Aids Alert International
Are former Soviet nations plodding down wrong path?
Experts lack optimism for the region
Researchers and AIDS activists who have witnessed AIDS’s destructive path across the world have nearly two decades of observations and data to show how the epidemic can be halted in countries where it begins primarily as an IDU (injection drug use/injection drug user) transmission problem.
The trouble is that no one has been able to convince Russia, other former Soviet Union countries, and the United States who has influenced illicit drug policies in that region, of these well-founded strategies.
Jail time replaces programs
Instead of supporting harm reduction strategies, such as needle exchange programs, which have been proven scientifically to reduce the spread of HIV, Russia and some of its neighbors are arresting drug users wherever they can be found. This includes those who show up at needle exchanges sponsored by international organizations, says Kasia Malinowska-Sempruch, director of the international harm reduction program at the Open Society Institute in New York City.
"There are entire prisons where hundreds of women are locked up for having a few grams of drugs," Malinowska-Sempruch says. "It’s clear the U.S. is definitely supporting this process, so I think U.S. policies and blind replication of those in other places are obviously having very damaging effects in countries."
As a result, IDU has fueled a rapid growth in the region’s HIV epidemic.
Between 1987 and 1996, there were only 1,000 cases of HIV diagnosed in Russia, and most of these were cases of transmission within hospital settings or among men who have sex with men, says Robert Heimer, PhD, an associate professor of epidemiology, public health and pharmacology in the department of epidemiology and public health at the Yale School of Medicine in New Haven, CT.
Heimer recently visited Russia to observe firsthand the impact of its HIV epidemic.
Then in 1996, the nation’s epidemic took off, and another 1,500 HIV cases appeared; and this time most of these were from IDU transmission, he says.
"It changed because of the change in the Russian situation," Heimer explains. "All of a sudden, with the end of the Cold War and with borders down, it was easy for Russia to be a through-port of heroin from Afghanistan and into Europe — the stuff sort of fell off the boat, as it were."
Plus, Russia’s socioeconomic climate worsened, resulting in youth alienation, increasing risk behaviors, and vast increases in drug use, sexually transmitted diseases, and increases in crime, Heimer says.
By 1997, the number of HIV cases had climbed to 4,300; in 1999, there were 20,000 HIV cases; in 2001, there were 88,000 HIV cases; and now there are nearly 250,000 HIV cases, Heimer says.
How many are undiagnosed?
And these numbers only represent the people who are known to have HIV because they were registered as a new HIV case when they went into drug treatment or were arrested for drugs. There could be four-to-six times that many people who are HIV-positive and undiagnosed, Heimer says.
"I’m not sure any other nation has seen a drug-related epidemic like Russia’s on a nationwide scale, although it’s similar to what happened in New York among the 2,000 or so IDUs who lived in New York at the last half of the 1970s when HIV prevalence went from 0% to 50% in four years," Heimer says.
In some Eastern European cities the HIV infection rate among IDUs is greater than 60%, says Malinowska-Sempruch.
The Open Society Institute supports 200 harm reduction programs in the region, providing needle exchange, methadone maintenance, and other services to IDUs; and its work is just a drop in the bucket as far as what is needed, she says.
"Between 3% and 6% of IDUs are receiving HIV-prevention services; so obviously, the epidemic we’re seeing now is not going to stop," Malinowska-Sempruch says. "Our hope is that we are offering local best practices."
By setting an example for local governments, the needle exchange programs are starting to catch on in the region, and some Eastern European communities are beginning to submit applications to the Global Fund for harm reduction programs, she notes.
Draconian policies hamper efforts
However, that work is hampered by the region’s draconian drug enforcement policies, which emphasize locking up users and even setting up quotas of drug user arrests for police to meet each month, Malinowska-Sempruch says.
"So we have had people picked up outside of needle exchange programs, and this is a serious complication that does not work in preventing the HIV epidemic," she states.
There are plenty of examples of cities where such policies resulted in major increases of the HIV epidemic, including Edinburgh, Scotland, where heroin use skyrocketed in the 1980s, and in response, pharmacists began to withhold needles from being sold over the counter, Heimer says.
"The HIV prevalence went from zero to 45% in an 18-to-24-month period between 1983 and 1985," he adds.
Antineedle exchange policies in New Jersey in the 1990s also have shown in various studies to have resulted in a spread of HIV among IDUs. By contrast, nations such as Australia and Canada never had a major HIV epidemic among IDUs because they embraced and funded needle exchange and other harm reduction services.
There is no doubt that IDUs will change their behavior and use clean needles that are readily available, Malinowska-Sempruch says.
"I’ve never had a person argue why they will not use a clean needle," she says. "It’s a lack of political will and moral judgment values that makes harm reduction difficult."
Harm reduction outreach workers have begun to make an impact on local police, however, adds Malinowska-Sempruch.
"What we are slowly noticing is that cops also are starting to worry about an HIV epidemic," she says. "So now when we approach police officers, they are, in principle, supportive of the idea of needle exchange."
Law enforcement vs. public health
Still, so long as the Russian government requires police to arrest drug users, there will be a conflicting relationship between public health best practices and law enforcement.
"It’s clear public health officials understand what needs to happen, but the decision-making power is within the Ministry of Justice or the drug control program, and the two parts are not talking with each other," she says.
The epidemic also has hit a region that faces long-term economic trouble with large populations of people who have no health insurance, so very few people who are infected with HIV have access to antiretroviral treatment and other health care services, Heimer says.
By incarcerating drug users, Russia is helping to spread HIV and tuberculosis, which is rapidly transmitted in prison, she adds.
"People sometimes spend two-to-three years in pretrial detention before they get a hearing, and so their jails are not designed for long-term incarceration and have overcrowding," Heimer explains.
"Every once in a while there’s a general amnesty with people released in droves with untreated TB."
Is it already too late?
While the international community is stepping up response to the Eastern European HIV epidemic, it may be too late to stop the epidemic from spreading to the population at large.
Only 15% of the Russian people with HIV infection have acquired the virus through non-IDU transmission, but this trend is unlikely to continue because the average age of IDUs in Russia is the mid-20s.
This means that HIV-infected drug users likely are engaging in other risky behaviors, including having unsafe sex with multiple partners, Heimer says.
"So you have the double-whammy problem of IDUs with unsafe injection practices and unsafe sexual practices, and these are expected to result in a generalized HIV heterosexual epidemic possibly within the next five-to-seven years," she points out.
"And if that happens, then we’re not talking about 1 million or 2 million people infected; we’re talking about 10 million to 20 million people infected, which is one-seventh of the Russian population as a whole and one-fourth to one-fifth of the adult population, and that’s as bad as the epidemic in South Africa."