A Candle Lit from Both Sides
The HIV Epidemic in Russia*
Jean-Paul C. Grund, Ph.D.
Adapted from: Jean-Paul C. Grund: A Candle Lit From Both Sides: The Epidemic of HIV Infection in Central And Eastern Europe. In Karen McElrath (ed): HIV and AIDS: A Global View. Westport, Ct. USA: Greenwood Press, 2001. (ISBN 0-313-31403-9)
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Until 1995, less than 1100 HIV infections were registered in the Russian Federation. Most of these resulted from sexual and nonsocomial (originating from unsterile hospital procedures) transmission. In 1995 this epidemiologically soporific picture started changing drastically in two ways. Firstly, reports on epidemic HIV outbreaks in various former Soviet Union states started to surface, and, secondly, these new infections were almost exclusively associated with another major public health crisis that until then had been largely ignored: the rapid diffusion of drug injecting. At the end of the year 2000, there were an estimated 300,000 people living with HIV in Russia; of those, 170,000 were infected in the new millennium. Most of these infections are among injecting drug users, suggesting that the social networks of drug injectors have provided an almost custom-tailored infrastructure for the virus to spread through Russia and the former Soviet Union.
In 1995 the first reports appeared on epidemic outbreaks of HIV infection among injecting drug users (IDUs) in different parts of the former Soviet Union (FSU), including the Ukrainian Black Sea ports Odessa and Nikolayev and Svetlogorsk in southern Belarus. In the Russian Federation, Kaliningrad first reported a rapidly escalating number of HIV infections among IDUs, but the outbreak was not contained to this East Sea enclave. In 1996 and 1997 cities all over the Russian map, including Krasnodar, Nizhnyi Novgorod, Rostov Na Donu, Saratov, Tula, Tumen and Tver, reported epidemic HIV spread among IDUs, and early 1999 the epidemic hit the federal capital Moscow. A year later, 9985 HIV infections have officially been registered in the city and an additional 13,509 infections in the surrounding Moscow oblast (administrative region). By April 2001 all 89 oblasts had reported HIV cases. Overall, the number of registered new cases in Russia has increased exponentially, from 196 in 1995, to 18,218 in 1999. With 56,630 new cases, the year 2000 incidence superceded the total prevalence of all previous years combined (29,190 cases). At the start of April 2001 the total number of registered cases reached 103,024. Around 90% of cases were among injecting drug users, mostly teenagers and young adolescents, but children aged 11 to 14 years have also become HIV infected through injecting drug use. Even this massive upsurge understates the actual pace of the epidemic and the "dark figure" is estimated to be 5 - 10 higher.
Running after the Facts
HIV reporting in Russia is based on mandatory mass screening and a two-stage registration process introduced in 1987. Screening targets include both low risk (e.g. pregnant women, blood donors, occupational groups) and vulnerable populations (drug users, prisoners, STD patients). Registration includes recording of all test results and referral of positive results to an AIDS center for confirmation, history taking, official registration, and treatment (when available). Because of intense stigmatization and potentially serious consequences (losing one's employment or driver's license, ongoing police harassment, imprisonment) many people are unwilling to disclose a history of drug use, or simply do not show up for further examination at these clinics, resulting in delays in reporting, considerable under-reporting and biased distributions over transmission categories. Since the early 1990s testing policies for low risk populations have become less stringent, but routine mandatory screening without informed consent and pre- and post-test counseling of high risk populations, including identified drug users, prisoners and STD patients remains a routine exercise. Investing millions of dollars in this costly but inefficient pursuit have not stopped the virus from spreading like wild fire through the country's IDU networks. Encouraged by UNAIDS, Ukraine and other FSU countries-which are experiencing highly similar HIV epidemic among IDUs-implemented sentinel surveillance in 1999, but up to the present day Russia has resisted introducing this far more accurate and much cheaper methodology of HIV surveillance.
Colliding Epidemics: HIV and Injecting Drug Use
Rapid HIV spread has been associated with transmission among IDUs around the world, sometimes resulting in increases of HIV prevalence among drug injectors from less than 5% to 30 to 50% in one to three years. But, nowhere else is the overall proportion of reported cases associated with drug injecting as high as in Russia and some of its neighbors.
Escalating Numbers of Injecting Drug Users
While certainly not unknown before the breakdown of communism, drug use seems to have rapidly increased in the 1990s. According to the Russian ministry of internal affairs the number of people undergoing drug treatment was 249,000 in 1996, up from 91,000 two years earlier. The country's ministry of health reported a more modest increase: from 25,000 in 1990 to 85,000 in 1996. This discrepancy illustrates the unreliability of the Russian statistics. Before the political changes drug use was officially non-existent and consequently not enumerated. In reality drug users were persecuted indiscriminately by militia, sentenced to many years in prison, committed to inhumane mandatory treatment and other repressive measures. Nowadays these practices still prevail in many parts of Russia with the result that drug users avoid contact with drug treatment and other health institutions. As a consequence, the official number of registered drug users is only a small proportion of the real size of the drug user population. Estimates of the total number of drug users range from 600,000 to one or two and a half million, suggesting that about 1% of the Russian population is involved in drug use. "Rapid Situation Assessments," conducted as part of MSF/Holland's training program, as well as ethnographic research suggest that in particular the use of injectable opiates has become a regular feature of the social ecology in many Russian cities. As one outreach worker in Volgograd explained, "People drink or inject in this place." Likewise, an epidemiologist in Rostov Na Donu thought that "it [was] difficult to find a building in this town that is not affected by drug use."
Drug Injecting Russian Style: Zamogon Revisited
It seems that the typically Russian tradition of "Zamogon" (moonshine) has been extended to other psychoactive substances. While more recently the use of (imported) heroin has increased drastically in many cities, drug use patterns in Russia are characterized by a tradition of kitchen production of drugs. Simple 'bathtub chemistry' is used to process opium poppies or opium gum into a strong injectable opioid cocktail, and ephedrine-based medications into injectable methamphetamine and methcathinone, both powerful psychostimulants. The prevailing perception among Russian drug users is that, perhaps apart from cannabis, drugs are to be injected, which adds dramatically to the potential for drug related harm.
Friendship Networks, Drug Injecting, and HIV Transmission
Many risk behaviors identified in drug injecting-related HIV epidemics elsewhere are relevant to the reported rapid spread in Russia. Sequential use (sharing) of syringes and needles has been reported from many cities, including Moscow, St. Petersburg, Kaliningrad, Nizhniy Novgorod, Rostov Na Donu, Volgograd, Pskov and many others. In a recent study of syringe exchange program (SEP) participants in five Russian cities, 38% (N=1076) of the participants said that before they joined the SEP, they had injected with a syringe that was previously used by someone else. After joining the program this decreased to 11%, suggesting that syringe exchange can be an effective instrument in controlling the spread of HIV among IDUs.
However, a number of region-specific risk factors can be identified, associated to the home preparation of injectable drugs, in particular opiates. Using water and common household chemicals, IDUs boil opium poppies or opium gum into a strong injectable cocktail of opioid alkaloids, which contains heroin and is known under a number of different names in the region, including "Cheornaya" (black). A typical feature of the self-production and use of opiates is that is it mostly conducted within friendship groups. Cooking Cheornaya is a collective process in which drug-using friends collaborate closely, not only in preparing the drug, but also in creating the conditions for this daily ritual, as was explained by a group of IDUs in Rostov Na Donu: "It is very seldom when you use alone. At minimum you use with two or three people. … "Somebody has money for drugs, a second knows where to get good drugs, a third has some anhydride or a place to cook and yet another has syringes. … It is also much cheaper to use in groups."
During the cooking process, several cooking utensils rapidly go from hand to hand, including special 'cooking' syringes and needles. While the latter are normally not used for injecting, this may not hold in situations of scarcity or confusion. Studies in other regions have correlated the sharing of drug preparation utensils with the transmission of hepatitis C. When the drug is ready for consumption it is divided by squirting it from one syringe into those of the collective. This technique-termed "Frontloading" or "Syringe-Mediated-Drug-Sharing" (SMDS)-has been described in many other parts of the world and is associated with HIV seroconversion. The mentioned study of Russian syringe exchanges found that, in contrast with needle sharing, both of these risk behaviors were to a much lesser degree affected by participation in the needle exchange program. Collective use of drug paraphernalia other then needles and syringes only went down from 82% before, to 73% after joining the program, while SMDS decreased only from 58% to 48%. The practice of injecting with friends itself barely changed after joining the program, going from 91% to only 86%. Thus, the persistent practice of group injecting and its communal aspects in particular seem to produce very high rates of certain HIV/Hep risk behaviors, which to a large extent may account for the rapid diffusion of HIV among Russian IDUs.
The Potential for Secondary Spread
WHO's director general, Dr. Gro Harlem Brundtland, recently warned Moscow that "in just three to four years, Russia may well have a generalized epidemic" emanating from the current epidemic among IDUs. Therefore it will be essential to gain a better scientific understanding in Russia of the circumstances under which HIV is transmitted among IDUs, and of the potential for secondary spread into non-IDU populations. Russian drug injectors may be subject to intense state repression, but they appear to remain fairly well integrated in family structures and social networks that are not necessarily built around drug-related activities. In addition, most Russian drug users are young and sexually active, while many only inject occasionally and the stigma associated with this activity seems relatively low. When the stigma against drug injecting is limited, and when IDUs spend relatively more time in "non-drug" networks, they are likely to meet more sexual partners who do not inject drugs, than when they only socialize with other drug users. Thus, the sheer magnitude of the fast-paced, post-communist epidemic of drug injecting and its apparent normalcy in many communities is likely to become a critical link in the epidemiological chain towards a generalized HIV epidemic.
Obstacles to controlling HIV/AIDS: A Candle Lit From Both Sides
Transition and Tradition
Russia is undergoing a transition process from a closed society with a state-controlled economy towards a more democratic, open society with a free market economy-until now, with various results. For most people the price for economic and political liberalization has been a significant drop in the quality of life, including unemployment and decreased access to housing, health care and social services. Where formal economies stagnate, informal economies have mushroomed and organized crime is growing rapidly. Increasingly, illicit drugs are becoming a prime commodity within this "shadow economy." The region's transition process, its communist legacy, and the associated economic crises in many parts of the region can be seen to hamper the response to the HIV epidemic in many ways.
Despite the writings on the wall, governmental responses only developed after significant HIV outbreaks among IDUs were firmly established. Instead of timely introducing public health-based HIV prevention programs targeting IDUs, governments relied on outmoded and ineffective mass screening procedures and police repression of drug users.
One of the most important lessons in the global HIV epidemic is that successful responses require "multisectoral and multilevel" approaches. However, such thinking does not tie in well with the bureaucratic legacy of the communist era. The Soviet approach to management was strictly hierarchical and multi-layered, and few structural changes have taken place in the bureaucracy. Russian governmental health structures remain extremely complex and the number of local, state and federal institutions involved in HIV prevention planning runs into the double digits, often working in a highly competitive atmosphere, characterized by the absence of inter-agency collaborations and of information sharing. Such a culture of secrecy and competition is fueled by the scarcity of funds, but in essence a remnant of the communist past. Absence of sufficient funding is nonetheless a genuine issue. Salaries of health and other government workers are often months behind, while operational budgets for HIV prevention are grossly inadequate. In fact, most needle exchange programs in Russia exist on foreign funding.
A positive NGO climate is absent, as NGO legislation and regulations are unnecessary complicated, while many state health workers consider NGOs as a new set of competitors in a shrinking market. On the other hand, many NGOs in the HIV/AIDS field are closely linked to government institutions. Several NGOs involved in needle exchange are run by the head physician and staff of AIDS centers. While this provides AIDS center staff a change to operate outside the rigid state structures that determine their usual work, the primary function of this type of NGO seems to be attracting and channeling non-governmental and foreign funding. Some of these initiatives have built impressive needle exchange projects, but elsewhere middle-aged epidemiologists and laboratory workers in white coats have taken up the outreach profession.
Is Russia Different?
Russian policy makers and professionals alike seem to believe that the situation in their country is not comparable to any other place in the world. "My country is different," is a mantra that many foreign consultants have heard over and over again, where "my country" can be substituted by "our mindset," "our drug users' mentality" and other variants. While referred to as "Russianness," this phenomenon seems part of the initial response of countries around the world that get confronted with HIV in deviant or otherwise unpopular segments of the population (e.g. sexual or ethnic minorities). Russianness includes a mistrust of "western" research and approaches, a pessimistic believe that Russian IDUs will not respond to pragmatic interventions, and a moral dismissal of many aspects of what UNAIDS has termed "Best Practice." The explicit ban in the 1998 Russian drug law on the use of methadone in the treatment of opiate addiction serves as an apt example. Particularly strong are misconceptions of drug users and their ability to adjust their behaviors. Many narcologists and psychiatrists were trained to believe that, after their first injection, IDUs have on average three to four years to live, and that drug users are "hopeless" cases, who do not care whether they live or die.
Along with these ideas comes an unwarranted belief in repressive approaches and mandatory treatment, and in areas such as drugs, prostitution and infectious diseases Russian health and law enforcement structures (Internal Affairs) have traditionally maintained fairly cooperative relationships. In particular "Narcology" maintained close ties with Internal Affairs. A psychologist of a narcological center in the south of Russia put it in plain terms: "The relations with the police are good, they do a lot of mutual work." One can certainly find "enlightened" Russian police officials with more pragmatic ideas on drug use and HIV, especially outside of the capitals (and political spotlight). But overall the position of Internal Affairs towards innovative HIV prevention programs, such as needle exchange has been very negative. The first two needle exchange programs in Russia (in St. Petersburg and Yaroslavl) were closely monitored and frequently hassled by Internal Affairs. Perhaps because the St. Petersburg and Yaroslavl programs took a lot of the political heat, most of the newer SEPs in Russia have some sort of agreement in place with local branches of Internal Affairs. Outside of the political spotlight, at the oblast and city levels, the authorities have more autonomy and they seem less dogmatic and sensitive to pragmatism. However, they cannot totally ignore the federal (drug) laws or the views of the Ministry of Internal Affairs. Furthermore, despite these agreements street militia continues to hassle drug users around SEPs, including confiscating or destroying injection equipment obtained at the program.
A related matter seriously complicating the development of adequate responses to the HIV epidemic in Russia is the new drug legislation, passed by the Russian Duma in April 1998. Substitution treatment of opiate addiction with methadone is forbidden under this repressive drug law, while syringe exchange and other HIV prevention activities might be interpreted as abetting to drug use.
Colliding International Concerns: Drugs, AIDS and Human Rights
The June 2000 UNAIDS Report on the Global HIV/AIDS Epidemic reads that "many factors in vulnerability-the root causes of the epidemic-can best be understood within the universal principles of human rights." The report continues with pointing towards a number of factors that engender vulnerability to HIV/AIDS, including lack of respect for "freedom of expression and association," "the rights to liberty and security," "freedom from inhuman or degrading treatment," and "the right to privacy and confidentiality". Historically, Russia does not have a good reputation for championing human rights, but to drug users just about all of these rights are meaningless. Police often persecute drug users with HIV/AIDS, subjecting them to unwarranted searches and unlawful entry of their homes.
UNAIDS insists that successful interventions can only develop when partnerships are created, and communities-including the drug user community-are taken into trust and not confronted (UNAIDS 1999). Nonetheless, the dominant approach towards the community hit hardest by the HIV epidemic in Russia is, just as elsewhere, rooted in a mixture of repression and grave disrespect for human rights. This contradiction illustrates perhaps the most essential problem in policy making for HIV prevention among IDUs: the fundamentally different goals and interests of the international struggle against HIV/AIDS and the globalized war on drugs.
This combustible mixture is likely to be exacerbated by yet another volatile ingredient: the abysmal treatment of ethnic minorities, in particular the Roma. Roma live in impoverished communities in many Russian cities and an increasing number of Roma are involved in drug injecting. Both the World Bank and UNAIDS have warned that the more marginalized and oppressed minority populations are, the more vulnerable they become to HIV epidemics. Indeed, many factors point towards an increased vulnerability of the Roma for HIV infection, including barriers to clean needles and other HIV prevention services, as well as social-economic matters, such as the community's structural exclusion from the mainstream economy. Against the background of a mounting drug war atmosphere in Russia, involvement in drugs is likely to pose a genuine threat to both the already compromised health status and the historically delicate human rights situation of the Roma communities.
Glimmers of Hope?
Despite this grim picture, there are signs that a response is developing in Russia. Medecins Sans Frontieres/Holland (MSF/H), Medecins Du Monde (MDM) and the International Harm Reduction Development program (IHRD) of the Open Society Institute (OSI) have played a leading role in developing the initial response by forming a strategic alliance, the Russian AIDS Prevention Initiative-Drugs (RAPID). This alliance is unique in the world in the sense that it combines an intensive training on HIV prevention among IDUs (conducted by MSF/H) with a grants program (funded by IHRD/OSI Russia) and technical support . The initiative was developed in consultation with the Russian ministry of health. It has trained 200 health care providers and other professionals from 61 Russian cities and in 2001, XX syringe exchanges and other harm reduction programs were funded. RAPID maintains close collaborative relationships with UNAIDS, WHO and other UN agencies, which support these efforts and work hard to convince the Russian government to develop harm reduction approaches towards the HIV epidemic among IDUs.
More than anywhere else, the rapid pace of HIV spread in Russia is fueled by illicit drug injection. The overall response to the epidemic has developed at a pace too slow to control further spread. The widespread nature and relatively high level of community tolerance of drug injecting may set the stage for a rapid secondary diffusion into the general population by way of sexual transmission. With its growing magnitude, a realization grows that drastic, unconventional and innovative measures are required to control the HIV epidemic. Supported by a number of international organizations, researchers, activists and professionals have started to develop syringe exchange and other harm reduction projects. Research from around the world has built a strong scientific case for such harm reduction approaches and after initial-largely ideological-resistance, support for this comprehensive approach is steadily growing in Russia. Of course, interventions must be culturally sensitive to individual cultures facing the epidemic. However, the international experience shows that certain "best practice" harm reduction interventions can transcend cultural specificity. A lackluster response of archaic bureaucratic structures can therefore not be hidden behind a front of "Russianness" or its regional variations.
The dominance of Internal Affairs in matters of public health is a main obstacle to the struggle against HIV/AIDS. Its repressive approach has alienated drug users from the public health system, seriously increasing their vulnerability. Furthermore, Internal Affairs is a vocal opponent of needle exchange, methadone treatment and other "best practice" interventions that can contribute to controlling the HIV epidemic among IDUs. The influence of Internal Affairs raises serious human rights concerns, not only concerning the treatment of drug users in general, but in particular with respect to the increasing number of drug users from stigmatized ethnic minorities, such as the Roma. Their disenfranchised status is expected to result in rapid HIV spread in their communities, but also further complicate the human rights aspects of the epidemic, as they may become easy scapegoats for the failures of the authorities in controlling the twin epidemics of drug injecting and HIV.
It may perhaps nowhere else become more obvious than in Russia and other FSU states, how from a public health perspective, the HIV epidemic among drug injectors has become a sentinel measurement for assessing the success of our drugs and AIDS policies. As international financier and philanthropist George Soros wrote "there is perhaps no other field where our public policies have produced an outcome so profoundly at odds with what was intended." While the recent introduction of repressive drug legislation suggests otherwise, with up to 90% injecting drug users among its registered HIV cases, Russia can simply not afford for its leaders to jump on the bandwagon of the global drug war. One should not forget that, from a biological viewpoint, the struggle against HIV/AIDS is an inter-species battle, while the global war on drugs has become an intra-species conflict.
Jean-Paul C. Grund
Jean-Paul C. Grund is a drug policy scholar, specialized in field studies of drug use, and its social, health and policy concomitants. In the recent past, Dr. Grund conducted a study of drug use and HIV risks among the Roma/Gypsy population of Central and Eastern Europe and evaluation studies of needle exchange in Russia and Eastern Europe. He was the founding Director of the International Harm Reduction Development program at The Lindesmith Center, which fostered the development of practical harm reduction programs in Central Eastern Europe and Russia. He also was the first Research Fellow in Residence at this New York based drug policy research center, which is part of the Open Society Institute.
Dr. Grund holds an advanced degree in Clinical and Developmental Psychology from Utrecht University and received a Ph.D. in Social Science from the Medical and Health Sciences Faculty at Erasmus University in Rotterdam, The Netherlands. Dr. Grund is the author of numerous articles and two books on drug use culture, HIV, and their social-political determinants. *
In the early 1980s he worked with the Dutch "Junkiebonden," the first drug user self-organizations. In his hometown Rotterdam he founded and directed the first outreach program for drug users and organized community-based needle exchange.
His research interests include the international diffusion of drug use patterns and administration routes, and their public health aspects, as well as the spectrum from recreational to compulsive drug use patterns and their associations with social-economic, cultural, drug market and drug policy factors.
Currently Dr. Grund works at the United Nations HIV/AIDS program (UNAIDS).
* Drug Use as a Social Ritual: Functionality, Symbolism and Determinants of Self-Regulation.
Rotterdam: Instituut voor Verslavingsonderzoek, 1993. Available at:
Grund, Jean-Paul & Blanken, Peter. 1993.
From chasing the dragon to chinezen. Rotterdam, the Netherlands: IVO. Available at http://www.drugtext.org/books/grund/CHASDRAG.html