Taking shelter briefly from the 20-degree cold in an activist group’s van near the outskirts of Moscow, Ivan, 26, recounted his closest call with HIV. He was shooting heroin with a group of people and didn’t have his own syringe, so the next man over offered him his own. Ivan was about to take it when an acquaintance warned him the man was “sick” – that he was HIV positive.
“That’s how people I know got infected, they shared syringes or slept with someone,” Ivan said. “Not everyone says that they are ill. Some don’t say anything so they won’t diminish their self-esteem.”
Ivan was lucky; an increasing number of Russians are not. HIV infections continue to fall worldwide, but Russia is in the throes of an HIV “epidemic”, as even some government officials are now styling it. The Andrey Rylkov Foundation, whose van Ivan was standing in as his girlfriend Masha received free medical consultation for a bone infection, is the only group that regularly does HIV prevention street work in Moscow. Four to five nights a week, they hand out needles, condoms, bandages and literature outside pharmacies that sell tropicamide eye drops, used to amplify the effect of low-grade heroin.
Vadim Pokrovsky, head of the federal Aids centre, this week told journalists that more than 27,500 Russians with HIV had died in 2015, a 13% increase on 2014. At least half of those died from Aids, he later confided, so their deaths could have been prevented.
HIV is spreading with increasing speed, with about 95,000 new cases in 2015 compared with 90,000 in 2014, most of them from drug use and heterosexual sex. That represents a much higher per-capita rate than in the UK, for instance, where there were 6,151 new HIV diagnoses in 2014.
In January, Russia reached a sad milestone when a 26-year-old woman from the Rostov region became the millionth person officially diagnosed with HIV. Pokrovsky estimated that the actual number of people with HIV is as high as 1.5 million.
“The tempo of growth is not slowing down, it’s high, and we need to strengthen prophylactic measures,” Pokrovsky said. “In five years it will double, up to 3 million people by 2020.” Maxim Malyshev, a Rylkov Foundation activist and former drug user who has been HIV positive since 1997, said: “Statistically, the problem can no longer be ignored. On the streets we constantly see that people are getting positive diagnoses.
“Treatment is unavailable for drug users. People don’t want to know their diagnosis, since it’s scary and there’s no way out.” Russia’s HIV policy is failing on two fronts, according to Pokrovsky: not enough is being spent on treating those who already have the virus, and effective measures are not being taken to protect those at risk of contracting it.
Instead of adopting standard harm reduction programmes, state agencies have promoted abstinence from sex and drugs and called for the development of an HIV prevention scheme to “reflect real national interests”. The stigma surrounding HIV is such that, in December, the television presenter Pavel Lobkov made the unprecedented move of declaring he was HIV positive during a live broadcast. Lobkov hoped to spark discussion about Russians’ view of HIV.
This week, Pokrovsky spoke out about a health ministry strategy to combat the spread of HIV, due to be presented to the government in March. The state has so far shown little inclination to commit significant funds to the scheme.
An extra 20bn roubles (£182m) was allocated to HIV prevention in 2016 after the health minister, Veronika Skvortsova, called for the number of HIV patients receiving antiretroviral therapy to be raised from the current 23% to 60%. But Alexander Yezdakov, an HIV activist with the movement Patient Control, said the funding was unlikely to be enough. Patient Control runs a website called pereboi.ru so that patients can report frequent shortages of antiretroviral medicines, blood tests and tuberculosis medication at local state Aids centres throughout Russia.
“If there was the right amount of financing, then there wouldn’t be this problem with disruptions [of treatment], or it would be very small,” Yezdakov said.
Pokrovsky said the real goal should be to extend treatment to 90% of HIV patients, as in other countries, and said that to begin halting the epidemic the state would have to spend at least 150bn roubles this year on treatment and preventative measures like harm reduction. Right now in Russia, such preventative measures are virtually nonexistent.
In the conservative political climate that has strengthened during president Vladimir Putin’s third term, harm reduction therapy – a standard approach in the west to limit the spread of HIV among at-risk groups like drug users and sex workers – has been shunned. Sex education is not taught in schools, with children’s ombudsman Pavel Astakhov famously saying “the best sex education that exists is Russian literature”.
Treatment with the common opioid drugs methadone and buprenorphine is banned in Russia, ruling out substitution therapy programmes to wean addicts off drugs. Three drug users have sued Russia in the European Court of Human Rights, arguing the ban on substitution therapy is discriminatory. A decision is expected within weeks, said Anya Sarang, an HIV activist.
As a result of this conservative approach, 55% of new HIV infections result from intravenous drug use and 43% from heterosexual sex, said Pokrovsky. This could change “if there was a rational approach to prophylactics”, including state adoption of harm reduction programmes at least in a few test regions, he said.
For now, the risk to drug users like Ivan remains high. The harm reduction work of Rylkov activists is little more than a tiny bandage on a vast and rapidly bleeding wound.
• Some names have been withheld