Pubdate: Tue, 25 Jun 2002 Source: Wall Street Journal (US) Copyright: 2002 Dow Jones & Company, Inc. Contact: http://www.wsj.com/ Details: http://www.mapinc.org/media/487 Author: MARK SCHOOFS JAILED DRUG USERS ARE AT EPICENTER OF RUSSIA'S GROWING AIDS SCOURGE St. PETERSBURG -- When Alexander Multanovskiy was locked up in Kresty jail, a squalid, overcrowded brick complex built in the late 19th century, he blocked out the misery with heroin. The 25-year-old Russian believes that's how he contracted HIV, the AIDS virus, from one of his fellow inmates. "We were using the same needle," he says. Prisoners like Mr. Multanovskiy are helping make the former Soviet bloc home to the world's fastest-growing HIV epidemic, according to a report last year from the United Nations' AIDS program and the World Health Organization. Between 1996 and 2001, the number of registered new HIV infections in Russia annually surged to more than 87,000 from about 1,500. The rapid increase in infections and the huge number of Russians using injection drugs have fueled concern that the country could soon be host to one of the world's worst AIDS crises. But Russia faces an enormous challenge to containing the disease, as harsh drug laws send droves of HIV-positive patients into prisons, where treatment is minimal and the disease spreads through shared needles and sexual contact. Drug use soared in Russia amid the social disintegration following the collapse of the Soviet Union. Enforcement of harsh drug laws, largely unchanged since Soviet times, has helped flood Russia's jails and prisons with HIV carriers. About a sixth of the country's roughly 195,000 registered people with HIV are currently in jail, and many others who are now free have previously been incarcerated. At Kresty, which had fewer than 10 inmates with HIV in 1997, more than 1,000 have the AIDS virus today, out of a total of about 7,800 prisoners. HIV prevalence is far higher in prisons than in the general population, but health officials fear the figures are poised to rise both inside and outside prison. Russia's drug users number as high as four million of the country's 145 million people, according to some estimates. Intravenous drug use is the principal source of HIV infection in the country. Draconian drug statutes mean possession of even a minute amount of heroin can bring years behind bars. With the prevalence of needle-sharing in prison and the tendency of drug users to be jailed more than once, some experts project ever-rising infection rates across Russia through infected drug users moving in and out of prison. Andrei Kozlov and Vadim Pokrovskiy, two of Russia's leading HIV researchers, fear the infected prison and drug-using populations could provide the opening the virus needs to work its way into the general population. Judging from Russia's high rates of sexually transmitted diseases such as syphilis and gonorrhea, HIV could spread rapidly from drug users through sexual contact. Prison officials acknowledge that the disease could spread unnoticed. Usually, inmates are tested only when they enter prison or if they get sick. Prison officials say they have no reliable estimate for how often HIV is transmitted in prisons. The Ministry of Justice, which runs the country's prisons, has pushed to reduce overcrowding and to reform the legal code so that fewer addicts are sent to prison. "We want to improve our legislation to protect young people committing their first, not-very-serious crime," says Yuri Kalinin, deputy justice minister. The prison leadership has won praise from AIDS advocates for piloting new approaches to HIV control. But change has been slow and piecemeal. A visit to Kresty reveals the magnitude of the problem and the obstacles to solving it. Located on the Neva River in St. Petersburg, Kresty is the largest of the country's SIZOs, from the Russian for "pre-trial detention center." With the surge in drug crimes, these jails have become severely overcrowded in recent years because all suspects, innocent and guilty, are held in SIZOs until their trial verdict -- a process that usually takes months and can take more than a year. Each cell measures about 10 square yards. Crammed into that space are two three-tier bunk beds and as many as 10 prisoners. They sleep in shifts. Inmates and even some prison officials say the crowding makes controlling contraband such as drugs and syringes nearly impossible. Guards are underpaid and susceptible to bribery. Inmates pass drugs and syringes, along with innocuous messages and cigarettes, through what they call the "internet": black ropes they dangle down the exterior brick walls or fling from one barred window to another. Like most Russian prisons, Kresty tightly restricts access to condoms, because sex isn't allowed. It also restricts bleach, which can sterilize needles and tattooing instruments but can also be used to attempt suicide or attack other prisoners, officials say. Prisoners are supposed to be given an HIV test when they arrive. As in most Russian penitentiaries, Kresty's main defense against the spread of HIV is keeping infected inmates and uninfected ones in separate cellblocks. But as the case of Mr. Multanovskiy shows, segregation doesn't always work, and it can even promote the spread of the disease by making inmates feel they know who is infected and who isn't. Mr. Multanovskiy, broad-shouldered and blond, offers an incongruously clean-cut appearance in his black prison uniform. A drug user before he came to the SIZO, he says he tested negative for HIV upon arrival in March of last year. A senior prison doctor, who reviewed his medical record, could only confirm that Mr. Multanovskiy was placed in a cell with inmates who were all supposed to be free of HIV infection. After eight months, during which time Mr. Multanovskiy says he and his cellmates thought it was safe to share needles, he tested positive for the AIDS virus and was transferred to the block for infected prisoners. Prison medical authorities say lapses are rare. But evidence of mistakes isn't hard to find. Penal Colony Three in the small town of Dimitrograd conducts its own HIV tests on all prisoners arriving from SIZOs, because officials of the institution say the SIZOs often run out of money to perform the tests. Through June 7 of this year, the tests turned up five previously undetected HIV carriers, according to Sergei Tskhmistrenko, chief of the colony. Eight such cases turned up last year and three the year before. All of these inmates were probably held with HIV-negative prisoners in SIZOs, Mr. Tskhmistrenko says. In interviews, four HIV-infected prisoners who stayed in various SIZOs said they spent from one month to six months incarcerated with prisoners who weren't supposed to have the AIDS virus -- a fact confirmed by prison officials. One of the four prisoners said he knew he was HIV-positive and told fellow inmates but not prison authorities, for fear they might mistreat him. But the other three said they didn't know they were infected. One of these men admitted to sharing needles with his cellmates, and another said he shared his shaving razor. At Kresty, two HIV-negative prisoners -- Dmitri Vasiliev and Alexander Lotzman -- said three infected prisoners were plucked from their midst at various times. These cases weren't confirmed by Kresty officials, but they acknowledged that HIV testing was sometimes delayed for lack of money, syringes, test tubes or fuel for the car used to deliver blood samples to the laboratory. Infected inmates also can slip through a biological hole in the net. The test detects antibodies to HIV, not HIV itself. Since it can take the immune system as much as several months to generate those antibodies, inmates can test negative when they actually have an HIV infection. Perhaps the most dangerous aspect of the segregation policy is that it encourages prisoners to believe they can safely share needles. A 2000 survey of 1,200 Russian prisoners conducted by the humanitarian group Doctors Without Borders found that about 8% of inmates admitted to injecting drugs in prison. Of those, almost two-thirds said they shared syringes. "The striking thing is the risk-taking behavior," says Murdo Bijl, director of AIDS Foundation East West, an organization created by Doctors Without Borders to deal with AIDS in Russia. "If there is HIV in this group, it will be fairly quickly transmitted." Change Outside Jails Some critics say change must begin outside the jails, with Russia's tough criminal code and its hard-line medical establishment. The drug laws practically guarantee that anyone caught with any quantity of heroin, the most popular injection drug in Russia, can expect to spend a long time behind bars. Possession of up to five one-thousandths of a gram -- a gram is 1/28 of an ounce -- can draw as much as three years' imprisonment. Possession with intent to sell or process, a charge that nets many addicts who sell small amounts to support their habit, can bring a decade in prison. Russia's medical establishment has largely opposed reforming the penal system and treatment of drug addiction. Many doctors who hold influential positions today were educated under the authoritarian Soviet public-health system. They disagree with Western methods of treating heroin addiction and controlling HIV, especially needle-exchange programs, which provide addicts with free clean syringes, and methadone therapy. Some doctors, such as Alexei Mazus, director of the Moscow AIDS Center and one of the most prominent AIDS physicians in Russia, oppose needle-exchange programs. They fear the practice lures youths into addiction. Studies show that such programs have been effective in other countries in reducing HIV infection without encouraging drug use. Methadone is illegal in Russia. Prisoners suffering from withdrawal rarely receive any treatment and may resort to used needles and whatever is available to cope with the wrenching physical and psychological stress of withdrawal. "Unfortunately, we don't have methadone, so [prisoners] use home-made drugs ," says Pytor Prokopenko, commander of Matrosskaya Tishina, Moscow's main SIZO. An alliance of prison authorities, the Russian drug-control police and human-rights advocates has put forward a bill to overhaul the drug law. It would increase penalties for big-time dealers but reduce them for small-time users. One major change would be to raise the official recommendation on the amount of heroin that could lead to a serious prison term. The earliest this bill could take effect, however, would be the end of this year. Russian prison reform has been fitful, as well. Last year, a law took effect that limited to six months the time suspects could be held in a SIZO after their trials began. But on July 1, that reform will be stricken from the books, allowing authorities to hold prisoners for the duration of their trial. SIZO overcrowding is likely to worsen. Under U.S. federal law, possession of 100 grams of heroin will earn a first-time offender a mandatory five-year sentence. It's unlikely that a federal prosecutor would take a case involving five one-thousandths of a gram, and a state court probably wouldn't sentence a first-time offender to jail for that amount. In the U.S., many experts consider the incarceration of drug users one of the main contributing factors to the spread of HIV among African-Americans, the hardest-hit group in America. Most U.S. prisons also don't distribute condoms or needles in prison. A few of Russia's penal colonies have started selling condoms. In an effort to improve its AIDS prevention programs, the Ministry of Justice is collaborating with various Western aid organizations, such as the French doctors' group Medecins du Monde and the Open Society Institute, funded by financier George Soros. There are some signs of progress: Education has reduced HIV risk behavior among inmates, according to surveys by AIDS Foundation East West. The foundation has also started a pilot program with the Justice Ministry to distribute bleach and condoms. But the program began only this spring and doesn't operate in all prisons. These efforts could help limit the spread of the virus, but they can't help those already infected. Last to Get Drugs The vast majority of Russians with HIV were infected in the past few years. But because HIV typically takes more than five years to reach full-blown AIDS, the country has not yet been hit with an onslaught of sick people who require the expensive cocktails of so-called antiretroviral AIDS drugs . Despite their high numbers among the infected, prisoners will almost certainly be the last to get those drugs . The prison system can barely afford the most basic health measures. Prison officials recently reported that almost a quarter of inmates in St. Petersburg SIZOs lacked their own bedsheets. Released prisoners are referred to specialized AIDS Centers, but they also are strapped for funds. The richest, in Moscow, has funds to give antiretroviral drugs to just 500 patients. Some leading AIDS doctors frankly say they won't treat HIV-infected addicts, whom they see as unlikely to stick with the demanding regimen of antiretroviral pills. Since prisoners overwhelmingly acquire the virus by injecting illegal drugs , many won't qualify for treatment. "Homeless people and drug addicts will be at the end of the list," says Dr. Mazus, of the Moscow AIDS Center. AIDS activists say the Russian health establishment has stacked the deck against drug users by denying them methadone and other therapies that could stabilize their lives and help them adhere to the complex AIDS regimens. The prevailing attitude, charges Kasia Malinowska-Sempruch, who coordinates AIDS-prevention programs for drug users in the former Soviet bloc for the Open Society Institute, is that "HIV and drug use will take care of each other." - --- MAP posted-by: Keith Brilhart