Pubdate: Sun, 24 May 2015
Source: Observer, The (UK)
Copyright: 2015 Guardian News and Media Limited
Author: Alecc Luhn


Infection rates are set to hit three million, but drug use and unsafe 
sex - the main causes - are rife. Alecc Luhn talks to those ignored 
by aid programmes

Almost as soon as two HIV-prevention activists set up outside the 
pharmacy in the outskirts of Moscow with two huge backpacks of 
supplies, a skinny young man with mussed hair and an impish grin 
quickly walked up to them.

"Do you have any ointment?" he asked, lifting up the leg of his 
tracksuit trousers to show a mass of red sores.

Asking what else he might need, the activists put antibiotic 
ointments, bandages and clean needles in a plastic bag.

"I don't have any immunity, and this stuff is expensive in the 
pharmacy," the young man said, giving his name only as Pavel, 28. His 
health problems arose from drinking and injecting heroin.

Asked if he takes steps to protect himself from contracting the 
Aids-related virus, he said he got clean needles, condoms and advice 
from the activists from the Andrey Rylkov Foundation.

This was Maryino, a far-flung district in south-east Moscow Drug 
addicts tend to gather near the nondescript pharmacy here because it 
sells tropicamide eye drops, which are typically used to dilate the 
pupil, without a prescription. Users add tropicamide to intravenous 
drugs to amplify the effect of the low-grade heroin they're using.

More than a dozen used needles were scattered in the parking lot and 
park outside the pharmacy, where a few middleaged women were walking 
their dogs.

"We call them snowdrops," said activist Lena Remnyova, who was giving 
out flyers inviting people to a drive to clean up the used needles. 
"Some people find flowers when the snow melts; we find needles," said 
colleague Asya Sosmina.

Moscow is at the epicentre of a rising HIV epidemic: while the number 
of those infected in Russia pales in comparison with the numbers in 
sub- Saharan Africa, it is one of the few countries where rates are 
growing rather than declining.

The government does not offer substitution therapy or harm reduction 
outreach, and the impact of grassroots groups such as Rylkov, which 
has only 15 staffers, is limited.

The official count of Russians living with HIV has risen to 930,000 
from 500,000 in 2010, and the actual number is probably much higher. 
(Of those registered, some 192,000 have already died.)

Vadim Pokrovsky, head of the federal Aids centre in Moscow, predicted 
this month that at least two million Russians are likely to be 
officially registered as HIV-positive within five years, and a total 
of three million will have the virus.

According to Pokrovsky, the failure stems from a lack of funding and 
the Kremlin's family-values-based approach to HIV prevention. Funding 
for fighting the disease has increased to 21bn roubles (UKP270m) this 
year, but most will go to antiretroviral therapy rather than 
preventative measures, he said.

"We need to spend 10 times more on prevention," Pokrovsky was quoted 
as saying earlier this month. "We need many more resources and we 
need some political decisions  and changes in the law in connection 
with methadone and the private lives of individuals."

The reasons behind the HIV epidemic are twofold: intravenous drug use 
and unsafe sex. More than 60% of HIV-positive Russians are thought to 
have used drugs, but the most common method of spreading the disease 
is heterosexual intercourse. Yet what groups like the World Health 
Organisation see as the most effective treatment of intravenous drug 
addiction is illegal in Russia. Opioid substitution therapy 
programmes to wean addicts off drugs are banned, and the use or 
distribution of methadone is punishable by up to 20 years in prison.

Crimea, annexed from Ukraine in March 2014, served as a case study in 
the effects of such an approach. For many of the 800-plus patients 
who had been undergoing substitution treatment there, being cut off 
from these programmes was a death sentence.

Michel Kazatchkine, the UN special envoy for HIV/Aids in eastern 
Europe and central Asia, said in January that 80 to 100 of these 
patients had died.

Pokrovsky has proposed introducing sex education to Russian schools, 
but in December children's rights ombudsman Pavel Astakhov, who once 
argued that the "best sex education there is, in fact, is Russian 
literature and literature in general", pledged it would "never" be 
taught in Russia.

"Most Russians are not in an official marriage, and a change in 
partners can lead to infection," said Ilya Lapin, an HIV prevention 
advocate. "A man infects himself and then he infects his partner. The 
problem is the lack of knowledge and education, even though it's 
easier to teach prophylactics than treat the disease."

Instead of harm reduction programmes to improve the safety of drug 
addicts as a first step toward curing addiction, the official policy 
is one of rehabilitation in state-run institutions. But the paperwork 
required and strict schedule inhibits many drug users, and only 
10-15% of patients at the city's substance abuse centre make it 
through the month of detox and on to the free rehabilitation programme.

The lack of outreach has driven organisations such as the Rylkov 
Foundation to hit the streets for guerrilla harm-reduction work.

Five evenings a week, part-time employees like Remnyova and Sosmina 
stand near pharmacies selling tropicamide over the counter, mostly in 
the outlying districts of the city, where the drug problem is most acute.

Besides clean needles and bandages, they hand out HIV and hepatitis 
tests, the organisation's newspaper and other HIV prevention 
literature, and naloxone, a drug that can be injected to help reverse 
an overdose.

"Our government thinks you need to just get rid of your drug 
addiction and your life will all work out," said Maksim Malyshev, a 
former heroin user who kicked his addiction with the help of harm 
reduction activists and became outreach coordinator at the Rylkov foundation.

"But we're realists because many people in our team are from the 
subculture, people who used drugs, people who still use drugs. To 
just quit completely doesn't work, so we try to do things a different way."

In the two hours before the pharmacy closes, 14 men and seven women 
accept bags of medical supplies and quickly whispered advice from the 
two activists. As they stand near the pharmacy, its security guard 
comes out to berate them for helping drug users. He leaves them alone 
after they point out that it's his pharmacy that is selling drugs 
without a prescription.

Many addicts  knowing there is widespread stigma against them among 
both medical personnel and the population at large  are deterred from 
seeking help or getting treatment for infections. "When people see my 
hand and how varicose it is, they say get out of here," said Sveta 
Yevseyeva  an occasional heroin user for the past 10 years  of the 
discrimination she faces every day. She can't get a job because she's 
on a register of known drug users, to which people are added if 
picked up by the police while high or if they leave detox early.

Many of those who stopped said they were aware of HIV prevention 
methods but that clean needles and medical products were hard to afford.

"We try to use clean needles and not share with unknown people, only 
with ones we know aren't sick," said one man who would give his name 
only as Sergei. But he admitted that a friend of his had been 
admitted to emergency care two months ago with Aids.

Activists hope President Vladimir Putin will adopt a more progressive 
approach to HIV prevention before it's too late. "Organisations like 
ours inform him, we send him reports, we do independent reports, we 
study international recommendations," Lapin said. "We talk about 
this, but he doesn't hear us."
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MAP posted-by: Jay Bergstrom