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Russia's Misguided Effort to Stop HIV

By Maria S. Stoyadinova

The HIV epidemic in Russian continues, despite the nation's efforts to expand treatment. Unfortunately, those efforts aren't focusing on the primary source of the problem -- injecting drug users. If Moscow is serious about curbing the epidemic, it needs to sharpen its focus on that high-risk population in much the same way Thailand focused its HIV efforts on its own high-risk population, commercial sex workers.

First, some data that illustrates the problem.

At the end of February, the Russian news agency RIA Novosti reported that the number of new HIV cases in Russia last year exceeded 50,000 (compared to 40,000 only two years ago). According to the 2008 UNAIDS estimates, 940,000 Russians are living with HIV, which amounts to a 1.1% HIV prevalence rate among adults aged 15-49. By comparison, in 2007 no Western European country had an HIV prevalence higher than 0.6% (with the majority of the region within the 0.1%-0.2% range). At the same time, the majority of HIV infections in Russia (83% according to Avert.org) occur among injecting drug users (IDUs). By contrast, Avert estimates that only 8% of the infected people in Western Europe are IDUs, and that more than half of the infections there have occurred through heterosexual transmission.

After 2005, Moscow sharply increased state spending on HIV programs. In 2007, Russia spent $445 million on HIV. By the end of the year, the number of Russians receiving anti-retroviral medication had increased to 31,094 (from 14,681 in 2006). Unfortunately, the social group comprising the largest portion of Russia's HIV population -- injecting drug users -- is not receiving an adequate portion of the state funding, nor is it incorporated in any significant prevention efforts. In 2007, only 24% of IDUs in Russia were reached by prevention programs.

If Moscow wants to curb the epidemic, it needs to sharpen its focus on injecting drug users. In that respect the country can learn from successful interventions in other world states. One example of a country where an HIV epidemic was effectively controlled in the past was Thailand during the 1990s.

While the cultural and historic contexts of Thailand and Russia are quite different, there is one core similarity between the two countries' epidemics that makes the lessons from Thailand very valuable for the Russian administration. In both states, HIV prevalence was primarily focused within one high-risk social group (commercial sex workers in the case of Thailand and IDUs in the case of Russia). In both cases that group was a marginalized segment of society, occupied with illicit activities. The success of the Thai HIV campaign shows that targeting prevention programs towards the core high-risk group in the country can effectively curb the epidemic among the entire population.

A 2003 paper in Health Policy by Ainsworth, Beyrer and Soucat, clearly outlines the steps that Bangkok took, which eventually led to a sharp reduction of HIV prevalence in Thailand during the 1990-2000 period. The Thai government administered widespread public awareness efforts and a "100 Condom Program" in the nation's brothels, both of which were very effective in changing high-risk behavior. At the same time, there was widespread collaboration between the government and law enforcement authorities in the implementation of the "100% Condom Program.". Brothel owners and sex workers were encouraged to participate in it, free from fears of arrest or prosecution, even though prostitution was illegal in the country.

Russia can greatly benefit from implementing similar strategies with respect to injecting drug users. Two important interventions for IDUs can be particularly useful in Russia's case -- needle exchange programs (in which injecting drug users can exchange used needles for clean ones) and substitution therapy (treating heroin dependency with methadone or buprenorphine, thus reducing the high-risk behavior of needle sharing). Currently in Russia, the first of these interventions is highly underutilized, while the latter is illegal.

According to a report, sponsored by the Open Society Institute, between 2006 and 2007 Russia actually decreased the number of government-funded needle exchange programs from 15 to 3, despite the fact that the majority of drug users in Russia (of which there are between 3 and 6 million) fall within the IDU category. At the same time, substitution therapy is currently forbidden in Russia and is facing very strong political and scientific opposition, even though the method is deemed highly successful in the treatment of heroine addiction by the international medical community.

Moscow is also stifling public debate on the subject. Vladimir Mendelevich -- a Russian doctor openly supportive of the need for substitution therapy in Russia -- was twice investigated by prosecutors for his statements, and even had his website closed down, since it contained information on the topic.

Aside from re-focusing its HIV efforts on prevention among IDUs through higher funding for needle-exchange programs and the legalization of substitution therapy, Russia should also attempt to alleviate its persecution of drug users, the way Thailand did with its sex workers during the "100 Condom Campaign." Currently, police harassment of IDUs is endemic in Russia and prevents people from participating in needle exchange programs. At the same time, seeking treatment for drug addiction in the country at times requires registering in a national database, a step that can later affect a person's ability to find jobs or housing.

In order for Moscow to control the spread of HIV among injecting drug users, it needs to make sure that they won't be punished for seeking help or engaging in safe practices.

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The views expressed are those of the author and do not necessarily represent those of the Johns Hopkins University.

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