The HIV and AIDS epidemic in eastern Europe and central Asia is changing.1^–2 Despite data limitations, this region shows the fastest growth in HIV in the world.3 At the end of 2004, between 920 000 and 2.1 million people in the region were living with HIV, compared with about 160 000 in 1995. Most countries in the region have low level epidemics, with less than 1% prevalence among pregnant women and less than 5% prevalence among high risk groups. The countries most affected are Ukraine, Russia, and the Baltic states, but incidence is also increasing elsewhere. The driving force in most countries has been intravenous drug use, but other contributors include migration, commercial sex work, increasing rates of sexually transmitted infection, widening economic disparities, and multiple high risk behaviours among prison populations.

Rhodes and Simic describe in detail the risk environment that prevails in eastern Europe and the western Balkans.1 As national borders have been progressively opened, HIV risks have migrated across them along with people and goods, including illicit drugs. Civil society protections have not kept up with this globalisation, nor have legal frameworks that consider members of vulnerable groups as criminals or social deviants. But people with HIV infection are not deviants: they are predominantly young (more than 80% of new HIV cases occur in people younger than 30); they may be disenfranchised groups such as the Roma; they may be transport workers with sexually transmitted infection; and they are certainly heterosexual partners of intravenous drug users (the main bridge population).

DeBell and Carter (see p 216) describe how poverty and wealth disparities in Ukraine create fatalism and hopelessness about social risks and the exploding HIV epidemic.2 There is a critical lack of investment in health systems and in effective national strategies to control the spread of HIV. Corruption, trafficking, and stigma triangulate to isolate HIV outside the mainstream of health systems, thus assuring that official action will be slow.