On a chilly September evening in Novogireyevo, a Moscow suburb of concrete apartment blocks about 16 kilometers east of Russian President Vladimir Putin’s Kremlin compound, a young woman in an orange hoodie approaches Sasha Mazay with an offer that might save his life.
Mazay, 33, is one of Russia’s estimated 2.4 million users of injected drugs. The woman, a charity volunteer, is handing out clean needles, condoms and overdose treatments -- a small step in an effort to stem one of the world’s fastest-growing HIV epidemics, Bloomberg Markets magazine will report in its February issue.
Mazay, who shoots up a homemade stimulant called mulka, accepts the syringes, saying he hasn’t contracted HIV -- yet. His ex-wife, also a drug user, died from AIDS complications six weeks earlier.
“Of course I share needles, but it’s with friends, and I trust them,” he says. “There’s no way to quit. I try not to think about it.”
Hidden from the outside world and abetted by policies that critics say promote infections rather than curbing them, the HIV scourge plaguing Russia is one that even the poorest countries have begun to subdue.
As Putin puts the final touches on preparations for the $48 billion Winter Olympics in Sochi and strives to expand Russian influence in international affairs, 1.3 million of his countrymen have the life-threatening virus that causes AIDS, according to the Russian Federal AIDS Center.
Among the top 20 global economies, only India, with a population almost nine times bigger than Russia’s 143 million, has more people living with HIV, according to the Joint United Nations Programme on HIV/AIDS, known as UNAIDS, and the U.S. Centers for Disease Control and Prevention.
New infections in Russia jumped 13 percent to 70,453 in 2012 and were on track to climb a further 10 percent in 2013, says Vadim Pokrovsky, director of the AIDS center.
At the root of Russia’s woes is an unchecked outbreak among addicts: 21 percent of the world’s HIV-positive injecting-drug users live in the country, compared with 15 percent in the U.S. and 10 percent in China, the UN Office on Drugs and Crime says.
Russia’s surging epidemic runs counter to the global trend. Worldwide, annual HIV infections dropped by almost a third to 2.3 million in 2012 from 2002. In South Africa, they tumbled by 38 percent to 370,000. South Africa still leads the world in total cases, with 6.1 million HIV-infected people. India has 2.1 million; the U.S., 1.1 million; and China, 780,000, according to UNAIDS and the CDC.
Russia trails in curtailing HIV infections because it forbids or refuses to fund approaches that have worked elsewhere, says Michel Kazatchkine, the UN secretary-general’s special envoy on HIV/AIDS in Eastern Europe and Central Asia.
The country bans methadone, a treatment the World Health Organization recommends to curb heroin use and thus prevent infection from contaminated needles, under a 1998 law that prohibits addictive drugs.
Such heroin-replacement treatments have become mainstays of HIV prevention in the U.S., China and neighboring Ukraine. Russia doesn’t fund clean-needle programs, which the WHO says reduce HIV’s spread, leaving the task to a patchwork of local charities.
“There is a climate of suspicion about everything that comes from the West -- and the U.S. particularly,” Kazatchkine says. “I don’t see much progress coming in Russia unless it changes quite radically. It’s so shocking. The nation’s HIV policies result in death and suffering that could be avoided.”
Instead of funding heroin-substitution and clean-needle programs, Russia is trying to curb HIV with measures designed to fight drug use and addiction.
Prime Minister Dmitry Medvedev in March approved an eight-year, 212 billion ruble ($6.4 billion) plan to identify addicts and promote healthy lifestyles through education and cultural and sports events. The 94-page document calls methadone more dangerous than heroin in terms of the risk of accidental overdosing and specifies that addicts can’t substitute one drug for another.
“The experience of Ukraine and other countries, followers of harm reduction, is not evidence of their effectiveness,” Alexei Mazus, the Russian Health Ministry’s head specialist on diagnosis and treatment of HIV infection, wrote in an e-mail. “Programs that are proven to have a high preventive effectiveness are being implemented in the Russian Federation.”
Pokrovsky, the Russian AIDS center director, disagrees. He says anti-drug efforts don’t stem HIV. A medical doctor who diagnosed the first HIV case in the then-Soviet Union in 1985, Pokrovsky, 59, has fought the virus for three decades.
He says efforts to stop heroin abuse in the 2000s prove his point. A government crackdown pushed addicts onto intoxicants such as krokodil, which users inject more frequently than heroin, increasing infection risks. The concoction is based on the pain reliever codeine mixed with gasoline, iodine, acid and phosphorus, according to the New York State Office of Alcoholism and Substance Abuse Services.
Russia in 2012 sought to stamp out krokodil by making codeine prescription only. Users switched to other homemade mixtures, and some now shoot up eyedrops. Drug abusers are frequently turned away from hospitals and often arrested and imprisoned, charities that work to counter HIV say.
“These repressive measures are the main means of combating drugs here in Russia and the main measure to prevent HIV, too,” Pokrovsky says.
Russia has also stymied international aid groups that fight HIV. In 2009, the government was set to take over and expand programs, including needle distribution, sponsored by the Geneva-based Global Fund to Fight AIDS, Tuberculosis and Malaria. The Health Ministry backed out, leaving the programs unfunded, says Nicolas Cantau, the fund’s project manager for Eastern Europe and Central Asia.
“Suddenly, everything was wrong,” recalls Cantau, who says the challenge was ideological, not medical. “Everything that the Global Fund had supported was not good; harm reduction didn’t work. We ran into a closed door.”
The fund still supports some HIV-prevention programs in Russia among drug users, sex workers and gay men but on a smaller scale, he says.
In 2012, Russia shuttered the Moscow offices of the U.S. Agency for International Development, which supported more than 200 organizations working on HIV. Russia accused the group, which also financed human-rights and vote-monitoring efforts, of interfering in the country’s affairs.
“This is a matter of attempting to influence domestic politics, including elections at different levels and civil-society institutions,” the Russian Foreign Ministry in Moscow said on its website.
Putin signed legislation that year requiring groups getting outside aid to register as foreign agents and face tighter restrictions.
“We are committed to stay on the side of those who want to see a more democratic, more just Russia,” U.S. State Department spokeswoman Victoria Nuland said in a statement at the time.
Putin enraged AIDS and gay-rights activists in June when he signed a law that prohibits distributing to minors “propaganda” on homosexuality. While no more than 2 percent of reported HIV cases in Russia originate from gay sex, the law will make it harder to prevent infections among gay men, Pokrovsky says.
“Now, this group will be more secretive,” he says, seated in his office in Moscow’s Infectious Diseases Hospital No. 2, in a quiet neighborhood where czars once kept falcons for hunting.
A June survey of 1,600 people by the state-run All-Russia Center for the Study of Public Opinion found 88 percent supported the law.
“There is opposition to sexual education in schools or safe-sex campaigns,” says Anya Sarang, president of the Andrey Rylkov Foundation for Health and Social Justice, a Moscow-based group that works to prevent HIV. “There is no real HIV prevention at all.”
Putin softened his public comments on homosexuality in November after gunmen fired on one of Moscow’s best-known gay clubs. That same month, assailants attacked pro-gay-rights activists in St. Petersburg with air guns, shooting one man near his eye, according to the RIA Novosti News Agency.
“We should not create any xenophobia in society on any principle against anyone whatsoever, including against people of nontraditional sexual orientation,” Putin said in a meeting with leaders of political parties not represented in parliament.
HIV is flooding through Russia at a time when Putin is poised to showcase the Winter Games in February, followed by soccer’s 2018 World Cup. The government has refurbished Moscow’s downtown, reconstructed the world-famous Bolshoi Theatre and built new apartments and ski resorts.
At the same time, Russia is navigating a slowing economy and weakening demand for its oil and gas exports, which totaled $435 billion in 2012 and powered 7 percent average annual expansion during Putin’s first two terms as president, from 2000 to 2008. Gross domestic product growth has dropped or been unchanged in every quarter since Putin won a third presidential term in 2012.
Russia would have to spend at least $2.6 billion a year on methadone-type treatments, needles and AIDS drugs to reverse the HIV epidemic, the World Bank estimates. That’s on top of the $595 million it spent in 2013 to test and treat infected people, a sevenfold rise in seven years.
Treatment programs would have an immediate impact and costs would drop in two to three years, according to the World Bank. If Russia doesn’t act, expenses will mount and disruption to workers and families might further damp the economy, deprive the army of recruits and tear at the social fabric.
“You’ve got impacts on the health system,” says David Wilson, director of the World Bank’s Global HIV/AIDS program. “You’ve got impacts on the social system, you’ve got impacts on child rearing, you’ve got impacts on crime and antisocial behavior, all of which exert a toll.”
Without effective AIDS prevention, Pokrovsky is seeing another disturbing trend. HIV cases acquired through heterosexual sex are rising, accounting for about a third of new infections. That may signal the epidemic is entering the general population, he says. AIDS in 2010 was the third-biggest cause of premature death in Russia, behind heart disease and stroke, up from 10th in 2005, according to the Institute for Health Metrics and Evaluation at the University of Washington.
While HIV incidence is growing, Russia is making progress against other lingering health issues. Life expectancy, the second-lowest behind Kazakhstan in the WHO’s 53-nation European region, has risen to 69 years from 65 a decade ago. Russia’s abortion rate, once double its birth rate, remains Europe’s highest but is dropping, as are infant deaths, suicide rates and deaths from alcohol poisoning.
Russia, along with former Soviet states Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan, has geography against it when it comes to HIV. The countries lie along the drug route from Afghanistan to Europe, and each has seen infection rates climb since the USSR broke up in 1991.
“When you’re a zone of traffic, you’re also a zone of consumption,” says the UN’s Kazatchkine, who headed the Global Fund from 2007 to 2012. “And when you’re a zone of consumption, you’re also a zone of infection.”
Ukraine is making progress against HIV. Unlike Russia, it has taken advice -- and money -- from the Global Fund and other Western groups and has set up methadone clinics and clean-needle programs. Ukraine in 2012 reported its first drop in new infections since 1999.
Ruslan Rotar is one beneficiary. Born, raised, addicted and infected with HIV in Russia, he fled to Ukraine in 2012 to get methadone.
Outside a yellow-brick building in Poltava, an eastern city of 300,000, Rotar, 34, says the treatment is keeping him off heroin and out of the cemetery. He’s just taken his pills at the clinic inside, opening his mouth wide so a nurse can see he has swallowed them. He says if he returns to Russia, he’ll be back on drugs.
“I’m trying to avoid going back. I can’t quit,” Rotar says. “There’s no infrastructure. There’s no organization that can help me.”
Rotar was dealing heroin at 17 in Tolyatti, a town 1,000 kilometers (620 miles) southeast of Moscow that’s home to OAO AvtoVAZ (AVAZ), the maker of Lada cars. A police crackdown in the late 2000s made heroin scarcer and diminished the quality. Users switched en masse to krokodil.
“If you’re on a system like krokodil, you’re shooting up permanently,” says Rotar, who says the concoction can kill within a year. “You cook up, shoot, cook up, shoot. It’s like a job; it’s nonstop.”
HIV lowered Rotar’s defenses to infections, including tuberculosis. He says hospital officials in Russia kicked him out because he took drugs. Those interruptions in treatment caused another complication: His TB became drug resistant. At a hospital in Poltava, Rotar got care for his TB and methadone for his addiction. Drug users aren’t turned away, hospital manager Svetlana Gromova says.
Rotar says methadone isn’t perfect; it’s affecting his memory, a documented side effect. But it’s helping him get his life together.
“I’m taking care of myself, and I’m starting to think different,” he says. “I can function.”
Kiril Petrov, a former addict who’s now a coordinator with City Without Drugs in Yekaterinburg, Russia, dismisses such efforts. His organization favors an enforced cold-turkey approach.
“Methadone is a drug, and we are against drugs,” says Petrov, whose group seeks to curb dependency in a region where 1,117 people of every 100,000 have HIV. “It doesn’t work in Russia,” he says.
The same goes for needle exchanges. “If you are given needles, it’s a kind of propaganda: Go and use drugs,” he says.
Petrov says drug addiction isn’t an illness.
“This is a kind of frivolity that you allow yourself,” he says. “If you organize yourself and are more strict, you will manage to cope.”
On the outskirts of Yekaterinburg is a grim illustration of the unchecked consequences of Russia’s AIDS epidemic: a hospital on Kamskaya Street for HIV and TB patients that locals call the Last Way.
“It doesn’t have this name for nothing,” says Ivan Zhavoronkov, a consultant with local charity Chance Plus. “Every day, someone dies.”
On an unusually warm Friday in September, about 10 people talk and smoke on concrete benches in the hospital courtyard under a crab apple tree. Most of the 65 patients are too weak to leave their beds. They say a single television provides entertainment after administrators removed power sockets from rooms when patients started using them to cook up drugs.
Lucia Mokina weighed 39 kilograms (86 pounds) when she was admitted in March, weak and vomiting. She was diagnosed with HIV in 2007 and with TB in 2013.
“I’ll be here for a long time,” says Mokina, 35, wearing a pink jacket over a blue T-shirt with a panda on it. Mokina says she’s tried to quit drugs four times. “Nobody helped; they just took my money,” she says.
Pokrovsky, Russia’s most-experienced HIV official, bemoans policies that lead to scenes such as those at the Last Way. He says the government is putting his countrymen at risk and denying him proven tools -- from methadone to clean needles to tolerance of homosexuals -- to make a difference reining in HIV.
“The situation is really serious,” Pokrovsky says softly. “We have no effective prevention measures. We can only expect the most negative scenario.”
To contact the reporters on this story:
Simeon Bennett in Geneva at firstname.lastname@example.org;
Stepan Kravchenko in Moscow at email@example.com
To contact the editors responsible for this story: Phil Serafino at