Isolation from the HIV contagion of Western Europe, whose IDUs and homosexually-active men had very little contact with similar people on the other side of the Iron Curtain.

    Inadequate surveillance, such that the Soviet bloc countries greatly underreported actual incidence of HIV disease.

Much has changed since the fall of the Berlin Wall and the Iron Curtain. The patterns of HIV disease are gradually becoming clear. There are 22 countries in this region; they divide neatly into four disease patterns:

(A) Predominantly gay/bisexual men. In four countries- the Czech Republic, Hungary, Slovenia, and Croatia- men who have sex with men comprise at least half the reported AIDS caseload. These countries are closest to Western Europe, and have had a particularly large flow of visitors from countries such as Germany and France whose HIV caseloads are predominantly gay. The Baltic States (Estonia, Latvia, and Lithuania) only reported 41 cases through 1996, but 33 were among gay/bi men, so they appear to be conforming to this Pattern. This may result from their close cultural and physical proximity to Scandinavia, where two-thirds of all cases are among men who have sex with men.

(B) Predominantly IDUs. The AIDS caseloads of Poland, Ukraine, and the new Yugoslavia (Serbia + Montenegro) are at least half IDUs. In that way, those countries are like Italy and Spain.

(C) Predominantly heterosexual contact. Seventy-one percent of Bulgaria's 45 adult cases, and 57% of Romania's 441 adult cases, were ascribed to this transmission group. I suspect that most of these "heterosexuals" are actually men who were either IDUs or homosexually active, or- in Romania's uniquely notorious case- infected in hospitals through dirty needles.

(D) Still largely AIDS-free. Nine countries (Albania, Slovakia, Belarus, Georgia, Azerbaijan, Kazakhstan, Kirghizstan, Tajikistan, and Uzbekistan) each reported fewer than 15 cases through 1996. Is this because there have been so few HIV-infected Western tourists? Or because so few people from these countries go to Western Europe for work or tourism? Or is poor surveillance overlooking an AIDS problem which is actually there?

Russia, by far the largest of the Second World countries, is a special case. The data reported to the European Center showed only 155 cases through 1996, of whom 47% were gay/bi men and none were IDUs. However, surveillance data released in June 1997 indicate that there are now about 100,000 HIV-infected Russians, of whom 70% are IDU:s: Pattern (B). This would mean that by 2005 Russia's AIDS caseload could match that now re-ported by Italy: 37,000 cumulative diagnoses of whom two-thirds are IDUs.

Russia is clearly a case of bad surveillance. But seven of the nine countries listed above in Pattern (D) were, until 1991, joined with Russia in the Soviet Union. Perhaps all of them have the same legacy of incompetent Soviet-era surveillance, and actually have big-sized AIDS problems conforming to Pattern (B).

So, it seems that AIDS in the Second World is evolving a lot it did in Western Europe, with a lag time of at most a few years. As in Western Europe, the epidemic takes a mostly "gay" form in some countries, and a mostly "IDU" form in others. Pattern (C)- predominantly heterosexual transmission- is as rare in Second World countries as in the First World countries, but is common in the Third World.

(MidCity Numbers, June 1997)