infection among Key Populations in the Belgorod Region for 2023–2025." URL: https://docs.cntd.ru/document/406486018?ysclid=m91q4hvv4118558740

⁸ Department of Labor and Employment of the Belgorod Region and the Belgorod Center for AIDS Prevention and Control. Methodological recommendations "Organization of HIV Preventive Work and the Promotion of a Healthy Lifestyle in the Workplace." Available at: https://www.belecocentr.ru/downfiles/vich.pdf

⁹ Ministry of Health of the Russian Federation. Clinical recommendations "HIV Infection in Adults." Moscow; 2024. Available at: https://cr.minzdrav.gov.ru/preview-cr/79_2?ysclid=maqpfdvdhg762593191

¹⁰ Joint United Nations Programme on HIV/AIDS. Fast-Track Cities: Ending the AIDS Epidemic. Geneva; 2014. Available at: https://www.unaids.org/en/resources/documents/2014/20141201_Paris_declaration (date of access: March 30, 2025).

¹¹ World Health Organization. WHO has released new global lists of countries with a high burden of tuberculosis, HIV-associated tuberculosis, and drug-resistant tuberculosis. URL: https://www.who.int/news/item/17-06-2021-who-releases-new-global-lists-of-high-burden-countries-for-tb-hiv-related-tb-and-drug-resistant-tb (date of access: 30 March 2025).

¹² Zhukova E.V. Clinical and epidemiological features of HIV infection among men who have sex with men in the Moscow region. URL: https://rusneb.ru/catalog/000199_000009_011604001/ (date of access: March 30, 2025).

¹³ Territorial body of the Federal State Statistics Service for Belgorod Oblast (Belgorodstat). Meeting of the Belgorodstat board. June 19, 2024. URL: https://31.rosstat.gov.ru/news/document/239251; Federal Law of October 3, 2018 No. 350-FZ "On Amendments to Certain Legislative Acts of the Russian Federation on the Appointment and Payment of Pensions"; Order of the Ministry of Health of the Russian Federation dated July 19, 2024 No. 378n "On Amendments to the Procedure for Conducting Preventive Medical Examinations and Dispensary Observation of Certain Groups of the Adult Population, Approved by Order of the Ministry of Health of the Russian Federation dated April 27, 2021 No. 404n."

About the authors

Alexey I. Mazus

Moscow City Center for AIDS Prevention and Control

Email: mazus@yandex.ru
ORCID iD: 0000-0003-2581-1443

D. Sci. (Med.), Prof., Head

Russian Federation, Moscow

Irina V. Nikolaeva

Belgorod Center for AIDS Prevention and Control

Email: nikolaeva.irvl@yandex.ru

chief doctor

Russian Federation, Belgorod

Anastasiia A. Antonova

National Research Center for Epidemiology and Microbiology Named after the Honorary Academician N.F. Gamaleya

Author for correspondence.
Email: anastaseika95@mail.ru
ORCID iD: 0000-0002-9180-9846

Cand. Sci. (Biol.), senior researcher, Leukemia virus laboratory

Russian Federation, Moscow

Anna I. Kuznetsova

National Research Center for Epidemiology and Microbiology Named after the Honorary Academician N.F. Gamaleya

Email: a-myznikova@list.ru
ORCID iD: 0000-0001-5299-3081

Cand. Sci. (Biol.), leading researcher, Head, Leukemia virus laboratory

Russian Federation, Moscow

Daria A. Ogarkova

National Research Center for Epidemiology and Microbiology Named after the Honorary Academician N.F. Gamaleya

Email: daria@ogarkova-dvorkina.ru
ORCID iD: 0000-0002-1152-4120

junior researcher, Laboratory of mechanisms of population variability of pathogenic microorganisms

Russian Federation, Moscow

Antonina A. Akimova

Belgorod Center for AIDS Prevention and Control

Email: aidsaepid@list.ru

Head, Department of prevention and epidemiology

Russian Federation, Belgorod

Andrei A. Pochtovyi

National Research Center for Epidemiology and Microbiology Named after the Honorary Academician N.F. Gamaleya; Sechenov First Moscow State Medical University

Email: a.pochtovyy@gmail.com
ORCID iD: 0000-0003-1107-9351

Cand. Sci. (Biol.), Head, Biotechnology laboratory, National Research Center for Epidemiology and Microbiology Named after the Honorary Academician N.F. Gamaleya; Associate Professor, Department of medical genetics and postgenomic technologies, Sechenov First Moscow State Medical University

Russian Federation, Moscow; Moscow

Anatoliy S. Vinokurov

National Research Center for Epidemiology and Microbiology Named after the Honorary Academician N.F. Gamaleya

Email: anatol-vinok@mail.ru
ORCID iD: 0000-0001-6848-3609

junior researcher, Biotechnology laboratory

Russian Federation, Moscow

Daria D. Kustova

National Research Center for Epidemiology and Microbiology Named after the Honorary Academician N.F. Gamaleya

Email: kustovadaria@yandex.ru
ORCID iD: 0000-0002-8382-275X

junior researcher, Laboratory of mechanisms of population variability of pathogenic microorganisms

Russian Federation, Moscow

Ruslan R. Adgamov

National Research Center for Epidemiology and Microbiology Named after the Honorary Academician N.F. Gamaleya

Email: bacter@yandex.ru
ORCID iD: 0009-0002-7514-5944

researcher, Laboratory of mechanisms of population variability of pathogenic microorganisms

Russian Federation, Moscow

Elena V. Tsyganova

Moscow City Center for AIDS Prevention and Control

Email: tsyganovaelena@yandex.ru
ORCID iD: 0000-0002-3410-2510

Cand. Sci. (Med.), Head, Scientific and clinical department

Russian Federation, Moscow

Inna B. Kulikova

Ministry of Health of the Russian Federation

Email: kulikovaib@minzdrav.gov.ru
ORCID iD: 0009-0003-4466-1396

Cand. Sci. (Med.), Director, Department of emergency medical assistance organisation and health risk management

Russian Federation, Moscow

Andrey N. Plutnitskiy

Ministry of Health of the Russian Federation; Federal Medical Biophysical Center Named after A.I. Burnazyan

Email: plunitsky@yandex.ru
ORCID iD: 0000-0002-2933-267X

Dr. Sci. (Med.), Deputy Minister of health of the Russian Federation; Head, Department of public health with a course in medical and social expertise, Medical and Biological University of Innovation and Continuing Education, Federal Medical Biophysical Center named after A.I. Burnazyan

Russian Federation, Moscow; Moscow

Vladimir A. Gushchin

National Research Center for Epidemiology and Microbiology Named after the Honorary Academician N.F. Gamaleya; Sechenov First Moscow State Medical University; Lomonosov Moscow State University

Email: wowaniada@yandex.ru
ORCID iD: 0000-0002-9397-3762

Dr. Sci. (Biol.), leading researcher, Head, Laboratory of mechanisms of population variability of pathogenic microorganisms, National Research Center for Epidemiology and Microbiology Named after the Honorary Academician N.F. Gamaleya; senior researcher, Department of virology, Lomonosov Moscow State University; Head, Department of medical genetics and postgenomic technologies, Sechenov First Moscow State Medical University

Russian Federation, Moscow; Moscow; Moscow

Aleksander L. Gintsburg

National Research Center for Epidemiology and Microbiology Named after the Honorary Academician N.F. Gamaleya; Sechenov First Moscow State Medical University

Email: gintsburg@gamaleya.org
ORCID iD: 0000-0003-1769-5059

Dr. Sci. (Med.), Professor, RAS Full Member, Scientific supervisor, National Research Center for Epidemiology and Microbiology Named after the Honorary Academician N.F. Gamaleya; Head, Department of infectology and virology, Sechenov First Moscow State Medical University

Russian Federation, Moscow; Moscow

References

Supplementary files