Stigmatisation undermining Russia’s HIV control eﬀorts Despite conciliatory language, continued marginalisation of vulnerable groups in Russia is likely having negative consequences on the HIV epidemic. Talha Burki reports.
www.thelancet.com/infection Vol 15 August 2015
human beings.” The industrial city of Yekaterinburg, on the border of Europe and Asia, was the site of the controversial City Without Drugs, a treatment centre, which faced criminal investigations amid allegations that patients were kidnapped, beaten, and handcuﬀed, and maintained on a diet of bread and water. The programme’s founder, Yevgeny Roizman, was subsequently elected mayor of Yekaterinburg. “People think he is a hero, that he was saving the city from
“…patients were kidnapped, beaten, and handcuﬀed, and maintained on a diet of bread and water” drugs”, said Sarang. Yekaterinburg and its region of Sverdlovsk is facing one of the largest HIV epidemics in Russia. Michel Kazatchkine, UN Special Envoy for HIV/AIDS in Eastern Europe and Central Asia, points out that the stigmatisation even extends into the health-care system. “In health centres, people will sometimes come up with absurd excuses to turn away drug users—they will say ‘come back when you are oﬀ drugs, that is when we will allow you to access treatment’”, he explained. Law enforcement can be heavyhanded and repressive. All of this stigmatisation encourages IDUs to remain in the shadows. “They are not seeking services because they feel that once they declare themselves as drug users, they will face arrest and harassment from the police”, said Kazatchkine. Around a third of IDUs are thought to be infected with HIV, and in some places this proportion is close to three-quarters. Moreover, the services that are available for IDUs are restricted. “There is basically no access to harm
reduction interventions—there is very little needle exchange and no opioid substitution therapy”, Kazatchkine told The Lancet Infectious Diseases. Needle exchange is not illegal in Russia. The criminal code forbids incitement to drug use, but it allows for HIV/AIDS programmes involved in needle exchange, assuming these programmes have the approval of the Federal Drug Control Service and local health authorities. “The idea of the legislation was that the authorities would develop a mechanism on how to approve needle exchange programmes, but even though they have been working on this for years, nothing has happened”, said Sarang. This delay could be down to oﬃcial disapproval of such programmes, or it could merely be bureaucratic inertia. “In this country it is impossible to get two ministries to work together”, points out Sarang. But the initiatives her organisation runs are unimpeded by the authorities. So why the dearth of similar programmes? “Fear is probably the main problem—people do not want to risk their reputation or relationship with the local government”, offers
Ria Novosti/Science Photo Library
On June 17, President Vladimir Putin chaired a state council meeting on Russia’s drugs policies. “We need to work more eﬀectively with those who have only just begun taking drugs”, he stated. “What is most important here is not punitive measures, but an effective system of prevention, treatment, and rehabilitation.” The president, whose tough conservatism has earned him the support of Russian nationalists and the Orthodox Church, struck a conspicuously liberal tone, affirming that “medical measures alone are not suﬃcient here; medical assistance must be followed up with social rehabilitation programmes to help people return to a full and normal life”. He spoke against forcing addicts into treatment centres and praised civil society groups working in drug rehabilitation. “I think that we should include them in the national system of comprehensive rehabilitation and resocialisation of drug users that we are developing”, Putin concluded. Whatever form the new national system takes, it has an enormous task on its hands. Injecting drug use drives Russia’s HIV/AIDS epidemic, with injecting drug users (IDUs) comprising 57% of newly diagnosed cases in 2013 (although this represents a substantial decrease from the 90% or so of a few years previously). An estimated 1·8 million Russians inject drugs, the highest number in the world. They face enormous stigma. Anya Sarang of the Andrey Rylkov Foundation for Health and Social Justice, the only nongovernmental organisation to provide street outreach work with a needle and syringe programme in Moscow, talks of thugs harassing her clients. “Drug users are demonised and hated”, she said. “In Russian society they are constructed as animals, people think they don’t deserve to be treated as
For the BBC radio documentary see http://www.bbc.co.uk/ news/magazine-32792830
Sarang. UNAIDS’ regional director Vinay Saldanha believes that local authorities are reluctant to support harm reduction in the absence of clear guidance from federal authorities. “We are engaged in a constructive dialogue with the Russian Government on looking at the global evidence that shows that harm reduction is safe and effective. We are also encouraging Russia to implement some of the easier things to reduce the number of new HIV infections in the country, like treatment as prevention”, he said. About 1 million people with HIV live in Russia. Prevalence is on the rise. “The data is clearly indicating that the epidemic is deteriorating signiﬁcantly”, said Saldanha. “Russia has the largest epidemic in the region, and several indicators suggest that they have not yet turned the corner”. In May, the head of Russia’s federal AIDS centre warned that Russia’s HIV caseload could reach 3 million within the next 5 years. Russia’s continued refusal to permit opioid substitution therapy concerns experts. Methadone is banned. Instead the country relies on a treatment system predicated on socalled detoxiﬁcation. Experts known as narcologists address addiction with a mixture of psychotherapy and the prescription of drugs to ease withdrawal. “There is no good
peer-reviewed evidence for the eﬃcacy of the Russian system”, notes Kazatchkine. “The Russian health authorities claim to have good results, but even if they do, these are only applied to a very small part of the population, as compared with the millions who use drugs in the country—it cannot have an impact on epidemic growth”. Rehabilitation is diﬃcult to access through the public health system, and private sector alternatives tend to be expensive and often have a religious tenor, which many drug users find off-putting. Russia’s aversion to methadone seems to be ideological—in a recent BBC radio documentary, the country’s chief narcologist joked that “methadone is similar to treating the vodka alcoholic with cognac”—and their opposition is unlikely to soften in the immediate future.
“Russia has the largest epidemic in the region…they have not yet turned the corner” The Russian Government has repeatedly aﬃrmed its commitment to tackling the HIV/AIDS epidemic. It has one of the oldest HIV surveillance systems in the world. “HIV/AIDS is an issue that again seems to be rising up the policy agenda in Russia”, said Saldanha. “The Russian Ministry of Health has made a lot of progress in scaling up programmes in some areas like access to HIV treatment and preventing mother to child transmission, including among injecting drug users”. Drug procurement is now under the aegis of the regional authorities and control eﬀorts are well funded. Nonetheless, the authenticity of Russia’s commitment is undermined by 2013 legislation banning the promotion of homosexuality. Notably, Putin’s council speech referenced drug addicts returning to a “normal” life, all of which is in keeping with a notion of cementing traditional family values and forcing
drug users, men who have sex with men (MSM), and sex work (which is illegal in Russia) to the margins of society. The marginalisation of MSM further complicates the ﬁght against infectious diseases. Oﬃcial statistics suggest that MSM comprise less than 3% of the HIV-positive population, but this is certain to be an underestimate. “MSM are not going to admit the way they got the infection”, said Sarang. “AIDS is still considered very much a medical issue in Russia, to be left to doctors and medical services”, stated Kazatchkine. “No-one thinks about changing the way that society looks at marginalised groups, these investments are lacking, and the political leadership that would allow for this investment to happen is lacking as well”. Prevention remains woefully underfunded (although in this, Russia is hardly unique). “We are certainly encouraging our partners in Russia to use a more focused approach to not only test people for HIV, but to scale up evidence-based prevention programmes among the regions and populations that are most aﬀected”, said Saldanha. But he concedes that, when it comes to drugs policies, this can be a tricky process. Worryingly, the growth in the number of Russians accessing treatment is much slower than the growth in the number of new cases of HIV. UNAIDS estimates that treatment covers about 35% of HIV-positive patients in Russia, against a global mean that hovers at about 60%. It is diﬃcult to see how all this can be addressed without Russian society overturning its attitudes of judgment and discrimination, and establishing a legal framework that is less hostile to vulnerable groups. “Maybe it will only be when the epidemic is more visible in the day-to-day life of the citizens, as more heterosexual infections occur out of the original nucleus of the vulnerable population, that the country will react”, posits Kazatchkine.
Talha Burki www.thelancet.com/infection Vol 15 August 2015