Risky sexual behaviour,taboo of HIV/AIDS and HIV-prevention topics: interviews with HIV-positive immigrants from the former Soviet Union

Sir: The article of Wall et al. in the International Journal of STD & AIDS (2006) described determinants of risky sexual behaviour in Russia in the light of the HIV epidemic. ¹ We found it interesting to interview some of the immigrants to Bavaria Federal State of Germany from the countries of the Former Soviet Union (FSU) with a high prevalence of HIV, following their HIV diagnosis, about their attitude toward HIV/AIDS. There have been no studies on the subject involving FSU immigrants with HIV infection to Western Europe or America.

Germany is one of the European countries with a high number of FSU immigrants. In the last 18 years over two million ethnic German resettlers, Jewish refugees and their relatives immigrated to Germany, ² and the immigration process is still going on. Russia, Kazakhstan and Ukraine were the three most common countries of origin for ethnic German resettlers in 2005 (n = 35,396), with 59.6, 31.7 and 3.7%, respectively. ³

In 2005 UNAIDS estimated the HIV prevalence in sexually active people aged 15-49 years in Ukraine, Estonia, the Russian Federation and the Republic of Moldova as the highest in East Europe, at 1.4, 1.3, 1.1 and 1.1%, respectively. ⁴ The number of HIV-positive FSU immigrants in Germany is not published, but an increasing number of HIV diagnoses in immigrants newly arrived from the FSU regions with a high prevalence of HIV infection is to be expected in the next years.

Since the beginning of 2004, six FSU immigrants have been diagnosed with HIV infection at our Department of Dermatology. A 1.0-1.5 h semi-structured interviews in Russian (a common language in the post Soviet Union area) were conducted with four of them after obtaining their written consent:

All respondents mentioned that HIV infection was transmitted by unprotected sex (without a condom). None of the respondents used intravenous drugs. Despite a very small sample of the interviewed HIV-positive FSU immigrants, two important aspects regarding the attitude to HIV/AIDS were determined: tabooing of the topics of sexual life, STDs and HIV/AIDS in personal and social environment leading to inappropriate HIV/STI prevention, and a pronounced fear of stigmatization should the HIV diagnosis be discovered.

All of the participants said that the Soviet school curriculum had insufficient sexual health education content, limited only to the human reproduction system; ‘There was Anatomy, of course, but the teacher never brushed on the subject of sexual intercourse’ (No. 2). No information about STDs and HIV prevention was included at all in the school course; ‘In my time, there was nothing like the sex education today’ (No. 4). With regard to this issue, interviewee No. 4 referred to the easily available information on sex and STDs in modern popular magazines, rather than the regular sex education in modern schools in FSU countries. The poor sexual health and STDs education was accompanied by tabooing of the topic of sex and STDs prevention in the Soviet society and in the Soviet family, leading to the development of psychological complexes; ‘That's the problem - complexes; I've had complexes since my childhood, that topic was a taboo, something dirty…’ (No. 2). The taboo of STDs and HIV/AIDS topics in personal and social life seems to have led to the firm conviction ‘It will never happen to me!’ (No. 2), resulting in disregard for personal HIV prevention measures and in risky sexual behaviour without using a condom; ‘People don't want to deal with it [HIV] - ‘It is not for us, it is not our world’ (No. 1).

Despite the fact that all the respondents were well informed (e.g. in radio, TV or magazines) about HIV/AIDS and its sexual transmission, they had not used a condom during sexual intercourse with strangers; ‘We all have heard about it, but until you are personally affected, you don't care. One hears or reads about it, and one forgets. It's written about in the newspapers, but one reads and soon forgets’ (No. 3).

The definitive stigmatization and discrimination of HIV-positive people in Russia in social and professional aspects was well described. ⁵ Our HIV-positive FSU immigrants show panic at the idea that their HIV diagnosis could be found out by a family member or by a close friend, or by German social and immigration agencies who sponsor FSU immigrants; ‘If my mother finds out that I am infected she will be terribly shocked!; You can't tell anyone about it’ (No. 2). For this reason, in spite of their lack of German speaking skills, the HIV-positive FSU immigrants do not bring a Russian speaker with them for interpretation to doctor's or psychologist's appointments; ‘If I tell my friend about my disease, she will run from me like from the plague’ (No. 2). Adequate medical treatment or care in such cases is almost impossible.

Misconceptions about HIV/AIDS with knowledge gaps,^6,7 poor German language skills, social and cultural differences between the FSU countries and Germany, including public health systems, ⁸ tabooing of the HIV/AIDS topic in social life, together with risky sexual behaviour, could make HIV prevention and care for immigrants from the FSU countries very difficult. In light of the HIV epidemic in the FSU countries and the continuing political immigration of ethnic Germans resettlers and Jewish refugees, followed by a growing professional immigration, an increasing number of new HIV infections in these groups should be expected. The public health systems in Germany and Europe are not prepared to adequately carry out HIV prevention for these groups. The attitude of HIV-positive FSU immigrants regarding HIV/AIDS has not been sufficiently investigated. Our small group observation shows the importance and a growing need to research the awareness and attitude regarding HIV/AIDS of FSU immigrants to Europe or America in the wake of the HIV epidemic in their countries of origin.