The Risk Lies in Not Knowing HIV AIDS Awareness and Acceptance towards PLWHA
TPAA - On the Frontline of an Epidemic
1. On the Frontline
of an Epidemic
The Need for Urgency in Russia’s
Fight Against AIDS
A Report of the U.S.-Russia Working Group Against HIV/AIDS
On the Frontline
of an Epidemic
The Need for Urgency in Russia’s
Fight Against AIDS
A Report of the U.S.-Russia Working Group Against HIV/AIDS
4. I I I
C O N T E N T S
IV FOREWORD
V OVERVIEW
1 CHAPTER 1: RUSSIA’S HIV/AIDS EPIDEMIC: STATUS AND OUTLOOK
2 High-Risk Groups and Bridge Populations
Injecting Drug Users
Sex Workers
Prison Population
4 Worrisome Trends
5 Projections for Russia’s HIV/AIDS Epidemic
7 CHAPTER 2: POLICY IMPLICATIONS
7 National Security Concerns
Military and Security Capacity
Demographics
Regional and Local Concerns
9 Economic Performance and Growth
10 Implications for the International Community
12 CHAPTER 3: PUBLIC POLICY AND LEGISLATION
12 Political Awareness and Funding
13 Legislation and Human Rights
Law on Drugs and Psychotropic Substances
Russian Criminal Code
15 Mobilizing for Action
16 Recommendations
18 CHAPTER 4: PREVENTION
19 Targeted Interventions
20 General Prevention
20 Recommendations
22 CHAPTER 5: TREATMENT, CARE, AND SUPPORT
22 Need for Treatment
23 Covering the Cost of Treatment
24 Cost of Not Treating
24 Recommendations
27 CONCLUSION
28 APPENDICES
28 A: Notes
30 B: Working Group Members
32 ABOUT THE SPONSORS
5. I V
F O R E W O R D
Throughout history, there have been many moments that required Russia and the United States
to join forces in a powerful alliance for the benefit of the international community. We fought side
by side in two world wars. We have explored the frontiers of space together. And, after the
horrific events of September 11, 2001, we joined forces in a global fight against international
terrorism.
The publication of this report of the U.S.-Russia Working Group Against HIV/AIDS repre-
sents the beginning of a new strategic partnership between our two nations, this time to
confront an equally significant threat to global peace and prosperity—the rapid and devastating
spread of HIV/AIDS in Eurasia. We are grateful to the EastWest Institute and its Board for launch-
ing the Working Group and helping to create Transatlantic Partners Against AIDS (TPAA), an inde-
pendent organization that will work to advance the Working Group’s policy recommendations and
programmatic initiatives.
The statistics are staggering; the forecast is grim. The implications of the HIV/AIDS epidemic
for both countries’ populations, economies, and national security are sobering. Yet, there is hope,
and powerful voices are calling us to action. Russian President Vladimir Putin acknowledged the
threat that HIV/AIDS represents to Russia in his May 2003 address to the Federal Assembly. At
our opening meeting in Moscow, U.S. Secretary of State Colin L. Powell declared, “The most terri-
ble weapon of mass destruction on earth today is the HIV virus that causes AIDS.”
There remains a short window of opportunity to avoid the catastrophe toward which Rus-
sia, which has the world’s fastest-growing HIV infection rate, and its neighbors are headed. We can
either surrender separately to this deadly affliction, or we can join together in a concerted offen-
sive against HIV/AIDS in Russia, its region, and across the globe.
The history of Russian-American collaboration has demonstrated that if we bring our best
and our brightest together toward a common purpose, we can change the course of history. No
other two nations can bring more resources, talent or genius to this battle.
This is our moment.
Mikhail Margelov Leo Hindery, Jr.
TPAA Co-Chairman TPAA Co-Chairman
Chairman, Foreign Affairs Committee Chairman and CEO
Federation Council of the Russian Federation YES Network
6. V
O V E R V I E W
John E. Tedstrom
President, Transatlantic Partners Against AIDS
AIDS is a global threat that affects us all. Its destructive reach extends far beyond the sphere of
public health,threatening social stability,economic performance,and national security. The United
States has struggled with HIV/AIDS for over 20 years. At least 440,000 Americans have died from
AIDS-related conditions, many more than would have if American political leaders had acted early
in the 1980s to confront the epidemic in its initial stages. Over time, however, the commitment of
the U.S. government to prevent the spread of HIV and treat people living with HIV/AIDS produced
remarkable results. New infections have dropped from 150,000 per year to 40,000 per year, and
AIDS-related deaths have been cut in half.
The United States has not defeated AIDS and its leaders continue to make mistakes. From
2000 to 2001, the rate of new infections in the United States rose for the first time since 1993, and
more than half of the 40,000 new infections in 2002 were found among people younger than 25—
startling statistics that speak to America’s ongoing struggle with this epidemic. Nevertheless,Amer-
ica’s experience demonstrates that dramatic improvements can be achieved when political
leadership is partnered with strong support from business and labor leaders, civil society, and peo-
ple living with HIV/AIDS.
HIV entered Russia more than a decade after the United States but has since struck with a
vengeance. The estimated rate of HIV prevalence in Russia is already several times higher than the
U.S.rate,and the prognosis for the epidemic’s development in Russia is terrifying.Given the late arrival
of HIV to Russia, its leaders have a unique window of opportunity to learn from the successes and
mistakes of other nations that are battling this epidemic. Experience from other parts of the world—
including from countries in North America, Western Europe, East Asia, Africa, and Latin America—
can provide Russia with lessons and ideas to develop its own strategy to fight against AIDS.
HIV/AIDS threatens to exacerbate severely Russia’s already worrisome demographic decline
and hinder its progress toward President Putin’s goal of doubling GDP by the end of the decade.
HIV is clustering with other sexually transmitted infections and multi-drug resistant tuberculo-
sis, presenting serious healthcare challenges. Independent experts in Russia and the West esti-
mate that over 1.5 million Russians are already infected with HIV; under worst-case scenarios, as
many as 8 million Russians, or over 10 percent of the adult population, could be infected by 2010.
Behind each one of these figures are innumerable personal tragedies that reach far beyond the
shocking statistical data. Unless strong, compassionate policies are adopted now, the tragedy will
only worsen.
Stigma and ignorance are HIV’s most powerful allies. In Russia, just as in the United States
and many other countries,marginalized groups have been the first to suffer. These groups are either
ignored or isolated,driving the infection underground. But then the virus spreads. When it hits uni-
versity students and young professionals, societies finally realize that HIV does not discriminate.
It infects the millionaire and the sports hero, the politician and the television star with the same
vengeance as it does the factory worker, university student, or newborn baby.
The epidemic in Russia is now growing fastest among the general (non-drug using, het-
erosexual) population. Over 80 percent of those infected are young people under the age of 30. Their
7. V I O N T H E F R O N T L I N E O F A N E P I D E M I C
illness and early death would rob Russia of its next generation of teachers, doctors, mothers, sol-
diers, and artists.
A strong,confident Russia—one that is democratic,prosperous,healthy,and successfully inte-
grated into the international community—would advance global stability and security. HIV/AIDS
threatens Russia’s ability to achieve its full potential and should be a top priority not only for Russ-
ian leaders, but also for policymakers throughout the world.
This report of the U.S.-Russia Working Group Against HIV/AIDS is the product of strong, prin-
cipled international collaboration. Written by a team of Russian and non-Russian Working Group
members, the report offers an independent, candid assessment of the current state of the epidemic,
articulates the response of various sectors battling the virus, and provides concrete policy recom-
mendations to Russian and Western leaders, corporate executives, and community activists.
The hard work and analysis provided by our Working Group has resulted in a report that is
rich in insight and practical ideas. The key policy recommendations include:
b Russian President Vladimir Putin declared in his annual presidential address to the Fed-
eral Assembly in May 2003 that HIV/AIDS represents a threat to Russia’s national secu-
rity. The President’s declaration marks an important milestone toward creating the
necessary political environment to confront the epidemic. President Putin’s next step
should be the creation of a new State Committee or Interagency Committee on HIV/AIDS.
This agency would have authority to coordinate policy across ministries, between fed-
eral, regional and local jurisdictions, and with international partners.
b The Russian government should quickly expand funding to combat the country’s HIV
epidemic. Russia’s federal AIDS budget for 2003 is only 122 million rubles (about $4 mil-
lion). In contrast, Brazil, a country of roughly the same population and per capita income,
will spend over $200 million this year on treatment alone. The Russian government has
found hundreds of millions of dollars in recent years to fund other priority projects. It now
must mobilize the resources required to address the strategic challenge of HIV/AIDS iden-
tified by President Putin.
b An official proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria should be a
top government priority. Achieving this will require the timely establishment of a genuine
country coordinating mechanism (CCM) that reflects the interests of Russian federal and
regional institutions, people living with HIV/AIDS, and representatives from civil society.
b Russia urgently needs to adopt a more decisive policy regarding the treatment of people
living with HIV/AIDS. Compulsory licensing,production of generic drugs,and procurement
of drugs at significantly reduced prices are all important ways of ensuring appropriate
access to treatment. Russia can draw on the successful experiences of many countries
around the world that have met this challenge to ensure the availability of treatment in
a manner that is fair, efficient, and sustainable.
b Structural reforms of Russia’s healthcare system will make distribution and monitoring
of treatments more effective and provide better-coordinated care for those living with HIV.
Access to treatment is currently centralized and controlled by a small group of federal and
regional AIDS Centers, and medicines are procured through a narrow channel of under-
paid bureaucrats tied to the Ministry of Health. Individual doctors must be given the train-
ing and authority to prescribe antiretroviral drugs and treat patients independently of the
AIDS Centers.
8. T H E N E E D F O R U R G E N C Y I N R U S S I A ’ S F I G H T A G A I N S T A I D S V I I
b Across the globe, civil society organizations and people living with HIV/AIDS have played
essential and productive roles in the fight against AIDS. The Russian government should
do more to support these groups and facilitate their inclusion in the planning and imple-
mentation of HIV/AIDS programs.
b The Russian government can use Russia’s international prominence to great advantage as
it steps up its efforts to combat HIV/AIDS. Within the Commonwealth of Independent
States, Russia can help lead an aggressive regional response to HIV. Moscow will host the
G-8 Summit for the first time in 2006, and President Putin can highlight his leadership
by demonstrating a strong track record on HIV/AIDS and articulating a clear agenda for
the future.
b The Paris Club of Foreign Debtor Countries and Russia should engage in negotiations to
retire Soviet-era debt in exchange for increased federal spending on HIV programs.
b HIV/AIDS in Russia has been and will be linked—directly or indirectly—to injecting drug
use, especially among young people. Already, an alarming number of Russian teenagers
are sharing needles and becoming infected with HIV. International experience demon-
strates that targeted interventions for drug users,including increased access to social serv-
ices, needle exchange and substitution therapy programs, sharply reduce the spread of
HIV. Contrary to opponents’ claims, there is no evidence that such interventions increase
drug use. The Russian government should urgently implement policies and enhance
resources for pragmatic prevention, education, and treatment programs for drug users.
b Russian authorities should improve and enforce policies that guarantee the rights and lib-
erties of all people living with HIV/AIDS. These citizens currently face widespread dis-
crimination, including in the workplace and in accessing health and social services.
b Concentrated and isolated populations, such as prisoners and the armed forces, are breed-
ing grounds for HIV and TB in Russia. Policies and programs should be implemented to
educate, treat and protect these populations, which already have infection rates signifi-
cantly higher than the general population.
b Russia’s business and labor communities represent untapped but potentially powerful
allies in the fight against HIV/AIDS. International experience has shown that business and
labor leaders can initiate effective HIV education campaigns that help people stay healthy,
protect the rights of all employees (including those already infected),and ensure that busi-
ness productivity is not undermined by the impact of AIDS.
The HIV/AIDS epidemic in Russia can only be addressed successfully through the imple-
mentation of a comprehensive, integrated approach based on best practices in the fields of educa-
tion and prevention; treatment, care and support; and human rights. Curbing the epidemic will
require the implementation of serious reforms in legislation and healthcare systems; the elimina-
tion of stigma and discrimination; expansions of federal resource allocation; and urgent, decisive
leadership from government officials, business executives, and civil society representatives. None
of these tasks will be easy. But every one of them will have a broad, positive impact on Russia and
should be supported by the international community. By initiating these important changes at
home,Russia’s leadership can create a legacy of accomplishment and compassion,and demonstrate
its commitment to addressing a truly global menace.
9. V I I I
250,000
FIGURE 1: Growth of Reported Cases of HIV Infection
in the Russian Federation, 1994-2002
Source: Data from the Russian Federal AIDS Center, 2003
OfficiallyRegisteredCasesofHIVInfection
201 1,525 4,366
200,000
150,000
100,000
50,000
0
1994 1995 1996 1997 1998 1999 2000 2001 2002
163 4,058
19,953
59,257
88,422
50,378
Year
Total Number of Reported Cases of HIV Infection Annual Number of Newly Reported Cases of HIV Infection
10. 1
C H A P T E R 1
RUSSIA’S HIV/AIDS EPIDEMIC:
STATUS AND OUTLOOK
Russia has recently emerged as a new epicenter in the global HIV/AIDS pandemic, with one
of the world’s highest rates of new infection. As of August 2003, there have been more than
245,000 officially diagnosed cases of HIV infection in Russia, over 80 percent of which were
reported in the last three years.1 It is widely acknowledged, however, that Russia’s official
statistics represent only a fraction of the actual number of HIV-infected Russians;most experts
estimate that the true number is somewhere between 1.5 million and 2 million citizens,or over
2 percent of the adult population.2
Epidemiologists warn that up to 8 million Russians—over 10 percent of the adult popu-
lation—could be infected by 2010, under worst-case scenarios.3 The epidemic is growing fastest
among young people aged 15-30, the very same group that should be leading Russia into the 21st
century.Figure1showsthedramaticgrowthofRussia’s HIV epidemicbetween1994andmid-2003,
as measured by official cases of HIV diagnosis registered with the Russian Federal AIDS Center.
Recent reports that the rate of new HIV infection in Russia is declining are almost
certainly misleading. Since 2000, the number of people in high-risk groups tested for HIV has
declined dramatically. According to official statistics compiled by the Russian Federal AIDS
Center, the number of injecting drug users tested for HIV infection dropped from a high of
524,300 in 2001 to 331,100 in 2002; this may explain why there were only 10,298 cases of HIV
infection registered among drug users in 2002,when almost three times that figure were diag-
nosed in 2001. Moreover, the federal government has recently stopped the supply of HIV test
kits to the regions;for those regions that cannot afford to purchase their own test kits,the num-
ber of tests (and the number of officially diagnosed HIV-positive people) has therefore declined.
Although HIV infection has been reported in virtually all of Russia’s 89 regions, there
11. 2 O N T H E F R O N T L I N E O F A N E P I D E M I C
are a number of geographic“hot spots”where HIV prevalence rates are much higher than aver-
age. Russia’s largest urban centers, Moscow and St. Petersburg, are epicenters for HIV/AIDS, as
are the strategically important cities of Kaliningrad, Togliatti, Norilsk, and Khanty-Mansiysk.
In Norilsk, over 1 percent of the adult male population is already officially diagnosed with HIV.
At the end of 2002, 11 regions of the Russian Federation reported HIV-prevalence rates
above 300 cases per 100,000 citizens. Of greatest concern are six regions that have prevalence
rates higher than 500 cases per 100,000: Sverdlovsk oblast (which includes Yekaterinburg);
Leningrad oblast; St. Petersburg; Samara oblast; Irkutsk; and Orenburg oblast. According to the
Russian Federal AIDS Center,39 percent of the entire Russian population is now living in regions
where between 0.2 percent and 0.6 percent of the population is officially diagnosed with HIV.
High-Risk Groups and Bridge Populations
Over the past decade, HIV transmission in Russia has been concentrated within a number of
high-risk populations, among which there is considerable overlap: (1) injecting drug users
(IDUs);(2) sex workers;and (3) prisoners.Men who have sex with men (MSM) and migrant work-
ers, especially those from Central Asia, are additional populations with high concentrations
of HIV. The future of Russia’s HIV/AIDS epidemic will turn on the degree to which these high-
risk groups serve as“bridge populations”for transmitting the virus into the heterosexual,non-
drug using population. Notable indicators that this shift is already underway include the rapid
rise in curable sexually transmitted infections in the general population and the growing rate
of new HIV infections among women over the last two years.
Injecting Drug Users
Since the early-1990s, drug use in Russia has exploded. Russia’s Ministry of Health estimates
that drug use soared by 400 percent between 1992 and 2002.4 According to numerous stud-
ies, drug users in Russia represent a larger share of the total population when compared to
other countries.5
There is a direct connection between injecting drug use and HIV.Given the widespread
use of shared needles and other equipment, HIV has spread swiftly through Russia’s drug sub-
culture in the past five to seven years, representing over 80 percent of all reported cases of HIV
infection with a known mode of transmission.HIV has already begun moving rapidly from that
sub-culture to people who have no direct contact to drugs, often through unprotected sex.
Russia is wedged between opium-producing Afghanistan and major drug markets
in Western Europe,making heroin and other opiates easily accessible. Russia’s long and porous
southern border, manned by underpaid and overworked customs inspectors, border guards,
and Interior Ministry officers,is especially susceptible to drug trafficking and transport of illicit
goods. The demand for illegal drugs has increased over the past decade, driven by a combi-
nation of factors, including the difficulties of Russia’s ongoing economic and political transi-
12. T H E N E E D F O R U R G E N C Y I N R U S S I A ’ S F I G H T A G A I N S T A I D S 3
tion,deteriorating education and healthcare systems,and a nationwide shortage of social serv-
ices and recovery programs for drug users.
Illegal drug use is especially rife among Russia’s youth. In May 2003, Russia’s Min-
ister of Education reported that 4 million young people between the ages of 11 and 24 were
using illicit drugs, and that about a million of them were drug dependent;6 around the same
time, an Education Ministry survey reported that 8 percent of Russian youths bought illegal
drugs every day.7 Both statistical and anecdotal evidence indicate that drug use among young
people in Russia continues to climb. This trend, together with a shortage of high-quality con-
doms and a lack of information about safer sex, suggests that conditions are ripe for the virus
to spread rapidly among Russia’s non-drug using youth.
Sex Workers
Sex workers constitute a second important high-risk group with the potential to spread HIV
into the general population. Since the collapse of the Soviet Union, sex work in Russia has
increased dramatically. In Moscow,the number of professional sex workers is believed to total
between 13,000 and 30,000.8 In St. Petersburg,the number of full-time prostitutes is estimated
at about 8,000.9
But sex work is not confined to those two cities. Port communities,mining cities,and
industrial centers are well-known for high concentrations of sex workers. A recent U.S. Cen-
ters for Disease Control and Prevention (CDC) study revealed high levels of epidemiological
exposure to sex workers in a number of cities in Saratov oblast, for example. Depending upon
the city under consideration,the researchers estimated the annual number of sex worker con-
tacts per 100,000 persons in the general population to range from a low of 33,000 to a high
of 730,000.10 If the pattern in Saratov mirrors other regions across Russia, the implications
for the spread of HIV, as well as for other public health problems, are dire.
Sex workers are widely known to engage in high-risk behavior. Leaving aside the
large number of sexual partners, condom use is erratic and there is considerable overlap
among sex work and injecting drug use. Targeted interventions in this community are essen-
tial to an effective overall HIV strategy.
Prison Population
With nearly 900,000 people held in prisons and pre-detention centers, Russia has one of the
world’s highest ratios of inmates to total population: an estimated 1 percent of the popula-
tion aged 20-64 is currently incarcerated.11 According to official Ministry of Justice data, as of
early 2003, over 37,000 inmates in Russian prisons and pre-detention centers were HIV posi-
tive.12 This would mean that 4.1 percent of Russia’s inmates are living with HIV—a rate nearly
30 times higher than registered for Russia’s non-incarcerated population. But HIV infection
rates among prisoners are certainly even higher than that; programs for testing Russian
inmates for HIV are poorly run and coverage is inconsistent.
Russia’s overcrowded prison system also harbors a myriad of risk factors that facil-
13. 4 O N T H E F R O N T L I N E O F A N E P I D E M I C
itate the spread of HIV. According to one survey,20 percent of Russian prisoners acknowledged
injecting drugs while incarcerated;13 another report, for Tyumen oblast, indicated that up to
one-third of young drug-using prisoners began using drugs in jail.14 Sex is also a major risk
factor for inmates: one survey of prisoners with 1.5- to 10-year sentences reported that 85
percent had sexual encounters while in prison.15 The vast majority of sexual encounters are
unsafe, as condoms are generally unavailable to prisoners.
The conditions and policies under which prisoners live create a breeding ground for
other infectious diseases, including drug-resistant tuberculosis. HIV and TB have high rates
of co-infection,and when prisoners are released into the general population,they all too often
carry both. Roughly one-tenth of Russia’s inmates now test positive for tuberculosis.16 In short,
the Russian prison system serves both as an incubator for the spread of HIV and other infec-
tious diseases, and also as a vehicle for spreading HIV into the general population when
inmates are released.
Worrisome Trends
In light of the dramatic rate of increase of HIV in recent years, the prognosis for the future
development of the epidemic is grim. The total number of persons living with HIV in Russia
will certainly continue to increase for several years—even if effective prevention programs
were implemented today.
Although Russia’s HIV epidemic has been largely concentrated among high-risk pop-
ulations, there is mounting evidence that the virus has already begun to move beyond these
groups into the general population. As recently as 2000, 90 percent of the country’s new offi-
cially registered HIV cases were attributed to injecting drug use. By 2002, however, the per-
centage of HIV cases ascribed directly to drug use fell to 36 percent, while the number of cases
attributed to heterosexual transmission rose to over 12 percent.17 Another indication that the
epidemic has spread more widely into the general population is the sharp increase in the num-
ber of babies born to women with HIV. In 2002, there were over 2,700 babies born to HIV-
positive mothers, an increase of more than 230 percent over 2001.18
Alarming trends in the incidence of curable sexually transmitted infections (STIs) also
point to the potential for HIV to spread into the general population. STIs greatly increase the
likelihood of HIV transmission,and their presence indicates that sexually active people are not
using protection. In 2002, the reported incidence rates for a number of STIs were many times
higher in Russia than comparable figures from Western European countries.19
The prevalence of STIs in some ostensibly “low-risk” populations is also remarkably
high. A survey recently conducted in St. Petersburg, for example, found that 15 percent of
university students questioned had at least one sexually transmitted disease.20 These trends,
14. T H E N E E D F O R U R G E N C Y I N R U S S I A ’ S F I G H T A G A I N S T A I D S 5
especially against the background of high rates of injecting drug use among Russian young
people, suggest a very dangerous mix of risky behavior.
Projections for Russia’s HIV/AIDS Epidemic
In planning an effective strategy to confront Russia’s HIV crisis, Russian policymakers must
consider a range of possible medium- and longer-term scenarios.21
Figures 2 and 3 demonstrate the impact of HIV on Russia’s life expectancy and work-
ing age population, respectively, under three different, but reasonable scenarios for the epi-
demic. The “mild” scenario presumes that Russia’s HIV prevalence peaks at 2 percent of the
adult population by 2025; the “intermediate” scenario assumes a 6 percent prevalence rate;
and the “severe” scenario assumes a 10 percent prevalence rate.22
Under the “mild” scenario—which some experts suggest Russia has already reached or
exceeded—Russia would have over 5 million cases of HIV infections by 2025, and over 3.4 million
persons in Russia would have died of AIDS. All gains in life expectancy would be rolled back for
15 years, and life expectancy would be four years lower than it would have been without HIV.
FIGURE 2: Projected Life Expectancy: Russia, 2000-2025
50
55
60
65
70
75
2000 2005 2010 2015 2020 2025
Year
LifeExpectancyatBirth(years)
75,000,000
80,000,000
85,000,000
90,000,000
95,000,000
100,000,000
105,000,000
2000 2005 2010 2015 2020 2025
FIGURE 3: Working-Age Population: Russia, 2000-2025
Year
U.S. Census Projections Mild Epidemic Intermediate Epidemic Severe Epidemic
PopulationAge15-64
U.S. Census Projections Mild Epidemic Intermediate Epidemic Severe Epidemic
15. 6 O N T H E F R O N T L I N E O F A N E P I D E M I C
Under the “intermediate” scenario, a cumulative total of 11 million people would
have contracted HIV in Russia by 2025—with 8.7 million deaths related to AIDS. The “severe”
scenario is extraordinarily grim: by these calculations, over 7 million people in Russia would
be living with HIV in 2025, and over 12 million would already have died of AIDS.
These projections illustrate the concrete challenges that HIV/AIDS represents for
Russia—challenges that must be confronted with decisive action. Even under the “mild”
scenario,HIV would be a horrendous humanitarian disaster for Russia,with an average of over
200,000 AIDS-related deaths each year beginning in 2010. In all cases, the impact of HIV on
Russia’s labor force is strong and negative.
The epidemic has much broader implications for Russia as well: by adversely impact-
ing the health and the size of Russia’s economically active population, the HIV epidemic will
exact serious costs in terms of economic performance. Foregone productivity and economic
growth due to HIV/AIDS will not only affect living standards. By negatively impacting the size
of Russia’s GDP, the epidemic will also limit Russia’s economic power—and by extension, Rus-
sia’s influence on the international stage. Even without considering the possibility of destabi-
lizing social tensions unleashed by the epidemic, Russia will potentially face severe adverse
consequences in the areas of national security and economic stability if it cannot successfully
control its HIV/AIDS epidemic. The numerous, multifaceted, and complex policy implications
of these trends will require a top-level, strategic commitment of resources for years to come.
FIGURE 2: Projected Life Expectancy: Russia, 2000-2025
50
55
60
65
70
75
2000 2005 2010 2015 2020 2025
Year
LifeExpectancyatBirth(years)
75,000,000
80,000,000
85,000,000
90,000,000
95,000,000
100,000,000
105,000,000
2000 2005 2010 2015 2020 2025
FIGURE 3: Working-Age Population: Russia, 2000-2025
Year
U.S. Census Projections Mild Epidemic Intermediate Epidemic Severe Epidemic
PopulationAge15-64
U.S. Census Projections Mild Epidemic Intermediate Epidemic Severe Epidemic
16. 7
C H A P T E R 2
POLICY IMPLICATIONS
The magnitude of Russia’s current HIV epidemic and its potential growth over the next several
decades make the disease an undeniable threat to national security,prosperity,and international
relations. Although Russia has had several years of steady economic growth, the country’s GDP
per capita is relatively small compared to the rest of Europe,and its political system remains vul-
nerable to shocks. There has been little official acknowledgement among Russia’s senior polit-
ical leaders that its surging HIV epidemic ranks among the country’s top national security
priorities; indeed, AIDS is not even mentioned in Russia’s current National Security Doctrine.
President Putin publicly acknowledged the threat from AIDS for the first time in his
annual address to the Federal Assembly in May 2003. Now, Russian leaders across the politi-
cal and governmental spectrum must work together to devise and implement a comprehen-
sive strategy to deal with that threat.
National Security Concerns
Military and Security Capacity
Russia’s military leaders have acknowledged that the size of Russia’s armed forces, which
currently totals roughly 1.2 million, will decline significantly in the future, with no indica-
tion of stabilization.23 Given Russia’s aging population,rising rates of male mortality,and lower
birth rates, even optimistic projections warn that by the year 2020, the Russian military will
only be able to field an army of 600,00o-700,000 conscripts. These estimates do not take
into account the rapidly deteriorating state of health among potential conscripts: during the
past several draft campaigns,nearly 40 percent of all draftees were rejected due to inadequate
17. 8 O N T H E F R O N T L I N E O F A N E P I D E M I C
mental or physical health.24 Moreover, the number of young conscripts who are found to be
using drugs has increased sharply in recent years, with serious implications for readiness.
According to data received by the Duma Defense Committee in October 2002, about 20 per-
cent of draftees were drug users and every 40th draftee (i.e., 2.5 percent) was a drug dealer.25
Since HIV infection disproportionately affects young men in Russia—particularly those who
are injecting drug users—the growth of HIV/AIDS will further limit the ability of the Russian
armed forces to recruit and maintain healthy personnel.
A shrinking cohort of young healthy men to serve in the Russian military would con-
ceivably weaken the ability of the Russian armed forces to control the country’s already porous
southern border. A smaller,overstretched military and less secure borders would likely dimin-
ish the country’s counterterrorism activities and undermine efforts to prevent trafficking in
drugs, illicit goods, and people—the kinds of threats that the Russian National Security Doc-
trine warns are dangers to Russian stability and security.
Demographics
As indicated in Chapter 1, the Russian population is shrinking, largely because of emigration,
declining life expectancy among men, and a birth rate below replacement level. The Russian
government’s conservative projections warn that by 2050, the country’s population will fall
by 30 percent from 143.6 million to 101.3 million; its worst-case scenario predicts that the pop-
ulation could drop to 77.2 million, a reduction of nearly 50 percent.25 The growing burden of
HIV/AIDS,which will have a disproportionate toll among Russia’s emerging generation of young
workers and military conscripts, will only serve to hasten the population decline. To date, HIV
has affected more men than women in Russia. While this trend is changing as the epidemic
matures, we can expect greater rates of infection among men for the foreseeable future.
Regional and Local Concerns
Certain regions of Russia face particularly devastating consequences.The surge in new HIV cases
in Russia’s Far East, for example, raises important questions about whether enough people will
remain in the region to fulfill even the most basic economic tasks. Today, the region is home to
a population of only 8 million, and territories such as Primorskiy Krai are facing a rapidly grow-
ing HIV/AIDS epidemic.In regions of Russia already confronting serious economic difficulties and
population shortages, HIV/AIDS represents an immediate threat to growth and stability.
The threat of HIV/AIDS to Russia’s national security is also linked to the problem of
the “re-export” of the virus. The Russian economy depends heavily on a steady and growing
supply of workers from other countries in the Commonwealth of Independent States (CIS).
At present,there are an estimated 10 million foreigners living and working in Russia. The Russ-
ian government provides few medical and social services for foreigners residing on its terri-
tory, which results in much higher rates of disease and disability among this population. This
largely disenfranchised and stigmatized migrant population, which has little or no access to
18. T H E N E E D F O R U R G E N C Y I N R U S S I A ’ S F I G H T A G A I N S T A I D S 9
information, testing, or treatment for HIV, could quickly become a vehicle for transmission
of HIV and other infectious diseases across borders.
From the perspective of other countries in the region,Russia’s HIV epidemic is a desta-
bilizing factor that threatens their own populations, economies, and national security. Given
the rapid escalation in Russia’s HIV epidemic, leaders from other CIS countries are concerned
that workers who return to their countries from Russia will bring with them new cases of
HIV infection, including strains of the virus that are resistant to available therapies.
Infection rates in Ukraine are comparable with those in Russia. Estonia, Latvia and
Lithuania—three European Union accession states—already harbor some of the highest rates
of HIV infection in Europe. And HIV is quickly emerging as a serious health risk throughout
Central Asia,where injecting drug use is rising sharply.Each of Russia’s CIS neighbors has fewer
resources than Russia does,which suggests that treatment and prevention programs through-
out the CIS will be ill-equipped to address the needs of a fast-growing epidemic.
Negative public attitudes about people living withHIV and AIDS are also a serious threat
to stability, especially as AIDS begins to claim the lives of large numbers of Russian men and
women. Surveys indicate that up to 30 percent of Russians would support programs to isolate
HIV-positive citizens from the rest of society. 27 Such opinions indicate the extent of fear and
misinformation about the disease that exists in Russian society. In many other countries facing
an advanced epidemic, negative and hostile attitudes toward HIV-positive citizens have led to
open conflict,especiallyinsmallcitiesandruralareas.Inordertoavoidthisoutcome,Russianeeds
to educate its population about HIV/AIDS in a way that reduces stigma and discrimination.
Economic Performance and Growth
The potential for HIV to impact Russia’s economy is especially severe because the disease dis-
proportionately affects people aged 15-30 and is occurring alongside an already steady decline
in Russia’s working age population that is expected to continue over the next several decades.
According to the World Bank, if current HIV transmission trends persist, Russia’s GDP in 2010
would be up to 4 percent lower than it would have been in the virus’ absence; by 2020, the
Bank predicts that the loss would have risen to over 10 percent.28
In most cases, HIV-infected individuals are afflicted by few debilitating symptoms
in the first few years after infection and are thus able to continue working. In some respects,
this is what Russia is experiencing now. However, HIV/AIDS will ultimately lead to a decline
in the supply of labor—both in productivity among workers affected by HIV and in absolute
numbers of workers as death rates rise.
HIV reduces productivity both directly and indirectly. The direct effects are increased
sick leave,the impact of related medical conditions,more frequent accidents,and reduced abil-
19. 1 0 O N T H E F R O N T L I N E O F A N E P I D E M I C
ity to perform. These effects come from HIV itself as well as co-infections and conditions such
as anxiety and depression that often plague people living with HIV. In addition, the produc-
tivity of family members, caregivers, friends, and others who build and maintain support
systems generally diminishes at the same time. HIV/AIDS not only affects marginalized and
disenfranchised populations, but increasingly is also striking the general labor force through-
out the economy, including in strategically important industries such as mining, oil and gas.
The aging of Russia’s population threatens to magnify the negative impact of HIV/AIDS
on Russia’s economy and healthcare system. As the Russian population ages, the majority of
pensioners will require expensive health care that the working-age population will struggle to
provide. A large and growing HIV-positive population will add to that fiscal burden.
HIV will also limit Russia’s economic prospects by requiring the diversion of resources
to provide medication and care for the sick and to implement comprehensive prevention pro-
grams. Such resources could,in the absence of a growing epidemic that requires massive funds
for immediate consumption, be invested in fueling economic growth and increasing the
nation’s savings rate. Thus, HIV/AIDS will have serious consequences not only for the govern-
ment’s fiscal health but also for long-term economic investment and growth.
As Russia races to catch up to major economies in Europe and North America and
achieve President Putin’s goal of doubling GDP by the end of the decade, even minor
reductions in Russia’s productivity and rates of growth would significantly reduce the abil-
ity of the Russian economy to compete with those of other industrialized nations.
Implications for the International Community
The Russian Federation shares borders with 12 countries from the Baltic Sea to the Pacific Ocean—
including countries in the West that are already in or are about to join NATO and the European
Union. In the East, Russia shares a long border with China, the world’s most populous country,
home to another emerging HIV crisis, and a source of intermittent friction for many years.
Russia’s emergence on the international scene as an increasingly effective and reli-
able partner whose long-term, strategic economic and political interests align with those of
other major democracies has been the hallmark of international affairs in the last decade. Rus-
sia’s progress in the last three years has been especially promising.Its robust economic growth,
its improving relations with Europe and the United States, and its movement toward WTO
accession are all signs of a strategic push toward modernization and integration that will serve
Russia well in the years to come. Russia’s partnership in the international war on terrorism
has been crucial to making the world a safer place. These developments, largely engineered
by President Putin, have gained the support and respect of Russia’s international peers. As
Russia continues on this path, however, HIV will make progress more challenging. A resolute
approach to Russia’s HIV crisis will limit the impact of the virus at home, improve interna-
20. T H E N E E D F O R U R G E N C Y I N R U S S I A ’ S F I G H T A G A I N S T A I D S 1 1
tional public opinion about Russia, and deepen Russia’s relationships with partners around
the world that have been grappling with the epidemic for some time already.
In many parts of the world, international multilateral agencies and bilateral donors
have worked in partnership with national governments to provide leadership and signifi-
cant funding for HIV prevention efforts and AIDS treatment initiatives. Scarce resources among
donors creates an imperative to spend HIV-targeted resources in areas of the world most
affected by the virus—namely,a handful of countries in sub-Saharan Africa and the Caribbean,
where infection rates are many times higher than in Russia or its region. However, given Rus-
sia’s rapid rates of new infection, officials around the world are beginning to take notice.
After five years of intense negotiations,Russia is now poised to receive a $150 million
loan from the World Bank to address tuberculosis and HIV/AIDS. The HIV/AIDS component of
the loan will allocate $50 million to support capacity building, surveillance, program devel-
opment, and interventions for prevention and care over a period of five years. By tripling the
resources that the Russian federal government is currently allocating for HIV/AIDS, the World
Bank project represents an historic opportunity for the Russian government to scale up its
investments to combat the virus.
The Global Fund to Fight AIDS, Tuberculosis and Malaria represents another poten-
tially significant opportunity for Russia to greatly expand the scope and depth of HIV/AIDS
activities. Unfortunately, Russia remains the only country in the CIS that has not submitted
a successful Global Fund application,29 in part because the Russian government has not yet
convened the requisite meeting of a “country coordinating mechanism” (CCM) to apply for a
grant. More than two years after the establishment of the Fund, Russia’s failure to submit a
CCM-endorsed application in each of the Fund’s three grant cycles has frustrated many in the
Russian HIV/AIDS field and has raised concerns among Russia’s international partners.
Other international donors and private foundations,including the UN agencies,USAID,
DFID, CIDA, TACIS, several European bilateral donors, and the Open Society Institute (OSI), also
play important roles in Russia’s response to HIV/AIDS. In some cases, these donors are prepar-
ing to reduce their assistance budgets in the coming years. While in many respects Russia
deserves to be“graduated”from these programs,HIV-associated funding should be considered
separately and should not be reduced. Going forward, strategic coordination among and
between these agencies and other groups can and should be enhanced.
Russia’s struggle with HIV does not exist in a vacuum. Indeed, in many respects, Rus-
sia is only now beginning to experience what other countries have struggled with for 20 years
or more. As Russia completes its transition and becomes more modern and integrated into the
global system, it is bound to face global challenges such as HIV, just as it enjoys the benefits
of greater security and increased prosperity. The international community has made HIV/AIDS
a global issue, and recognizes that conquering HIV requires a coordinated international
approach. Every country has a stake in every other country’s success in the fight against AIDS.
Strong partnership and coordination between Russia and its international partners at this rel-
atively early stage in Russia’s epidemic are essential.
21. 1 2
C H A P T E R 3
PUBLIC POLICY
AND LEGISLATION
The magnitude of Russia’s HIV/AIDS epidemic has far outgrown the ability of existing govern-
ment programs to combat the epidemic. Recent developments indicate that key Russian poli-
cymakers recognize the severity of the crisis and are prepared to develop a more comprehensive
national HIV/AIDS strategy.President Putin’s address to the Federal Assembly in May 2003 made
clear that the epidemic is no longer a taboo subject within the upper echelons of government.
Political Awareness and Funding
A sense of urgency in confronting the HIV/AIDS epidemic in Russia has long been missing
and sorely needs to be corrected. Most Russians erroneously view HIV as a disease that only
afflicts injecting drug users (IDUs), sex workers, prisoners, and men who have sex with men.
As in many other countries, Russian politicians and government officials have been reluc-
tant to address a problem that seems to affect only marginalized groups in society and has
not yet wreaked the economic and social havoc that a generalized epidemic would certainly
inflict. The instinct in Russia, as elsewhere, has been to rely on restrictive policies that aim
to detect and contain HIV within marginalized groups. In Russia, this has included the incar-
ceration of drug users without access to treatment and support; compulsory testing on the
basis of so-called risk groups; restrictions on employment, marriage or sexual activity based
22. T H E N E E D F O R U R G E N C Y I N R U S S I A ’ S F I G H T A G A I N S T A I D S 1 3
on HIV status;and compulsory notification of partners. These efforts have already proven inef-
fective at containing the epidemic in Russia, as evidenced by the rapid escalation in infec-
tion rates over the past several years.
Inadequate federal funding for HIV/AIDS research,surveillance,prevention,treatment
and support reflects the low priority ascribed by the Russian federal government to fighting
the epidemic. Russia developed its first federal AIDS program in 1993 under the leadership of
the Russian Ministry of Health. But, federal funding for the program was cut off entirely in
the years 1996 and 1997, not resuming until 1998.30 The current Russian Federal AIDS Pro-
gram (2002-06) allocates only 122 million rubles ($4 million) per year for all federally funded
HIV/AIDS prevention and treatment programs, which translates into less than 500 rubles ($16)
a year per diagnosed case of HIV infection.31 Russia’s regions devote additional funding to the
problem, but total government spending for domestic HIV/AIDS programs in the Russian Fed-
eration does not exceed 600 million rubles ($20 million) a year. By comparsion, the U.S. fed-
eral government will spend over $14 billion (425 billion rubles) in 2003 on its domestic HIV/AIDS
programs.32 The wide gap between comparable U.S. and Russian spending is not a matter of
resource ability as much as one of priorities.
The Russian Ministry of Health also devotes inadequate resources and personnel to
its Department of HIV/AIDS Prevention. The Russian government’s lead office dedicated to coor-
dinating federal HIV/AIDS activities is staffed with just five full-time personnel.33 The HIV/AIDS
secretariat at the Brazilian Ministry of Health, meanwhile, currently has about 250 staff.
In the area of treatment,current resources are sufficient to cover the cost of highly active
anti-retroviral therapy (HAART) for fewer than 2,000 patients. As the number of patients rapidly
increases over the next several years,the additional cost of treatment will quickly overwhelm the
limited budget of the Ministry of Health,thus making it impossible for ministry officials to cover
even a fraction of future treatment costs without significant expansions in federal funding.
Legislation and Human Rights
The Federal Law on AIDS, enacted in August 1995, is Russia’s most important and compre-
hensive piece of HIV/AIDS legislation, addressing a wide range of issues related to HIV test-
ing,confidentiality,anti-discrimination measures,and the right to medical treatment.34 Under
this law,the Russian state guarantees anonymous and confidential HIV testing; pre- and post-
test counseling; thorough epidemiological surveillance; and free access to medical care and
social welfare services for infected individuals. The law also requires the government to pro-
vide public information about the epidemic, develop and implement public education and
awareness campaigns to prevent infection, and include sex education in school curricula. The
law specifically prohibits discrimination against people living with HIV/AIDS, and states that
23. 1 4 O N T H E F R O N T L I N E O F A N E P I D E M I C
HIV-infected citizens possess all the rights and freedoms guaranteed by the Russian Consti-
tution, including access to employment, housing and medical care.
There is widespread evidence, however, that the human rights guarantees contained
in this law are regularly violated. Several studies have documented that people with HIV in Rus-
sia are frequently denied their most basic rights to privacy, health care, education and work.35
Access to treatment for people with HIV, both for opportunistic infections and for HIV itself, is
available only on a limited basis. Russian health personnel often refuse to provide treatment
andotherhealthcareservicestopeoplewithHIV,aswellastodrugusersandsexworkers.Employ-
ers regularly require prospective employees to be tested for HIV, refuse to hire people with HIV,
and dismiss them if their diagnosis becomes known.HIV-positive children are not admitted into
schools and kindergartens. Such human rights abuses are not the byproduct of inadequate leg-
islation, but instead are the result of inadequate implementation of the Federal AIDS Law.
Law on Drugs and Psychotropic Substances
Other existing Russian laws directly contradict the Federal AIDS Law, thus limiting effective
HIV prevention strategies and discriminating against people living with HIV. The most con-
troversial of these is the 1998 Federal Law on Drugs and Psychotropic Substances, which can
be interpreted as prohibiting activities that are intended to reduce the individual and social
harms associated with drug use, including the prevention of HIV infection among drug users.
According to a number of reports, police and other law enforcement officials often interpret
this law and its provisions as license to scrutinize, harass, and arrest those suspected of using
drugs—and to deny them services that can reduce their risk for contracting HIV.36 As a result,
Russia’s prison system is being flooded with drug users who continue to use drugs while in
prison but often do not have access to clean needles or substitution therapy.37
Although there is no legal basis in Russia to implement much needed prevention and
treatment programs among IDUs, many NGOs operate comprehensive harm reduction pro-
grams, often with the support and endorsement of senior officials at the Federal Ministry of
Health and from regional and local officials. For example, the Federal Ministry of Justice has
authorized an NGO-sponsored prison outreach program for inmates and prison guards. Exist-
ing harm reduction programs, however, reach only a small percentage of IDUs and members
of other at-risk populations who most need their services. Many drug users are wary of access-
ing harm reduction services out of fear of being harassed or arrested by law enforcement
authorities when visiting a needle exchange program or seeking counseling. As a result,many
IDUs stay underground, thus decreasing their access to services and simultaneously limiting
the impact of prevention and treatment programs.
The Federal Law on Drugs and Psychotropic Substances also forbids the medical use
of methadone and buprenorphine for the treatment of drug addiction. Russia justifies its posi-
tion on methadone on the basis of compliance with its international obligations to control the
spread and use of illegal drugs.38 Some other countries that are signatories to international
24. T H E N E E D F O R U R G E N C Y I N R U S S I A ’ S F I G H T A G A I N S T A I D S 1 5
drug control conventions, such as Canada and Australia, make methadone available for sub-
stitution therapy as an effective means to treat heroin addiction. Russia could take the same
approach. The overall impact of the Law on Drugs and Psychotropic Substances with regard to
HIV is a legal environment that isolates a key high-risk population in Russia that is already heav-
ily affected by HIV, thus limiting the potential to prevent the transmission of HIV to others.
Russian Criminal Code, Article 122
Under Article 122 of the Russian Criminal Code,it is a criminal offense to knowingly put some-
one else at risk for contracting HIV. The law itself, however, is vague and makes no mention
of whether specific activities (i.e. consensual sex with a condom, failing to inform medical
staff of one’s HIV-positive status, etc.) qualify as putting someone else in danger of contract-
ing HIV. If the law is interpreted broadly,an HIV-infected person who is aware of his or her sta-
tus is not legally permitted to have sexual intercourse at all,even if this intercourse is voluntary
and a condom is used. Activists in the region are adamantly opposed to Article 122, arguing
that it limits an individual’s constitutional rights to freedom, privacy and family life, and also
serves as a disincentive for Russians to find out their HIV status.
Mobilizing for Action
The legal environment that is necessary for an effective response to HIV/AIDS is unlikely to
emerge in Russia without serious debate. Recent efforts by conservative federal policymak-
ers to increase mandatory prison terms for drug-related crimes have been followed by new,
high-profile initiatives to re-criminalize voluntary sex between adult men. In June 2003, sev-
eral representatives of the Public Health Committee of the Moscow Municipal Duma intro-
duced legislation that would require employers to initiate mandatory testing for drug use and
HIV and would authorize municipal authorities to test all injecting drug users, sex workers,
street children, the homeless, and others they deem to be at high-risk for HIV. Moscow offi-
cials have dismissed concerns that mandatory testing would violate human rights, with one
Municipal Duma representative going so far as to declare that “democracy today is incom-
patible with public health.”39
Policies such as those being considered by the Moscow municipal legislators are
driven by a deep fear of HIV/AIDS and misinformation about how the virus spreads. If the Russ-
ian government does not effectively resist these types of initiatives, they could have a disas-
trous effect on efforts to control the epidemic. International experience has demonstrated that
repressive policies are not only ineffective at controlling the spread of HIV, but that they
weaken the legal environment needed to implement comprehensive HIV prevention and sup-
port programs. Experience elsewhere has also shown that high-level political leadership plays
25. 1 6 O N T H E F R O N T L I N E O F A N E P I D E M I C
a crucial role in raising public awareness of the realities of HIV/AIDS and ensuring that those
already infected receive adequate care and lead productive lives. Russian policymakers and
law enforcement officials must work harder to guarantee the rights of people living with
HIV. Only when the rights of people with HIV are protected in a meaningful and concrete
way will more individuals be willing to test voluntarily for HIV, and more importantly, take
measures to ensure that they protect themselves and others from infection.
The Russian Ministry of Health, in close cooperation with a consortium of local NGOs,
recently established a consultative “Advisory Council on HIV/AIDS.” The purpose of the council
is to facilitate cooperation between government, civil society, and international organizations
active in the HIV/AIDS field, and to develop programs and techniques to control the disease in
Russia. While the creation of the Advisory Council is an important first step, the council is not
a substitute for a high-profile State Committee or Interagency Committee on HIV/AIDS. The
Russian government needs to engage senior representatives of all federal ministries with mem-
bers of the Russian parliament and the Presidential Administration in order to develop and
oversee the Russian government’s federal HIV/AIDS strategy. Responsible and decisive leader-
ship—including key support from the State Duma, the Federation Council, and the Presiden-
tial Administration—would significantly improve Russia’s ability to respond effectively to its
HIV crisis.
Recommendations
b Exercise bold leadership and take decisive action. President Putin’s public mention
of AIDS in May 2003 was an important step toward creating the necessary political
environment for effectively combating the epidemic. Political leaders and govern-
ment officials should seize the window of opportunity Putin’s statement has cre-
ated and increase their attention to and involvement in the fight against HIV/AIDS.
b Establish a State Committee or Interagency Committee on HIV/AIDS. This new fed-
eral committee would have authority to develop and overseeHIV/AIDS policies and pro-
grams across ministries and between federal,regional and local jurisdictions as well as
with international partners. The creation of such a committee would also elevate the
political profile of HIV/AIDS and provide the Russian government with a much-needed
focal point for all future advocacy efforts.
b Greatly expand federal funding to meet the growing resource needs of HIV/AIDS.
Grants and loans from international institutions and bilateral donors are not a sub-
stitute for the Russian government’s own domestic funding for HIV/AIDS. The Russ-
26. T H E N E E D F O R U R G E N C Y I N R U S S I A ’ S F I G H T A G A I N S T A I D S 1 7
ian government must increase the availability of funding and other federal resources
to a level that adequately meets growing needs for research, prevention, treatment
and support of people living with HIV/AIDS.
b Make HIV a national security priority. By including HIV in Russia’s National Secu-
rity Doctrine, Russian officials can provide leadership and motivate elected officials,
regional leaders,experts and activists to step up their efforts in the fight against AIDS.
b Capitalize on Russia’s international prominence. Russia can help lead an aggres-
sive regional response to HIV within the Commonwealth of Independent States,thereby
helping reduce the spread of HIV/AIDS across borders and bolstering regional stability
and economic growth. Through its membership in the G-8, Russia can demonstrate
to the broader international community its ability to lead on a complex issue of global
importance. Bold and effective measures in response to HIV/AIDS over the next two
years could be used to great advantage when Russia hosts the G-8 Summit in 2006.
b Seek support through the G-8 for relief of Soviet-era debts in exchange for increased
domestic spending on HIV/AIDS. The G-8 also has considerable leverage over the
agenda of other international institutions, such as the Paris Club of Foreign Debtor
Countries. Russia, which is still paying off Soviet-era debts held by the Paris Club,
could pursue relief of those debts in exchange for pledges to increase its own domes-
tic spending on HIV/AIDS.
b Ensure the rights and liberties of people living with HIV/AIDS.Individuals infected
with HIV often face severe discrimination, including in the workplace and in access-
ing health care. Russian political leaders should work to expand legislative protec-
tion for people living with HIV/AIDS and ensure that laws are implemented in a rapid
and measurable manner. In order to ensure that policies and programs reflect the
concerns of people living with HIV, representatives from the HIV community should
be included as partners throughout the process of policy development and program
implementation.
b Make a successful application to the Global Fund to Fight AIDS, Tuberculosis and
Malaria a top government priority. Achieving this will require the timely estab-
lishment of a genuine country coordinating mechanism (CCM) that reflects the needs
and interests of Russian federal and regional institutions,people living with HIV/AIDS,
and representatives from civil society. The CCM must be charged with developing a
coordinated, transparent proposal that integrates the areas of research, prevention,
education, counseling, diagnostics, treatment, care and support.
27. 1 8
C H A P T E R 4
PREVENTION
Developing and implementing effective HIV prevention strategies is difficult in every soci-
ety, in large part because HIV is a moving target that is rarely contained in marginalized and
isolated demographic groups.Therefore,prevention programs must be multifaceted,ultimately
reaching all members of society—including those who may not be aware that they are at
risk for infection. The countries that have been most successful in reducing HIV transmission
rates are those in which frank, nonjudgmental prevention campaigns recognize the realities
of human nature and are combined with easy and consistent access to safer-sex informa-
tion and materials, counseling, and other social services.
By endorsing and adopting pragmatic and universal prevention strategies that have
proven effective in other countries, the Russian government can quickly improve its ability
to combat the HIV epidemic. Conservative policies in Russia continue to block sex education
in most schools and limit the ability of more progressive policymakers to initiate targeted pre-
vention campaigns for socially marginalized groups including injecting drug users (IDUs),
sex workers, prisoners, and men who have sex with men. Along with other groups increas-
ingly at risk for infection, such as migrant workers and ethnic minorities, members of these
populations are in dire need of relevant, accessible, and realistic information about HIV. Russ-
ian officials will make little headway in reducing transmission unless they work with high-
risk groups, not against them, in an effort to change potentially risky behavior.
Inadequate federal policies and financing for HIV prevention to date have meant that
the nascent Russian civil society has played a vital,albeit limited,role in HIV prevention efforts.
Some 60 nongovernmental organizations (NGOs) currently operate HIV/AIDS programs in Rus-
sia, most of which focus on prevention among high-risk groups and defending the rights of
people living with the virus. These civil society groups represent an important source of com-
28. T H E N E E D F O R U R G E N C Y I N R U S S I A ’ S F I G H T A G A I N S T A I D S 1 9
munity-based experience and accurate information about high-risk groups that government
officials should tap as they consider new prevention strategies. Already, authorities in some
50 Russian regions have begun to employ the prevention and social support methods devel-
oped by NGOs and to support the efforts of the NGO sector.
Many Russian NGOs, particularly those operating outside of Moscow and St. Peters-
burg,still face significant obstacles that threaten their very viability. They are chronically short
of funds, mostly because philanthropy remains a novel concept in Russia, and there are few
mechanisms in place to transfer government funds to support their work.In addition,although
many NGO workers are highly motivated and educated,they frequently lack knowledge about
non-profit and resource management,social marketing,and public relations.More widespread
application of international non-profit standards and norms would help rectify these prob-
lems and also serve to reduce authorities’ mistrust of NGOs.
Targeted Interventions
Because Russia’s HIV epidemic is linked so closely to widespread injecting drug use, any suc-
cessful approach to containing the virus must work closely with the drug-using population.
Such a strategy should include targeted education programs that reduce the likelihood of peo-
ple choosing to use drugs for the first time; counseling and substitution therapies that help
eliminate or reduce use among current users;and needle exchange programs to limit the virus’
spread among people who continue to use drugs. Studies from communities around the world
over the past 20 years have shown that HIV infection rates among IDUs decline, often rapidly
and steeply, when such “harm reduction” services are readily available. As a result, it is a pre-
vention strategy supported by nearly all leading international public health organizations,
widely practiced in many Western European countries, and increasingly common and suc-
cessful in other nations such as Canada and Australia.
Given the high incidence of HIV transmission among IDUs in Russia, it is only logi-
cal to include an aggressive harm reduction regime as part of an overall strategy to confront
HIV. By some accounts,more than 100 harm reduction programs have been established in var-
ious Russian cities over the past decade, often by international NGOs working in tandem with
local health agencies. Their work has been made difficult because these programs are tech-
nically illegal. Still, many local and regional governments have come to respect their efforts
and rely on such programs.
Like the rest of society, drug users want to protect themselves and others from HIV,
even if they are not able or willing to stop using illegal drugs. For the benefit of the nation’s
overall health, they should be given the opportunity to keep themselves and others safe.
29. 2 0 O N T H E F R O N T L I N E O F A N E P I D E M I C
General Prevention
The average Russian’s misconceptions about HIV/AIDS are proof that the limited and tenta-
tive prevention programs aimed at the general population to date have been ineffective. Most
observers agree that mass media campaigns and realistic health education policies should
be developed and implemented as the first steps in a comprehensive prevention strategy for
the future. The government needs to become more supportive of and involved in safer sex
campaigns and in education efforts designed to reduce the stigma associated with HIV/AIDS.
Russia’s high literacy rate, as well as the fact that virtually every home has a television, makes
mass media an effective way to deliver the message.
Russia’s nascent NGO sector has shown initiative in devising thoughtful prevention
programs. NGO-sponsored mass media campaigns are growing in number and have proven
effective in communicating HIV prevention messages to young people and members of high-
risk groups. These campaigns have provided a forum for young people to talk about issues
related to reducing HIV risk,such as condom use and safer sex. Yet funding for these programs
and others like them has been scarce at the very time when their scale and reach should be
intensified.
Government authorities should reach out to experienced NGOs, both domestic and
international, and also to foreign governments that have faced burgeoning HIV epidemics in
previous years.Prevention strategies that were effective in helping increase HIV awareness and
reduce transmission rates in other countries could conceivably be adapted to Russian cultural
mores. Policymakers should never lose sight of the ultimate goal, which is to provide open
and honest information about transmission and how young people in particular can protect
themselves. This will require overcoming taboos against sex education in schools and recog-
nizing the fact that teenagers across the country continue to experiment with sex and drugs.
Recommendations
b Adopt policies that encourage the growth of civil society. The government can help
foster an increase in philanthropy among Russian businesses and individuals by pro-
viding more extensive tax incentives for charitable giving, helping to establish train-
ing programs for NGO leaders, and improving NGO monitoring systems. Such
developments would greatly increase resources available to civil society groups and
significantly alleviate lingering distrust of NGOs’ financial and decision-making
processes.
30. T H E N E E D F O R U R G E N C Y I N R U S S I A ’ S F I G H T A G A I N S T A I D S 2 1
b Promote partnerships between civil society and government agencies. Government
partnership and support for NGOs would be a significant move forward in strength-
ening the financial sustainability of NGOs,many of which are better placed than gov-
ernment agencies to provide prevention services to high-risk communities. NGOs
should also be more directly involved in forming the national AIDS strategy as well
as those of regional and local governments.
b Adopt realistic prevention strategies that mitigate the risks of HIV infection among
high-risk populations, including injecting drug users. International experience
demonstrates that targeted, nonjudgmental interventions with drug users, includ-
ing increased access to social services in addition to needle exchange and substitu-
tion therapy programs,sharply reduces the spread of HIV among drug users. Contrary
to opponents’ claims, there is no evidence that such interventions increase drug use.
Russian officials should legalize harm reduction programs and allow the use of sub-
stitution therapy for drug users seeking to wean themselves off of heroin.
b Target youth through increased sex education in schools. Young people are among
the most vulnerable to HIV infection, often because they are ignorant about how
the virus is transmitted and do not believe they are at risk. Sex education programs
need to be adopted in all the nation’s schools and should be based on the assump-
tion that many young people are indeed choosing to have sex and need to know how
and why to take protective measures.
b Reach out to minority groups and isolated populations with targeted awareness
and education messages. Unless minority groups and isolated populations—such as
migrant workers, prisoners, and military personnel—are provided with targeted
information campaigns and other prevention and education programs,they will con-
tinue to represent high-risk sources for the spread of the epidemic.
b Promote public discourse on the risks of HIV infection. Restricted discussion in the
mass media on the effects of drug use, sex, and related issues must be relaxed if
Russian citizens, especially young people, are to have any hope of learning how to
protect themselves and others from HIV.
31. 2 2
C H A P T E R 5
TREATMENT, CARE, AND SUPPORT
Need for Treatment
Russia’s 1995 Federal AIDS Law, which was written when there were barely 1,000 diagnosed
cases of HIV infecti0n, guarantees free access to treatment and related healthcare support
for all Russian citizens diagnosed with HIV. Since the HIV epidemic began to surge in 1997,
however, some 250,000 new patients have been diagnosed with the virus. Yet, current
resources are sufficient to cover the cost of highly active antiretroviral therapy (HAART) for
fewer than 2,000 patients. Although most of the key antiretroviral (ARV) drugs—including
some of the newer combination drugs—have been registered in Russia, they are not avail-
able to most of the people who need them.40 Additionally, the continued widespread use of
monotherapy in Russia risks causing HIV drug resistance, which, in terms of overall public
health, may be more damaging than no treatment at all.
Many of Russia’s AIDS Centers do not have the expensive laboratory equipment for
CD4 testing, viral load testing, and ARV resistance testing that are required to effectively mon-
itor AIDS treatment,and even fewer have the psychological or support services to complement
drug therapy.41 Moreover,most patients are unaware of their rights and responsibilities related
to HIV treatment, and AIDS Center personnel often complain about the lack of information
materials available for distribution to HIV-infected patients. Even if treatment and support
were readily available for all Russians who require it, many patients do not know enough
about their condition to request treatment or seek counseling.
Over the next several years, the demand for treatment will increase more than one
hundred-fold as most, if not all, of the quarter-million HIV-infected individuals already regis-
tered with the authorities become ill and require treatment, care, and support. The likely
32. T H E N E E D F O R U R G E N C Y I N R U S S I A ’ S F I G H T A G A I N S T A I D S 2 3
demand is even greater when the hundreds of thousands of HIV-infected Russians who are
not officially diagnosed or who do not know their status are factored into the equation.
At the most basic and humane level, reliable access to treatment and support is nec-
essary to help keep HIV-infected people alive. It has also been shown to have a major benefi-
cial effect on prevention efforts because at-risk individuals have a greater incentive to get
tested and know their serostatus if treatment that can prolong their lives is readily available.
Whether they test positive or negative, people who know their status are far more likely to
change behavior that puts them and others at risk (thus reducing transmission), and to seek
out other social and healthcare services. Such developments tend to de-stigmatize HIV/AIDS
and increase the amount of attention paid to the epidemic by policymakers and the popula-
tion in general.
Covering the Cost of Treatment
Cost remains a major barrier to treatment in Russia. Russian health agencies continue to pay
some of the highest prices in the world for HAART and other HIV/AIDS medications: triple-com-
bination therapy in Russia ranges from 180,000 to 460,000 rubles ($6,000 to $15,000) per
patient, per year—equal to or more expensive than the retail cost in far wealthier countries.
For the minority of Russian patients who have the necessary financial means, it is often
cheaper to travel elsewhere in Europe to purchase a six-month supply of antiretroviral med-
ications than it is to purchase the same supply at market prices in Moscow.
There are a variety of reasons for such high costs. Russia does not qualify for dis-
counts reserved for low-income countries such as those in sub-Saharan Africa. Unlike their
European or North American counterparts,Russian health agencies do not purchase sufficient
quantities of antiretroviral drugs to negotiate volume discounts. And, unlike Brazil and Thai-
land, Russia has not begun producing antiretrovirals domestically as part of a cost-saving
effort. Brazilian policymakers,for example,have managed to provide antiretroviral therapy to
all who need it through a combination of domestic production and negotiating substantial
price reductions on imported drugs.
Thus far, the Russian federal government has responded to the growing need for
treatment and care by allocating a growing proportion of its small HIV/AIDS budget to drug
procurement. While perhaps an understandable priority given the deadly nature of the illness,
increased funds for treatment come at the expense of already inadequate budgets for pre-
vention and education.
Given the limited resources of the federal Ministry of Health, the burden to provide
treatment has fallen increasingly on the regional governments, which are already collectively
purchasing the majority of antiretroviral drugs in Russia.Only a small number of economically
33. 2 4 O N T H E F R O N T L I N E O F A N E P I D E M I C
prosperous regions may be able to meet the growing needs of treatment, however. Without
far greater levels of federal assistance,the majority of Russian regions that are facing fast-grow-
ing epidemics will be hard-pressed to mobilize additional resources adequate to treat their
patients with HIV/AIDS, thus indirectly consigning thousands of people to death from AIDS.Such
regional discrepancies in levels of care have already placed additional strain on both health
authorities and people living with HIV. Fleeing discrimination, stigma and lack of treatment
options, thousands of HIV-infected Russians have moved from poorer provincial areas to large
cities such as Moscow or St. Petersburg. Even then, though, they are often unable to access
HIV-specific treatment or most social services because they lack local residency permits.
Cost of Not Treating
Based on current prices and official rates of infection, by the year 2008, Russia will have to
spend over 36 billion rubles ($1.2 billion) per year just on medication to treat eligible HIV/AIDS
patients. Even if Russia can lower the cost of treatment to $2,000 per patient per year (as
in Ukraine), it will still cost 15.2 billion rubles ($500 million) per year—a sum larger than the
entire budget of the Russian Ministry of Health for treatment and prevention of all infec-
tious diseases.
The long-term financial and social costs, however, could be even greater if adequate
treatment is not provided now. If treatment access does not improve, mortality rates for AIDS
in Russia are expected to increase from 500 deaths per month by 2005 to an optimistic scenario
of 21,000 deaths per month by 2020.42 Such a death toll could conceivably overwhelm the Russ-
ian healthcare system, which lacks adequate hospital space to care for such an onslaught of
critically ill patients. Given the magnitude of this growing problem, the Russian government
as well as the foreign organizations and agencies working in the HIV/AIDS field must make
access to treatment a priority for more attention, stronger policies, and adequate resources.
Recommendations
b Prioritize universal access. The Russian federal government should take steps to
meet its commitment to cover all the costs of diagnosis, treatment and monitoring
for all HIV-infected citizens who require access to antiretroviral treatment,regardless
of where they have a residence permit or how they were infected with the virus.
Universal access to antiretroviral therapy would help to reduce stigma, improve pre-
34. T H E N E E D F O R U R G E N C Y I N R U S S I A ’ S F I G H T A G A I N S T A I D S 2 5
vention by creating incentives for voluntary testing, and provide important health
benefits for people affected by HIV.
b Aggressively seek price discounts for antiretroviral drugs. The Russian government
must urgently engage foreign and Russian pharmaceutical and diagnostics manu-
facturers to negotiate accelerated price reductions of antiretroviral drugs and related
lab diagnostics that are fair, efficient, and sustainable. Neighboring Ukraine, whose
epidemic mirrors Russia’s, has proved this is possible: Under the framework of the
UNAIDS Accelerated Access to Care Initiative, the Ukrainian Ministry of Health has
successfully negotiated price reductions of 70-87 percent with representatives of the
four largest international pharmaceutical companies producing antiretroviral drugs.43
Given the expected size of the Russian market for these drugs, pharmaceutical com-
panies are likely to consider sizable price reductions, but only if the Russian govern-
ment undertakes serious efforts to negotiate these terms.
b Ramp up domestic production of antiretroviral drugs and import cheaper generic
versions. Policymakers should investigate the current patent status within Russia
of existing antiretroviral drugs and determine how best to lower the cost and increase
availability of HIV medicines. Two possible strategies would be to domestically pro-
duce generic drugs primarily for the country’s own citizens, as Brazil and Thailand
do, or to import generics from other countries such as India (a policy known as “par-
allel importing”). A combination of these two policies is also worth considering.
b Manage treatment more effectively. Access to antiretroviral treatment and lab diag-
nostics must be provided on a consistent basis for all patients who need treatment.
This requires the Russian Ministry of Health to facilitate the creation of a federal treat-
ment database to monitor the number of patients who require treatment, purchase
and supply drugs on a timely basis to ensure adequate supply, and support a reserve
fund of antiretroviral medication and lab diagnostics to avoid any gaps in the sup-
ply of treatment.
b Coordinate treatment policies and strategies nationwide. The national and local
governments should work closely together to ensure that access to treatment no
longer varies widely across the country. To achieve this goal, resource allocation
should be streamlined so that poorer regions receive funds that are equal on a per
capita basis with those available to wealthier areas,taking into account variable costs
of living. Removing regional discrepancies in treatment availability and health care
could help stem interior migration of HIV-infected people and their families.
b Decentralize treatment and procurement of medication. Structural reforms of Rus-
sia’s healthcare system will make distribution and monitoring of treatments more
35. 2 6 O N T H E F R O N T L I N E O F A N E P I D E M I C
effective and provide better-coordinated care for those living with HIV. Access to treat-
ment is currently centralized and controlled by a small group of federal and regional
AIDS centers, and medicines are procured through a narrow channel of underpaid
bureaucrats tied to the Ministry of Health. Individual doctors must be given the train-
ing and authority to prescribe antiretroviral drugs and treat patients independently
of the AIDS Centers.
b Improve the capacity of Russian medical establishments,including its federal and
regional AIDS Centers and independent clinics and physicians,to administer treat-
ment. A comprehensive national treatment strategy must include training for health-
care workers and infrastructure development for laboratories and clinics. The
procurement of essential equipment and supplies for administering and monitoring
treatment should be a top priority.
b Increase access to palliative care and social services. People living with HIV/AIDS
require many other kinds of services in addition to medication.HIV-infected Russians
should receive adequate counseling and information in order to understand their
rights, make informed decisions about treatment options, and learn how to avoid
infecting others. Those who are dying need thorough and non-discriminatory pal-
liative care. Others may require mental health services, legal and housing assistance,
or general health care provided by caregivers who are knowledgeable about HIV and
treat their patients properly.
36. 2 7
C O N C L U S I O N
By mid-2003, an estimated 1.5 million to 2.0 million Russians were living with HIV. The vast major-
ity of them were infected in the past five years, indicating a galloping transmission rate that shows
no sign of abating.
Although undeniably daunting, such dire statistics should provide even greater urgency for
action.Recently,it appears as though the Russian government has recognized the HIV crisis for what
it is: a serious, potentially debilitating threat to the country’s economic, social, and national secu-
rity future. President Putin’s acknowledgement of HIV as a strategic threat to Russia is an impor-
tant step forward. Experience throughout the world has shown conclusively that without
forward-looking political leadership from the very top, a society’s response to the epidemic is likely
to be limited and ineffective.
Within Russia,leaders at every level of government,business,and civil society should accept
President Putin’s implicit challenge concerning HIV and organize themselves to enhance their poli-
cies and programs in a decisive and coordinated way—working together with Russia’s international
partners as extensively as possible. Russia’s civil society leaders have begun to build a strong foun-
dation based on their own experiences and on international best practices; local, regional, and fed-
eral level officials can build on this foundation.
Russia must quickly begin to address the resource challenges that the HIV epidemic will
bring. Within the next two or three years, the number of very ill patients who require extensive
care will increase dramatically. There is time to prepare for this certain outcome, but no time to
waste. The Russian government and parliament must begin to find adequate resources, make deci-
sions about how to procure treatment most effectively, and initiate reforms within the health-
care sector.
Russia’s HIV epidemic brings with it the opportunity to set new standards on a host of
human rights issues. Because HIV is so closely linked to injecting drug use,a strong,principled stand
on harm reduction—including education programs that promote safer sex and realistically address
the issues that prompt young people to use drugs—will prove essential as Russia moves forward.
Russia’s international partners, in particular the United States and other G-8 countries, can
and should play a vital role in helping Russia battle its epidemic. Now is not the time for these part-
ners to reduce their financial support for programs that would fight HIV/AIDS, including those
programs that support the development of a strong Russian civil society.
This report is the product of months of dedicated work by a unique group of people. The U.S.-
Russia Working Group Against HIV/AIDS included a diverse mix of policy experts, business lead-
ers, activists, institutions, and scientists from both sides of the Atlantic. Many more people
participated in our efforts by attending meetings as observers and by granting interviews,providing
data, and reviewing drafts of this report. Importantly, our Working Group included people living
with HIV/AIDS from both Russia and the United States; this report benefits enormously from their
valuable insights. We take inspiration from their strength and commitment to improving the wel-
fare of their fellow citizens. This report is dedicated to their spirit.
37. 2 8
A P P E N D I X A
REFERENCES
1 Data provided by the Russian Federal AIDS Center, Moscow.
2 Estimates of the prevalence and outlook for the epidemic can be found in: Christof Rühl, Vadim Pokrovsky, and
Viatcheslav Vinogradov, The Economic Consequences of HIV in Russia, Moscow:The World Bank Group, May 15, 2002;
available electronically at: http://www.worldbank.org.ru/ECA/Russia.nsf/ECADocByUnid/56435B1EA108E164C3256CD1003FBE54;
The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and China, U.S. National Intelligence Council, September 2002;
available electronically at: http://www.cia.gov/nic/pubs/other_products/ICA%20HIV-AIDS%20unclassified%20092302POSTGER-
BER.pdf; Murray Feshbach, Russia’s Health and Demographic Crisis: Policy Implications and Consequences,Washington:The
Chemical and Biological Arms Control Institute, 2003.
3 U.S. National Intelligence Council, The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and China, op. cit.
4 Francesca Mereu,“Russia: Fighting ‘Soviet Calamity’ of Drug Addiction is Uphill Battle,” Radio Liberty/Radio Free
Europe, September 2002.
5 For a recent comprehensive survey and analysis, see Kasia Malinowska-Sempruch, Jeff Hoover and Anna
Alexandrova, Unintended Consequences: Drug Policies Fuel HIV Epidemics in Russia and Ukraine, New York: Open Society
Institute, International Harm Reduction Development, 2003, p. 10.
6 “4 Million Young Russians Take Drugs,” RIA Novosti, May 19, 2003.
7 “Russia-Drugs: Young Russians Spend Over One Billion Dollars a Year on Drugs: Study,” Agence France-Presse, April
2, 2003.
8 Dr. Tatyana Smolskaya,“Prostitution in St. Petersburg,” June 11-12, 1999; available electronically at
http://www.map.vip.fi/smolkaya.htm.
9 Ibid.
10 Sevgi O. Aral and Janet St. Lawrence,“The Ecology of Sex Work and Drug Use in Saratov Oblast, Russia,” Sexually
Transmitted Diseases, vol. 29, no. 12 (December 2002), pp. 798-805.
11 As of January 1, 2003, the GUIN (Department for the Execution of Sentences) of the Russian Ministry of Justice
held 877,000 prisoners, of which 145,000 persons were imprisoned at SIZOs (pre-trial detention facilities), as reported by
the Moscow Center for Prison Reform; available electronically at http://www.prison.org/english/ps_data03.htm.
12 Ibid. The Moscow Center for Prison Reform reported that the Russian Ministry of Justice held 37,200 HIV positive
inmates as of January 1, 2003, including 6,700 in pre-trial detention facilities.
13 David Holley,“Up to 1.5 Million Russians Have HIV, Government Says,” Los Angeles Times, April 18, 2003, section 1, p.
23.
14 “Mothers Against Drugs,” Russian Federation Resource Page of UNDCP/WHO Global Initiative on
Primary Prevention of Substance Abuse, 2001; available electronically at
http://www.who.int/substance_abuse/undcp_who_initiative/rusia.html.
15 Holley,“Up to 1.5 Million Russians Have HIV,” op. cit.
16 Valery Abramkin,“Reduction of Russia’s Prison Population: Possibilities and Limits,” Moscow Center for Prison
Reform, June 19, 2003; available electronically at http://www.prison.org.english/rpsys_3.htm.
17 Data provided by the Russian Federal AIDS Center, Moscow.
18 Ibid.
19 “Sexually Transmitted Diseases Rampant in Russia - Health Expert,” BBC Monitoring International Reports, June
18, 2003; available electronically at http://www.cdi.org/russia/johnson/7229-13.cfm.
20 John Curtis,“On Russia’s AIDS Front,” Yale Medicine, Spring 2003; available electronically at
http://info.med.yale.edu/extrnal/pubs/ym_sp03/aidsrussia.htm
21 This section draws on the work of Dr. Nicholas Eberstadt and is reproduced here at the written consent of the
author. For a more detailed analysis, See Eberstadt,“The Future of AIDS,” op. cit.
22 Ibid.
23 “Russia's Military Reforms: Progress Amid Chaos?” The Economist, November 16-22, 2002.
24 Dmitry Polikarpov,“Good Draftees Hard to Find,” The Moscow Tribune, October 12, 2001; available electronically at
http://www.cdi.org/russia/222-6.cfm.
38. T H E N E E D F O R U R G E N C Y I N R U S S I A ’ S F I G H T A G A I N S T A I D S 2 9
25 Murray Feshbach, Russia’s Health and Demographic Crisis: Policy Implications and Consequences, op. cit.
26 “Russian Population to Shrink by 30 Percent to About 100 Million People by 2050,” Interfax, March 28, 2002;
accessed electronically at http://www.cdi.org/russia/johnson/6160-3.cfm. For current official data, see the Russian State
Statistics Committee (Goskomstat) website at: http://www.gks.ru.
27 Robert Parsons,“AIDS Legacy of the Russian Dolls,” The Sunday Herald (UK), June 30, 2002.
28 Rühl, et al., The Economic Consequences of HIV in Russia, op. cit.
29 By comparison, the Global Fund has pledged $92 million to Ukraine, and Ukraine’s Health Minister is a voting
member of the Fund’s Board.
30 “HIV/AIDS in Russia: A USAID Brief”, July 2002; available electronically on the USAID website at
http://www.usaid.gov/pop_health/aids/Countries/eande/russiabrief.pdf.
31 This amount spent per year is based on official HIV infection data. If the Russian Federal AIDS Center’s estimate of
1.4 million infected persons is used, the cumulative annual spending per infected person amounts to about 134 rubles
($4.29).
32 For more information on trends in U.S. federal government spending on HIV/AIDS over time, see Priya Alagiri, Todd
Summers, and Jennifer Kates, Spending on the HIV/AIDS Epidemic:Trends in U.S. Spending on HIV/AIDS, The Henry J. Kaiser
Family Foundation, July 2002.
33 Paul Webster,“HIV/AIDS Explosion in Russia Triggers Research Boom,” The Lancet, vol. 361, no. 9375, June 21, 2003.
34 William F. Flanagan,“HIV/AIDS and Human Rights in Russia: Compliance and the Rule of Law,” Osgoode Hall Law
Journal, vol. 39 (2001), pp. 39-76.
35 AIDS Infoshare,“Human Rights in Russia,” Moscow, 1998.
36 Malinowska-Sempruch, et al., Unintended Consequences: Drug Policies Fuel the HIV Epidemic in Russia and Ukraine,
op. cit.
37 Rob Parsons,“Ray of Hope Enters Russian Prisons,” BBC, June 4, 2003. Also,“Russian Prison Population Decreasing,”
Interfax, June 3, 2003.
38 The Russian Federation is a signatory to the three core United Nations drug control conventions (1968, 1971, and
1988).
39 “Draft Laws Proposed by the Moscow City Duma Contradict the Constitution of the Russian Federation and
Generally Accepted Principles of the International Law,” Press Release, Central and Eastern European Harm Reduction
Network, July 8, 2003; available electronically at. http://www.ceehrn.lt/EasyCEE/sys/files/Moscow%20Duma-pressrelease-
en.doc, accessed 24 July 2003.
40 Shona Schonning,“The New and Growing Need for Access to HIV/AIDS Treatment, Care & Support in Russia,”
International Antiviral Therapy Evaluation Center (IATEC) Update, vol. 3, no.1, July 2003, pp. 6-7.
41 Ibid.
42 Rühl, et al. The Economic Consequences of HIV in Russia, op. cit.
43 Detailed information is available on the United Nations Mission in Ukraine website at
http://www.un.kiev.ua/en/pressroom/pressreleases/14/.
39. U.S.-RUSSIA WORKING
GROUP AGAINST
HIV/AIDS
CO-CHAIRMEN
Mikhail Margelov
Chairman, Foreign Affairs
Committee
Russian Federation Council
Leo Hindery, Jr.
Chairman and CEO
Yankees Entertainment and Sports
Network
MEMBERS
Eugenia Alexeeva
Director
Focus Media
Rob Anderson
General Director
Convergent Media Group
Alexander Barannikov
Committee on Legislation
Russian State Duma
David Barr
Consultant
Tides Foundation
Michele Berdy
Chief of Party
Healthy Russia 2020
Coit Blacker
Director
Stanford University Institute for
International Studies
Edward J. Burger
Director
Eurasian Medical Education
Program
Andrei Bykov
Chief Doctor, Regional AIDS Center
Samara Region
Mitchell Cohen
Executive Director
Partnership for Community Health
Nicholas Eberstadt
American Enterprise Institute
National Bureau for Asian Research
Sergey Emmanuilov
Regional Health Director
Arkhengelsk Oblast
Andrei Fedorov
Political Projects Director
Council on Foreign & Defense Policy
Anna Fedorova
Director of Operations
Population Services International,
Moscow
Leon Fuerth
Research Professor of International
Affairs
The George Washington University
Robert C. Gallo
Professor and Director, Institute
of Human Virology
University of Maryland
Biotechnology Institute
J. Clifford Gauntlett
Managing Director, Russia Online
Vice President, Golden Telecom
Mikhail Glubokovsky
Deputy Governor
Primorskiy Krai Region
Alexander Goliusov
Chief of Unit on HIV Prevention
Russian Ministry of Health
Mikhail Grishankov
Deputy Chairman, Security
Committee
Russian State Duma
Hans Groth
Director of Medical Affairs for
Europe and Canada
Pfizer, Inc.
Edward Harnaga
Vice President, Corporate Reputation
and Restructuring
Ruder-Finn
Michael Isbell
Consultant
UNAIDS
Donald Johnston
Secretary General
OECD
Imara Jones
Director, Initiative on HIV/AIDS
Viacom, Inc.
Alexander Kononets
Chief of Medical Department,
Russian Penal System
Ministry of Justice
Andrei Kozlov
Director
St. Petersburg Biomedical Center
Eugene Lawson
President
U.S.-Russia Business Council
Ed Mishin
Director
‘Together’ GLBT Educational Center,
Moscow
David Mixner
President
DBM Associates
Gennady Onishchenko
First Deputy Minister
Russian Ministry of Health
Igor Pchelin
Editor
‘Steps’ Magazine
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