Needle exchange schemes are under threat / Innokentiy Rakin, RHRN
The AIDS Powderkeg
Will the end of the road for Russian HIV prevention bring disaster?What happens when a country achieves too much prosperity for international aid? Russia—and its HIV problem—is about to find out, as a trio of major grants (see table) from the Global Fund to Fight AIDS, Tuberculosis and Malaria, which have established and run the country’s core HIV prevention efforts, expire this year and next.
“What’s going to happen when the money runs out—that’s a big question mark,” says Robert Heimer, a professor of epidemiology and public health at Yale’s School of Public Health who has worked on HIV prevention in Russia for more than 12 years. “There are no back-up plans.”
Russia holds a dubious distinction: while HIV infection rates in most hotspots in sub-Saharan Africa and Southeast Asia are falling, or at least stabilizing, in Russia they continue to grow. In January 2009, the Russian Federal AIDS Center listed about 500,000 people living with HIV, but most estimates place the actual number at more than a million. The country’s epidemic is driven by a steady rise in injection drug use, largely in young people between the ages of 25 and 35. About 1-2% of the country’s population—and up to 5% of the population in some urban areas, including St. Petersburg—consists of injection drug users, and about half of IV drug users are HIV positive. In some regions of the country more than half of IV drug users are HIV positive. In five out of six cases the source of infection is another intravenous drug user. If such a high incidence rate in a single group remains untamed, says Heimer, the epidemic could spread to the general population through sexual networks, making it much more difficult to control.
Almost all efforts to deal with the problem have come from nongovernment organizations (NGOs). A handful of programs providing drug users with clean needles began on a small scale in 1996, says Anna Sarang, who founded the Moscow-based Russian Harm Reduction Network in 2003. Over the following three years, the three Global Fund grants provided $250 million USD for HIV prevention and treatment programs, developing about 80 programs throughout the country which conduct needle exchanges and provide condoms, as well as services such as counseling and drug rehabilitation.
“The reason why the Global Fund came in,” says Nicolas Cantau, the Global Fund Portfolio Manager for Russia, “was to stimulate a national response.” The plan seemed to be working; infection rates in regions with harm reduction programs fell measurably, and the Russian government—at least on paper—began to build its own HIV treatment capacity. It also publicly promised to take over the prevention programs seeded by the Global Fund starting in 2009, when the first of the three grants, termed GLOBUS, was set to expire.
Last June, however, the Russian government abruptly changed its tune. “We were all taken by surprise,” says Cantau. About 400 million rubles ($13.4 million) budgeted for the Ministry of Health in 2010 to support the GLOBUS projects vanished into thin air, says Dmitriy Goliaev, head of the Russian Health Care Foundation, which administers one of the three Global Fund grants, itself set to expire this September. Instead of HIV prevention, the government unveiled an ambitious mass media campaign promoting a healthy lifestyle. “I can’t quite imagine how it’s possible to convince an addict to take up exercise or give up smoking,” Goliaev wryly told a Moscow newspaper in December.
Despite the fact that the country no longer met the Global Fund’s economic eligibility criteria for HIV funding—and had actually become a donor to the organization—an emergency decision last November voted to extend GLOBUS for two years with an additional $24 million, with the hope that the NGOs it supports can win back government support. “When [foreign] donors cease financing these harm reduction programs, these programs will simply disappear”—and HIV rates among drug users will again start to grow, says Larisa Badrieva, an infectious disease doctor and, since 1999, director of “Obnovlenie” (Renewal), a harm reduction program in the city of Kazan. Maybe that will spur the government to support prevention programs, she says, “but then we will have to start all over again.” (Officials at the Russian Ministry of Health did not reply to an e-mail and formal fax requesting comment about the future of HIV prevention programs.)
One reason for the government’s resistance likely lies in the fact that policy-makers simply have no access to public health information. “I have an education in public health, which I got in America,” notes Mikhail Volik, an infectious disease physician and regional director for Russia at AIDS Foundation East-West, a Dutch NGO working in Eastern Europe and Central Asia. But such training is essentially absent in Russia, he notes— indeed, the first graduate program in public health at a Russian university opened with the help of Yale University in 2003. “This raises a problem,” he says. “Even though the country has money, and there is the means to support such efforts, they often don’t rely on evidence-based interventions.”
That in turn leaves organizations like his in a bind, says Volik. “Even if the government would agree to finance [our programs],” he says, “it doesn’t mean our organization would be willing to accept the money, because it may not correspond to the principles towards which we are oriented in our work.” The plan for the next two years, he says, is to strengthen community-based organizations and to help officials appreciate the value of such programs. Other NGOs, such as Stellit in St. Petersburg, are doing the same. Government officials “are not evil, they are just misinformed and misguided,” says Heimer, who collaborates with Stellit.
Goliaev sees the situation more cynically. “I think [the government] decided it didn’t make sense to spend money on high-risk groups,” he says. “But in the coming years, we will see that this was a tragic mistake.” x
Photo: Needle exchange schemes are under threat / Innokentiy Rakin, RHRN
