By Amar Toor
Maxim Malyshev’s life changed with a phone call in 1997. He was addicted to heroin at the time, and had just been arrested for possession in his hometown of Tver, Russia, about 100 miles north of Moscow. Police ordered him to undergo tests for HIV, tuberculosis, and hepatitis C, like all arrested drug users in Russia. Now, on the other end of the phone, came the verdict.
“They called and said ‘You are HIV positive, please come in and we will give you information,’” Malyshev says over the phone, his girlfriend translating from Russian to English. It felt like a death sentence. Antiretroviral therapy could prolong his life, but for convicted drug users in Russia, it was all but impossible to access. Doctors gave him two or three years to live.
But Malyshev was lucky. After checking in and out of government treatment centers, where he was forced to undergo excruciating, cold-turkey detox, he found one of the few NGOs that could help. The Moscow-based Rylkov Foundation connected him with a private, less brutal rehab facility in a different region, and pushed him to undergo ARV therapy. These days, the 38-year-old works as an outreach coordinator for the NGO, providing clean syringes and counseling to other drug users.
Malyshev knows he’s fortunate, because so many of his drug-using friends were not. “There are not so many stories like Maxim’s,” says Asya Sosnina, Malyshev’s girlfriend. “[His friends] just die, or go to prison.”
That’s the fate that awaits thousands of HIV-positive people today in Russia, where an accelerating AIDS crisis is expanding beyond the stigmatized communities of needle-sharing drug users, putting millions of lives at risk. HIV infection rates have steadily declined across much of the world, but Russia is one of the few countries where they’re rising. Experts lay much of the blame on the Russian government, pointing to its longstanding ban on methadone (a proven treatment for heroin addiction) and firm resistance to sex education. With President Vladimir Putin continuing to push a nationalistic, socially conservative agenda, the crisis seems poised to get even worse.
In May, Vadim Pokrovsky, the head of Russia’s state-run AIDS organization, told AFP that the country’s HIV epidemic has worsened dramatically in recent years, warning that at least 2 million people will be infected with the virus within the next five years. Pokrovsky added that there are now around 930,000 Russians infected with HIV, citing official statistics, of which 192,000 have already died. The latest tally of HIV-infected Russians — which experts describe as an underestimate — is up nearly twofold from the 500,000 people reported in 2010.
Pokrovsky blamed the spike on the Russian government’s increasingly conservative policies on drug treatment and sex education. Injection drug users comprise around 60 percent of Russia’s HIV-positive population, but opiate substitution therapies like methadone remain illegal, despite widespread evidence of their effectiveness. And under the strong influence of the Russian Orthodox Church, Russian schools continue to prioritize abstinence and “traditional” values over prevention-based sex education. “Instead of distributing condoms we should be promoting sexual fidelity and healthy families,” Lyudmila Stebenkova, the head of Moscow’s health committee, said following Pokrovsky’s comments last month, “That is much more effective.”
But activists say that Russian President Vladimir Putin’s socially conservative, nationalist agenda has masked the reality of the country’s epidemic. “The [health] ministry prefers to say that the epidemic is under control, and because of Russia’s high morality and Christian orthodoxy, we are protected from everything,” says Anya Sarang, co-founder of the Rylkov Foundation. “The ministry just lies about it.”
Russia’s HIV epidemic has its roots in the early 1990s, when the Soviet Union dissolved and heroin began flowing in from Afghanistan. The virus spread rapidly among sex workers and needle-sharing drug users, but it has since expanded to broader populations. Young women are seen as the primary new group at risk.
At first, Russia’s clean needle exchange programs were financed by the Global Fund, an NGO that fights against the spread of AIDS, tuberculosis, and malaria. But the countryannounced a withdrawal from the Fund in 2010 (primarily over international guidelines on needle exchanges), and funding for those programs has evaporated. Clinics are barred from providing methadone, a substitute drug that helps wean patients off heroin, despite it being included on the WHO’s list of essential medicines. Those who use or distribute it face up to 20 years in prison.
Instead, many addicts, like Malyshev, are arrested and sent to state-run detoxification centers, where they are forced to go through withdrawal with the help of only sedatives. There are some private rehabilitation centers, but the costs are prohibitive for most users. Those who are arrested or quit the detox program early are automatically added to an official registry of drug users, which makes it difficult to obtain a job or receive a loan. That alone deters many from seeking treatment in the first place.
“I think you could probably point to Russia as a worst-practice for virtually every aspect of how to respond to an HIV epidemic concentrated among drug users,” says Daniel Wolfe, director of the International Harm Reduction Program at the Open Society Foundations, the George Soros-funded NGO.
Experts point to Crimea as a tragic case study. When Russia annexed the region from Ukraine in 2014, it swiftly ended opioid substitution therapy at drug rehab centers. Of the 805 addicts who had been receiving methadone, between 80 and 100 died, the UN’s AIDS envoy told journalists earlier this year. Most of those deaths were by suicide or overdose.
Russian doctors largely dismiss methadone and other substitution therapies, saying they only replace one addiction with another. “When an addict comes — along with her children — to a center where she can get methadone, I feel that this is wrong and hypocritical,” Elena Sokolchik, the head doctor at the Moscow Research and Practical Centre of Narcology, told the BBC. “I don’t want a kid to see addictive drugs distributed as if they were medicines.”
Chris Beyrer, an epidemiologist at Johns Hopkins University who has worked extensively in Russia, says this bias dates back to the 1970s, when the US began using methadone to treat soldiers coming back from the Vietnam War. The Soviet Union opposed it on anti-American, Cold War principle — a mentality that has seen a resurgence under Putin’s nationalist agenda. “They’re not a part of the modern evidence-based movement in medicine,” Beyrer says. “Their medical care, their health care, is shockingly bad and bizarre.”
Experts say this approach ignores the overwhelming scientific evidence in favor of substitution therapy. While methadone is addictive, it has proven effective when administered in controlled settings. In Ukraine, methadone clinics have been credited with reducing the rate of HIV infection. Across the border, they’re non-existent.
“It doesn’t make sense to anybody, and it’s not a good idea to try and ascribe rationality to this,” says Beyrer, head of the HIV epidemiology and prevention science program at Johns Hopkins. “It’s a bias, and it’s a very irrational one.”
Russia has made notable progress in providing ARV drugs to treat HIV, and allocated $375 million this year to fighting the virus. But only $3.5 million has been devoted to prevention and awareness, leaving organizations like the Rylkov Foundation to pick up the slack. That’s become increasingly difficult without government support, and amid a climate in which drug users are seen as criminals, rather than victims.
“I have had conversations with Russian government officials who have said things like ‘AIDS and drugs will solve each other,’” Wolfe says. “So I think there’s some question about whether or not Russia is actually committed to protecting the lives of everyone, or whether drug users fall into the category of ‘socially unproductive citizens’ [whom] the state might just as well do without.”
In some cases, the government has actively sought to muzzle organizations that promote anything other than approved HIV treatments. Sarang says her foundation’s site was shut down in 2012 for publishing documents on the efficacy of opioid substitution therapies, which the federal drug control service labeled as “drug propaganda.” They eventually moved the site to an American host and appealed to international organizations to draw media attention to the shutdown, but others have been forced to shut down. “We’re probably one of the few remaining activist organizations in Russia that are still active, because of the government oppression,” she says.
International organizations have been caught in the crackdown, too. The Russian government has forced many to register as “foreign agents” — a term synonymous with espionage. They have been subjected to arbitrary inspections and warnings, while some have been expelled. As Russia continues to sever ties with the West, the fear is that it will only be more difficult to monitor its HIV epidemic.
“I think it’s fair to say that they now have a widely disseminated epidemic,” Beyrer says. “And if there were new outbreaks, I don’t know how we would know that.”
Malyshev agrees that it’s become more difficult to do his job in recent years, but he declines to speculate on how the climate may change in the future. “It’s very hard to make [a] prognosis,” he says. “Because the last two years in Russia, [many] unexpected things happened. I just live for today.”
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