AIDS in Russia and Eurasia

HIV/AIDS in Russia and Eurasia Volume 1

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HIV/AIDS in Russia and Eurasia Volume 1 Edited by Judyth L .Twigg Foreword by Strobe Talbott

HIV/AIDS IN RUSSIA AND EURASIA, VOLUME

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© Judyth L. Twigg, 2006. All rights reserved. No part of this book may be used or reproduced in any manner whatsoever without written permission except in the case of brief quotations embodied in critical articles or reviews. First published in 2006 by PALGRAVE MACMILLAN™ 175 Fifth Avenue, New York, N.Y. 10010 and Houndmills, Basingstoke, Hampshire, England RG21 6XS Companies and representatives throughout the world. PALGRAVE MACMILLAN is the global academic imprint of the Palgrave Macmillan division of St. Martin’s Press, LLC and of Palgrave Macmillan Ltd. Macmillan® is a registered trademark in the United States, United Kingdom and other countries. Palgrave is a registered trademark in the European Union and other countries. ISBN-13: 978–1–4039–7057–2 ISBN-10: 1–4039–7057–2 Library of Congress Cataloging-in-Publication Data is available from the Library of Congress. A catalogue record for this book is available from the British Library. Design by Newgen Imaging Systems (P) Ltd., Chennai, India. First edition: December 2006 10 9 8 7 6 5 4 3 2 1 Printed in the United States of America.

Contents

List of Tables

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List of Figures

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Foreword Strobe Talbott

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Introduction Judyth L. Twigg

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1. The Early Days of the HIV/AIDS Epidemic in the Former Soviet Union Murray Feshbach 2. Russian Politics and HIV/AIDS: The Institutional and Leadership Sources of an Inadequate Policy Celeste A. Wallander

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3. NGOs and HIV in Russia: Lessons from a Unique Case Study Julie Stachowiak and Alena Peryshkina

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4. The Economic Impact of HIV/AIDS in Russia: Current Trends and Perspectives Shombi Sharp

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5. Has the Window of Opportunity Closed? The Contributions of Bilateral Donors Supporting HIV/AIDS Activities in Russia and Eurasia Vinay P. Saldanha 6. International Donor Support to the Eastern Europe and Central Asia Region: Opportunities and Challenges Bertil Lindblad

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7. HIV and Drug Use in Eurasia Robert Heimer, Robert E. Booth, Kevin Irwin, and Michael Merson

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8. Rights and Lessons Scorned: Human Rights and HIV/AIDS in Russia and Eurasia Joanne Csete

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9.

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AIDS and Security in Russia Harley Balzer

Notes on Contributors

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Index

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List of Tables

1.1 HIV Cases by Main Risk Factor, Annual Incidence, USSR, 1987–1990 4.1 Understanding Economic and Social Impact Level, Time, and Degree 4.2 Existing Models of the Economic Impact of HIV/AIDS in Russia 4.3 External Sources’ Prognoses of HIV Prevalence in Russia, 2005–2050 4.4 Optimistic and Mid-Range Projections of Three Models 4.5 Resulting Demographic Profiles from Three Optimistic and Mid-Range Scenarios 9.1 Estimate of Share of 18-Year-Olds Entering Higher Education

29 82 85 85 86 87 183

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List of Figures

1.1 1.2 1.3 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11 5.1

Contact Tracing Chart, First Known Case of HIV in the Soviet Union 10 HIV Incidence and Prevalence, USSR, 1987–1990 27 HIV Cases by Main Risk Factor, USSR, 1987–1990 28 Russian Population Projections in the Absence of HIV/AIDS 79 Age Density of HIV Infection in Russia at the End of 2002 83 World Bank “Optimistic” Scenario, Cumulative HIV Cases 88 ILO All Scenarios, Cumulative HIV Cases 88 Impact of AIDS on GDP Levels—Three Models 90 ILO Estimates of Medical Expenditures, All Scenarios 92 Social Policy Implications: ILO “Risk Group Saturation” Scenario 93 Russia Dependency Ratios by Age Structure 94 Impact on Life Expectancy, Medium Scenario 97 Effect of Declining Life Expectancy on HDI in Russia 97 Cost-Benefit Analysis of HIV/AIDS Prevention Programs in the Russian Federation 99 Amount of USAID Funding for HIV/AIDS for Countries in Former Soviet Union, 2000–2003 109

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Foreword Strobe Talbott

In nearly 40 years of travels in Russia, one encounter has made more of an impression on me than any other. It was a visit, on an unseasonably warm winter afternoon in early 2005, to the Outreach Center of the Botkin Infectious Diseases Hospital at 4 Kremenchugskaya Street in St. Petersburg.1 My fellow visitors from Washington and I later found out that the facility shares the building with the hospital’s morgue. We were there to meet with about 30 members of a support group for People Living With HIV/AIDS. The fact that those words are now capitalized says a lot about how awareness of the disease has spread through the global culture. The inclusion, in that phrase, of the word “living” carries a message of hope that those now infected will, thanks to currently available treatment, survive to see the disease defeated. But in St. Petersburg—one of the most severely afflicted cities in the country—that hope is dim. The number of those who stand a chance of treatment is a tiny fraction of those who are HIV positive. Therefore the overwhelming majority of our hosts in St. Petersburg— all of them young, most still in their twenties—will die within five to ten years. Knowing that, my fellow visitors and I were all the more struck by how healthy many of them looked. When they spoke, there was little self-pity, bitterness, resignation, or despair. Instead, they infused their end of the conversation with a spirit of solidarity, courage, and practicality, sometimes laced with wry humor. While they had different observations and questions, they offered variations on a single theme: their determination, truly, to live with the disease as long and as normally as possible, and to be active in their own treatment and care. They were therefore eager to learn about the price and distribution of

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antiretrovirals in the United States. They also wanted to ensure the health of uninfected spouses and partners, hence their curiosity about new methods of prevention under study in other countries—ones that were largely unknown in Russia, such as microbicides in the form of a vaginal gel or foam that could protect uninfected women and, unlike condoms, permit them still to have children. On the walls of the common room where we met were whiteboards and broadsides conveying basic facts and debunking widespread myths about transmission. The discussion left us in no doubt that these victims of HIV/AIDS were more knowledgeable about their disease than a number of the academic specialists, including doctors, with whom we had met in St. Petersburg and Moscow (some of whom believed that HIV could be contracted through sweat, tears, and saliva). Not surprisingly, these young Russians were critical of their government, the medical establishment, and prevailing attitudes among their fellow citizens: as one of them put it, “We are marginalized, stigmatized, and isolated.” In drawing them out on the shortcomings of Russian policy, we acknowledged that as Americans, we were mindful of our own recent history. It took the United States a number of years to overcome its own prejudices about the disease and its victims—and we still have a way to go. We expressed the hope that Russia would not repeat the mistakes of countries that were hit earlier by this plague. “Well,” said an artist and filmmaker at the AIDS Center, “our country has spent a lot of its history trying to catch up with yours. We’ve done it in bad ways. Let’s hope we can do it in some good ways.” Judy Twigg, the editor of this volume, was in St. Petersburg as part of our delegation. She has been a teacher for me and others in our crash course on HIV/AIDS in Russia, and she has assembled just the right group of authors here. In her introduction and their chapters, they lay out the problem with rigor, clarity, objectivity, and knowledge. Like medicine at its best, this book combines expert diagnosis with prescription of realistic and aggressive treatment—and, crucially, prevention. A recurring and overarching message is that the Russian government must open its eyes on the subject of HIV/AIDS. A country in denial is a country in danger. An effective campaign to combat HIV/AIDS also means that other countries, especially the United States, along with international organizations, must do more to help. But Russia has to be receptive to that help. As Joanne Csete and Robert Heimer and his colleagues

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stress, there is almost no testing for HIV/AIDS among the most highrisk and peripatetic parts of the population, such as soldiers, sailors, sex workers, truck drivers, and the police. As a result, the disease is all the more likely to spread. Reading the manuscript of this book, I found myself recalling Illness as Metaphor, the famous book-length essay that the late Susan Sontag published in 1978. Her principal point was that we should not regard disease—she had in mind particularly the one that would ultimately kill her, cancer—“as an evil, invincible predator.” Many Russians, including ones in high places, fall into that trap, only they see those stricken as an alien presence in their midst. Just as the American outbreak was, for years, regarded by religious and political conservatives as God’s punishment of gays, Russian authorities and much of public opinion regard HIV/AIDS—unlike, say, cardiovascular illnesses, hepatitis, and tuberculosis—as a “social disease,” to which undisciplined or unworthy members of society are susceptible. Many have kidded themselves into thinking that it is confined to “narcomaniacs.” They are in denial not only about the disease itself but about the extent to which one of the principal causes of its spread, drug use, is a mainstream phenomenon in Russia. Several chapters address the critical importance of needle exchange and other harm reduction measures. In 1988, Sontag updated her thinking in AIDS and Its Metaphors. She warned against describing the disease in “the language of political paranoia, with its characteristic distrust of a pluralistic world.” Once again, Russia is a case in point. There is an undertone of xenophobia in how the disease has, along with its sufferers, been politicized. Over the past few years I’ve heard talk in Moscow and elsewhere about HIV/AIDS either as “an African disease” (a deeply pejorative depiction in the Russian context) or as a “Western disease”—a curse that has been visited on Mother Russia because of her relatively recent openness to an outside world rife with heroin and homosexuality. Never mind, as the chapter by Bobrik and Twigg points out, that an unknown but probably growing number of Russians are being infected through heterosexual contact. In another sense, the Russian official response to HIV/AIDS is itself a metaphor: just as the state is leaving those people we met in St. Petersburg to their fate, it is jeopardizing its own survival. As several contributors to this volume stress, Russia is uniquely vulnerable to the epidemic. Unlike other countries at or beyond a tipping point—India, China, and South Africa—Russia faces a decline in its

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population. HIV/AIDS adds to the creeping demographic catastrophe that has been underway since Soviet times. Indeed, one reason that the USSR ended up on the ash heap of history is that its regime failed abysmally to fulfill the most basic requirement for the survival of any state: a demonstrated ability to take care of its citizenry. The Soviet system was dedicated to strength, but it was the wrong kind of strength—the kind that comes out of the barrel of a gun. One manifestation of the fallacy of Soviet power was a chronic health crisis and a steady decline in life expectancy. It is, to use a common Russian expression, “no accident” that the three countries with the world’s fastest rate of increase in HIV/AIDS infection during the late 1990s—Russia, Ukraine, and Estonia—are former Soviet republics. Russia’s post-Soviet leaders have so far failed to face up to, much less deal with, the looming calamity. Boris Yeltsin, in his understandable impatience to dismantle the Communist monolith, erred on the side of reliance on privatization, with all that entailed in corruption and inequity. Vladimir Putin has made the opposite mistake. In order, as he sees it, to salvage the integrity and primacy of the state, he has tried to resurrect the old top-down, center-outward paradigm of how Russia should be ruled, which the Soviet experience should have discredited; and he embodies the old mindset that equates strength with discipline, subjugation, and, inevitably, intimidation rather than the full participation of the citizenry in their own governance. In short, he’s offering an authoritarian version of the social contract, but he’s not delivering on his end of the supposed bargain. As this book, particularly the chapters by Murray Feshbach and Celeste Wallander, makes clear, state authority in Russia today is, by and large, subjecting HIV/AIDS to malignant neglect. In addition to the tragic human consequences within Russia of this obscurantist and self-deceptive policy, there are major international consequences as well. A sick, weak, dying Russia is a tragedy in its own right and a danger to the world, starting with its immediate neighbors. The St. Petersburg (or, as it is still officially known, the Leningrad) region is not just a disaster area in the making for Russia— it is, as a busy port city, an international hot spot, since carriers of the virus move across borders into the Baltic and Nordic states. If Russians look eastward, the geopolitical dimension of their health crisis is even more ominous. Their country is, territorially, the largest on earth. Its natural-resource-rich but underpopulated lands beyond the Urals share a nearly 3,000-mile border with China, which

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is resource-poor but the most populous country on earth. Even though China too has a serious HIV/AIDS problem, the percentage of its giant population that is infected is miniscule compared to Russia’s or Ukraine’s. It doesn’t take a crystal ball in the Kremlin or anywhere else to imagine how that match-up could turn out to be the one of the most destabilizing facts of the twenty-first century—and HIV/AIDS is an exacerbating factor. For that reason, along with basic humanitarian ones, it is vital that the U.S. government do more to put HIV/AIDS on the agenda of U.S.Russian relations. Judy’s introduction and Vinay Saldanha’s chapter on bilateral assistance make this point with the most force and specificity. In Russia as elsewhere, there is only so much that governments can do by themselves. That means partnering with civil society. The Russian government has cracked down on independent, grassroots, socially (not to mention politically) active organizations. It needs to do just the opposite—in general, for the health of Russian democracy, but also with regard to the physical health of the Russian people. To stand some chance of success, both Russian policy and Western collaboration with Russia on the issue of HIV/AIDS should give priority to rebuilding the health care system, including support for NGOs as caretakers, educators, and advocates. The communiqué issued by the Group of Eight (G8) leaders at the end of their summit in Gleneagles, Scotland in 2005 endorsed the goal of universal access to AIDS treatment by 2010 for anyone who needs it. Admirable and ambitious as that timetable is, its target date will be too late for many of the brave young men and women we met in St. Petersburg. As it happens, that city is where the G8 met in the summer of 2006. Given the magnitude of the threat his country faces, President Putin might have done worse than to take his seven guests to the Botkin Outreach Center. And since he didn’t make the offer, they should have gone on their own—and then told him what they saw, heard, and felt.

Note 1. I was part of a delegation jointly organized by the Center for International and Strategic Studies and the Brookings Institution to investigate HIV/AIDS in Russia in February 2005. Our task force issued a report in May 2005 that is available online at http://www.brookings.edu/fp/200505russia_taskforce.htm.

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Introduction Judyth L .Twigg

More than 40 million people around the world are currently living with HIV/AIDS. Almost five million of those were newly infected in the year 2005, and just over three million people died that same year of AIDS or AIDS-related causes. Although the bulk of global infections remain concentrated in sub-Saharan Africa, during the late 1990s the countries with the fastest growing rate of new infections were Ukraine and Russia. The international community has now recognized the urgency of the growing HIV/AIDS epidemic in the countries of the former Soviet Union: the Global Fund to Fight AIDS, Tuberculosis and Malaria has committed hundreds of millions of dollars to the region, and the U.S. National Intelligence Council in 2002 identified Russia as one of five countries at the crest of the “second wave” of global HIV. These volumes aim to provide a comprehensive, multifaceted, forward-looking examination of the HIV epidemic in Eurasia. According to UNAIDS, over 1.5 million people in this region are currently affected, with an adult prevalence rate at or near the critical one percent threshold in several areas. The majority of infections are in the most populous countries, Ukraine and Russia, as are the highest rates of infection. In all of the former Soviet nations, the epidemic follows a similar trajectory, even though each country is currently at a different point on the arc: initial relative isolation from the global pandemic, followed by a sometimes remarkably rapid incursion of the virus into the injection drug-using community. In those places where the epidemic is the most entrenched, there is considerable evidence—though still much uncertainty and debate—that HIV is moving through bridge populations, via heterosexual contact, into the general population. Because of its roots and continued concentration among injection drug users (IDUs), HIV in Eurasia remains an affliction of the young and male. As increasing numbers of women are affected, most through

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sexual contact with drug-injecting male partners, the issue of motherto-child transmission assumes ever greater importance. The current HIV/AIDS situation in all the Eurasian countries owes much of its scope and character to the shared legacy of the Soviet period. Most obviously, the economic and social chaos attendant with the collapse of the Soviet Union opened the regions’ borders to drug trafficking, as well as to the dislocation and despair that led many young men to seek solace in illicit drugs and many young women to resort to commercial sex. Fitful and uneven progress toward democratization, in those post-Soviet countries that have gone down that path at all, has posed challenges for the development of a robust, unfettered nongovernmental response to the epidemic—an essential ingredient to any effective national strategy and action. Indeed, in many instances, it is truly remarkable how much energy and expertise has begun to flourish among Eurasia’s HIV/AIDS NGOs, despite the considerable obstacles that continue to hinder their work. Another indispensible component of the fight against HIV is the active involvement of the people most affected: those living with the virus. The activist community in Russia’s major cities is finally growing in numbers and visibility. In May of 2005, for example, dozens of PLWHA, along with their supporters, chained themselves to a health ministry building in downtown Moscow and attempted to block off traffic on the adjacent major street. A deputy health minister came out of the building to engage them in dialogue—but police arrested 22 of the demonstrators for gathering without a permit. Also, the remnants of the Soviet system of health care, such as it was, are particularly ill-suited to addressing a fast-moving, socially based epidemic like HIV. The mass production mentality, for example, led the Soviet government to respond to the first reports of HIV in the late 1980s with a universal screening program; most governments in the region still have not overcome those old habits and moved toward more cost-effective and rational modes of testing and surveillance. The absence of a tradition of evidence-based medicine has resulted in the rejection of harm reduction programs, a refusal to legalize substitution therapy for drug addicts (despite methadone’s place on the World Health Organization’s list of essential medicines), and a continued reluctance to focus on vulnerable population groups. Governments throughout the region have been slow to acknowledge the seriousness of the HIV challenge. The most extreme case is Turkmenistan, where the authoritarian leadership admits to HIV cases numbering only in the single digits despite growing evidence of a

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significantly larger problem. In Russia, the highest levels of government remained virtually silent about the country’s epidemic until late 2005, even though official figures put the number of HIV cases at over 300,000, and reputable observers suggested that the actual number of cases approached one million. These discrepancies over the magnitude and dynamics of the epidemic point to one of the most serious challenges facing those engaged in the fight against it: it has become very easy to become embroiled, when discussing all the countries in the region, in an all-encompassing debate over the “real” number of cases, pushing aside much more important conversations about comprehensive strategies for education, prevention, and treatment. Yet the epidemiological uncertainties continue to cloud movement forward. Take Russia, again, as an example. Although official annual HIV incidence in Russia increased dramatically through the late 1990s, it slowed considerably from 2001 to 2004. Many Russian politicians and others concluded from these figures that the epidemic was diminishing, that it had spelled tragedy for many of the country’s injection drug users, but that once the IDU population was “saturated” with the virus, the problem had been effectively contained. Others, particularly those in the international analytical and activist communities, interpret this lull as a temporary pause (perhaps caused by significant changes in HIV testing practices) before which the numbers will follow a second, even more dramatic upturn fueled by breakout of the disease into the general, non-drug-using population. Narcologists in Moscow and St. Petersburg counter this assertion with their observation that injection drugs no longer seem to be the drugs of choice in Russia’s major cities, with young people turning more to alcohol and noninjectable “club” drugs instead. Reporting that most people now attending harm reduction facilities began injecting more than two or three years ago, they conclude that the decline in HIV is genuinely due to a decrease in the number of new injection drug users. The only sure conclusion to emerge from this uncertainty is that more research is needed to channel action in the appropriate directions. The question of whether Russia’s still concentrated epidemic has the potential to transform Eurasia into another sub-Saharan Africa hinges largely on the sexual mixing patterns of Russia’s IDUs and bridge populations—and we don’t have the behavioral surveillance necessary to tell us whether or not the countries in the Eurasian region are headed down that path. In the meantime, the international community, working with small but extraordinarily talented and committed groups of experts and

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activists in each of the Eurasian countries, has provided significant impetus to governmental action. As described in the chapters that follow, intergovernmental organizations (the UN agencies, the World Bank, the Global Fund) and global NGOs like Médecins du Monde-France, Doctors Without Borders, and the Open Society Institute have provided not only financial resources but also important analytic and technical assistance. In some cases, the actions of international agencies have served as key motivators for political commitment and institutional capacity building. The Global Fund’s unprecedented rescinding of a grant to Ukraine, for example, coupled with the dramatic events surrounding the Orange Revolution, have resulted in a renewed determination in that country to acknowledge and address its epidemic. A World Bank study in 2001 on the potential economic costs of HIV in Russia was presented at a meeting of Russia’s Security Council, and reportedly to the desk of its then prime minister, paving the way for the signing of a previously stalled $150 million Bank loan to tackle tuberculosis and HIV. Most importantly, the Global Fund’s insistence that applications for its funds come from a single Country Coordinating Mechanism has forced many countries in the Eurasian region, as well as around the world, to organize and clarify their institutional mechanisms for coping with and defeating HIV. Thanks largely to these international efforts, those working against HIV in Eurasia now find, as is the case in many other parts of the world, that the question is no longer exclusively one of finding sufficient resources to do the job. Instead, the major issue is becoming this: how should these new resources be spent so that they do the most good and, indeed, so that they do no harm? Here is where the greatest challenge and opportunity lie for Russia, Ukraine, and the other Eurasian countries. The post-Soviet environment is markedly different from that in southern Africa, southeast Asia, and other very poor regions where HIV has ravaged societies. In those areas, health systems are so poorly developed that money for HIV prevention and, particularly, treatment has to be channeled with great care, since the basic elements of a health care infrastructure and workforce necessary to deliver antiretroviral medications are currently lacking. The Soviet system, on the other hand, produced large cadres of physicians and nurses with more than sufficient skills to administer ARVs appropriately, along with an extensive network of clinics capable of reaching virtually all segments of the population. The expertise and institutions are present; the challenge is to ensure that HIV/AIDS treatment and prevention programs circumvent the perverse horizontal segmentation that characterized the Soviet health care system and that persists to this day.

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The battle against HIV/AIDS requires a multisectoral approach, not only within the health system narrowly defined—so that HIV specialists can and will freely collaborate with narcologists, venero-dermatologists (experts in sexually transmitted infections), general practitioners, and others—but also between health and other sectors such as education, criminal justice, economic development, and even national security. The rigid and persistent divisions of labor and authority that plagued the Soviet system will hinder the response to HIV unless these barriers can be effectively eliminated; unchecked, they will isolate HIV as relevant only narrowly within the confines of the health sector. HIV/AIDS must be treated as but one component of the even larger overall health and demographic crisis facing each of the Eurasian countries. It will be tragic if the current international spotlight focused on HIV in this part of the world diverts attention and resources away from the similarly urgent dilemmas of cardiovascular disease, alcohol and tobacco abuse, childhood morbidity, and other devastating afflictions. On a more positive note, however, the tragedy of HIV could be transformed into a singular opportunity if the infusions of resources and policy attention stemming from HIV are integrated across the entire health sector, from the restructuring of health services delivery to the strengthening of pharmaceutical industries to the empowerment of individual consumers of health information and services. An established body of research has demonstrated a strong, reciprocal correlation between a society’s level of economic wealth and equality on the one hand, and its population’s health on the other. More recently, it has been speculated that a similar, demonstrable relationship exists between a country’s progress toward democracy and the health of its people. The states of the post-Soviet region and their response to the unique challenges of HIV/AIDS may provide an organic case study for this latter proposition. Only an open society, with free exchange of ideas and multiple channels of contribution to the policy-making and implementation processes, can diminish or erase the stigma that inevitably accompanies HIV and effectively empower all of the essential combatants in the fight against it. Early in 2006, Russian President Vladimir Putin signed into law a series of new restrictions on the activities of Russian NGOs and their international partners. Russian leaders should recognize that HIV/AIDS constitutes a much greater threat to their country’s vital interests than do imagined espionage activities by foreign NGOs. Given the certain and significant impact of the virus on each of Eurasia’s societies, economies, and polities—regardless of the future trajectory of the epidemic in each country—it is imperative that every potential weapon against it remain available.

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The contributions to these volumes are designed to provide a multidimensional examination of the challenges presented by HIV/AIDS in Eurasia. In volume one, Murray Feshbach, the Western world’s leading expert on Soviet and post-Soviet health and demography, sets the stage with an account of the USSR’s counterproductive responses during the early days of the HIV epidemic. The subsequent chapters provide, in turn, a cogent set of explanations for Russia’s inadequate and reluctant policy response, a case study of the remarkably energetic and effective nongovernmental efforts to fill the vacuum left by official inattention, and a comparative overview of existing models of HIV’s inevitable impact on the Russian economy. Bertil Lindblad, the head of UNAIDS in Moscow, then provides a concise but comprehensive overview of international assistance efforts throughout the region, followed by a insightful analysis of bilateral partnerships written by Vinay Saldanha, who for many years led the Canadian government’s exemplary Canada AIDS Russia Project. The volume concludes with a series of in-depth examinations of several specific issues critical to the understanding of HIV/AIDS and its consequences in Eurasia: injection drug use, which remains the primary transmission route for the virus throughout the region; HIV and human rights, intertwining concerns everywhere around the globe but nowhere more so than in the countries studied here; and the national security implications of the epidemic, including its potentially startling military, economic, political, and social ramifications. Volume two consists of country- or region-specific chapters on the epidemiological and socioeconomic drivers of HIV/AIDS and policy responses in Russia and the rest of Eurasia, most authored by the leading experts on the ground conducting the fight against the epidemic in their own societies. The compilation of a book of this scope is inevitably a collective effort, even if only one editor’s name appears on the cover. I am deeply grateful, first and foremost, to each of the chapter authors for their willingness to share their breadth of experience and depth of expertise. Helen Stallings, Tanja Zlatkovic, Aaron Larrimore, and Eric Johnson provided capable and dedicated research and editing assistance. Thanks also to Tanya Loginova, Cindy Buckley, and Celeste Wallander for their advice at critical stages of the project, and most particularly to Celeste for generously including me in many of the CSIS Russia and Eurasia Program’s HIV/AIDS-related activities. Finally, I am indebted to Strobe Talbott for his compelling foreword to this volume, and most of all to Murray Feshbach for over a decade’s worth of information sharing and mentoring without which this project would never have become possible.

1 The Early Days of the HIV/AIDS Epidemic in the Former Soviet Union Murray Feshbach

Like many problems in the final years of the USSR, incongruity between state practices and reality fueled the spread of HIV. Denial of the existence of promiscuity, homosexuality, drug use, and commercial sex work in the Soviet Union created an atmosphere of ignorance about the danger that these practices presented in intersection with the worldwide spread of HIV. In October 1985 (prior to the first recorded case of HIV in the USSR), Pyotr Nikolayevich Burgasov, USSR deputy minister of public health, chief state public health physician, and member of the USSR Academy of Medicine, made a statement in which he spouted the “party line” on social propaganda but, at the same time, admitted that HIV was a dangerous problem that needed to be addressed: AIDS is a dangerous disease; it must not be underestimated. No cases of this disease have been reported here in our country. The reason for this is that the problem is largely a social one, since it is connected with sexual promiscuity—this, alas, is tolerated in certain circles in the West, but it is unnatural for our society . . . Nevertheless, we are carefully studying all aspects of the new disease, for we do not live in isolation in the world. (“Portrait . . . ,” 1985)

His statement is quite confusing because if the USSR had indeed been separated from the West by its social practices then it really would have been isolated from the world. In 1990, D. J. Peterson of Radio Liberty spoke to the issue of the Soviet Union’s isolationist policies before perestroika, which limited the contact of its citizens with foreigners and thus delayed the onset of HIV infection in the USSR (Peterson, 1990).

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If the Soviets had “superior” social mores, then HIV would not have spread to the USSR. In fact, although the existence of social problems was officially denied, they clearly existed in reality. There were sex workers, promiscuous persons, and drug users, but they were hidden from view by a layer of propaganda. Even if individual citizens saw that these behaviors existed, official denial created a false sense of security, confusion, and fear. Could they trust their own observations if everything they heard and read contradicted them? When officials did admit that some of these behaviors existed in the Soviet Union, they placed the blame on foreigners and Western countries for “infecting” Soviet citizens, contaminating Soviets with their social ills, and, according to a disinformation campaign, producing the HIV virus in a laboratory to attack the world. At the same time, HIV was spreading throughout the country and around the globe. The forces of imposed silence and scapegoating created an explosive combination of ignorance, anger, and fear. As soon as a mistake was made due to ignorance—a result of silence and denial—the person who made the mistake was blamed and punished as a scapegoat. This climate led Soviet citizens, most notably officials and specialists, to respond with ambivalence, avoidance, and confusion. The most shocking statement was made in 1987 by 16 young graduates of a medical institute in a letter to the AIDS Research Group led by Dr. Vadim Pokrovskiy, the head of the Federal AIDS Center at the Central Epidemiology Research Institute. They stated their conviction in refusing to treat persons with AIDS, since they believed that this disease would do away with all the “unsavory” elements of society: Dear colleagues: We graduates of a medical institute are categorically opposed to combating the new “disease” AIDS! And we intend to do everything in our power to impede the search for ways to combat that noble epidemic. We are convinced that within a short time AIDS will destroy all drug addicts and prostitutes. We are confident that Hippocrates would have approved of our decision. Long live AIDS! (Nivikov, 1987)

There are myriad problems with the point of view expressed in the letter. Most outstanding is the authors’ assumption that HIV/AIDS was a disease that would remain isolated in certain “deviant” groups rather than spreading throughout society. Given that these individuals were supposed to be medical professionals, they should have realized that HIV infection does not remain isolated, but spreads to the general population: children, spouses, blood transfusion recipients, and others. If HIV/AIDS were to “destroy” all the sex workers and drug addicts, then it would also eliminate anyone in their spheres of contact.

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The hatred and ignorance pronounced in the letter from the 16 young physicians does differ significantly from many statements from government officials at the time, who instead simply denied the existence of HIV and related social problems in the Soviet Union. In reaction to the letter, Komsomol’skaya Pravda printed this: Strangely enough, the pernicious delusion of these 16 new physicians was once shared, to all appearances, by the former leaders of our public health service. How else can one explain the fact that, in the early 1980s, when AIDS was already raging in many countries, peace and quiet reigned in our country? Our medicine maintained its stubborn silence. And when that silence became altogether untenable, it began limiting itself to reassuring medical and philosophical pronouncements, saying that there was no social base in the Soviet Union for the appearance of AIDS, and that we therefore had nothing to worry about. . . . Drug abuse and homosexuality are not essential to its spread, though we have our share of both phenomena . . . The public was deprived of information and hence of the ability to prepare itself, to learn the extent of the danger and realize that the loathsome disease would soon make its way to our country. Such is the harm that deliberate silence has caused! Soviet people’s knowledge about AIDS, until recently at least, was at the level of wisecracks and jokes. (Nivikov, 1987)

When the Soviet government tried to do something about the spread of HIV, its own policies stood in the way. People did not understand the scope of the problem or how it affected them. The stigma and discrimination propagated by these doctors and by the society and government of a quarter-century ago persists to this day.

Earliest Cases The first case of HIV in the Soviet Union, as reported by Dr. Viktor Zhdanov, director of the Ivanovsky Institute of Virology in Moscow, at the Second International Conference on AIDS in June 1986, was a 14-year-old girl who was infected by a blood transfusion in 1975 and diagnosed in 1984 (“Bohdan Nahaylo Finds . . . ,” 1986; “The USSR’s . . . ,” 1987, p. 6). Her case quickly disappeared from the records, perhaps because of the shame of having infected a child because of a medical mistake (Albergo, 1988, p. 12). A promiscuous bisexual translator who spread the illness in the Soviet Union upon his return from Tanzania exemplifies a more stereotypical risk group from this era. His case has been reported as

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first recognized in March of 1986, but another source says his status was revealed in December 1985 in Sovetskaya Kul’tura (Altman, 1989; “The USSR’s . . . ,” 1987, p. 8). Further confusion stems from contradictory information concerning his profession, as well as the fact that these dates are prior to March 1, 1987, the so-called official date of the first case of HIV in the former Soviet Union. Due to the novelty of the epidemic, Pokrovskiy and his colleagues were able to perform detailed contact tracing (figure 1.1) and uncover the impact

?

?

?

? ?

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AFRICA

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- AIDS Patient - Seropositive Woman - Seropositive Man - Seropositive Children - Seronegative Persons - Untested Persons - Sexual Contact - Blood Transfusion

? ?

Figure 1.1 Contact Tracing Chart, First Known Case of HIV in the Soviet Union Note: The penetration and spread of infection caused by human immunodeficiency virus has been detected in the USSR. The infection was brought by a homosexual man who got infected in East Africa in 1982. In the USSR, he infected five of his 22 sexual partners who, in turn, transferred the infection to three women by heterosexual intercourse. One of these women gave birth to a seropositive child. As the result of blood transfusion from a donor infected via a homosexual contact, five blood recipients were infected. Source: Pokrovskiy, Yankina, and Pokrovskiy, 1987.

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of this first infection, but not all of his sexual partners could be tested. Of his 22 male sexual partners, five were found to be HIV positive. Three of his partners’ 24 female sexual partners were found HIV positive, along with a child of one of these women. Several of his infected partners were blood donors. They infected five people, of whom two were children, by blood transfusion (Medvedev, 1990, p. 932). Although initially this “ground zero” case may not seem to pose a threat to, for instance, a heterosexual woman, contact tracing here reveals that women were infected either by blood donations from those he infected or by contact with their secretly bisexual male partners. Not only were women infected in this way, they passed the infection on to their children. Before the blood supply was actively and properly tested, an HIV-positive blood donor could also pollute a pool of unsuspecting persons through transfusion. Contact tracing reveals that a promiscuous bisexual male who had been living abroad could infect a wide range of people who were not aware of the danger he may have presented. A sex worker, Olga Gayevskaya, was the first official Soviet AIDS casualty in 1988 and serves as an example of the risk group of promiscuous persons who had contact with foreigners. The secrecy surrounding her death, as revealed by an argument in the media about its cause and the reluctantly gradual presentation of information such as her name, suggests that her death was most likely not the first AIDS death in the USSR, although it was the first such death reported (Trehub, 1988, p. 1). Dr. Andrey P. Kozlov, director of the AIDS Clinical Laboratory in St. Petersburg, noted, “I doubt Leningrad really had the first AIDS death. We were just brave enough to declare it” (Hamilton, 1989). Gayevskaya’s case is interesting from a historical and medical perspective because of the inefficiency in diagnosing her illness, the possible number and range of people she infected, and the fact that, despite being quite ill, she continued to engage in sex work until her death. She was diagnosed with AIDS postmortem. Although she had been tested for HIV in August of 1988, the results had been a false negative, a result of inadequate test systems and a shortage of diagnostic equipment. Since there was not enough reagent to test the samples separately, her blood serum sample had been combined with those of several other patients (Trehub, 1988, p. 6). Despite this fact, the doctors who eventually diagnosed her with AIDS were accused of complacency and blamed for not noticing the problem earlier (“Baby Dies of AIDS . . . ,” 1988). The uproar in the

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press when she finally was diagnosed reveals the reason why the doctors may have been reluctant to make such a diagnosis. Rather than complacency or neglect on their part, the doctors knew that the diagnosis would expose them to harsh criticism. Had they left “acute pneumonia” as the cause of death on her death certificate, they would not have had to suffer attacks in the media or possible legal consequences. Their incentive to cover up AIDS cases and deaths was perhaps greater than their incentive to identify them.

The State Response The Soviet state found itself caught between two mutually exclusive approaches to these early cases of HIV and AIDS. Its attempts to prevent the spread of HIV undercut its socialist propaganda, while its propaganda stood in the way of prevention. The government’s insistence that HIV was a Western problem made attempts to combat the spread of the disease in the Soviet Union appear unnecessary. If any preventive measures were to appear motivated, then this might have created a fear that the problem was bigger than officials were admitting. The Soviet Union’s two contradictory approaches to the spread of HIV created confusion, misunderstanding, and fear. Nonetheless, even in this atmosphere, the Soviet government took initial steps to provide an infrastructure for the prevention and treatment of the disease by disseminating information, building hospitals, establishing diagnostic laboratories, conducting AIDS research, and supplementing the pay of medical personnel who worked with HIVpositive persons. The Soviet government’s legislation on HIV/AIDS prevention was counterproductive. A law passed in August 1987 sacrificed human rights for HIV prevention and focused primarily on punitive measures, requiring foreigners living in the USSR for more than three months to undergo an HIV test, requiring Soviet citizens returning home after a month or more in a foreign country to be tested, enabling Soviet physicians to test anyone whom they suspected may be infected, and prescribing sentences of up to eight years in prison to those who knowingly infected others (Trehub, 1988, p. 5). As described by Zhores A. Medvedev in April 1990, this initial anti-HIV legislation created tension and fear between possibly infected people and medical authorities. Patients were afraid of being found HIV positive because of the discrimination that they might face, and medical personnel were

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terrified of being accused of accidentally infecting patients: The previous emphasis on punishment of infected people and the lack of any respect for their rights made cooperation between those at risk and the medical authorities impossible . . . The new legislation was intended to provide complete confidentiality of diagnosis, protect the rights of all patients, and provide some form of compensation if hospitals were responsible for the infection. (Medvedev, 1990, p. 934)

Medvedev goes on to reveal that while trying to create this new legislation, officials were committing further human rights abuses by isolating infected children and their mothers in a hospital in Moscow. A subsequent HIV/AIDS law with many of the same problems as the first was released in 1990. It was replaced in February 1995. The state’s early financial allocations for dealing with the spread of HIV provided inadequate resources for coping with the problem. In 1990, the state budget provided only 53 million (current) rubles for AIDS-related research and treatment (Medvedev, 1990, p. 934). In comparison to spending by other nations to combat HIV/AIDS—for example, the $1.6 billion annual allocation in the United States—this amount was very limited. The USSR relied on residual health care financing, where the health sector received whatever budget scraps were left after more important priorities were satisfied, despite warnings by experts (Blyuger, 1990). The lack of concern shown by G. N. Khlyabich, the USSR deputy minister of public health and chief state sanitary physician, in February of 1987 reveals that residual planning is what the government planned to use to cover HIV/AIDS costs: The Epidemiology Inspectorate has adequate resources. As far as the money we need is concerned, public health will continue to act as a family does when needing to buy something, simply redistributing its budget so that no inconvenience would be felt. (cited in Albergo, 1988)

On all counts––financial, legislative, and infrastructural––the Soviet Union’s preparation for preventing the spread of HIV was misguided and greatly underestimated the potential for rapid growth in the number of infections. Having created a social taboo around the subject of sex and denied the existence of “Western” social problems, the Soviets shot themselves in the foot when HIV appeared on the scene and Soviet people’s lives depended on their discussing sex and real-life social issues. This imposed ignorance about sexual matters, combined with punitive

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policies for those responsible for transmitting HIV, created an atmosphere of discrimination against people living with HIV and AIDS (PLWHA). Instead of informing its citizens, the Soviet Union terrified them, neglected sex education in schools, and created a scandal over each case diagnosed. A deliberate disinformation campaign further undermined measures to combat the spread of HIV. According to a detailed article published in the U.S. Department of State’s Foreign Affairs Note in July 1987, the Soviet government claimed that the AIDS virus had been “manufactured” by the U.S. Centers for Disease Control and the Pentagon at Fort Detrick, Maryland. The supposed first instance of this claim was in a letter from a “well-known American scientist and anthropologist” to the editor of the Indian daily newspaper Patriot in mid-1983. This alleged letter was cited extensively in Soviet sources—32 times in the first six months of 1987. Further research on the exact date on which the letter was published in Patriot, however, reveals that most likely no such letter was ever published in the newspaper. To give additional weight to their claims, the Soviet government had an East German biophysicist, Jacob Segal, issue a report arguing that the AIDS virus had been synthesized from two existing viruses, VISNA and HTLV-1 (“The USSR’s . . . ,” 1987). The claims made by Soviet and Soviet-sponsored sources proved to have no scientific grounds, horrifying Soviet scientists who were involved in the actual struggle against HIV. When a reporter asked Viktor Zhdanov, director of the Ivanovskiy Institute and a top AIDS expert, whether or not the United States had developed the virus, he replied resentfully, “That is a ridiculous question. Perhaps it was the Martians” (“The USSR’s . . . ,” 1987). Similarly, in April 1989, Andrey P. Kozlov denounced the disinformation campaign and gave his assurance that Soviet scientists never believed this preposterous claim. “Soviet scientists never supported the idea that this virus was created in the United States. It is necessary for the Americans to know that we were not responsible for this stupidity” (Hamilton, 1989).

Risk Behavior among Soviet Citizens Discussions of sex and sexual behavior were greatly stigmatized in the USSR. Little was actually known about the sexual behavior of Soviet citizens, creating a greater risk for the transmission of HIV to go unnoticed and a greater difficulty in identifying people who might have been at risk. Even in 1990, research on the actual sexual behavior of

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Soviet citizens was conducted only in big cities (“AIDS in the USSR,” 1990). Early studies revealed a lack of precautionary measures among Soviet citizens. A 1989 survey of homosexual and bisexual men in Moscow revealed a low level of condom use: of 53 men surveyed, “29 (56%) never used condoms, 17 (32%) used them from time to time, and no one used them all the time” (“Penetration and Spread . . . ,” 1990, p. 5). Sources from the time indicate that private medical treatment may have contributed to people’s limited knowledge of the patterns of growth of sexually transmitted infections (STIs) in the Soviet Union and may have even aided their spread. Given the taboo of having an STI, many people with such infections consulted private doctors. This resulted in their being excluded from officially registered numbers, creating an artificially low number of reported cases (“It’s Time to Wake Up!” 1989). As infection with STIs serves as a major indicator of HIV risk groups, the limited information about these infections constrained attempts to prevent the spread of HIV. Along with limited knowledge of sexual behavior and of persons with STIs, the Soviet government knew little about other risk groups, such as men who have sex with men (MSM), sex workers, and drug users. Other than denying that Soviet citizens engaged in the “deviant” sexual practices of the West, little was known about these groups and their behaviors. In reality, much went on behind closed doors that was not openly discussed and not officially recognized. In the end, it seems that the practices of Soviet citizens were not really so different from those of the “deviant” West. Within the realm of sexual behavior, particularly little was known about homosexuality in the Soviet Union. Beyond the typical policy of keeping quiet about questions of sexual behavior, homosexuality was prohibited by law in the Soviet Union. As such, until glasnost’, the Soviets claimed that there were no homosexuals living in the USSR. Given the punitive measures for homosexuality, MSM likely developed complicated ways of hiding their personal sexual orientation, making it more difficult to identify them when the time came for analyzing risk groups for HIV detection. The Soviets knew extremely little about the actual lifestyle of MSM, as revealed by a March 1990 statement about prisons: “It is known that penitentiaries for minors serve as a center for the spreading of homosexuality” (“AIDS in the USSR,” 1990). Multiple contact-tracing studies among MSM conducted at the time revealed that this group was actually quite large and was made up

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of persons from various social spheres, as one might expect. In 1988, it was estimated that perhaps one in 100,000 of the Soviet population was homosexual. Whatever the accuracy of that measure, a most important indication of homosexuality’s prevalence in the USSR before 1990 is a Soviet statement concerning the aforementioned translator who returned from assignment in Tanzania infected with HIV, which he passed on to at least 14 other individuals, including women and children. Whatever the implications for the prevalence of HIV, such evidence implies that homosexuality may well have been quite widespread in the general population as well as in the military (Feshbach, 1988). MSM in the Soviet Union had learned to fear discrimination long before the arrival of HIV. This fear would have made them even less likely to go for HIV testing or, if they were to be tested, more likely to hide their true risk factor. Another illegal practice, commercial sex work, went long unrecognized in the Soviet Union. Sources published before 1990 reveal that little was known about the scope of sex work, although its growth was quite visible. A statement made at a conference in Boston in March 1990 clearly defines the problem with government denial of the existence of sex work: Prostitution in the last few decades has become a very widespread phenomenon, among adolescents as among other groups. In the USSR there is no institution of bordellos nor an industry of prostitution. However, as a functioning phenomenon, prostitution is widespread and virtually unmonitored. (“AIDS in the USSR,” 1990)

In this atmosphere of denial, sex work spread widely and was relatively unmonitored, creating uncertainty as to how prevalent the phenomenon had become and which individuals were involved. In the beginning of 1987, it was estimated that there were 3,500 sex workers living in Moscow alone (Feshbach, 1988). This number has since grown exponentially, but its roots reach into the Soviet past. According to a fall 2004 report cited in Komsomol’skaya Pravda, there were at that time between 50,000 and 200,000 sex workers in Moscow, who collectively earned a total of $5 million daily (Vasil’eva et al., 2004, p. 18). As in the case of MSM, turning a blind eye to sex work left Soviet officials uncertain when it came time to test risk groups for HIV. Moreover, denying the existence of sex work in the USSR contributed

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to distrust in official information, since ordinary people could see the problem growing around them. Mirroring a familiar pattern, the Soviet Union also long denied the existence of drug use within its borders. Its blindness to drug use extended beyond even that of the other risk groups. As late as October of 1988, Dr. Valentin Pokrovskiy, a chief AIDS researcher and scientist, emphasized the low incidence of drug use in the USSR: “The incidence of [intravenous] drug abuse . . . is very low in the Soviet Union” (Trehub, 1988). By 1990, however, the number of registered drug addicts was admitted to be approximately 300,000, which was also proclaimed to be artificially low due to an inadequate counting method. Police estimated actual drug addiction to be an order of magnitude higher than reported. Injecting drug use was already quite high, with an estimated 60,000 addicts. With a short supply of syringes and needles, injection drug users (IDUs) were at considerable risk due to reuse of these supplies (“AIDS in the USSR,” 1990). The state’s long-term denial of this problem and its inadequate methods for identifying drug users reduced its knowledge of who belonged to this risk group or how to help them.

Education, Misinformation, and Discrimination Despite the Soviet Union’s puritanical policies on the subject of sex, the government did take a number of measures to educate people about the dangers of HIV and the risks of transmission under the Ministry of Education’s “State Program for the Prevention of the Spread of AIDS,” adopted in July 1987 for the years 1987–1995 (Feshbach, 1988). Before 1990, this program included the issuing of four brochures on HIV/AIDS (a total of twelve million copies for a country of approximately 280 million people), the distribution of the newspaper Anti-SPID, beginning in October 1989 (with a printing of four million copies), and a 15-minute program, “Attention: AIDS,” shown on Moscow television on April 2, 1988 (“AIDS in the USSR,” 1990; Albergo, 1988, p. 9). These educational measures were quite limited and had mixed results. At the very minimum, however, the increased demand for condoms revealed that Soviet citizens had, in fact, learned something about preventing the spread of HIV (Peterson, 1990, p. 9). Misinformation, discrimination, and panic reveal, however, that the

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educational measures adopted by the Soviets were not far-reaching enough. Even if the Soviet people had received sufficient education to understand the meaning of “safe sex,” they would have been hard-pressed to find a way to practice it, given the extremely limited availability of condoms and the high demand for them. Of the estimated one billion condoms needed in 1988, only 220 million were produced (an annual average of only three for each adult male), forcing the Soviet health authorities to buy condoms abroad using hard currency (Medvedev, 1990, p. 933; Trehub, 1988, p.5). The staff of Meditsinskaya gazeta did a countrywide search for condoms in late 1989. They found serious shortages of condoms, euphemistically called “Article Number Two,” across the Soviet Union (Petersen, 1990, p. 7). In 1990, the estimated demand for condoms went up to four billion for the 170 million people of reproductive age, but only a third of the amount needed were produced (“AIDS in the USSR,” 1990). Although Pokrovskiy made the argument in 1988 that condom production would not be given priority in the USSR, since contraception use ran counter to the country’s efforts to increase its (Russian) population, the Soviet authorities did succeed at greatly increasing condom production from 220 million in 1988 to 1.28 billion in 1990 (Feshbach, 1988). Despite such production successes by the end of 1990, condom demand in the Soviet Union still far exceeded supply. The problem was exacerbated by the failure of the command economy, as seen in the inability of the Ministry of the Fishing Industry to produce enough foil packaging for the required number of condoms (Petersen, 1990, p. 8). As a result of the increased demand for condoms and their limited supply, they were a hot item on the black market at the time, selling for much more than their official price of ten kopecks, with given estimates that range from 10–30 times up to 100–300 times the official price (“AIDS in the USSR,” 1990; Petersen, 1990, p. 8). The appearance of condoms on the black market further limited their availability through legal channels. When such profit was available, it created incentive for speculation and lower quality as well. Despite the distribution of pamphlets and other measures for sex education, courses about limited aspects of sexual life were first introduced in schools in 1989, and then only as electives. No mandatory courses were introduced and there were no textbooks or materials on the subject adapted to younger age groups (“AIDS in the USSR,” 1990). Moreover, the atmosphere of glasnost’ did not improve the

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situation. Although the media were freer to discuss sexual life, they strictly avoided discussing its “dark side.” As Peterson explained in June 1990, Today, the Soviet media is presenting the public with paradoxical and counterproductive messages about sexuality . . . For the many that are concerned about AIDS, the mass media has never dared to tell them in clear and explicit terms how and when they may contract the disease. The term “safe sex” has not entered the public health vocabulary yet. (Petersen, 1990, p. 8)

The Soviet people could not count on their educational institutions or the mass media to tell them how to avoid contracting HIV. A 1989 article from the Los Angeles Times reported that it was even difficult to recruit medical professionals to work with HIV-positive persons in the Soviet Union, given the lack of knowledge about the risk factors for transmission even among educated Soviets. Because of their lack of information and education on the HIV infection and how it is spread, many people did not know that the disease cannot be transmitted by casual contact, such as a sweaty handshake (Hamilton, 1989). Given their ignorance and fear of contracting HIV, rumors were rampant. In the early days of HIV/AIDS in the USSR, the anonymous clinic in St. Petersburg daily encountered long lines of people waiting to be tested, among which there was a group of about 50 people who returned to be tested repeatedly, although many of them did not engage in risky behaviors. The members of this group of 50 were panicked because they did not know how HIV was not transmitted: among them, one woman was afraid that she could catch HIV on the metro, and one man feared that he had been infected in a fistfight (Hamilton, 1989). The spread of such rumors and the resulting discrimination against infected persons prompted Literaturnaya gazeta (no. 18, 1989) to accuse health education institutions of “criminal inactivity” for not telling Soviet citizens how the disease is not transmitted, a problem that resulted in “witch hunts” (see Petersen, 1990, p. 10). Discrimination against PLWHA in the USSR had many faces and was largely due to the general lack of knowledge concerning how HIV was spread. The problem was complicated by the lack of confidentiality in medical processes at the time. In September 1989, Dr. Mikhail Narkevich pointed out that doctors still listed AIDS and other “socially significant” illnesses on the medical slips that patients had to submit to their employers to excuse an absence from work, violating

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patients’ confidentiality (Petersen, 1990, p. 11). There are many accounts showing how PLWHA suffered from discrimination due to the lack of confidentiality and to the ignorance of their fellow citizens. One of the most illustrative testimonials is from a patient from Leningrad who was essentially thrown out by the other inhabitants in his communal apartment: Normally, I live in a room in a communal apartment in Leningrad. But when I return, I will live with friends. [But when the others] in the apartment found out I am infected . . . they cut off the water coming to my room. They cut off my light. They don’t let me into the bathroom. They don’t permit me to use the stove. I’ve sold practically all my things from my place; I will sell my furniture and, probably, my room too, since they won’t let me live there. (Petersen, 1990, p. 10)

If this patient’s apartment-mates had understood that they could not catch HIV by sharing the same kitchen or bathroom with this person or even if they had not been able to find out his HIV status, then he could have at least lived out the rest of his life in peace in his old apartment. Discrimination against high-risk individuals and PLWHA manifested itself in many ways. Sometimes this discrimination benefited the high-risk individual and endangered society. For example, in April 1990 Medvedev reported that the AIDS scare made the police less willing to deal with high-risk individuals because they were afraid of getting HIV through casual contact. One result was that prostitutes were observed working out in the open without any police interference in downtown Moscow and Leningrad (Medvedev, 1990, p. 933). In this case, a group who presented no medical danger to the police was allowed the opportunity to infect others because the police were mistakenly afraid of approaching them.

The Response of the Soviet Medical Industry and Health Sector The Soviet ill-preparedness for the spread of HIV was not merely ideological but also economic and practical. As the contradictory and limited informational response to the appearance of HIV revealed inadequacies in the Soviet system, so did its limited material response. Sources from the period are replete with statements about the lack of necessary medical supplies. The need for such supplies appeared

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suddenly, but the planners could not adapt to satisfy this new demand. Even by buying foreign production equipment, they did not come close to meeting their own production plans, let alone the actual need for these products in the Soviet Union. There were many problems in trying to implement the production of new medical products. Production equipment sat unused. Materials and semi-fabricates from various parts of the USSR were not delivered on time. Units produced were of such low quality that they were unusable. Beyond the problem with an inadequate supply of disposable needles and syringes, even before the onset of HIV, the USSR suffered from an inadequate supply of reusable needles and syringes, creating a problem with transmission of disease in hospitals. A 950-bed hospital in the Krasnodar region was allotted only 200 needles for the first six months of 1982, roughly one needle per day (Seale and Medvedev, 1987, p. 304). At one needle per day, it would be physically quite difficult for medical personnel to make sure that the needle and the syringe connected to it were sterilized before each use. To deal with this shortage of needles, hospitals “straightened, sharpened, and removed the rust” from needles that had been used again and again (cited in Feshbach, 1988). When HIV began to spread, the desire to insure needle safety became an immediate imperative. Following world experience, the Soviets found that the only way to be certain that a needle was sterile was to use a single-use hypodermic. Before 1990, the Soviet Union produced very few disposable syringes, although they had already been manufactured in the West for a long time. With the onset of HIV, the Soviets initially had to buy these supplies from abroad with hard currency, but the effort still amounted to a major shortfall in meeting demand (Remnick, 1989). Estimated annual need for disposable needles and syringes was around six billion each, but the Soviet Union developed a plan to try to produce 3.9 billion disposable needles and 3.25 billion disposable syringes annually by 1991 (“Ministries Fail . . . ,” 1989, p. 2; Peterson, 1990, p. 6; Trehub, 1988, p. 5). Even these plans were not met. For the year 1988, only 4.5 million disposable needles were manufactured in the Soviet Union, according to Minister of Health Chazov. The production of disposable syringes was also a failure. Of the 400 million syringes planned for 1988, only 35 million were produced. By March of 1990, the situation had scarcely improved; only 25 percent of demand for disposable syringes was met, five percent by domestic production, and 20 percent by import (“AIDS in the USSR,” 1990; “Ministries Fail . . . ,” 1989; Trehub, 1988, p. 5).

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In sum, shortages of disposable syringes and needles plagued the period. Production planning was ineffective in responding quickly and efficiently to demand. As a result, the spread of HIV in hospitals from dirty needles and syringes was all but inevitable. What happened in Elista was a sad but probably inevitable intersection of ignorance, negligence, and ill-preparedness. An outbreak in this small city (population 85,000) in the Kalmyk Autonomous Soviet Republic occurred in late January 1989 due to the multiple reuse of an unsterilized syringe. Because of the hospital’s remote location and because it treated only children, it is likely that the medical personnel there were not expecting to encounter a patient with HIV. It is likely that the characterizations of HIV-positive individuals as drug users and promiscuous persons who have contact with foreigners and live in big cities deterred them from expecting that HIV could appear in their environment. It only took one infected child, whose father had contracted the disease through a blood transfusion or homosexual contact while living in Africa (although this information is somewhat suspect), to result in the initial infection of 27 others (Albats, 1989a, p. 13).1 Soon these numbers increased as the infection spread further. By May 1990, 75 children had been infected in Elista (Petersen, 1990, p. 6). These infected children went on to infect their mothers, who were breastfeeding them. Initially, five such cases were discovered. By May 1989, nine mothers had been infected through breastfeeding (Medvedev, 1990, p. 932). According to reports at the time of the initial outbreak in Elista, the nurse changed the needles, but she kept using the same syringe without sterilizing it, enabling the transfer of HIV. Enough virus to infect 20 people can remain in the chamber of the syringe if it is not properly sterilized (Albats, 1989a; “It’s Time to Wake Up!,” 1989). Although it is most likely, as insisted at the time by such experts as Dr. Vadim Pokrovskiy and Dr. Valentin Pokrovskiy (his father), that this was merely a case of pure negligence, the fact that the nurse changed the needles at all suggests that the situation may have been more complex (“AIDS Expert . . . ,” 1989; Remnick, 1989). Her changing of the needles suggests some level of precaution. It is likely that she reused one syringe because it was the only one available and time was short. Thus, if the needed supplies had been at hand, this problem could have been prevented. The children’s hospital in Elista was somewhat notorious for its poor record of sterilization. In 1988 alone, the head of the children’s

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hospital was fined by the local sanitary and epidemiological station 13 times, as there were outbreaks of salmonellosis and hepatitis, 123 children died there, and an estimated 14 percent of all syringes used there were not sterilized (Albats, 1989a; Medvedev, 1990, p. 932; Remnick, 1989). While these reports indicate that the children’s hospital in Elista had particularly poor infection control practices, the continued spread of HIV from Elista to hospitals in other areas reveals a deep structural problem in the universal lack of disposable, sterile syringes and the reuse of unsterile syringes (Remnick, 1989). As these children were moved from one hospital to another, outbreaks began to occur in those other hospitals for the same reason: reusing unsterilized syringes (Ballantyne, 1989). By May 1990, mass infections had been reported in the Volgograd oblast’ (46 infections), in the Rostov oblast’ (63 infections), and in the Stavropol’ kray (13 infections) (Petersen, 1990, p. 6). As such, the Elista incident revealed the failings of the Soviet Union’s educational, legislative, economic, industrial, social, and financial efforts against the spread of HIV. Medical personnel found themselves lacking many other necessary disposable supplies besides needles and syringes. These included, but were not limited to, disposable tubing for transfusions, dental instruments, and even examination gloves (“AIDS in the USSR,” 1990). With the lack of necessary supplies and equipment, doctors were required to improvise on a daily basis to try to prevent the spread of HIV. The discrimination of doctors against patients with HIV in this period was not completely without cause, given that the protective gloves furnished to medical personnel—when available—could be pierced by a needle, subjecting doctors to the risk of infection (“Anti-AIDS Campaign,” 1990, p. 4). Shortages in supplies and equipment also affected the ability of medical personnel to sterilize the reusable needles and syringes available. To be effective, sterilization must occur in conditions of over 57 degrees Celsius or approximately 130 degrees Fahrenheit. In the Soviet Union, effective sterilization was impeded not just by the reported shortage of autoclaves for the national dispensarization program initiated in 1982, but also by the officially announced nonavailability of hot water in 65 percent of rural hospitals (Feshbach, 1988). The production of high quality medical supplies and maintenance of the medical industry were not given sufficiently high priority. This fact became painfully clear when doctors were ill equipped to fight the spread of HIV. In the medical industry, if improvisation is necessary, it should be an exception to the rule rather than par for the course, as it had become in the Soviet Union.

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While doctors were deprived of the supplies and information they needed, cases of negligence among medical personnel destroyed the public’s trust in medicine’s ability to stem the growth of HIV in the USSR. The press of this period consists of a series of outcries against the medical industry (Albats, 1989b; “Anti-AIDS Campaign,” 1990; “It’s Time to Wake Up!,” 1989; Medvedev, 1990; Peterson, 1990; Remnick, 1989). A joke going around at the time was: “AIDS warns that the Health Ministry can be dangerous to you” (Blyuger, 1990). Although medical personnel were often made undeserving scapegoats for larger problems in these situations, in many cases they were indeed neglectful of their duties. Given the limited monitoring systems at the time and the prejudice that HIV was a Western problem, it is understandable how medical personnel in distant parts of the country could have spread HIV to patients through ignorance. Even though their working conditions were less than ideal and they lacked the necessary equipment, many commentators at the time were correct in claiming that the problem rested on the fact that sterilization was inadequately regulated and monitored (“AIDS in the USSR,” 1990; Medvedev, 1990; Peterson, 1990). Improperly sterilized equipment was responsible not only for the spread of HIV, but also for the high rates of infant mortality and hepatitis in the Soviet Union (Medvedev, 1990; “Ministries Fail . . . ,” 1989). Despite the fact that criminal responsibility for medical personnel who violated rules of sterilization was established in 1988, the consequences for improperly sterilizing equipment were minimal (“AIDS in the USSR,” 1990). In the first four months of 1990, 83 instances of improperly sterilized medical equipment were reported in the Volgograd region. Each time, the responsible party’s punishment was limited to a fine of ten rubles, even though that person could have infected several patients with HIV and other deadly diseases (Petersen, 1990, p. 7). Medvedev correctly identified the need for a reform of the entire medical system to raise standards and reduce the incidence of blood-borne infections (Medvedev, 1990, p. 933). This type of reform would have required substantial input of funds and effort. Only then could the public have sensed renewed trust in medical personnel’s ability and desire to protect them from disease. It has never been fully realized to this day. Given the growing distrust in medical personnel, private demand for syringes grew. Since people were afraid that they or their family members would become infected by an unsterilized syringe, they went looking for their own supplies to insure that they had clean syringes (Albats, 1989a; Peterson, 1990). Buying syringes at regular pharmacies

Early Days of the HIV/AIDS Epidemic

25

was illegal for all but a few persons with specific medical conditions. Thus, people tried to purchase them on the black market at inflated prices. In 1990, syringes on the black market in Volgograd sold for 10–20 rubles each, quite a large sum in that day (Petersen, 1990, p. 6). Black market speculation for needles and syringes further fueled the deficit in these goods in hospitals, since it created an incentive for medical personnel with access to these supplies to steal them and sell them on the black market. In October 1989, there were no syringes in Leningrad pharmacies, but plenty of them on the Leningrad black market, even though the city was the location of the largest producer of disposable syringes in the country, the “Lenmedpolimer” factory (“Update . . . ,” 1989, p. 2). Blood safety, not surprisingly, was also a significant issue in the late 1980s and early 1990s. As in other countries, donated blood was routinely screened only after several people were infected by blood transfusions. In October 1988, Minister of Health Chazov announced that all blood and tissues donated in the USSR were tested for HIV (Albergo, 1988, p. 15; Trehub, 1988, p. 5). Although this was supposed to be the case, by 1990 the quality of the test systems for blood was called into question, creating widespread suspicion about the quality and results of blood tests. Was the blood really safe? (“Anti-AIDS Campaign . . . ,” 1990, p. 3) As with other equipment, the Soviet Union was troubled by the low availability and poor quality of HIV test kits. The Soviets developed their own test kits in 1987. Although these were initially “found to be identical to foreign ones in terms of sensitivity and effectiveness,” these kits were later deemed unreliable and new kits were developed for mass production in 1988. In fact, the Soviet-produced diagnostic kits had a very high error rate of 10–18 percent (Albergo, 1988, p. 20; Medvedev, 1990, pp. 932, 934). Shortages of kits were not infrequent. In 1988, only 65 percent of the requested test kits were received by testing centers, according to Aleksander I. Kondrusev, the chief sanitary inspector of the Soviet Union, as cited in Meditsinskaya gazeta (Trehub, 1988, p. 6). Combined with the high error rate in test kits, and due to shortages in test kits, several tests were simultaneously done on each kit, yielding an even higher error rate. Given the inaccuracy of Soviet test kits, a positive result from a domestic kit was reportedly always checked with an imported test kit (“AIDS in the USSR,” 1990). This process only accounted for false positives. False negatives went unchecked, as in the case of Olga Gayevskaya, the Soviet Union’s first official AIDS mortality.

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Although over 55 million Soviet citizens were reported to have been tested for HIV by April 1990, officials at the time estimated that repeat blood donors, who had been double- and triple-counted, accounted for half of this number, making the actual number of people tested much smaller (Petersen, 1990, p. 5). The high number of blood donors tested means that a relatively low number of persons from high-risk groups were tested, groups whose members feared the stigma of a positive diagnosis (“It’s Time to Wake Up!,” 1989, p. 4). The lack of knowledge about persons from individual risk groups, as mentioned above, likely accounts for the small numbers of these people in the official prevalence figures for the USSR from 1987 to 1990.

HIV Prevalence in the Latter Days of the Soviet Union The number of HIV cases reported in the USSR between 1987 and 1990 was artificially low, as recognized even by leading Soviet health officials such as Leonid Ionin of the Academy of Sciences and Minister of Health Chazov (Feshbach, 1988; Trehub, 1988). Although the cumulative number of reported cases over the period was in the hundreds (442 by the end of 1990 to be exact, as shown in figure 1.2), it should have been in the thousands, according to Pokrovskiy in February 1989 (“AIDS Expert . . . ,” 1989). The low recorded incidence and prevalence of HIV in the Soviet Union was a result of inadequate testing of persons from risk groups and of doctors who were afraid to diagnose patients with HIV for political reasons (as noted previously by Kozlov) (Hamilton, 1989). Indeed, the problems with inadequate testing of risk groups and unwillingness by medical personnel to diagnose HIV have continued in Russia today. At the time, estimates of HIV prevalence were complicated by the issue of whether or not Kaposi’s Sarcoma (KS) necessarily signified AIDS when it appeared in young people, since in 1983 at the Aarhus Conference (one of the first international scientific conferences, held in Aarhus, Denmark, to discuss the definition of AIDS) it was agreed that KS in persons under 60, in the absence of any underlying cause of immune deficiency, was, by definition, AIDS (Seale and Medvedev, 1987, p. 303). This definition has been found not to be the case, but given that studies in this period found large numbers of KS patients under 60 in the Soviet Union, it may be one reason why the estimated

Early Days of the HIV/AIDS Epidemic 450

27

442

Number of Cases

400 339

350 300 250

268

200 150 100 50 0

71 24

103 47

24 1987

1988

Incidence

Prevalence

1989

1990

Figure 1.2 HIV Incidence and Prevalence, USSR, 1987–1990 Note: The figures shown in this chart are only for the years 1987 through 1990, although there is evidence that there were HIV cases stemming from blood transfusions before 1987. The “prevalence” figures are therefore somewhat deceiving, as they account only for the cumulative total official figures between 1987 and 1990. Source: VICh-Infektsiya, Informatsionnyy byulleten’, no. 8, 1997, p. 10.

prevalence figures for the period differ so greatly from the reported figures, in addition to the obvious undercounts. Prognoses made at the time ranged from high to absurdly inflated. These numbers may have added to the atmosphere of fear, distrust, and panic. As part of its “Anti-AIDS Campaign,” the popular weekly magazine Ogonyok published an estimate that 50 million people would carry HIV by 2006. That would be more than one-third of the total population of the Russian Federation today (143.2 million). Looking back, this extreme estimate exceeds the fall 2004 estimated number of cases of HIV by more than 50 times (according to Feshbach and Galvin, 2005). Other projections, such as those calculated at the N. F. Gamaleya Scientific-Research Institute of Experimental Medicine and cited by academician V. I. Pokrovskiy, while still high, more closely correspond to current estimates of HIV and AIDS prevalence. Predicting 1,045,000 cases of HIV infection and 30,000 AIDS cases by the year 2000, these mathematical projections were a bit premature but not entirely out of the ballpark (“Seroprevalence Study . . . ,” 1990). Although projected for 2000, these numbers most likely correspond to the situation that will exist with HIV/AIDS in Russia in

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the next several years. However, considering that these projections were made for the entire territory of the USSR, if the estimated prevalence figures for 2000 were added up from all the former territories of the USSR (not just the Russian Federation), the actual number of cases may more closely match those of the Gameleya Institute. The main transmission routes for HIV in the Soviet Union from 1987 to 1990 differed greatly from those in the West. In comparison with the West, where the main routes of transmission were homosexual contact and injection drug use, the majority of the early reported HIV cases in the Soviet Union were from medical accidents and sexual contact with foreigners, with a higher share for heterosexual contact than for homosexual contact (Petersen, 1990, p. 5). Despite the stigma surrounding drug use, the fact that none of the cases reported in this period were listed as being due to injection drug use shows a significant difference between the reported Soviet figures and the figures in the West. This distribution becomes especially interesting when one considers how HIV has spread to the present day, when IDUs account for the vast majority of HIV cases in Russia. Figure 1.3 and table 1.1 show the official annual incidence numbers by main risk factor for 1987 through 1990. The main recorded method of HIV transmission in the USSR between 1987 and 1990 was medical mistakes made during hospitalization; 56.7 percent of all new HIV cases recorded during the period

0.6% 4.7%

4.1%

Homosexual Contact

15.6%

Heterosexual Contact Blood Transfusion Recipient 17.2%

Hospitalization Born to Infected Mother

1.1% 56.7%

Breastfeeding of Infected Infant Uncategorized

Figure 1.3 HIV Cases by Main Risk Factor, USSR, 1987–1990 Source: VICh-Infektsiya, Informatsionnyy byulletin’, no. 8, 1997, p. 10.

Early Days of the HIV/AIDS Epidemic

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Table 1.1 HIV Cases by Main Risk Factor, Annual Incidence, USSR, 1987–1990 Main Risk Factor

1987

1988

1989

1990

1987–1990 Total

Number (%) Number (%) Number (%) Number (%) Number (%) Homosexual contact Heterosexual contact Blood transfusion recipient Hospitalization Born to infected mother Breastfeeding of infected infant IDU Uncategorized Total annual incidence

10 9

41.7 37.5

20 20

42.6 42.6

17 29

6.4 10.8

22 18

21.4 17.5

69 76

15.6 17.2

4 0

16.7 0.0

0 5

0.0 10.6

1 201

0.4 75.0

0 45

0.0 43.7

5 251

1.1 56.7

0

0.0

1

2.1

0

0.0

2

1.9

3

0.6

0 0 1

0.0 0.0 4.1

1 0 0

2.1 0.0 0.0

14 0 6

5.2 0.0 2.2

5 0 11

4.8 0.0 10.7

20 0 18

4.7 0.0 4.1

24

N/A

47

N/A

268

N/A

103

442

N/A

N/A

Note: N/A ⫽ not applicable. Source: VICh-Infektsiya, Informatsionnyy byulletin’, no. 8, 1997, p. 10.

were transmitted during hospitalization through inadequately sterilized medical supplies. In 1989, the year of the Elista tragedy, 201 (or 75 percent) of the 268 newly recorded cases of HIV were transmitted in this way. Another 14 cases in that year occurred when babies who had contracted HIV in a hospital transferred the disease back to their breastfeeding mothers. Another 45 cases of in-hospital transmission and another five cases of transmission through breastfeeding were reported in 1990, spin-offs from the Elista and related tragedies. The uproar raised by the press and the public about medical safety was not without cause; the main mode of HIV transmission in their country was the same as in the developing world, but the USSR was a major world power (“AIDS in the USSR,” 1990; Seale and Medvedev, 1987). At the same time, these numbers show that the blood supply in the USSR was more or less safe by 1988, although in earlier periods blood transfusions were a main factor of transmission in the USSR, accounting for eleven cases of HIV recorded before 1988 (“Seroprevalence Study . . . ,” 1990). To make a bad situation worse, according to the elder Pokrovskiy and others, the great majority of those accidentally infected in clinics and hospitals at this time were children, although the numbers published in official Russian sources do not reveal the ages of those infected in this early period (“AIDS Cases Rise . . . ,” 1990; Ballantyne, 1989;

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Petersen, 1990, p. 5). Detailed age distributions begin only in later years. In fact, a detailed study published in February 1990 reveals the overwhelming number of HIV cases in children versus adults in a number of regions (“AIDS Cases Rise . . . ,” 1990). At this time it was reported that in the Kalmyk Autonomous SSR, 75 of 92 PLWHA were children; in Volgograd oblast’, 46 of 59 PLWHA were children; in Rostov-on-Don, 63 of 69 PLWHA were children; and in Stavropol kray, 13 of 15 PLWHA were children. Thus, in these four territories alone there were 197 HIV-infected children, accounting for almost half of the 446 reported HIV cases at the time. Again, the uproar about medical practices in the USSR was not without cause, especially with the consequences it presented for children. In recent years, infection from medical mistakes has decreased substantially, as has the spread of the infection among children. As of September 1, 2004, children accounted for only 3.7 percent of all PLWHA (of the 291,512 reported cases of HIV, only 10,802 are among children) (AFEW [Aids Foundation East-West], 2004). Between 1987 and 1990, sexual contact accounted for 32.8 percent of all recorded cases of HIV, of which homosexual contact accounted for 15.6 percent and heterosexual contact accounted for 17.2 percent. Outside of medical accidents, sexual contact accounted for the majority of HIV cases identified during this period. At the time, V. V. Pokrovskiy speculated that perhaps these numbers were not higher because the virus was still absent in a number of sexually active subpopulations (“Penetration and Spread . . . ,” 1990). These populations were bound to come into contact with HIV in the future, especially given the increase in travel abroad and the easing of rules governing contact with foreigners during perestroika (Petersen, 1990, p. 5). Sexual contact with people from places where HIV prevalence was much higher introduced a greater chance of infection into the USSR. Although the infection was imported from abroad, concentrating on blaming contact with foreigners was a way of turning attention away from the behavior of the indigenous population (Petersen, 1990, p. 5). Once HIV had entered the USSR, one did not have to have sex with a foreigner to catch it. Short of extensive contact tracing it would be difficult to uncover the origins of all the HIV infections as they spread in the USSR. Yet the fact was that, as in other places worldwide, Soviet citizens needed to learn to take precautions to protect themselves from HIV, even if they never even met a foreigner.

Early Days of the HIV/AIDS Epidemic

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Conclusion Medical, economic, political, and ideological ill-preparedness exacerbated the spread of HIV in the early days of HIV/AIDS in the USSR. To this day, the atmosphere of denial, fear, and scapegoating surrounding HIV/AIDS continues to exist in the Russian Federation. The need to address the problem has become all the more urgent. In 1990, outside of radical prognoses, no one expected HIV prevalence to spread as far as it has, even according to official figures. Although the identity of the main groups affected by the virus may have changed, HIV still plagues the younger population in Russia. Whereas in 1990, children under 15 years of age accounted for at least 50 percent of PLWHA in the Soviet Union, today young adults, ages 15–29, account for over 80 percent of infections (Feshbach and Galvin, 2005). The current age distribution of HIV infection in Russia threatens to produce severe demographic consequences if it remains unchecked.

Notes The author thanks Amanda Murphy for research assistance. 1. Albats (1989a) says that he was infected in the Congo, while Altman (1989) says he was infected in Guinea.

References AFEW [AIDS Foundation East-West] (2004) www.afew.org/statistics/russia.htm. “AIDS Cases Rise to 446; 19 Deaths Reported” (1990) Translated in FBIS-SOV90-037, February 21. “AIDS Expert Urges Universal Preventative Measures” (1989) Moscow Television Service, translated in FBIS-SOV-89-026, February 9. “AIDS in the USSR” (1990) “The Moscow Interlegal Research Center’s Postfactum Special Information Release,” cited in Kolokol (Bell) Council of Experts, presented at the Spring Research Forum, Boston, MA, March 15–17. Albats, Ye (1989a) “Beware,” Moscow News, 8. ——— (1989b) “Save Our Children from AIDS!” Ogonyok, September. Albergo, G. A. (1988) “The Soviet Approach to the AIDS Epidemic,” term paper for the course “Demography of the USSR,” Professor Murray Feshbach, Department of Demography, Georgetown University, December 12. Altman, L. (1989) “Health Official Traces Virus Trail,” New York Times, June 4. “Anti-AIDS Campaign” (1990) Ogonyok, 4. “Baby Dies of AIDS in Soviet Black Sea Resort” (1998) Reuters, November 8. Ballantyne, A. (1989) “Russian HIV Chain Trace to One Child,” The Guardian, June 5.

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Blyuger, A. (1990) “Latvian Academician’s Report on AIDS,” translated in JPRSUPA-90-013, March 13. “Bohdan Nahaylo Finds the Soviet Press Nervous in Dealing with the Disease” (1986) Spectator, October 4, 1. Feshbach, M. (1988) “Is There an AIDS Problem in the USSR,” paper presented at the conference of the World Political Science Association, Washington, DC, August 30. Feshbach, M., and C. Galvin (2005) HIV/AIDS in Russia: An Analysis of Statistics (Washington, DC: Woodrow Wilson International Center for Scholars). Hamilton, M. (1989) “Soviets Acknowledging AIDS as More than Western Problem,” Los Angeles Times, April 22. “It’s Time to Wake Up! AIDS and Venereal Diseases Are More than Merely a Medical Problem” (1989) Interview with Luba Shetsiruli, translated in JPRSUPA-89-057, October 12. Medvedev, Zh. A. (1990) “Evolution of AIDS Policy in the Soviet Union: The AIDS Epidemic and Emergency Measures,” British Medical Journal, 300, April 7, 932–934. “Ministries Fail to Provide Needed AIDS Equipment” (1989) Interview with S. Blagodarov, translated in FBIS-SOV-89-098, May 23. Nivikov, A. (1987) Komsomol’skaya Pravda, August 1. “Penetration and Spread of Human Immunodeficiency Virus in Homosexual Population in Moscow” (1990) Translated in JPRS-ULS-90-021, December 11. Peterson, D. J. (1990) “USSR—The Soviet Experience with AIDS,” Radio Liberty, June 7. Pokrovskiy, V. V., Z. Z. Yankina, and V. I. Pokrovskiy (1987) “Epistemological Investigation of the First Case of the Acquired Immuno Deficiency Syndrome (AIDS) Detected in the USSR,” Zhurnal Mikrobiologii, (12) (December 1987):6–10. “Portrait of an Insidious Enemy” (1985) Trud, October 6; translated in The Current Digest of the Soviet Press, 37(40):27. Remnick, D. (1989) “Unwashed Needles Infect 27 Infants with AIDS: Soviet Hospital Failed to Sterilize Syringes,” Washington Post, January 30. Seale, J. R., and Zh. A. Medvedev (1987) “Origin and Transmission of AIDS: Multi-Use Hypodermics and the Threat to the Soviet Union,” The Royal Society of Medicine, 60. “Seroprevalence Study, Forecast of AIDS in USSR” (1990) Translation in JPRSULS-90-011, July 11. “The USSR’s AIDS Disinformation Campaign.” (1987) Foreign Affairs Note, July 6. Trehub, A. (1988) “Soviet Media Report First Soviet AIDS Death,” Radio Liberty Research, 470(88), October 19. “Update on Shortage of Disposable Syringes” (1989) Translation in JPRSUPA-89-064, December 6. Vasil’eva, L. et al. (2004) “Moskovskiye prostitutki zarabatyvayut v den’ $5,000,000,” Komsomol’skaya Pravda, 211, November 9.

2 Russian Politics and HIV/AIDS: The Institutional and Leadership Sources of an Inadequate Policy Celeste A.Wallander

The Russian Federation is the largest country in the world. It spans eleven time zones and borders four geopolitical regions: Europe, the Middle East, Central Asia, and East Asia. It carries weight and responsibility as one of the world’s major political powers, as a member of the G8, and with a seat on the UN Security Council as a permanent member. Although weakened relative to the Soviet era, its nuclear and conventional military forces are among the few with a truly global reach, and its military technology makes Russian arms highly competitive on global markets. It is the second largest exporter of energy (after Saudi Arabia), and taking into account both oil and natural gas, Russia has the world’s largest energy reserves. It is a wealthy country by world standards, and in terms of economic growth Russia has outperformed the United States and Europe for the last five years. As a global power, Russia also suffers the global pandemic of HIV/AIDS. Russia does not have the world’s highest prevalence rate, nor the largest number of people living with AIDS. Compared to large countries such as China or India, Russia (with a population of 144 million) is unlikely to contribute dramatically to the global burden of tens or even hundreds of millions of people living with and dying of AIDS. But for the past few years, Russia has had the sad distinction of having one of the highest growth rates of HIV infection in the world. At the end of 1999, there were 31,000 officially registered officially registered Russians infected with HIV. By April 2005, Russia’s Federal AIDS Center

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Celeste A.Wallander

reported 315,000 officially registered HIV-infected persons. Arguably, while the growth rates could be viewed as a statistical artifact (any increase from a small number will result in a high growth rate), the spread of the disease in Russia over the last decade has been explosive. Although reliable numbers are impossible to come by (an issue that will be explored later), credible professional estimates are that the true number of HIV-infected Russians is in the range of one million. This means that about one percent of the adult population is HIV infected, a standard benchmark for an HIV pandemic poised to become a generalized national health crisis, not one concentrated merely in highrisk groups such as injection drug users (IDUs) or men who have sex with men (MSM). Russian and international experts understand quite well the HIV/AIDS situation and the threat it poses to Russia’s future. Russian scientists, activists, and health officials have been working for years to prevent the spread of HIV within high-risk groups, and from such groups to the general population. Select regional and local governments, the appropriate UN agencies, and international foundations and NGOs have launched pilot programs for the study and prevention of the spread of HIV. Many devoted and brilliant people have labored for years in their determination to spare Russia the experience of denial and inattention that plagued countries like the United States some 20 years earlier. In the context of Russia’s post-Soviet transition, however, HIV/AIDS is just one of many pressing political, economic, social, and health problems. It is not easy to convince national leaders that the spread of HIV requires more attention and resources when other health crises, such as a shrinking population due to cardiovascular disease and alcoholism, appear to be a more immediate and tangible threat to the country’s future. It requires truly visionary leadership to devote political and financial resources to a disease that is perceived to be a problem of socially “maladapted” and marginal people when Russia’s children attend crumbling schools and are taught by underpaid teachers. And while it is true that Russia’s economy has had strong growth since 1999, the explosive growth in HIV infection began in the 1990s, when the economy was still suffering from a 50 percent reduction in GDP, near hyperinflation, and low real incomes. As a result, Russia, like so many—too many—countries before it, has been terribly slow to confront the problem of HIV and take effective action to prevent its spread to the general population. Although President Vladimir Putin has made reference in several speeches to the problem of Russia’s demographic and health decline, until late 2005, he publicly mentioned HIV/AIDS in this context only once, in May

Russian Politics and HIV/AIDS

35

2003 (Putin, 2003). Russia faces many challenges in mounting an effective response to the problem of HIV, but none is more important than the failure of the country’s national leadership to fully grasp the essence of the problem, which is the first step to a national policy necessary to prevent Russia from becoming a high-prevalence country. The key to a national response lies in the Kremlin, which has been silent. This may, however, be changing. In March 2005, Deputy Prime Minister Aleksandr Zhukov gave a speech in Moscow identifying AIDS as a problem of national security and economic development for Russia. And in the weeks after that speech, the Russian government reported that President Putin had put the issue of HIV/AIDS on the agenda of the May 2005 Russian Security Council meeting (Coalson, 2005). Most importantly, in early 2006 Putin promised a dramatic increase in federal funding for the fight against HIV/AIDS in Russia, amounting, if fulfilled, to a thirtyfold expansion of available resources. These developments suggest that some in the leadership have begun to think about HIV in high priority terms and as more than a simple health issue. The question is whether Russia’s political system can handle the challenge of such a complex disease.

Russian Politics Today The Russian political system is shaped by its Soviet legacy, but it is not the Soviet political system. The Soviet legacy is important for several key reasons. First and foremost is the sheer size and scope of the government and bureaucracies. Despite privatization and the emergence of market economics, the state plays a larger role in health, education, and the economy than in most European countries. Private health facilities exist, but the vast majority of Russians continue to receive health care in the state system (Twigg, 2000). The role of the state in the Russian economy and everyday life has changed a great deal in the past 15 years, but the Russian state remains a large factor (McFaul, Petrov, and Ryabov, 2004). A second Soviet institutional legacy that matters is the vertical nature of government institutions and bureaucracies and the vastly underdeveloped nature of horizontal institutional linkages for policy coordination and implementation. In Russia, as in the Soviet political system, the result is (at best) duplication and compartmentalization of policy and government services. To the extent there was an interagency process in the Soviet Union, it was a function performed by the Communist Party. In a political system where initiative came from the top, vertical structures provided for greater control in order to keep lines of responsibility clear, and to be certain that one would not be

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Celeste A.Wallander

held responsible for failings outside one’s areas of responsibility. And in a political system where power worked from top to bottom, there was no reason to devolve authority or responsibility to middle levels of ministries where they might coordinate across institutions (Hough and Fainsod, 1979, chap. 7). The result is that the Russian government lacks institutions for coordination or sharing responsibility for policy across ministries or government agencies. The system relies on policy direction from the top, and on the ability to delegate issues or problems to specific ministries or agencies that then handle them within their own vertical structure. There is little incentive to share responsibilities: budgets are allocated to ministries and agencies in accordance with their mandates, so why spend resources in cooperating to meet another ministry’s responsibility? If the Ministry of Health is tasked with preventing HIV, why should the Ministry of Education spend scarce resources on educational programs that meet those needs? The third Soviet institutional legacy important for politics and policy on HIV is the nature of state-society relations and the very underdeveloped nature of civil society in Russia. The Soviet political system prevented the development of autonomous nongovernmental groups and was based on an ideology in which the state and Communist Party had the sole right and responsibility to provide for the well-being and needs of their citizens. To the extent that organizations existed in the professional, social, or related spheres, they were created and managed by the state or Party. As a consequence, Russia does not have much experience with civic activism in public life. In post-Soviet Russia, the development of an autonomous civil society that can be a source of ideas, expertise, and motivation for the government has been problematic. In recent years, the Putin government’s efforts to control demands and dissent in the political and economic system have extended to political and apolitical civil society groups, NGOs, nonstate media, and nonstate business interests (Mendelson and Glenn, 2002; Sperling, 1999). While the Soviet legacy is important for understanding Russian politics and policy on HIV, just as important are distinctive features that have structured Russia’s post-Soviet political development. The first to note is the absence of the Communist Party as a parallel policy structure. The Party was the mechanism for control of the country and for ideology. But it also served the functions of formulating policy, monitoring implementation, and pressing policy effectiveness (at least in terms of Party objectives). If the Politburo deemed a policy objective to be a priority and chose to devote resources to achieve that objective,

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37

it could use the mechanisms of the Communist Party that, in effect, served as a parallel government structure to monitor and encourage implementation (Bialer, 1980, chap. 3 and 8; Hough and Fainsod, 1979, chaps. 11 and 12). In other political systems, the monitoring and implementation functions of government can be created by competitive political parties, where the goal of winning the next election creates an incentive to show successful performance. Investigative professional media or civil society nongovernmental organizations can also play this role. In Russia, political leaders are accountable at best to one another within the elite, competitive political parties are absent, and the lack of independent professional media and effective citizens’ watchdog groups preclude any kind of outside incentive for policy effectiveness (McFaul, 2002). Finally, Russia’s political system faces certain challenges of effectiveness because Russia is a federation, but it is more an administrative federalism than a political federalism. Regions and localities have responsibilities in areas such as social services, education, and taxes, but these are defined by the central government, which can remove or add to the scope and burdens (Bunce, 1999). Regions and localities receive budget resources from the center, but since they have power over neither the scope of their policy responsibilities nor over the size of those budgetary resources, there can be a considerable mismatch between what regions are supposed to achieve and what they do. Holding them accountable to voters (a mechanism increasingly difficult in a federal system where regional leaders can be appointed or dismissed by the federal government) should be one way to improve performance, but since tenure in office depends more on relationships with local business, or on the support of the federal government, the mechanism does not function for effective federal governance, given Russia’s current political evolution (Hough and Fainsod, 1979, chap. 13; Petrov, 2001; Stoner-Weiss, 1997). It is in this institutional context that one needs to understand the specific politics of the Yeltsin and Putin presidencies. It was a political terrain that produced the proto-democratic, chaotic, corrupt, weak state of the Yeltsin era. But it is also this very terrain that has produced a neoauthoritarian, more predictable, corrupt, strong state of the Putin era (Shevtsova, 1999 and 2003). Most contemporary analysis focuses on how the current Russian political system has evolved to be very different from the Russian political system of just five years ago. But for understanding Russian policy on HIV/AIDS and the future

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willingness and capacity of the Russian political system to cope with the challenge, it is as important to understand their commonalities. The same excessive vertical stovepiping, lack of accountability, corruption within the state, and weak civil society that contributed to a weak policy response in the 1990s and that resulted in the explosive growth of HIV in the late 1990s and early 2000s will continue to hamper an effective response, even with a stronger state. Furthermore, the nature of a stronger Russian state under the Putin leadership does not address the sources of institutional weakness, and it exacerbates the weakness of mechanisms for good government and effectiveness inherited from the Soviet political system. Over the past five years, the Russian leadership has achieved a greater degree of control over Russian political, social, and economic life. In addition to the erosion of competing political parties, it has made the upper house of Parliament, the Federation Council, subordinate to the presidential administration through the power of appointment, and this method of eliminating political independence has now been extended to the governors of Russia’s 89 regions. The chances for the development of independent political parties to challenge the leadership’s hold on power has been further crippled with the passage of new regulations. It is now more difficult for new parties to register (to be registered a party must have at least 50,000 members, with members in every one of the 89 regions), let alone attract enough of a national following to win seats in the lower house of Parliament, the Duma (a party must now gain seven percent of the vote instead of five percent to win seats). The Putin leadership argues that it has sought control for good reasons: for stability and an effective state. In contrast to the chaos of the 1990s and the hijacking of the Russian state to the interests of greedy oligarchs, Russia is now run by security professionals with the goal and capacity to pursue economic growth, improvement in social conditions, and Russia’s status as a respected great power in the world (Surkov, 2005). Thus, the argument of Russia’s leadership is that its retreat from liberal democracy is necessary for stability, and that developments in Russia away from the institutions of democracy (independent political parties, independent judiciary, independent civil society, independent media, independent legislature, and independent regional and local governments) have been necessary to correct for the excesses of the 1990s, in which the state was effectively captured by narrow selfish interests that weakened it and stole national assets (Gustafson, 1999; Shliefer and Treisman, 2000).

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The problem is that the Putin leadership has created a state that may be strong in silencing independent voices and in preventing independent activities, but it is a state that increasingly cannot effectively govern a modern twenty-first century Russia in a complex global environment. The Russian state is very good at stamping out dissent and defeating independent political, social, and economic forces. But it is virtually helpless in advancing economic reforms that would create a promising investment climate on a national scale outside of the energy sector (and the state has even failed to attract serious investment in the energy sector, as evidenced in problems with stalling production in 2005). The state has not had the dexterity to use the oil price windfall of the past six years to spark growth and innovation for small and medium enterprises, or for modern industrial sectors where Russia’s enormous human capital of highly educated scientists and engineers could make the country a global competitor. It has failed to broker a compromise of domestic energy prices, a necessary condition for joining the World Trade Organization. It has failed to develop effective reform of the country’s social benefits programs, a measure vital to Russia’s future fiscal health, social equity, and economic competitiveness. By not engaging local leaders, social groups, and nongovernmental experts in its plan for overhaul of the social benefits programs, the government failed to anticipate the mass protests across the country that resulted from its unilateral announcement of a reform that was perceived by society as unfair and a threat to the poor and vulnerable (World Bank, 2005; VOA, 2005). The weaknesses of Russia’s overall political institutional context for effective public policy are apparent in its HIV/AIDS institutional setup, which was created in the late Soviet period. Russian HIV/AIDS surveillance and care exist in a separate centralized system of AIDS centers and laboratories. Federal and regional AIDS centers are isolated from the health care system as a whole. These centers are funded by earmarked programs in the federal, regional, and municipal budgets, and they bear sole responsibility for HIV testing and health care for people living with HIV and AIDS. Complicating matters even further was the devolution of authority and responsibility for social services to the regional level in 1993 (Danishevski and McKee, 2005; World Bank, 2004).

Russian Leadership and Priorities If the institutional context of Russian politics is an unlikely source of an effective government response, neither the policies nor the priorities

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of the Putin government favor making HIV/AIDS a government priority. Although tactics and specific policies have shifted over the past five years, the overall objective of Russian policy has remained consistent: economic growth to increase the country’s wealth and power, and therefore to reestablish Russia as a great power on the global stage (Legvold, 2001; Wallander, 2005). Early in Putin’s first term, this was usually expressed in terms of doubling GDP, although this specific goal has been dropped. The objective is also often cast in terms of Russia’s assuming a place as a European power, with the implied levels of economic wealth, social well-being, and political influence. In terms of domestic policy, the Putin leadership has focused on certain important reforms such as tax and regulatory changes to spur growth by simplifying the business climate. But mostly, in terms of domestic policy, Russian growth has been built on reaping the benefits of high global energy prices while implementing a more disciplined macroeconomic policy. With Russian government budgets in better balance, the currency has been relatively stable, inflation has been held to about twelve percent annually, and the cycles of budget arrears and nonpayments have been broken (Desai and Idson, 2000; Woodruff, 1999). The government has also exercised fiscal discipline in creating a Stabilization Fund for holding its substantial surplus energy revenues in an effort to prevent currency appreciation and inflation. It has used part of these revenues to pay off international debt, thereby improving the government’s bond rating and reducing interest rates. The emphasis on fiscal discipline has meant that social spending has not substantially increased. While the government is now paying pensions, government wages, and social benefits (a considerable improvement over the situation in the 1990s), it has not substantially overhauled its approach to investing in social programs, including health. Putin has identified health as a major problem for Russians, but the prescription has for the most part consisted of exhortations to healthier living and exercise, not major government reforms in the health sector (WHO, 2005). The Putin leadership’s popularity and social support for his government over the past five years have been based on economic growth, the government’s hard line on the war in Chechnya, and the sense of a more confident government and powerful country. This is not an environment in which the Russian leadership is inclined to admit that it, like India, South Africa, Nigeria, and China, faces a crisis of health, social stability, and development. Such comparisons do not fit with the leadership’s chosen image on the world scene and the one it projects at

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home (Medvedev, 2005). The government’s claim to leadership is that it has brought stability and relative prosperity back to Russia after the period of the 1990s when Russia was weak and ineffective at home and abroad. The issue of HIV/AIDS has to be understood in this context. Anyone who begins to explore the issue of HIV in Russia learns very early in discussions with Russians not to compare their country to Africa either in terms of the nature of its vulnerability or in terms of its potential for a generalized epidemic. One is warned early on that Russian officials and opinion leaders do not like to be compared to Africa because Russia is European, has nuclear weapons, and is a major international player. HIV does not fit the image of Russia in its domestic and foreign policy. This context is quite apparent in Putin’s public statements. For example, in his 2004 state of the union message, he said, Now, for the first time in a long time, Russia is politically and economically stable. It is also independent, both financially and in international affairs, and this is a good result in itself. . . . We want high living standards and a safe, free and comfortable life for the country . . . We want to strengthen Russia’s place in the world. . . .We must grow faster than the rest of the world if we want to take the lead within today’s complex rules of global competition. We must be ahead of other countries in our growth rate, in the quality of our goods and services and level of our education, science, and culture. This is a question of our economic survival. It is a question of ensuring that Russia takes its deserved place in these changing international conditions (Putin, 2004).

Many countries have been slow to understand and accept the threat that HIV poses to their societies. The United States was itself plagued by denial, and to this day it has not done enough to prevent the disease from continuing to infect its most vulnerable citizens. Russia’s response is not at all unique (CSIS Task Force on HIV/AIDS, 2005; Shilts, 1988). Russian policy, however, is burdened more than that of many comparable countries facing the second wave of global HIV/AIDS by the contradiction inherent in its leadership’s national strategic objectives in the economic and political spheres both at home and abroad. The leadership’s policy aspirations themselves, as a result, have become an obstacle to an effective policy response to HIV/AIDS at home. Furthermore, the Russian leadership’s policy of reestablishing its position as an international great power has hampered an effective engagement with the international community, which has a great deal

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of sad experience that could help Russia mount a more effective national response. Because the Russian government has not been willing to make HIV/AIDS prevention a national priority, engagement at the official level, through health- and development-related agencies of the United Nations, has been uneven, slow, and uncoordinated. The government of Russia has been quite vocal about its disinterest in further loans from the IMF and the World Bank, given the stability of its current financial situation. The $150 million World Bank loan for HIV and TB, in fact, is one of the last World Bank-sponsored projects in Russia.

Public Policy and the Politics of HIV/AIDS The government of Russia has been reluctant to discuss, let alone confront, the fact of its HIV epidemic. The predominant mindset has been that HIV is a problem of developing countries, not industrial powers like Russia, and that Russia is properly seen as an international donor helping to solve the global AIDS problem rather than as a country suffering from it. It is emblematic that President Putin has mentioned HIV/AIDS to a domestic Russian audience on only very few occasions, even while he has engaged U.S. President Bush as a partner on the issue many times on the international stage. Russia has pledged $20 million to the Global Fund while allocating only $4–5 million per year from its federal budget to its own targeted fight against HIV/AIDS. A handful of government agencies, particularly some related to law enforcement, remain hostile to established international norms in the fight against HIV. Governments, however, are not monoliths, and in recent months there have been significant indications of a shift in attitude among some Russian public figures and agencies.1 Important officials in the Ministry of Health and Social Development have become more candid and enlightened in their discussions, and HIV/AIDS spending within the ministry is reported to be increasing (although underreported, apparently to avoid attracting unwanted political attention). Russia’s response to HIV/AIDS is most commonly characterized by health and policy experts as a “medical approach,” that is to say, as a problem of the medical prevention and treatment of individuals. A more comprehensive public policy approach would address HIV/ AIDS in light of the complicated issues relating to education, economic development, human and political rights, and broader public health. Russia is far from the first or only country to have tried to address

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HIV/AIDS in narrow medical terms. However, to prevent a more generalized crisis, international expert agencies such as UNAIDS have made it clear that Russia, like those other countries, will have to adopt a comprehensive public policy approach (UNDP, 2005, chap. V). Given the realities of Russia’s political system, this will not happen until it is understood and acted upon by the Russian presidential administration. In the first decade or so of its HIV/AIDS policy, the Russian government allocated responsibility for the disease to the Ministry of Health and its infectious disease departments, and to the Federal AIDS Center, institutionally an agency of the Ministry of Health. Regional and local AIDS centers are expected to report to the Federal AIDS Center, but are financially and in practical terms answerable to their regional or city governments and their oblast (regional) ministries or committees of health. Until 2003, the Russian government did not have a federal interagency body for HIV/AIDS to manage or coordinate policies for prevention in the health, justice, educational, or other government policy areas. In 2004, the Russian government created a national Coordinating Council on HIV/AIDS. The council is chaired by Gennadi Onishchenko (Russia’s head medical official for infectious diseases and former deputy minister of health) and includes not only a number of ministries and state agencies but also NGOs and nonstate expert groups (Morrison and Wallander, 2005). The Coordinating Council may be a first step toward a more comprehensive public policy approach in a Russian strategy for combating HIV/AIDS. By 2005, the council’s existence had supported better discussion and assessment of prevention initiatives and had legitimated the discussion of nonmedical aspects of HIV/AIDS—such as human and political rights issues and the challenges of developing programs for prevention among marginal groups such as drug users. One of the council’s strengths in 2004–2005 was to bring nongovernmental groups into discussions of policy and program implementation. This is especially important in Russia, given the limited opportunities for civil society groups to play a role in affecting policy through elections. The potential impact of the council is constrained, however, by the realities of the Russian political system, given the greater authority and power of the presidential administration relative to the government under the prime minister and the functional ministries. The power and authority of the council is limited because it is not chaired by a high-level official of the presidential administration. It does not

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meet regularly, and it does not have the credibility or political resources to create and implement a true interagency public policy on HIV/AIDS. The practical importance and potential role of the Coordinating Council becomes apparent when one considers some areas of public policy coordination that the Russian government has faced or will face in the coming years. In 1999, the number of HIV-infected individuals in the penal system of the Ministry of Justice (MOJ) was 4,100. By the end of 2004, the MOJ and the Ministry of Health and Social Development (MOHSD) reported that there were 42,000. Both ministries have a good track record of working together and with NGOs on prevention and treatment campaigns. The MOJ runs an extensive testing and monitoring system and has adapted its procedures for HIV-infected prisoners to protect their rights under Russian law. For example, resisting early typical reactions to attempt to isolate HIVinfected prisoners, MOJ prisons in consultation with the MOH and NGOs adopted procedures more consistent with actual transmission risk factors, and no longer isolate prisoners. The MOJ has cooperated with NGOs in prevention and education programs among prisoners and, according to Russian and international NGOs and donors, has been progressive and practical in cooperating on programs to address the threat of HIV-TB co-infection (CIRA, 2005). In contrast, experts report that the lack of close coordination with the Russian Ministry of the Interior and local law enforcement agencies has made it difficult to see progress in the complicated and sensitive area of prevention outreach among IDUs and commercial sex workers. Not surprisingly, in many localities law enforcement officials view needle exchange or condom distribution projects as facilitating drug use and prostitution and have either targeted such programs or harassed them. Until recently, Russia’s strict drug laws have been widely interpreted by federal and local law enforcement officials as effectively criminalizing needle exchange programs. The government recently decriminalized possession of small amounts of drugs (under the law possession of ten or fewer doses is viewed as being for personal use rather than for illegal drug trafficking and thus is not a criminal offense), which may make it easier for harm reduction HIV prevention projects to operate, but only if local officials understand the Russian law (Levinson, 2004).2 This requires not only coordination among ministries at the federal level, but a deliberate effort to educate and monitor law enforcement officials at the regional and city levels. Harm reduction programs have been outlawed or harassed, partly because of

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misunderstanding, but also because ambiguities in Russian law can allow local authorities to claim an interpretation that outlaws needle exchange as a measure that encourages drug use (TPAA, 2005). The evidence is that such education and training programs can work and contribute to more effective prevention and policing. One NGO in St. Petersburg offered the city police administration an education program on HIV, drug use, and needle exchange after learning that police officers targeted their needle exchange efforts because they believed drugs were being sold and exchanged as well. Working with the city police, the NGO helped to create a training and education program that not only reduced police harassment, but led in some instances to an interest on the part of some police officers to be tested to learn their HIV status.3 Such stories at the local level are encouraging, but to be effective in a nationwide strategy, they need to be initiated and monitored at the federal level, with coordination among health and law enforcement officials. This is the type of interagency activity that the Coordinating Council needs to manage. Another example is the need for the Ministry of Defense (MOD) to begin to improve its understanding of and planning for the effects of growing numbers of HIV-infected young men in a personnel system that still depends on mass conscription, and will for some time. The MOD faces not only the challenge of assessing the health and HIV status of potential new conscripts, but also of monitoring conscripts and officers during their terms of service and, obviously, undertaking prevention and education programs, given that military service is performed by a particularly at-risk group (Frolov, 2005). Another vital aspect of the need to integrate health policy planning into related government responsibilities are Russian economic policy planning and government budgetary processes. The numbers make it clear that the Russian government will be overwhelmed by the resource demands of the dual need to scale up both prevention and treatment programs in the coming few years, if the political leadership were to make HIV/AIDS a national policy priority. The problem is not merely the amount of money that will need to be budgeted for improving clinics, training health care providers, purchasing equipment for testing and monitoring, and of course providing ARV drugs. The problem is that an effective national strategy will require new streams of funding to the education system for prevention programs, to the scientific community for research and education of scientific and health professionals, to the military for prevention and monitoring programs,

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and to programs to work with business and media for education and outreach programs (USAID, 2005). In order to be able to conduct the kind of needs assessment and management system for working with multiple ministries and agencies of the federal government (and possibly with regions and cities as well), the Ministry of Finance will need to be involved in an effective interagency mechanism such as the Coordinating Council. This would be a new function for the Coordinating Council, and it will require officials to evolve even more from a strictly medical approach, beyond public health, to comprehensive public policy. As the scope of the coordination grows, it will be important to involve the power and authority of the presidential administration more than ever. To date, Russia’s legislative bodies have not provided the type of oversight or motivating role in health policy that might help to spur the executive branch to a more proactive policy. Given the highly centralized nature of Russia’s political system and the weakening in recent years of political parties, the Russian Duma (the lower house of Parliament) has not had the kind of grassroots independent political role that might bring regional and constituency issues before a basically conservative ruling party. Although one should not exaggerate what is possible in terms of opposition legislative activism in the Russian political system at this time, there are nonetheless developments worthy of note in some political contexts. The Russian Duma has formed a parliamentary working group on HIV/AIDS 16 members strong, in late 2005, with a focus on spotlighting the virus as a national priority and concentrating budgetary resources on the epidemic. About a year ago, this caucus sponsored hearings on HIV, and during the 2005–2006 budget cycle it introduced $70 million in budget amendments providing counterpart financing for the World Bank-sponsored project on tuberculosis and HIV, and funding HIV vaccine research, prevention, and education. This newly formed parliamentary caucus on HIV/AIDS (including members from both the Duma and the Federation Council), though small, is nonetheless organized, focused, and vocal. The caucus could become the core of a legislative capacity to develop expertise, engagement, and the power to finance programs and shape laws to support a national strategy on HIV/AIDS in the coming years.4 There are also pockets of effective government response at the local and regional levels. For example, in St. Petersburg the city administration has devoted resources to HIV prevention and services for PLWHA. The city health department works effectively with the city AIDS center, a large infectious disease hospital (the Botkin Hospital),

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St. Petersburg State University, and NGOs. The city supports needle exchange programs, and the local police administration has worked with an NGO on education programs for police personnel so they will understand that needle exchange programs do not promote drug use but are health interventions for harm reduction—that is, preventing unsafe drug use-related practices from causing a fatal disease—which is a globally accepted and effective health policy.

Russian Society in Politics While the Russian government has been slow to respond to HIV/AIDS and has tended to misallocate resources and efforts when it has responded, there are a number of active and highly expert Russian and international NGOs working alone or in cooperation with local and regional governments on HIV prevention and related health services. The scope of their prevention and service work is impressive: from public awareness campaigns, to media projects, to outreach programs for high-risk groups (IDUs, commercial sex workers, MSM, and street children). Some of the NGOs operate solely on a local level, while others operate in several high prevalence or at-risk regions nationally.5 At least as important for Russia’s future work on prevention and treatment of HIV/AIDS, other than the specific programs and services provided by the 200 or so NGOs in the HIV issue area, is the fundamental capacity that has been built in this “third sector” over the past decade and a half. It is important not to overstate the size and impact of these efforts: these are small NGOs with limited budgets and the capacity to reach only a limited number of at-risk Russians, and still fewer Russians in the general population. NGOs do not have the capacity themselves to provide the prevention and treatment services that Russia needs in order to avert a generalized pandemic in the coming years. Nonetheless, they provide the expertise and experience that can contribute to a national HIV/AIDS policy. The single best illustration of the sophistication and catalytic potential of the NGO sector is its unique role in bringing the Global Fund to Russia. Because of the institutional peculiarities described earlier, the Russian government failed to create a Country Coordinating Mechanism (CCM) as required by the Global Fund in order for a country to submit a proposal and administer successful grants. The lack of capacity was exacerbated by the Russian government’s lack of motivation in the early years of the Global Fund: the Putin government was willing to be a donor to the Global Fund, but it was reluctant to

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be an applicant. Concerned by the lack of official movement and the prospect of Russia missing the opportunity to secure funding for pilot programs at a time when Russian government funding remained limited but the need for effective programs was rising, a number of NGOs cooperated in developing a proposal to focus on prevention (including prevention of mother-to-child transmission) and capacity building in the community of PLWHA. The proposal was successful, and the programs supported by the Global Fund grant were initiated in 2004 and were still well underway in 2006. In addition to the successful proposal and funded programs, the efforts of the NGO Consortium had a potentially more significant capacity-building effect for Russia: it sparked the creation of an official CCM that submitted an ultimately successful proposal in the fourth round of the Global Fund grants focused on scaling up treatment. In 2005, Russia began to implement a $120 million program for what is projected to be treatment of some 50,000 infected Russians. However, in an aspect of the successful proposal that is both worrisome and not surprising, the Global Fund grant will not be to the Russian government itself, but to what has been reported as a “government organized nongovernmental organization” (“Russia and the Global Fund . . . ,” 2005). That such an entity exists in Russia today is not surprising, given the Russian government’s success in eliminating independent media and independent political parties. The Russian government in the past few years has been establishing governmentrun or government-sponsored youth movements, think tanks, and information services designed not only to shape and control information and activities, but also to squeeze out activities by independent entities. What is surprising is that the international community, in the form of the Global Fund and United Nations, has agreed to go along with the Russian government’s creation of a “government” NGO. It creates potential conflicts with the genuine NGOs that have proven so effective in the HIV/AIDS field, largely because of their independence and professionalism. It also raises serious questions about whether and how the Russian government will be held accountable for the funds that it has been granted and for the programs it has pledged to implement in order to receive Global Fund support. Will the Russian government be held accountable for the funds and policies, or will the government NGO be the responsible institution? This is likely to become a much more visible and important issue for Russia and HIV/AIDS. As the work of NGOs shifts from providing services to advocacy, and as HIV/AIDS becomes more of a

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mainstream issue for Russian government and society, it should be expected that state-society relations may become in some respects more conflictual. For example, with the growth of PLWHA NGOs, we should expect that advocacy and policy issues will shift from quiet corridors at conferences and meetings among well-trained experts to public activities and demands on the Russian state to respect the human and political rights of PLWHA. HIV/AIDS is, like any health issue, political as well as social. To date in Russia it has not been a public political issue, but in the coming years this is certain to change. Part of the reason it is already changing is the development of NGOs and related efforts by and for PLWHA. International experience shows that PLWHA play a key role in building national commitment and effective public policies on HIV. PLWHA have a unique and essential expertise and understanding of how their existing political and social systems deal with HIV/AIDS—whether bad or good—and of the necessary effective conditions for prevention and treatment. To put it more bluntly, PLWHA know what led them to become infected, so they know what needs to be done to prevent others from becoming infected. And PLWHA know what kinds of stigma, discrimination, persecution, or support they face, so they have a key perspective on how to make their political system meet the needs of its citizens. Beginning in 2004, groups of PLWHA in Kaliningrad, Moscow, and St. Petersburg have staged public demonstrations that have received significant media coverage, and some of these have prompted encouraging government rhetoric in response. As discussed earlier, despite strong legal guarantees on the books, the reality of Russian policy on HIV is much more complicated. In terms of primary concerns about access to ARV therapy and guaranteeing rights to employment, health care, and social services, the picture is not good. Russian health officials often state publicly that all those requiring treatment are getting it free as required by Russian law. It does not take long in a conversation with Russians living with HIV, however, to find evidence that this is not the case.6 And regardless of their legal rights, PLWHA are reluctant to reveal their status to family, friends, or employers for fear of discrimination for which they have no practical redress from the Russian legal and political systems. In the case of a February 2005 demonstration by PLWHA, the protestors were taken to a holding jail where they were able to meet with their lawyers and proper legal and police procedures were followed, but after the lawyers left several of the protestors were beaten before being released. These stories are not unique to Russia, but they illustrate that

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Russia is entering a crucial stage in the social and political evolution of the epidemic, when individuals living with HIV cannot or will not remain hidden while society and officials remain largely uninformed and fearful about people with the disease. A progressive leadership role on HIV/AIDS should be an obvious strategy for the business community, given the effects of HIV on a country’s labor force, its productivity, and its development.7 But it is also a challenge, because of the stigma and denial attached to the disease. The response of Russia’s business community reflects not only the nascent need to tackle the issue as one that affects business interests by affecting society, but also the general context of perception that HIV/AIDS is a disease of marginalized and undesirable groups at the fringes of Russian society. Some of the more progressive, efficient employers in the private sector—particularly those like the automobile industry in Togliatti, which has been heavily affected by the epidemic— are reputedly encouraging the government to do more. International businesses, particularly those experienced in other parts of the world with the effects of HIV/AIDS on their operations and bottom line, are interested in opportunities to engage constructively with labor and the Russian government.8 But in Russia’s current political climate, Russia’s business leaders are waiting for political leadership on HIV/AIDS. There is little to gain and much to lose by pushing the Putin leadership on a difficult social and political issue. Russian business is already unpopular in the eyes of society, particularly those very large important companies owned by the “oligarchs,” which would have to be at the center of a national business strategy on HIV prevention and care in the workplace. A strategy for engaging Russian business in the coming years would most productively lay the groundwork for a business role in private sector support for a national government strategy—once the Russian political leadership has chosen to make the commitment itself.

The Political Problem of Credible Numbers The politics of HIV/AIDS policy in Russia is complicated at a fundamental level by the problem of uncertainty about basic numbers. What might at first glance be an issue for technical and epidemiological experts becomes a major political factor in discussions about public policy and AIDS in Russia. Russia does not have an adequate surveillance system for tracking and understanding HIV/AIDS. Its testing system has swung from one extreme of testing broadly but not

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systematically to the current process in which the federal government has devolved responsibility for managing and financing testing to the regions. It does not systematically do sentinel surveillance of high-risk groups, such as Russians with tuberculosis or sexually transmitted infections. As a result, virtually no one believes that the officially reported figures regarding HIV in Russia are accurate, and anyone working on HIV/AIDS in Russia becomes involved in discussions on how far off the official numbers actually are (Feshbach and Galvin, 2005). There are several important political results of the noncredibility of Russia’s HIV statistics. The first is that warnings from Russian and international observers that the Russian government and its society should make HIV/AIDS prevention a priority in health and public policy are not credible. With official Russian numbers just over 300,000 and with the numbers of new infections reported each year actually declining, many in Russia do not believe—or choose not to believe—warnings of a serious problem. Second, with greater numbers and clarity on other diseases, such as cardiovascular disease and alcohol abuse, it is understandable that Russian officials and citizens view these health threats as a greater priority than HIV/AIDS (Gerber and Mendelson, 2005). AIDS is a less visible disease even when the numbers are reliable and well understood, especially for a country like Russia that remains in the early stages of infection in the population. Without credible official numbers, it is not surprising that Russian officials are disinclined to view the disease as a priority. Third, because so many of the warnings and projections of higher numbers have come from international experts and officials with international health organizations, Russians find it easier to dismiss them as serving a non-Russian—or even anti-Russian—agenda. Given the Russian government’s profiling of the country as one moving to reclaim status as a great power on the international scene, with a permanent seat on the UN Security Council and as one of the G8 global leaders, the HIV message is an unwelcome note to a newly confident and assertive global Russia. The problem of unreliable numbers and a poorly functioning surveillance system is therefore key to the challenge of an effective Russian public policy to prevent a generalized HIV/AIDS pandemic. Russia needs a better HIV/AIDS surveillance system on health policy grounds alone: accurately measuring aspects of the spread and impact

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of HIV/AIDS can contribute to the effectiveness of a society’s control efforts once the decision to mount such a response has been made. However, accurate and credible numbers are important in Russia not only for how to combat the disease, but whether to combat it. Russia’s politics of HIV/AIDS will be misguided and contentious unless and until its leaders and public believe that they face a threat worth fighting.

Conclusion Preventing HIV infection and coping with AIDS is a challenge for any country and political system, and Russia is by no means unique in responding slowly and ineffectively. However, after several years of interviewing and working with Russian and international experts on the disease in Russia, I am convinced that Russia is particularly vulnerable to a generalized HIV/AIDS crisis because of the nature of the political system I have outlined. Russia suffers many vulnerabilities common to other countries dealing with AIDS (including the United States) such as limited financial resources and a failure to embrace programs with proven effectiveness for prevention (including health education and needle exchange). But Russia’s greatest vulnerabilities to HIV/AIDS today are political: the excessive centralization of government relative to regional and local authorities; the failure of federal ministries to coordinate and cooperate for a comprehensive public policy response that involves the health, justice, interior, defense, education, finance, and economic ministries; and the absence of political competition and oversight necessary for effective public policy. More than anything, knowledgeable experts and officials in Russia are waiting for President Putin to signal that, it is acceptable to act. On a trip in 2005, I was told time and again that, given what a socially sensitive issue HIV/AIDS is, no one wants to risk taking the initiative only to find themselves the target of the presidential administration for charting an unwelcome independent policy course, however important or well conceived. The politics of HIV/AIDS in Russia are so complicated because they ultimately require the Russian leadership to compromise on two things that they have come to view as priorities: unquestioned control of state and society, and Russia’s image as a wealthy and powerful global great power. The sad irony of the politics of HIV/AIDS for Russia is that the policies of its current leadership continue to make the country vulnerable to the very weakness it fears.

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Notes Research for this chapter was supported by a grant from the Gates Foundation, which is not responsible for the views or analysis herein. The author is especially indebted to Steve Morrison, Sarah Mendelson, Peter Hauslohner, and Phil Nieburg for invaluable guidance and discussion over several years. Nancy Lord and Natalia Moustafina provided vital research assistance for this project. 1. The discussion in this section is based on the author’s numerous interviews and discussions with Russian government officials, Russian health officials and experts, Russian and international NGO activists, Russian people living with HIV/AIDS, American government officials, American health professionals, and officials with international organizations in the UN network. Interviews took place in Moscow, St. Petersburg, Atlanta, New Haven, Washington, Geneva, and New York over a two-year period. 2. As of June 2005, there is a draft law in the Russian Duma to reverse this decriminalization. 3. Based upon the author’s interviews and research in St. Petersburg in May 2004 and October 2004. 4. Author’s meeting with the parliamentary group, February 2005. For more on the parliamentary group, see www.tpaa.net/index.html. 5. See the chapter by Stachowiak and Peryshkina in this volume. 6. Based on the author’s interviews in St. Petersburg and Moscow, April 2004, May 2004, and February 2005. 7. See the chapter by Sharp in this volume. 8. Based on the author’s interviews with business executives in Moscow, New York, and Washington.

References Bialer, S. (1980) Stalin’s Successors: Leadership, Stability, and Change in the Soviet Union (Cambridge: Cambridge University Press). Bunce, V. (1999) Subversive Institutions: The Design and the Destruction of Socialism and the State (Cambridge: Cambridge University Press). CIRA [Center for Interdisciplinary Research on AIDS] (2005) Project web site, cira.med.yale.edu/research/russiatb-aids.html. CSIS (Center for Strategic and International Studies) Task Force on HIV/AIDS (2005) Various country reports, www.csis.org/hivaids/index.html. Coalson, R. (2005) “AIDS Awareness Campaign Off to a Slow Start,” RFE/RL Political Weekly, 5(15), April 14, rferl.org/reports/rpw/2005/04/15– 140405.asp. Danishevski, K., and M. McKee (2005) “Reforming the Russian Health-Care System,” The Lancet, 365, March 19. Desai, P., and T. Idson (2000) Work Without Wages: Russia’s Nonpayments Crisis (Cambridge, MA: MIT Press). Feshbach, M., and C. Galvin (2005) HIV/AIDS in Russia: An Analysis of Statistics (Washington, DC: Woodrow Wilson International Center for Scholars).

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Frolov, V. (2005) “The National Security Implications of the HIV/AIDS Epidemic in Russia,” annex 2 to UNDP (2005). Gerber, T., and S. Mendelson (2005) “Crisis among Crises: Public and Professional Views of the HIV/AIDS Crisis in Russia,” Problems of Post-Communism, 52(4): 3–15, July and August. Gustafson, T. (1999) Capitalism Russian-Style (Cambridge: Cambridge University Press). Hough, J., and M. Fainsod (1979) How the Soviet Union Is Governed (Cambridge, MA: Harvard University Press). Legvold, R. (2001) “Russia’s Unformed Foreign Policy,” Foreign Affairs, 80(5): 62–75, September/October. Levinson, L. (2004) The Russian Drug Policy: Time of Changes (Moscow: Human Rights Institute). McFaul, M. (2002) Russia’s Unfinished Revolution: Political Change from Gorbachev to Putin (Ithaca, NY: Cornell University Press). McFaul, M., N. Petrov, and A. Ryabov (2004) Between Dictatorship and Democracy: Russian Post-Communist Political Reform (Washington, DC: Carnegie Endowment for International Peace). Medvedev, S. (2005) “Russia at the End of Modernity: Foreign Policy, Security, Identity,” in S. Medvedev, A. Konovalov, and S. Oznobishchev, eds., Russia and the West at the Millenium: Global Imperatives and Domestic Politics (Garmish: George C. Marshall European Center for Security Studies). Mendelson, S., and J. Glenn, eds. (2002) The Power and Limit of NGOs (New York: Columbia University Press). Morrison, S., and C. Wallander (2005) “Russia and HIV/AIDS: Opportunities for Leadership and Cooperation,” report of the CSIS Task Force on HIV/AIDS, Joint Brookings-CSIS Delegation to Russia, February 20–26 (Washington, DC: CSIS). Petrov, N. (2001) “Consolidating the Centralized State, Weakening Democracy and the Federal System,” Russian Regional Report, East-West Institute, 6(23), June 19. Putin, V. (2003) “State of the Nation Address to the Federal Assembly,” May 16, www.ln.mid.ru/brp_4.nsf/0/b9c87040d4a8fce2c3256ec9001d199a? OpenDocument. ——— (2004) “Address to the Federal Assembly of the Russian Federation,” May 26, president.kremlin.ru/eng/text/speeches/2004/05/26/2021_64906.shtml. “Russia and the Global Fund Sign New AIDS Grant” (2005) Website of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, www.theglobalfund.org/ en/media_center/press/pr_050608a.asp. Shevtsova, L. (1999) Yeltsin’s Russia: Myths and Reality (Washington, DC: Carnegie Endowment for International Peace). ——— (2003) Putin’s Russia (Washington, DC: Carnegie Endowment for International Peace). Shilts, R. (1988) And the Band Played On: Politics, People, and the AIDS Epidemic (New York: St. Martin’s Press). Shleifer, A., and D. Treisman (2000) Without a Map: Political Tactics and Economic Reform in Russia (Cambridge, MA: MIT Press).

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Sperling, V. (1999) Organizing Women in Contemporary Russia (Cambridge: Cambridge University Press). Stoner-Weiss, K. (1997) Local Heroes: The Political Economy of Russian Regional Governance (Princeton, NJ: Princeton University Press). Surkov, V. (2005) “The West Doesn’t Have to Love Us,” interview in Der Spiegel, June 20, service.spiegel.de/cache/international/Spiegel/0,1518,361236,00.html. TPAA [Transatlantic Partners Against AIDS] (2005) HIV/AIDS, Law, and Human Rights: A Handbook for Russian Legislators (Moscow: TPAA and UNAIDS). Twigg, J. (2000) “Unfulfilled Hopes: The Struggle to Reform Russian Health Care and Its Financing,” in M. Field and J. Twigg, eds., Russia’s Torn Safety Nets: Health and Social Welfare during the Transition (New York: St. Martin’s), 43–64. UNDP [United Nations Development Programme] (2005) HIV/AIDS in Eastern Europe and the Commonwealth of Independent States (Geneva: UNDP), 195.68.179.50/HIV_AIDS_report/English_version.htm. USAID [United States Agency for International Development] (2005) “Request for Applications,” section C, program description, www.fedgrants.gov/ Applicants/AID/OM/MOS/postdate_1.html. VOA [Voice of America] (2005) “OECD Issues Scathing Report on Russian Economy,” June 20, www.voanews.com/english/2005–06–20-voa11.cfm. Wallander, C. (2007) “Global Challenges and Russian Foreign Policy,” in R. Legvold, ed., Twenty-First Century Russian Foreign Policy and the Shadow of the Past (forthcoming from Columbia University Press, New York). Woodruff, D. (1999) Money Unmade: Barter and the Fate of Russian Capitalism (Ithaca, NY: Cornell University Press). World Bank (2004) “The Health Sector,” Russia Health Policy Note, siteresources. w o r l d b a n k . o r g / I N T R U S S I A N F E D E R AT I O N / R e s o u r c e s / 3 0 5 4 9 9 1094736798511/518266–1095240406846/Health_PN_eng.pdf. ——— (2005) Russian Economic Report, no. 10, March, www-wds. worldbank. org/external/default/WDSContentServer/IW3P/IB/2004/03/24/000160014-2— 6-324172304/Rendered/PDF/356010ENGLISHORER101eng.pdf. WHO [World Health Organization] (2005) “Core Health Indicators,” www3.who.int/whosis/core/core_select_process.cfm.

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3 NGOs and HIV in Russia: Lessons from a Unique Case Study Julie Stachowiak and Alena Peryshkina The goal of the government is to develop rules and work to transform them into laws, while the goal of business is to make money.The objective of organizations in the social sector is to promote the health and well-being of people . . . These organizations serve another, no less important, goal.They awaken the feeling of civil responsibility. All that one can do in the role of individual citizen is to vote once every couple of years and to pay taxes regularly. By participating in the work of organizations of the social sector, one can correct or amend certain problems that they see in society. —Alena Peryshkina, director of AIDS infoshare

Understanding AIDS in Russia has much more to do with one’s feelings about and grasp of the essence of Russia than about biological aspects of HIV transmission or paradigms of social epidemiology that have been imported from other settings. In the twelve years since the founding of AIDS infoshare, an NGO founded by myself and two Russians, my colleagues and I have existed in a unique world where we were able to observe, simultaneously, the reactions and actions of international “experts” and “players,” as well as Russians in roles ranging from ministry officials to people newly diagnosed with HIV infection. All the while, the Russian epidemic was following its own path, a curve virtually untouched by all of the “urgent attention” that it received—the high-level meetings, the international funding, the press conferences and reports, and the scandals and accusations.

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That is not to say, however, that progress has not been made. NGOs working in AIDS have been pioneers in helping to determine the direction of post-Soviet civil society since its rocky beginnings and have brought attention to controversial and politically embarrassing aspects of Russian society as well as approaches to disease control that were hindering prevention and care efforts. And, while perhaps not in a way that will affect statistics and graphs, countless individuals have had their lives touched and changed by the work of NGOs, including people vulnerable to HIV infection, those already diagnosed with the virus, and those people involved with NGOs in their struggle against AIDS.

A Glimpse at the Evolution of Civil Society in the USSR and Russia Soviet policy toward civil society was based on the beliefs of Karl Marx, who viewed civil society as a means for the bourgeoisie to oppress the proletariat and further their own interests (Knox, 2005). As the main thrust of most organizations and movements that constitute modern civil society is to give assistance and a voice to vulnerable people, Soviet ideology ran counter to such ideas. The state was mandated to ensure that there simply were none who were vulnerable, under the “from each according to his abilities, to each according to his needs” vision of Soviet communism. People were, of course, called into service as volunteers to help their neighbors, from citizens’ brigades charged to maintain public places to groups of children dispatched to work on collective farms or paint schools. These activities, however, were not self-motivated or organized; rather, they were approved, mandated, and managed by the state. As time passed and international communication increased, the citizens of the USSR entered their own uneasy period of enlightenment, when they began to receive and spread reports of things outside of their borders being different—better—than they had been told. As Western images in the form of movies, magazines, and other media gained wider underground circulation, Soviet citizens began to wonder if their government’s definition of “good enough” was as good as it could get. By the 1980s, the black market was a huge economic force that brought in goods to desperate consumers no longer satisfied with long lines and dwindling selection at stores named simply “Fruits and Vegetables” and “Clothes.” In addition, as it turned out, there were vulnerable people in society whose needs were not being met by

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empty state promises. Most of these people scrabbled along on their own to find medicines and other necessities on the black market, but some began to find each other. The Committee of Soldiers’ Mothers was one of the first groups to say out loud, “This just isn’t right!” and spread reports about the horrors suffered by their sons. These early pioneers in confronting the state had one huge advantage that gave them the necessary courage and determination to persevere: these bereaved mothers felt they had nothing to lose. At the same time, Gorbachev was putting forth his ideas for reform (perestroika) and the openness (glasnost) that he hoped would help people understand and support his radical approaches to governance. Once these official “cracks” began to appear in state domination, however, the citizenry rushed to squeeze through them in attempts to meet their basic needs and growing desires for a better quality of life. Watching the situation with interest, Sovietologists saw civil society emerging, all basing their conclusions on different clues: Frederick Starr saw “unsanctioned economic and social activity” as signaling this change, Hosking and Tismaneanu pointed to “social movement overtly opposing Soviet-style communism’s environmental and militaristic policies,” and Moshe Lewin saw an “urban culture built on modes of communication and interpersonal contacts which were beyond the control of the regime” (Hosking, 1990; Lewin, 1988; Starr, 1988; Tismaneanu, 1990). Each of these clues point to a coalescing of dissatisfaction with the status quo. People were beginning to organize themselves to solve their own problems. While the historic events leading up to and following the dissolution of the USSR are clearly beyond the scope of this chapter, it is imperative to keep in mind that civil society and their component NGOs were not born in a static environment. At the time when some people began laying the foundations for civil society, others channeled their desire for change in different directions, covertly at first, then with gusto and determination during the chaos that ensued in the early post-Soviet days. For the first time, Russia saw the appearance of independent media (the successor of home-spun illegal samizdat), political parties, presidential and parliamentary elections, and the creation of private business. All of these institutions exerted varying degrees of direct and indirect influence on civil society, which should be regarded as an appendage of the complex new creation that was the newborn Russia. Today, there are over 65,000 NGOs in Russia (“Sins,” 2000).

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The Simultaneous Dissolution of the Soviet Union and Appearance of HIV in the Region At precisely the same time that citizens began to organize (usually in ways that were illegal to some degree according to Soviet law) to meet financial, consumer, and social needs that were not being addressed by the government, AIDS was being recognized as an epidemic in the West. While the Soviet Union’s devolution was becoming increasingly apparent to all, government officials pointed to the American HIV epidemic as an outward sign of the depravity of such an indulgent culture. When HIV was first identified in the USSR in 1987 (in a naval officer who had been stationed abroad), the index case served to solidify the conviction of Russian public health officials that HIV was still a foreign problem, not a Russian one. A 1988–89 four-city outbreak of nosocomial infections transmitted among infants through injections and blood transfusions, however, brought immediate action from the government. HIV was regarded as another infectious disease threat, eliciting a response that was similar to the approaches that had worked in the past to manage sexually transmitted infections and tuberculosis, all of which were based on case finding through mandatory testing, contact tracing, and laws in the Criminal Code against “putting others at risk of transmission.” Immediately a network of 89 AIDS centers was established across the country, with the mandate to screen huge numbers of citizens in order to find all cases of HIV (Bingham and Waugh, 1999). The first cases of HIV among adult Russian citizens were identified as having been transmitted through homosexual sex. At this time, and until 1993, “homosexual acts” were illegal under Article 121 of the Criminal Code, with many men turned in to the authorities by their own physicians. But gay men and lesbians were beginning to organize as well. According to an entry written for the Encyclopedia of Homosexuality, In 1984 a handful of gay men in Leningrad attempted to form the first organization of gay men. They were quickly hounded into submission by the KGB. It was only with Gorbachev’s glasnost that such an organization could come into existence in 1989–90. The Moscow Gay & Lesbian Alliance was headed by Yevgeniya Debryanskaya, and Roman Kalinin became the editor of the first officially registered gay newspaper, Tema. Organizations and publications proliferated. The summer of 1991 saw the first international conference, film festival, and demonstrations for gay rights in Moscow and Leningrad. This was followed

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almost immediately by the attempted coup. Reversion to a more conservative regime would clearly have threatened their recent gains, and legend has it that many gay activists manned the barricades protecting the Russian White House and that Yeltsin’s decrees were printed on the Xerox machines of the new gay organizations. (“Russian Gay History,” 1990)

These early activists, however, were understandably not anxious to take up the issue of HIV wholeheartedly, as they were occupied with asserting their basic human rights (including freeing people who had been imprisoned under Article 121), not preaching to people about safe sex.1 Meanwhile, the stage was being set for the epidemic that would reveal itself several years later. Although there are many factors that led to the vulnerability of Russia’s population to HIV, many of them can be directly traced to the economic and societal breakdown that occurred with the dissolution of the USSR in 1991. What has been called “economic and social transition,” but translates into the domination of organized crime, must be seen as one of the primary causes of sex work and drug use. Looking back at the situation, experts have identified many additional contributing factors to the HIV epidemic in the Russian Federation, including the rapid diffusion of IDU; population migration and mixing; modes of drug production, distribution, and consumption; declines in public health funding and infrastructure; and political, ideological, and cultural transition (“Drug Injecting . . .,” 1999; Rhodes et al., 1999). Other factors that led to vulnerability were gender roles, sexual mixing patterns, a poorly controlled private medical sector and growth of self-medication, alcohol abuse, and increased opportunity for travel and migration within and outside the Russian Federation (Amirkhanian et al., 2001; Bingham and Waugh, 1999; Kalichman et al., 2000). At the time, however, no one could have predicted a specific outcome that would emerge from the chaos that defined Russian life. Furthermore, even had the dangers been identified, there were too many daily crises that required immediate attention by the state as well as individuals to ensure short-term survival; there was no time for long-term plans.

The Founding of AIDS infoshare The creation of AIDS infoshare was not a carefully planned response to an obvious need. We had no strategic plan, no funders, no

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infrastructure. It was started, as are many NGOs, fueled by enthusiasm and blind confidence that “if we care so much, surely others will too.” I arrived in August 1993 to direct a largely nonexistent office of a now-defunct U.S.-based organization, which had a fuzzy mandate to prevent AIDS in Russia. Alena Peryshkina was to be my deputy, having worked for this organization for a year, and her husband Stas (Stanislav) Erastov was kept busy obtaining supplies, changing money, and performing all other duties considered too tedious or dangerous for two young women. The three of us worked out of my apartment, largely trying to figure out what we were supposed to do based on vague directives, and waiting for funding that had been promised by our Board of Directors in the United States. We had been working this way for about six weeks when the Supreme Soviet attempted a coup of the Russian White House in early October of 1993 and tanks were rumbling through the streets of Moscow. At this point we had still received none of the promised U.S. money for activities, and I received no support or direction and very little sympathy when I called the executive director upon hearing weapons being fired near my apartment. Soon after, we decided that if the three of us were going to be doing things on our own, we might as well implement our own ideas in the way that we wanted, rather than follow directives with no support. I had also figured out, much to my horror, that the main thrust behind the activities of my employer was to spread the word of Louis Hay, a new age “health guru” who claimed people contracted and lived with AIDS because they “wanted to” and as a result of “mental patterns” that lead to such symptoms, not as a result of a virus.2 I announced to Stas and Alena that we were starting our own organization. I was to be executive director, Alena was program director, and Stas was technical director. Although pleased with his title, Stas pointed out that directors usually had someone or something to direct, which we did not. I felt this was a minor point and convinced them that if we put forward a bold face and proceeded with confidence, we could achieve whatever we wanted.

1993–1996:The Early Period in the Russian HIV Epidemic and Our Response While we groped along with ideas for our new creation, Russia itself was in chaos. Very little food was readily available in stores, and what

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was there was out of reach for many people as price controls were being released and inflation at times exceeded 300 percent. This led to memorable scenes of a babushka standing in the bakery repeatedly counting the 16 kopeks in her hand (the price of bread in the Soviet Union since the 1950s), then squinting again at the sign reflecting the overnight jump in price to three rubles. Organized crime families and their lackeys owned Moscow and openly flaunted it. I remember an accidental jab from an Uzi slung over the shoulder of a young man jockeying for a position in front of a kiosk window to buy ice cream. At this time, AIDS in Russia was hardly a blip on the radar screen, both domestically and internationally. Other health and social problems dominated the headlines. A diphtheria epidemic raged, homelessness of the elderly and the very young was becoming quite visible, and multidrug-resistant tuberculosis was beginning to command attention. Against this backdrop, USAID and an accompanying entourage of U.S. private voluntary organizations (PVOs), as well as European organizations, began to arrive with money and mandates that seemed vague to many of us working in the trenches: “promoting democracy” and “protecting health.” The year 1993 also heralded the arrival of George Soros’ money and desire to fix many of Russia’s problems. While not initially focused on HIV, Soros would have a meaningful impact in the world of HIV prevention. In the still small world of AIDS, the international money was sensed as far as the depths of Siberia, resulting in the seemingly overnight explosion of what some called “QuaNGOs,” or quasi-governmental NGOs. These were organizations formed within some of the 89 governmental AIDS centers, often by the directors themselves. The hope was to get money to do HIV prevention and education—activities that were mandated by law even though there was funding only for mandatory HIV antibody testing. The problem was that there was virtually no history of self-established organizations, and these people were physicians. None of them therefore had ever written a grant proposal, designed a program, or in many cases even met a member of their target audience. It was basically a cadre of people with poorly printed business cards and some, but not all, of the necessary facts about HIV. Just before AIDS infoshare came into being, a handful of other NGOs had been founded, also to address HIV. In Moscow, there was AESOP and the Russian NAMES Foundation, among others. We were all still figuring it out, trying to define ourselves. In the spirit of “collaboration” we met a couple of times to form tenuous, short-lived, and uneasy alliances, but mostly we all tried to look after our own survival and sustainability.

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Alena, Stas, and I were feeling our way along with our fledgling organization. I spent my evenings poring over a stack of books about operating nonprofit organizations that I had picked up on a trip home to the United States. This tentative knowledge allowed me to make pronouncements with unfounded confidence and bravado about our “mission” and “strategy.” Together, we wrangled with ideas for the Russian translation of “infoshare,” as the verb for “sharing” has a rather negative connotation (delit’, which translates most literally into “divide”) and arrived at “infosvyaz” (infoconnection). We also struggled with our cultural differences. My American upbringing said to me, “You can do anything, as long as you put the effort in,” while the Russians were brought up with the Soviet mentality of “you can do what you have received training to do and are assigned to do—if you are given permission, that is.” Initially, Stas and Alena questioned our ability to perform the functions needed to run an organization (accounting, legal matters, fundraising), as well as our suitability to be involved in what was still considered a medical problem, as we were not physicians. These doubts were squashed, however, by the necessity to get the managerial and organizational jobs done and by our lack of resources to hire anyone else to do them. In those early days, one of the biggest sources of contention among us was not the content of the messages that we were trying to get out, but rather the conflict between my obsession with how the finished product looked (I maintained that just because Russians were accustomed to receiving information printed on newsprint and full of typographical errors, we did not have to adhere to this standard) and Alena’s insistence that there were better ways to spend our time than proofreading letters or brochure text over and over again. A memorable moment was the day that we met with the young man whom we had commissioned to illustrate the cover of our first brochure, “Take me” (double entendre intended). Although the idea was to communicate that women indeed had the power to protect themselves from HIV and sexually transmitted diseases, the proposed illustration was of a woman in a cowering crouch, hiding her face in her hands. Alena and Stas were horrified when my first response was a resounding “no”; this work came from the “artist,” after all, and therefore he was the “expert” on how our brochure should be illustrated. In the end, we used a revised illustration that depicted Cupid surrounded by a cloud of hearts and flowers—not my first choice for an empowerment message, but at least not overtly scary. I quickly learned that my way of doing everything “by the book” in Moscow was not going to get us anywhere quickly. We had decided that the

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only way for our endeavors to be successful would be for us to collaborate with the government, or at least to get their approval for what we were doing. I pressed Stas and Alena to set up meetings with the appropriate parties at the Ministry of Health. The first several “meetings” consisted of Stas and Alena waiting for hours in the entry hall to be called in for the meeting, then being dismissed at five o’clock in the evening after having seen no one. Stas then decided to be resourceful. He told the guard an elaborate fictitious story about his aunt working in the ministry’s kitchen and needing house keys and directions somewhere, with the result that the confused man allowed Stas access to the building. Stas proceeded to walk through the kitchen to the office of the director of the AIDS Department of the Ministry of Health of the Russian Federation, where he introduced our organization and began a collaborative relationship that flourishes to this day. AIDS infoshare was originally conceived as a simple project that we thought would have about a two-year duration. We would act as a repository and source for accurate and up-to-date information about HIV/AIDS. This became our priority after the need was illustrated by a visit from the director of a Siberian AIDS center, who arrived bearing a tattered version of the U.S. Centers for Disease Control and Prevention mailing “Understanding AIDS,” an elementary explanation of HIV and its transmission and prevention sent to all U.S. households in 1988. The director asked us for help with translation, as this was the “most useful information on HIV he had found in the country,” and he had traveled to Moscow for just this purpose. Our first activity was to create a “library” of HIV information, a term that I insisted be used with reverence, although our shelves contained a sum total of five books and a small stack of brochures that I had brought with me from the United States. Realizing the inefficiency of a physical location to serve Russia’s 11 time zones, we designed our first large-scale project, SPIDNET, which was funded through USAID. We committed to distribute a large number of computers to the AIDS centers and/or NGOs (which, in the mid-1990s, were essentially the same thing), through which they could access documents electronically via a modem and a bulletin board system. Although we eventually distributed 42 computers (including a shipment of ten Macintoshes that actually resulted in the usually intrepid Stas weeping with frustration after his seventh attempt to free them from Customs), the connections were too tenuous and the concept too new for our original plan to succeed. We ended up instead creating “infodisks,” sets of two diskettes containing over 300 pages of HIV/AIDS reference material translated into Russian. Another project aimed at increasing the capacities of NGOs was one in which we would provide computers, training, and a small

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amount of money for ten Russian organizations to design and carry out an HIV/sexually transmitted disease education and prevention project among women. We were thrilled with the results, until we received an urgent call from a distraught NGO staff member in Chelyabinsk. For their project to create a brochure, they had assembled a committee, consisting of people from several medical specialties including gynecologists, psychologists, local AIDS Center staff, and venerologists (physicians specializing in the diagnosis and treatment of sexually transmitted infections). The brochure was written, produced, and accepted with approval and appreciation by physicians and patients in the city. The crisis arose when an American, working with a large PVO that was collaborating with the Russian Federation of Family Planning (RFFP), heard of this brochure and asked to have it translated to her. She evidently became overwrought upon hearing one part of the text advising women that they were not protected from STIs when practicing anal sex (a common form of contraception), and that they still must protect themselves with condoms if they were to engage in this act. As a fellow American, I was pressed into defending the project, and was called “immoral” and “disgusting” for pressing my sexually aberrant views on innocent Russians (I had not even seen the brochure at this point). She threatened to take the case to the U.S. Congress to ensure that we would never again receive U.S. funding. The crisis was resolved when it was revealed that her Russian partner organization, RFFP, was enthusiastically distributing the brochure and had been involved in its creation. Needless to say, the entire incident left my Russian colleagues shaken and wary of American “experts.” One of our biggest early lessons came in the form of “Russia AIDS Relief” (RAR), a project conceived by the first person that we hired, a man living with AIDS and one of the first “activists” in Russia.3 The idea was simple. We would create a distribution center for clothes and other donated items for PLWHAs, as well as a fund through which people who were in the hospital for more than a month could receive a small amount of cash (the ruble equivalent of $25) in order to purchase vitamins, fruit, or other things to make their stays more bearable. I convinced my expat friends to contribute cash, and church groups and embassy employees donated clothes and nonperishable food and hygiene items to our warehouse, which was staffed by two lovely and dedicated men with HIV. We were proud of our creation and convinced that we were actually helping people, until we received a threatening call from a man with HIV who was heading a group that had formed in order to bring a lawsuit against AIDS infoshare.

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This group was convinced that we had fraudulently solicited millions of dollars to help PLWHAs and that we were withholding the funds from them. After a couple of months of threats of this nature, we decided to close down the project and focus on other activities.

1996–2002: HIV Explodes in Russia As discussed above, the seeds of the Russian AIDS epidemic were being sown as the Soviet Union was dissolving. Many aspects of the domination of organized crime were growing even more visible, with frequent gruesome reports of gangland-style beheadings and car explosions. The sex trade, completely under the control of crime families, was inescapably obvious, with large groups of scantily clad women lining the road that led from Sheremetevo-2 (the international airport), outnumbering guests in hotel lobbies and stopping men outside of museums and McDonald’s. Completely invisible to most, however, including all of us at AIDS infoshare, was the epidemic of injection drug use that was taking hold. We followed reports of large numbers of injection drug users (IDUs) testing positive for HIV in cities in Ukraine, but for some reason we still did not recognize IDUdriven HIV as a threat to Russia. We simply did not see it coming. Then 1996 arrived. Our pokey little epidemic curve shot skyward overnight, fueled almost entirely by cases among IDUs, leaving us shocked and befuddled. AIDS centers and affiliated NGOs were also at a loss. In the vertical organization of Russia’s public health programs and policies, drug users were the domain of narcological centers that addressed their problems with inpatient, cold-turkey detox programs. In the estimation of the AIDS centers, there was nothing that could be done to prevent HIV among IDUs. There was no substitution therapy, and needle exchange programs were in the gray area between “frowned upon by the state” and “illegal.” The Open Society Institute’s International Harm Reduction Program, however, began boldly fostering and funding harm reduction programs across Russia beginning in 1996. Several projects were supported by other international organizations, such as a needle exchange bus in St. Petersburg funded by Medicines du Monde, and an outreach project in Moscow run and supported by Medecins Sans Frontieres-Holland (Sarang, Stuikyte, and Bykov, 2004). At AIDS infoshare we plugged along, with enough of our own challenges, as well as successes, to keep us distracted from the huge

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changes in the epidemic. It had taken some time for us to establish a system for getting money in the form of dollars into Russia from our U.S. bank account. We eventually developed a relationship with a bank whereby dollars could be wired in for a four percent fee, often after a delay of several weeks. It was (and still is) disadvantageous to operate solely through a Russian bank account, as it was virtually impossible to obtain cash from accounts (especially in dollars, which carried a 40 percent fee to liberate them), the ruble was still unstable, and there was a 40–60 percent tax on salaries (the staff insisted, wisely, on payment in cash dollars). In 1998, a banking crisis closed the bank that we had been using for wire transfers. This resulted in a need for me to travel to Russia carrying the cash we would need for expenses. On one trip, I carried over $40,000 in $100 bills in my battered JanSport backpack. I would then return to Johns Hopkins, where I had begun my PhD in Public Health, marveling at how the kind of details that formed my reality were never mentioned in my international health classes. In terms of the actual projects that we were tackling, the one leap of faith that stands out and continues to be one of our foci today was the act of reaching out to sex workers. In 1996 Lucy Platt, a British woman who was working for us as an intern, said that she wanted to approach this population. Stas, Alena, and I all told her in no uncertain terms that she was to do no such thing. The only thing we knew about these women and their work was that it was controlled by organized crime syndicates. We felt responsible for Lucy and also feared for ourselves and the organization if something went wrong. She defied us and spent her evenings, unbeknownst to us, climbing into vans where shivering girls waited for clients and visiting the apartments that several sex workers shared. She got to know the pimps. Lucy was one of the first people outside the sex industry to gain insight into how sex work functioned in Russia, who these women were, how they lived, and what their risks were. From her initial work came our sex work outreach project and, several years later, a subsequent large-scale National Institutes of Health (NIH)-funded epidemiological study. For several years we continued to focus mainly on the dissemination of information through projects such as our library, from which people could request 100 photocopied pages from our catalog quarterly. We also developed collections of “necessary” documents and information on a wide range of topics related to HIV, including human rights, prevention, treatment of opportunistic infections, and voluntary testing and counseling. It became clear, however, that while our

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programs were successful in terms of our output measures of “AIDS centers served” and “pages sent,” the “share” in “infoshare” was simply not happening. The information was being hoarded by those who requested it, not disseminated further once it arrived at its destination. When examined with a cold objective eye, our successful indicators were deflated. Rather than blanketing the country in new knowledge, we were spending a huge amount of money and effort to get information to a couple hundred individuals, most of whom were not empowered to make changes or otherwise use the information. It was at this time that we decided to collaborate more closely with the government and work on a policy level, as well as to begin to look more closely at what was actually needed before acting. We began using terms like “evidence-based programs” within the organization, and began designing research projects in order to collect the necessary “evidence.”

2002–Present: Recent Years Claims have been made in recent years that the composition of incident cases of HIV in Russia has shifted substantially from IDUs to the general population, namely to women who are infected through sex. It is clear to me, however, that we simply do not know what is happening with the Russian HIV epidemic. In 2003, over 50 percent of cases of HIV were of indeterminate route of transmission (Feshbach and Galvin, 2005; Pokrovsky, 2004). Also, while most are in agreement that the current system has not captured all the cases, there is no consensus on what the official total should be multiplied by to give an accurate picture of the situation. The one fact that cannot be argued is that the official numbers provide a solid, objective, concrete minimum count of people with HIV and that these people will need treatment in the future, or in some cases, are in need of it now. This has been the recent focus of urgency for government and NGOs. In 1998, the executive director of UNAIDS, Peter Piot, announced that Russia had the fastest growing epidemic of HIV in the world. This catalyst mobilized money and attention from larger organizations. Healthy Russia 2020, the American International Health Alliance, and IREX are recipients of millions of American dollars that have been directed toward AIDS in recent years. The multilaterals (UNAIDS, WHO, UNDP, etc.) have also intensified their efforts around HIV. The leadership and staff of many NGOs working on the ground have felt either excluded or threatened by the activities of these big players. We at AIDS infoshare decided that it was important to interact with some

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of these groups to the extent that we could, and we made a point of becoming familiar with their programs and strategies. In 2003, AIDS infoshare, namely Alena Peryshkina, was elected to be the European representative of the five-member NGO group within the Program Coordinating Board of UNAIDS. In 2003, AIDS infoshare joined a group of NGOs in Moscow consisting of Population Services International, AIDS Foundation East West, FOCUS Media, and the Open Health Institute to apply for a third-round grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria. This request was approved with a budget of $89 million (Webster, 2003), to be spent over five years to increase the capacity of governmental institutions and nongovernmental organizations in ten regions. The money is going toward networking and support for people living with HIV/AIDS; prevention and education activities among vulnerable groups, such as sex workers, prisoners, drug users, and youth; provision of palliative care; lobbying and capacity building to improve access to treatment; media campaigns related to prevention of HIV transmission and stigma; human rights education and monitoring; and prevention of mother-to-child transmission. For several political and logistical reasons, this grant was one of only a very few the Global Fund has ever approved without going through a governmentcentered Country Coordinating Mechanism. In recent years, AIDS infoshare has undergone many changes, as has the environment in which we operate. In 2002, my colleagues at Johns Hopkins Bloomberg School of Public Health and I wrote and successfully submitted a large-scale epidemiological research proposal to the National Institute on Drug Abuse of the National Institutes of Health to study HIV and sexually transmitted infection risks and disease levels among female sex workers in Moscow. In 2003, the Russian Federation signed a $150 million loan from the World Bank to put programs in place to address tuberculosis and HIV. The HIV/AIDS component of the loan “will allocate $50 million to support capacity building, surveillance, program development, and interventions for prevention and care over a period of five years” (“World Bank Approves Loan . . . ,” 2003). This represents a tripling of the resources that had been devoted to HIV/AIDS by the federal government at that time.

Conclusion Some people observing events in Russia rejoiced when President Vladimir Putin listed AIDS as one of his country’s problems in his

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State of the Nation address in 2003, as it was felt that this represented a giant step forward in the struggle against the virus. Many people have spent recent months wringing their hands over some of Putin’s moves that are considered threatening to democracy and civil society, such as continuing his campaign in Chechnya and his proposals aimed at consolidating state power through tighter election control, restoring the death penalty, and imposing more restrictions on foreigners. Among my friends and acquaintances, it is the Americans who are far more interested and concerned than most Russians about Putin’s moves. Even the recent major restructuring of the main governmental ministries that deal with AIDS has caused little worry among those working in the NGO sector, as it is simply a matter of keeping track of the people you work with and remembering their new titles. The biggest change in Russia that has begun to negatively affect NGOs is, paradoxically, the apparent increase in the health of the Russian economy. This upswing includes the proliferation of large and medium-sized businesses and corporations, as well as the fact that Russia seems to be learning how to effectively mobilize and profit from its wealth of natural resources. Russia has jockeyed its way into the G8 and has recently increased its contribution to the Global Fund. Moscow’s main street, Ulitsa Tverskaya, is home to Tiffany & Co. and TGI Fridays, and foreign-made SUVs (sports utility vehicles) and sedans jockey for position with Ladas and Moskviches. In short, Russia is beginning to look like a country that can take care of itself, especially in comparison to its neighbors in Central Asia and the Caucasus. Donors are therefore starting to look for other places to put their resources, feeling that the Russian government and private sector should step in to take up some slack. Lacking tax breaks or other incentives, Russian businesses have no motivation to put money into the social sector. And, although a middle class is emerging in Russia, private money is still largely concentrated in the hands of the very few. Most NGOs have no mechanisms to accept private donations from citizens. We have all been forced to accept one fact, as well: AIDS is a hard sell to Russians, period. In the minds of most, it is a disease isolated among drug users, prostitutes, and homosexuals, people many Russians would rather not even think about, much less donate money to help. Our history in the United States was different. Early on, AIDS began to have a face. It was Ryan White, the AIDS Memorial Quilt, Magic Johnson; it was something Elizabeth Taylor and Sharon Stone cared about.4

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The situation in Russia is entirely different. The stigma surrounding HIV is so great, as we learned in a recent research project among PLWHAs, that a majority of people have not told their families or anyone else of their diagnosis.

Recommendations Alena Peryshkina has identified some of the problems that need to be resolved if NGOs are to enjoy a successful future in terms of stability and impact: ●

●

●

●

There is a disparity in the number and quality of HIV-focused NGOs in the far geographic reaches of Russia. In the Far East, for instance, there are only four NGOs working in the field. In many cases, NGO personnel lack the necessary skills and training to carry out their work effectively. Many of the most educated and experienced people (who gained their experience through grassroots work) have been hired for much more substantial salaries by the larger NGOs and by PVOs on the ground. Work among and within NGOs is often fragmented as organizations continue to take a project-oriented approach, due to lack of operational funds as well as difficulties collaborating with one another and local governments. This fragmentation results in a lack of sustainability of activities, as well as both overlap and gaps in programs. Currently, there is a lack of Russian governmental funding or other substantial funding from Russian businesses, and NGOs therefore rely solely on foreign aid. This results in the aforementioned project-oriented approach to AIDS prevention and care, as well as external influence as to the nature of the programs implemented, depending on the mandate of the foundation or government providing the funds.

Peryshkina offers the following solutions: ●

●

A professional cadre to collaborate with the nongovernmental sector needs to be developed, by teaching and training governmental and municipal officials to work with NGOs. NGO personnel should also be taught about the workings of government. These combined efforts would allow governmental “outsourcing” and collaboration to increase the effectiveness of programs. One pressing example of this strategy would be to involve NGOs in treatment approaches implemented by AIDS centers to integrate patientcentered adherence programs, in order to reduce resistance to ARVs. The infrastructure of collaboration between governmental and nongovernmental agencies should be formalized, perhaps by the creation of an advisory council on HIV/AIDS in every region of Russia, familiar with local realities and charged with fulfilling specific objectives.

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There is a need for an objective and systematic analysis of the state of affairs of the nongovernmental sector, whereby activities and programs would be evaluated in terms of reach, effectiveness, and quality, with the goal of identifying overlap as well as gaps that need to be addressed.

In the end, I agree with this editorial that appeared in The Economist on January 29, 2000: NGOs can become self-perpetuating. When the problem for which they were founded is solved, they seek new campaigns and new funds. As NGOs become steadily more powerful on the world scene, the best antidote to hubris, and to institutionalization, would be this: disband when the job is done. The chief aim of NGOs should be their own abolition. (“Sins,” 2000)

Should it ever become the case that AIDS is no longer a problem for Russia and its most vulnerable citizens, we at AIDS infoshare pledge to be the first ones to close our doors. I have imagined that day as one in which we emerge, blinking and rubbing our eyes, to look at each other and say, “We did all we could.”

Appendix List of selected NGOs working in AIDS in Russia This information is from the website of aidsmap (www.aidsmap.com).

AIDS Foundation East-West (AFEW), Moscow Website: www.afew.org AFEW operates in Russia, Ukraine, Moldova, Kazakhstan, Kyrgyzstan, Uzbekistan, Tajikistan, and Mongolia through six program streams: media campaigns; HIV/AIDS programs in penal systems; HIV/AIDS care, support, and prevention of mother-to-child-transmission; HIV/AIDS counseling; HIV/AIDS treatment; work with injection drug users and sex workers.

AIDS infoshare, Moscow Website: www.infoshare.ru Documentation center; professional education; NGO development; health and human rights work; HIV/AIDS telephone help-line; support services; special projects with commercial sex workers, prisoners, MSM, and vulnerable youth groups.

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Beregi Sebya (Take Care), Chelyabinsk Email address: [email protected] Prevention programs for teenagers; support for individuals with HIV/AIDS; documentation center.

Humanitarian Action, St. Petersburg Website: www.humanitarianaction.org Needle exchange; prevention; social and medical assistance for children.

Siberian Initiative, Barnaul Website: www.sibin.ru Harm reduction; counseling; information; training; resource center for NGOs and governmental organizations working in the field of youth health and development.

Siberian AIDS-Aid,Tomsk Website: www.tomsk.aids.ru Education; information; organizational support; research; outreach; information resource center; web-design studio for NGOs; electronic hotmail; support groups and information.

Transatlantic Partners Against AIDS, Moscow Website: www.tpaa.net TPAA works to strengthen political will and mobilize governments, civic leaders, scientists, corporate executives, and international organizations in the fight against HIV/AIDS in Russia, Ukraine, and neighboring countries.

Notes 1. Soon after my arrival in Moscow, members of the same group formed an organization called “Triangle Association,” which would meet in Roman Kalinin’s club “Rainbow,” with the mandate of lobbying for release of prisoners convicted under Article 121 and trying to get a gay person (or at least a gay-friendly person) elected to parliament in the 1996 elections. An American friend of mine who is a gay man, suggested that we try to help the floundering organization, so we joined the Board of Directors. Fairly quickly I realized that my presence was too distracting, as a foreigner, but also as the only nonhomosexual on the Board (which resulted in much time devoted to discussion of this fact), so I left but continued to

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follow their progress. While the mission was noble, the organization was plagued with regular KGB raids of Rainbow, with people forced to lie on the floor before being arrested for “hooliganism.” However, the problem which I believe proved fatal to that organization was that which has also hindered many attempted projects started by people with AIDS—the unusual bravery and determination which allowed this small group of persecuted and stigmatized people to emerge and try to claim their rights, also meant that this was a collection of leaders and visionaries. For an organization or a movement to function at all, followers and supporters are also essential ingredients, and at that time, there was still too much fear, as well as people who were just beginning to find their own way, to convince large numbers of gay men and lesbians to listen to others tell them what to do or think. A brief story of the organization appeared in the Moscow Times, and can be found at www.gay.ru/english/communty/politics/1994a.htm. 2. At this time, she also claimed that people could heal themselves from AIDS through positive thinking and “finding joy.” 3. The term “activist” in Russia has a very different connotation than it does in the U.S., which can lead to a great deal of confusion. While Americans tend to think of people involved in protest-oriented groups such as ACT-UP or Greenpeace, Russians use the term to describe someone who, living with a problem or disease (such as HIV), has decided to do something about it by working in an NGO or engaging in independent activities, such as support groups. This definition may be shifting, however, with increasing contact between Russians and Westerners, especially at large conferences. 4. Paradoxically, this “normalization” of AIDS in the U.S. has led to funding crises among AIDS services organizations, as attention and money are captured by victims of terrorism, tsunamis and hurricanes, while AIDS is considered by many to be a chronic illness.

References Amirkhanian, Y. A. et al. (2001) “Predictors of Risk Behavior among Russian Men Who Have Sex with Men: An Emerging Epidemic,” AIDS, 15(3):407–412. Bingham, J. S., and M. A.Waugh (1999) “Sexually Transmitted Infections in the Russian Federation, the Baltic States, and Poland,” International Journal of STD and AIDS, 10(10):657–658. “Drug Injecting, Rapid HIV Spread, and the ‘Risk Environment’: Implications for Assessment and Response” (1999) AIDS, 13 (supplement A), S259–269. Feshbach, M., and C. M. Galvin (2005) HIV/AIDS in Russia: An Analysis of Statistics (Washington, DC: Woodrow Wilson International Center for Scholars). Hosking, G. (1990) The Awakening of the Soviet Union (London: Heinemann). Kalichman, S. C. et al. (2000) “The Emerging AIDS Crisis in Russia: Review of Enabling Factors and Prevention Needs,” International Journal of STD and AIDS, 11(2):71–75. Knox, Z. (2005) Russian Society and the Orthodox Church: Religion in Russia after Communism (London and New York: RoutledgeCourzon). Lewin, M. (1988) The Gorbachev Phenomenon (Berkeley and Los Angeles: University of California Press).

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Pokrovsky, V. I. (2004) Statistics on HIV Infection and AIDS (Moscow: Federal Scientific Methodological Center on AIDS of the Ministry of Health of the Russian Federation). Rhodes, T. et al. (1999) “HIV Infections Associated with Drug Injecting in the Newly Independent States, Eastern Europe: The Social and Economic Context of Epidemics,” Addiction, 94(9):1323–1336. “Russian Gay History” (1990) The Encyclopedia of Homosexuality (New York: Taylor and Francis). Sarang, A., R. Stuikyte, and R. Bykov (2004) Implementation of Harm Reduction Measures in Eastern Europe and Central Asia: Lessons Learned (Vilnius, Lithuania: Central and Eastern European Harm Reduction Network). “Sins of NGOs” (2000) The Economist, January 29. Starr, S. F. (1988) “Soviet Union: A Civil Society,” Foreign Policy, 70:26–41. Tismaneanu, V. (1990) “Unofficial Peace Activism in the Soviet Union and EastCentral Europe,” in V. Tismaneanu, ed., In Search of Civil Society: Independent Peace Movements in the Soviet Bloc (New York and London: Routledge). Webster, P. (2003) “Global Fund Approves Grants to Fight HIV/AIDS in Russia,” Lancet, 362(9397):1729. “World Bank Approves Loan to Help Russia Tackle HIV/AIDS and Tuberculosis” (2003) Lancet, 361(9366):1355.

4 The Economic Impact of HIV/AIDS in Russia: Current Trends and Perspectives Shombi Sharp

Accounting for some 70 percent of officially registered cases in Eastern Europe and Central Asia, the Russian Federation has witnessed one of the fastest growing AIDS epidemics in the world in recent years (UNAIDS, 2004, p. 48). This chapter provides an overview of current trends and perspectives in estimating the potential impact that HIV/AIDS may have on the Russian economy. Such analysis is crucial in framing public decision making concerning resource allocation and policy interventions and placing HIV/AIDS as a national priority. We approach this task beginning with a brief update on the status of the HIV/AIDS epidemic and key demographic and socioeconomic contextual factors. We then review the state of knowledge of the links between HIV/AIDS and the economy. This is followed by a synthesis of existing research and modeling, including methodology and results, on postulated demographic and economic impacts of HIV/AIDS in the Russian Federation. Models from the World Bank, the United Nations Development Programme (UNDP), the International Labour Organization (ILO), and the Imperial College London, among others, are discussed. We end with conclusions drawn from existing research and current trends, and propose directions for future research.

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HIV and Health in Russia Other chapters in these volumes investigate the nature of HIV/AIDS in Eurasia in considerable detail. This section will therefore be limited to a brief discussion of concepts necessary for understanding the rest of this chapter. Russia has experienced an explosive spread of HIV within its borders in less than a decade. Though official sources place the current number of registered HIV cases as of late 2005 at 318,794 (www.hivrussia.org), this statistic by definition represents only a minimum boundary with a significant majority of the population remaining untested (Rühl, Pokrovsky, and Vinogradov, 2002). Expert consensus estimates the actual total number of cases to be much higher, with the 2004 UNAIDS middle-range estimate at over 860,000 adults infected with HIV (UNAIDS, 2004, p. 48). Holding true to global experience, the overwhelming majority of cases are found among adults aged 15–49, the segment most responsible for generating economic activity. Nearly 70 percent of registered cases are clustered in the ten regions that comprise Russia’s most active economic centers (Russian Federal AIDS Center, 2004, pp. 20–21). Similar to epidemics in North America, Europe, Eastern Europe, and the other CIS (Commonwealth of Independent States) countries, HIV remains largely concentrated among “high-risk groups,” primarily injection drug users (IDU), who, despite a slowly declining share since 2000, may still account for up to 70 percent of new infections (Feshbach, 2005, p. 16). With an estimated adult (age 15–49) prevalence level exceeding one percent, Russia may have already passed this widely held “tipping point” beyond which it is believed generalization becomes ever more likely. Despite the continued spread among “high-risk” groups, there are indeed growing indications that the epidemic may be spreading to the general population through sexual contact with bridging populations, mainly IDUs and commercial sex workers (CSWs). According to John Stover (1999) of The Futures Group in a personal communication to the author, a classic IDU epidemic begins at a female-to-male ratio around 0.1, reaching 0.4 only after some 25 years, while a classic generalized epidemic rises much faster from the same baseline, peaking at 1.2 to 1.4 (i.e., more women than men newly infected) within 20 years. A range of indicators is signaling the real threat of a generalized epidemic in Russia: a rapid rise to nearly 40 percent in the share of women among new infections, a nearly fourfold increase in the share of heterosexual transmission, and a fivefold growth in the number

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Total Population (thousands)

of children born to HIV-positive women from 2000 to 2003 (Russian Federal AIDS Center, 2004, pp. 6–9). Official data indicate that the level of annually reported new infections has decreased significantly since reaching a peak of 88,487 in 2001 (www.hivrussia.org). For a number of reasons, caution is warranted in drawing conclusions from this apparent trend. For example, the head of the Federal AIDS Center noted in late 2003 that “the number of newly registered cases of HIV infection may be associated merely with changes in the constitution of the tested group,” as the numbers of drug users tested has fallen considerably (Pokrovsky, 2003). The fall in the number of HIV antibody tests conducted from 2002 to 2003, some 2.5 million, may indeed have a role to play in the reported drop in new HIV cases of 12,650 over the same period (Feshbach, 2005, p. 14). Further, an eleven percent increase in newly registered HIV cases, from 32,147 in 2004 to 35,554 in 2005 after three years of steady decline, gives an admittedly imperfect proxy statistic suggesting a possible increase in HIV incidence (www.hivrussia. org). Even if not at the world-beating rates of a few years ago, the fact that HIV continues to spread with alarming pace remains certain. Perhaps the most critical contextual factor for considering the economic impact of HIV/AIDS, given that AIDS impacts the economy largely through effects on human resources, is the dramatic population decline facing Russia even without AIDS. Due to the combined ill effects of crisis levels of mortality and fertility rates that have plunged far below replacement rates, Russia is already losing 150,000 145,000 140,000 135,000 130,000 125,000 120,000 2000

2005 UN Projections

2010

2015 Year

2020

U.S. Census Bureau Projections

Figure 4.1 Russian Population Projections in the Absence of HIV/AIDS Source: Eberstadt N., 2004, p. 35.

2025

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nearly one million people per year (Eberstadt, 2004, appendix). Population projections from both the UN Population Division and the U.S. Census Bureau foresee a sustained population loss over the long term (figure 4.1). Indeed, President Putin linked the dual threats of population decline and AIDS for the first time in his 2002 address to the Federal Assembly. The situation with the working age population is even more stark. The number of males aged 15–24 is set to decline by nearly half over the next 20 years in Russia, while the average 20-year-old male has only a 46 percent chance of reaching retirement (Eberstadt, 2004, pp. 26–27). A sense of the economic context is key to understanding the relationship between working age life expectancies and economic growth. Russia has enjoyed robust economic growth since the financial crisis of 1998, giving way to significant optimism concerning Russia’s economic prospects. The president has declared that Russia will double its GDP by 2010 (Gorshkov, 2003). While poverty levels have been declining since 2000, economic growth has yet to reverse major declines in health attainment and life expectancies since the end of the Soviet Union. Moreover, extreme inequality continues to push the boundaries of social cohesion. This recent growth, initially driven by export competitiveness of the devalued ruble, has given way to significant dependence on high market prices for the dominant extractive natural resource sector. The World Bank estimates, for example, that approximately 30–60 percent of Russia’s GDP growth in 2003 was due to “high” oil prices, while oil and gas alone accounted for 55 percent of total export revenues that year (World Bank, 2004, p.11). More recent economic data indicate that long-term economic growth expectations may not materialize.

The Economics of AIDS Analysis of the relationship between infectious disease-induced demographic shock and the economy has been applied to events dating back to the fourteenth-century bubonic plague, where a dramatic increase in mortality rates reduced Europe’s population by a third in just 15 years (Over, 1992). The study of the economic implications of HIV/AIDS, based largely on the premise of a “long wave” demographic shock, has evolved considerably since first gaining attention in the early 1990s. Table 4.1 provides an overview of the range of variegated impact across economic unit, time, and the severity of

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Table 4.1 Understanding Economic and Social Impact Level, Time, and Degree Level of Impact

Time of Impact

Degree of Impact

Does Evidence Exist that this Happens?

Individual

Early (immediate)

Always severe; variation by age and gender; physical and social (stigma and discrimination).

Yes: death and illness.

Household

Early, middle (1–5 years), and late (10 years and beyond/ intergenerational for households)

Severe emotional; variable financial depending on socioeconomic status, gender, ethnicity, and other social variables.

Yes: household studies. Orphans and the elderly especially afflicted.

Community

Early, middle, and late

Variable: dependent on scale, and resource base of the community. Likely to be long-term and profound but not necessarily readily visible.

Yes: services for orphans and the elderly, and local service provision, affected.

Production unit/ institution

Middle and late

Variable: dependent on the nature of an organization or institution’s activities, or type of production and labor mix.

Yes: firm/organizational surveys.

Sector

Late

Variable: dependent on location, production, use of labor, and sensitivity to investor sentiment.

Yes: some evidence but limited.

National/ macro

Late

Economic and demographic projections indicate possibility of significant aggregate impact in a generalized epidemic scenario.

Not yet: analysis based on economic and demographic models, with anecdotal evidence about the effects on government infrastructure.

Source: Barnett and Whiteside, 2002.

consequences, bearing in mind that all levels are part of one economic system and are therefore mutually reinforcing. Macro-, meso- (sectoral) and microeconomic modeling of the implications of HIV/AIDS has been carried out for a number of

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countries on several continents in the past 20 years. More recently, a handful of models addressing macro and meso impacts have been customized to the Russian Federation. There is a growing body of research demonstrating that socioeconomic factors, such as poverty, social exclusion, and broader “environmental” conditions, including social cohesion and inequality, increase the susceptibility and vulnerability of populations to HIV/AIDS (Barnett and Whiteside, 2002). The rapid socioeconomic change following the collapse of communism introduced a greatly increased risk environment vis-à-vis the spread of HIV, comprising a number of drivers including a loss in livelihoods, changes in sexual behavior and drug taking, and dramatic increases in population mobility (UNDP, 2004a, p. 37). A correlation between proxy variables for social cohesion and mortality has been demonstrated in attempting to explain the Russian “mortality crisis” of the 1990s (Kennedy, Kawachi, and Brainerd, 1998). This dynamic may also shift relative to the age and severity of the epidemic. The inverse relationship between educational attainment and susceptibility to HIV infection, for example, becomes increasingly prevalent as an epidemic progresses. Those without access to information and knowledge are soon left to face “exponential growth” in the spread of HIV (Vandemoortele and Delamonica, 2000). With severe inequality, diverging educational attainment, and growing social exclusion of particular population groups in Russia, it is instructive to consider the relationship between socioeconomic factors and the spread of HIV/AIDS. It is well established, for example, that conditions such as unemployment, poverty, and income disparity build the foundations for rapid HIV spread through increased migration, commercial sex work, and drug trafficking (Renton et al. 2004, p.13). In addition to overwhelming health care resources, AIDS attacks the social, economic, and demographic underpinnings of human development. With over 80 percent of PLWHA in Russia under the age of 30 (Russian Federal AIDS Center, 2004, p. 27), HIV/AIDS targets those age cohorts that would otherwise contribute an important share of economic production and demographic reproduction. Figure 4.2 depicts the age density of HIV distribution, showing the disturbing concentration of HIV among young people even under the age of 25. The following transmission mechanisms spell out how the economy may be affected, with the likelihood of macro effects increasing with prevalence

Economic Impact of HIV/AIDS in Russia 0.10

83

Men Women

0.09 0.08

Density

0.07 0.06 0.05 0.04 0.03 0.02 0.01 0.00 0

5

10

15

20

25 30 Age

35

40

45

50

Figure 4.2 Age Density of HIV Infection in Russia at the End of 2002 Source: ILO, 2004 (model output).

rates and epidemic generalization: ●

●

●

●

●

Reduction in human capital formation within, and across, generations. Generations affected by HIV/AIDS may not be able to acquire and transfer a broad or deep human capital base, providing less skill and knowledge to the firm-level and national production function, and reducing returns to investment in human capital over time (Bell, Devarajan, and Gersbach, 2003, p. 95). Reduction in labor force numbers. The firm, sector, and overall economy may suffer from a decrease in the number of workers with appropriate skill sets. This trend both reduces national growth potential and induces firms to shift toward capital-intensive production in the face of a reduced supply of skilled workers. Changes in population age composition. The dependency ratio of the economy will increase, and fewer workers will have to support a relatively greater number of very young and retired persons. This trend harms the integrity of pension systems. Reduction in labor force productivity. As workers progress from HIV to AIDS, they become increasingly sick and, if not treated, unable to perform their duties. Absenteeism and other effects on labor productivity make production more costly both for the firm and for the overall economy. Previous research has reasonably estimated a 50 percent loss in productivity averaged over the life cycle from the point of developing AIDS (Over, 1992, p. 1). Increase in wages and costs. As qualified labor becomes more scarce, wages and other costs may rise, in turn leading to losses in firm, sector, and national competitiveness.

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●

Lower public revenues and reduced national savings (private and public). These reductions result from decreased labor force levels and productivity, lower capital accumulation, and slower formal sector employment creation. Increased public health and social protection sector financing. Direct and indirect costs of care, treatment, and disability payments reduce public savings and place pressures on government budgets at national, regional, and local levels.

Modeling the Implications of HIV/AIDS: A Russian Federation Case Study As inaccessible as their inner mechanics may be to the layperson, models are simply mathematical descriptions of relationships among variables, integrating observation and theory in a proposed framework. Modeling can be applied to help our understanding of a number of complex behavioral relationships related to HIV/AIDS, from determining how the epidemic will spread to assessing effectiveness of various interventions and the economic implications of the epidemic. Models can be a powerful tool for advocacy (Nicholls et al., 2000, p. 25). In response to the growing epidemic in Russia, at least three models have been developed since 2002 to help investigate the potential economic impact. We review and compare them to provide a better overall understanding of current trends and perspectives, with a fourth model introduced later. Table 4.2 presents a brief description of each. Of the many ways in which HIV/AIDS can affect the economy, demographic change is considered the principal impact channel. Analysis of economic effects therefore necessarily begins with an examination of demographic change. This analysis in turn centers on estimates of HIV incidence, prevalence, and distribution within the population. Most attempts to model these dynamics begin with a range of scenarios comprising different assumptions about the nature of the epidemic. The relative immaturity of the epidemic in Russia, coupled with a lack of knowledge about transmission dynamics, makes confident projection difficult. This fact is immediately obvious when considering the range of estimates produced and quoted over the last several years (table 4.3). Given the discussion in the preceding paragraphs, the higher-end estimates, largely derived several years ago when the rapid annual growth in reported incidence seemed likely to continue, now appear

85 Table 4.2 Existing Models of the Economic Impact of HIV/AIDS in Russia Model

Brief Description

World Bank

Launched May 2002. Designed as an interactive model with user interface. Model comprises 26 input parameters (17 userdefined) and ten output variables (human and economic cost) with a forecasting period through 2050. Disability and health care benefits are modeled. Two author-derived scenarios (optimistic and pessimistic). See references for more details.

UNDP

Launched February 2004 (adaptation of Sharp, 2002). Comprises two aggregate growth models (Solow and Ramsey, with 40-year horizons) and a CGE model based on a World Bank Russian social accounting matrix (35 sectors, with a 20-year horizon). Demographics calculated exogenously using DemProj/AIMS, with five-year age cohorts. Health care (excluding ART) and disability benefits are modeled. Three scenarios (low, medium, and high AIDS). See references for more details.

ILO

Launched late 2004. Demographic, epidemiological, and economic projects exogenously determined in a partial equilibrium environment to assess changes in population and economically active cohorts, changes in employment and GDP, financial sustainability of the pension fund, costs associated with disability benefits, and health care expenditures. Five scenarios. See references for more details.

Sources: Rühl, Pokrovsky, and Vinogradov, 2002; Sharp, 2004a; ILO, 2004.

Table 4.3 External Sources’ Prognoses of HIV Prevalence in Russia, 2005–2050 Year

Prognosis

Source

2005 2007 2008

5 million 2–3% of Russians 7 million (one in every 25 Russians) ⬎7 million 8 million AIDS cases Optimistic: 2.32 million Pessimistic: 5.25 million 8 million (over 10% of adult population) 5.4–14.5 million 4–19 million 20.7 million lives will be lost 72 million

Rian van de Braak, AIDS Foundation East-West The Sunday Herald, quoting Dr. Vadim Pokrovsky New York Times

2008 2010 2010 2010 2020 2025 2045 2050

Source: Feshbach, 2005, p. 40.

The Baltimore Sun U.S. National Intelligence Council The Moscow Times, quoting the World Bank Transatlantic Partners Against AIDS Christian Science Monitor, quoting World Bank Nicholas Eberstadt, Foreign Affairs Reuters, quoting UNDP study Voice of America, quoting United Nations

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Table 4.4 Optimistic and Mid-Range Projections of Three Models Scenario/Model

World Bank

UNDP

ILO

Low/Optimistic

●

0.2 pop growth, 5% growth in IDU ● Prevalence multiplier 4 (initially 1% adult prevalence) ● IDU transmission rate 2 ● Non-IDU transmission 0.3 No mid-range scenario (only Pessimistic, which is not considered here)

Adult prevalence reaches a maximum 3% by 2015

●

Mid-range

“Decreasing infection”: falls by 50% (saturation of risk group)

“Constant infection” (i.e., reached peak in 2002) ● “Growing Adult prevalence infection”: nonlinearly reaches a by 50% toward end maximum 6% of review period ● “Saturation of the by 2015 IDU risk-group” (1 million people) ●

Sources: Rühl, Pokrovsky, and Vinogradov, 2002; Sharp 2004a; ILO, 2004.

implausible. Nonetheless, as we will see below, even optimistic to moderate scenarios are sufficient to threaten demographic and economic prospects in Russia. In the interest of plausibility, we therefore exclude high-end scenarios in our comparative examination of existing economic models. Table 4.4 presents the three models with stipulated scenarios. The resulting demographic profiles, upon which economic calculations are derived, are briefly outlined in table 4.5. We observe that these models diverge significantly in terms of prevalence projections. The World Bank “optimistic” scenario (figure 4.3) yields a slightly more severe outcome than the UNDP “low” scenario. All five scenarios in the ILO model (figure 4.4), however, foresee milder implications. This contrast appears largely due to the fact that the ILO model is the more recently developed, incorporating more conservative assumptions based on the decline in growth in registered new infections observed annually from 2002. Further, while the World Bank model employs a multiplier of four to calculate the estimated total number of HIV infections as a function of registered cases, the ILO model uses three, based on the ratio of new cases overall to new cases among pregnant women. While this methodology arguably brings greater confidence to modeling outcomes, the ILO assumptions appear exceptionally conservative, as only the most extreme scenario, the “risk group saturation” scenario, corresponds to

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Table 4.5 Resulting Demographic Profiles from Three Optimistic and Mid-Range Scenarios Scenario/Model

World Bank

Low/Optimistic Mortality from 500/ month (2005) to 21,000/month (2020)

UNDP

3.48 million Peak HIV deaths, a 2.6% 636,000 by 2006, population loss by peak AIDS 2020; 9.58 million 255,000 by 2011. deaths / 8.2% Employed labor population loss force reduced by by 2045 0.5% (2010) and 1.4% (2050)

Cumulative HIV⫹ from 1.2 million (2005) to 5.4 million (2020)

Mid-range

None (only Pessimistic ––not considered)

ILO

Peak HIV 685,000 by 2007, peak AIDS 257,000 by 2012. Employed labor force is reduced by 0.5% (2010) and 2.3% (2050) 6.9 million deaths / 5.1% population loss by 2020; 16.39 million deaths / 14% population loss by 2045

Peak HIV 699,000 by 2008, peak AIDS 259,000 by 2012. Employed labor force reduced by 0.5% (2010) and 3% (2050) Peak HIV 1,169,000 by 2008, peak AIDS 385,000 by 2010. Employed labor force reduced by 0.9% (2010) and 5.4% (2050)

Sources: Rühl, Pokrovsky, and Vinogradov, 2002; Sharp, 2004a; ILO, 2004.

the most recent estimates of prevalence by UNAIDS: 860,000 in 2003 (UNAIDS, 2004, p. 48). While the impact channels discussed above may be relatively straightforward, understanding the effect of HIV/AIDS on the economy’s dependency ratios requires a more nuanced investigation. As the ratio of pensioners or children to the number of workers in the economy increases, captured as an increase in the youth or elderly dependency ratio, national savings decreases and social protection schemes are strained.

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Figure 4.3 World Bank “Optimistic” Scenario, Cumulative HIV Cases

Total Number of People with HIV and AIDS

Source: Rühl, Pokrovsky, and Vinogradov, 2002 (model output).

1,600 1,400 1,200 1,000 800 600 400 200 0 2002 2007 2012 2017 2022 2027 2032 2037 2042 2047 Constant Probability to be Infected Increasing Probability to be Infected Decreasing Probability to be Infected Increasing Average age to be Infected Risk Groups to be Fully Infected

Figure 4.4 ILO All Scenarios, Cumulative HIV Cases Source: ILO, 2004 (model output).

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We now turn to the main focus of this chapter, estimating the potential economic implications of the HIV/AIDS epidemic in Russia. It is important to reiterate that these are projections based in each case on a range of different, yet strict, assumptions. It is much too early in the epidemic life cycle, and the tools currently available to researchers are too limited, to speak of measuring actual impact. The following sections examine implications across three levels: macro-, meso- (or sectoral), and microeconomic (or business and household), integrating the results of modeling discussed above as appropriate. We conclude with a synthesis of these discussions vis-àvis the broader concept of human development in the Russian Federation. This stratified approach is necessary to capture the full scope and depth of potential consequences. While macroeconomic modeling requires a large number of assumptions and therefore faith in the modeling process, it is crucial for demonstrating effects beyond the more narrow fiscal impacts on health and social systems that are more commonly discussed. Meso and micro modeling are likewise important to provide solid foundations of knowledge both to feed macro investigations and to design effective sector-level responses.

Macroeconomic Implications As noted earlier, the demographic underpinnings of the models considered here are very different. Furthermore, the range of assumptions and parameters linking the demographic and economic spheres provides an additional dimension of individuality to each modeling approach. We therefore expect, and indeed observe, a divergence of impact profiles resulting from this process. The impact on GDP levels projected over time, however, is considerably more coherent across the three models than might be expected. Following the logic outlined earlier, we have selected the World Bank “Optimistic” scenario, the UNDP “Low” scenario, and the ILO “Risk Group Saturation” scenario for similar reasonability. In the very long term, the ILO model calculates an overall loss in GDP levels of approximately 5.3 percent, the UNDP model six percent, and the World Bank model ten percent (figure 4.5). The World Bank model further projects that investment declines of over two percent by 2010 and over nine percent by 2020 would exceed those of production, predicting slower growth in the long term. Indeed, both the World Bank and UNDP models find long-term annual growth rates reduced significantly by 2020, up to one percent

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Shombi Sharp 0

% Change

–2 –4

ILO

–6 UNDP –8 –10 WB –12 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050 Year

Figure 4.5 Impact of AIDS on GDP Levels—Three Models Sources: (Author-constructed from model output) Rühl, Pokrovsky, and Vinogradov, 2002; Sharp, 2004a; ILO, 2004.

and 0.5 percent respectively, as the economy’s productive potential is curtailed.1 For perspective, the average annual growth rate of Russia’s fellow G8 countries, to which it would theoretically converge over the long term, was only 1.5 percent in 2003 (World Bank, 2005c). All three studies therefore bear out the central thesis of HIV/AIDS impact channels: by increasing morbidity and mortality among the economy’s most productive age groups, while at the same time driving up health and social protection costs associated with treatment and care, HIV/AIDS can lower economic growth and exacerbate existing challenges to national health provision and social protection. A rigorous analysis must, of course, consider a number of additional dimensions. For example, per capita effects are less clear and depend on a number of modeling assumptions, including the relative prevalence among skilled and nonskilled labor and the share of HIV/AIDS financing from public and private savings (World Bank, 2003, p. 61). Further, calibration of the World Bank model shows that results are most sensitive to four key parameters: population growth, growth in the population of drug users, HIV transmission rates, and the estimated multiplier of registered to nonregistered HIV cases (Rühl, Pokrovsky, and Vinogradov, 2002, p. 4). Given the 15- to 50-year time horizon required for macroeconomic modeling, it is often difficult for long-term forecasts to compete with shortterm challenges vying for the attention of decision makers. It is therefore

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useful to complement these efforts with meso and microeconomic analyses that bring a shorter horizon into focus.

Mesoeconomic/Sectoral Implications Though HIV/AIDS impacts cut across all sectors, the most immediately visible sectoral impacts are in the health and social protection sectors. Growing evidence also points toward the potential for industry-level implications in Russia. The full impact of an HIV/AIDS epidemic on the health sector in Russia is difficult to overestimate, as the system itself is strained to provide adequate testing, counseling, treatment, and care to a rapidly growing population of PLWHA. An investigation of the systemic ramifications is beyond the scope of this chapter. Calculating direct costs associated with basic care, treatment of co-infections, and antiretroviral therapy (ART), however, is readily modeled and provides a basis for analysis. In the World Bank author-derived scenarios, for example, annual ART per-patient cost is estimated at $9,000. While efforts to reduce prices in Russia are well underway, a recent study by the Clinton Foundation found that the Russian government still pays over $7,000 per patient per year to procure combination ARVs (World Bank, 2005a , p. 14). While it is likely that prices will fall considerably in the coming years, this reduction has yet to be achieved in practice and must go much further to optimize the cost-benefit ratio of treatment provision. Leaving human costs aside, the World Bank model argues that budgetary impacts are so severe that only “hypothetically low” cost levels of under $500 per patient per year (already attained for many developing countries) will bring the economic benefits derived from ARV provision in balance with the fiscal resources consumed, assuming broad coverage. The importance of securing affordable prices and ensuring capable delivery systems as the number of people in need of ART rises dramatically each year in Russia, from an estimated 100,000 people today to nearly 500,000 by 2010, cannot be overestimated (WHO, 2004). The urgency becomes clear when considering that only 3,000 people at most are currently receiving ART through the public health service (Russian Federal AIDS Center, 2004). The ILO model, again based on far more conservative assumptions, confirms the potential for serious budgetary consequences (figure 4.6). Medical care for HIV/AIDS alone would consume from a quarter to nearly half a percent of GDP annually for many years, while the total

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Shombi Sharp 0.50 0.45 0.40

% of GDP

0.35 0.30 0.25 0.20 0.15 0.10 0.05 0.00 2002 2007 2012 2017 2022 2027 2032 2037 2042 2047 Year Constant Probability to be Infected Increasing Probability to be Infected Decreasing Probability to be Infected Increasing Average age to be Infected Risk Groups to be Fully Infected Figure 4.6 ILO Estimates of Medical Expenditures, All Scenarios Source: ILO, 2004.

annual health budget for the country is approximately five percent of GDP (WHO, 2006). A range of additional fiscal considerations directly relates to HIV/AIDS. Most notable are the financing of social disability benefits and additional strains on the pension system. While all three models incorporate some aspect of social disability financing, the ILO model was designed as a policy tool specifically for evaluating the impact of HIV/AIDS on social policy. We therefore take advantage of this enhanced sensitivity, combining several perspectives in one frame. Figure 4.7 employs the “risk group saturation” scenario, as discussed above, comparing changes in three key indicators: short-term disability benefit costs; the pension dependency ratio; and the affordable replacement ratio.2 From this graph, it is possible to discern significant and sustained AIDS-induced strains on Russia’s social policy mechanisms. Short-term disability benefit costs rise from an immediate seven percent increase to a nearly 13 percent additional burden for over five years from 2005 through 2010, and remaining over ten percent higher

HIV/AIDS impact (% change)

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14 12 10 8 6 4 2 0 –2 –4 –6 2002

2003

2005

2010 2015 Year

Short-Term Disability Benefits Costs System Dependency Ratio

2020

2025

2030

Affordable Replacement Ratio

Figure 4.7 Social Policy Implications: ILO “Risk Group Saturation” Scenario Source: (Author-constructed from model output) ILO, 2004.

for decades. The pension system is equally stressed, with the dependency ratio and affordable replacement ratio moving inversely, reflecting a significant weakening of pension system viability. Even within the next decade, Russia will employ only four workers for every three dependents (World Bank, 2003, p. 70). It is instructive at this point to take an even closer look, disaggregating the dependency ratio into its two constituent age groups: youth and elderly dependency. Figure 4.8, from the UNDP model, demonstrates the stylized nature of Russian demographic dynamics. In the “Medium AIDS” scenario, youth dependency is falling and remains relatively low due to subreplacement fertility rates. Elderly dependency rates, however, move in the opposite direction. This dynamic is exacerbated once the effects of the stipulated AIDS epidemic begin to thin out the working population. When examining industry-level impact, one must first observe that Russia remains heavily dependent on oil and gas extraction, accounting for 21.4 percent of GDP and exports equaling a fifth of GDP (World Bank, 2004, p. 1). Some studies have suggested that lower- and middle-income countries dependent on extractive industries are especially vulnerable to the stylized threat of HIV/AIDS (Futures Group International, 1999, p. 6). Labor associated with these industries tends to have a relatively high-risk profile, with commercial sex work playing a key bridging function.

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Shombi Sharp 40%

Dependency ratio

35% 30% 25% 20% 15% 10% 2000

2010

2020

2030

Year Youth Dependency

Elderly Dependency

Figure 4.8 Russia Dependency Ratios by Age Structure Source: UNDP, 2004a, p. 38.

Indeed, disaggregating data to the regional level demonstrates that high HIV prevalence and intensive natural resource extraction activity often coexist. Take, for example, Khanty-Mansi and Irkutsk, two regions with major oil, gas, and gold industries. Both feature prevalence rates more than three times the national average (Mikkelsen, 2003) with more than half of all newly registered cases of HIV arising from heterosexual transmission (Pokrovsky, 2003). Extreme adult prevalence rates of five to eight percent are reported in many mining and heavy industrial cities due largely to “a high rate of IDU among young industrial workers” (Feshbach, 2005, p. 39). Of the models under consideration, only the UNDP model analyzes potential effects at the industry level, employing a computable general equilibrium model with 35 productive sectors. Its results indicate that the extractive industries may be especially sensitive to an AIDS-induced shock to human capital supply. This dynamic is especially evident in the long run as parameters are adjusted to simulate greater capital mobility in an “open economy” scenario (Sharp, 2004a, p. 89). In an environment where Russia seeks WTO accession and further opening of its economy, the effects of HIV/AIDS on Russia’s labor force and health care

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budgets may present “serious counter-weights to energy-driven economic growth” (National Intelligence Council, 2002, p. 24).

Microeconomic Implications It is increasingly clear that HIV/AIDS is a serious issue for policy makers and business managers alike. Their response, however, is mixed. A recent survey conducted among human resource managers at 137 domestic and international companies operating in Russia found that nearly 60 percent of all respondents were not concerned about potential impacts on their companies’ profits through 2010, with only seven percent reporting HIV/AIDS workplace programs and only one company with a policy concerning employees living with HIV (TPAA, 2005a, p. 5). Due to the slow-onset nature of the epidemic, the timing of AIDS cost realization helps explain why, unless properly discounting the sums of all future HIV/AIDS-associated costs, managers may not be aware of the problem until AIDS-induced absenteeism, disability, and deaths are experienced—at which point the opportunity for optimal prevention has long passed (Rosen et al., 2003, p. 9). Considering that the vast majority of HIV cases in Russia have been registered only within the past five years, Russian companies may in fact employ many people in the asymptomatic stages without being aware of the AIDS crisis that looms just around the corner. There are indications, however, that the business community is beginning to wake up to the threat of HIV/AIDS. A handful of large Russian companies, including AvtoVaz and Wimm-Bill-Dann, and industry groups such as the Russian Union of Industrialists and Entrepreneurs (RSPP), have joined the effort to introduce comprehensive workplace policies and programs and to promote corporate social responsibility approaches to HIV/AIDS. The second annual “Russian Business Summit on AIDS” featured unprecedented levels of representation from government and business leaders. Alexander Zhukov, deputy prime minister of the Russian Federation, emphasized that in the face of demographic decline, HIV/AIDS “has become an issue of strategic, social, and economic security of the country” (TPAA, 2005b). Other than the individual, the household is the economic unit most directly affected by HIV/AIDS. At the same time, households are relatively difficult to model. Evidence from other countries suggests significant impacts. AIDS-affected households in Thailand consume on average approximately six months of total household income on

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out-of-pocket HIV/AIDS medical care (Pitayanon, Kongsin, and Janjareon, 1997, p. 11). Foregone earnings, however, constitute the greatest loss to households, as wage earners are struck down in their prime productive years (World Bank, 2003, p. 73). There is to date a lack of evidence addressing household impacts in Russia. Nonetheless, this level of analysis is particularly relevant in a country where a male mortality crisis and ballooning divorce rates have been straining the Russian household “even before the AIDS epidemic gathers force” (UNDP, 2004a, p. 43). A study currently under way by the Imperial College of London will help fill this gap through economic modeling based on household surveys.

Implications for Human Development The basic purpose of development is to enlarge people’s choices . . . People often value achievements that do not show up at all, or not immediately, in income or growth figures: greater access to knowledge, better nutrition and health services, more secure livelihoods . . . The objective of development is to create an enabling environment for people to enjoy long, healthy and creative lives. —Mahbub ul Haq

As eloquently stated by the economist Dr. Mahbub ul Haq, founder of the Human Development Index (HDI), human development proposes a holistic understanding of development that defies narrow metrics. A composite index, the HDI was therefore developed not to define human development but to provide a “powerful alternative to income as the summary measure of human well-being.” Three fundamental dimensions of human development are constructed through proxy constituents: a “long and healthy life” described by life expectancy, “knowledge” described by literacy rates and school enrollment ratios, and a “decent standard of living,” described by GDP per capita (UNDP, 2004b, p. 137). It therefore follows that we come to human development last, as an aggregate of all levels of impact considered to this point. Our modeling offers insights into two of the three impact channels comprising the HDI: life expectancy and GDP per capita. We have already examined the potential economic impact in Russia, but a generalized HIV/AIDS epidemic could significantly alter life expectancy profiles as well. Figure 4.9 demonstrates that, under the UNDP “medium AIDS” scenario, life expectancy could be reduced by nearly a decade. Even

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80 75 70 65 60 55 50 2000

2010

2020

2030

Year Baseline

AIDS

Figure 4.9 Impact on Life Expectancy, Medium Scenario Source: UNDP, 2004a, p. 45.

HDI value

0.78 0.76 0.74 0.72 0.7 0.68 Baseline

–1 year

–2 years

–5 years

–10 years

Change in Life Expectancy Figure 4.10 Effect of Declining Life Expectancy on HDI in Russia Source: UNDP, 2004a, p. 44.

with a stipulated adult HIV prevalence of two percent, nearly all projected improvements in life expectancy for Russia through 2025 would be lost (Eberstadt, 2004, p. 24). What sort of impact might this scenario have on HDI attainment? Figure 4.10 demonstrates that hard-earned HDI gains might be rapidly eroded through falling life expectancy alone. A ten-year loss, in line with the “medium scenario,” could shrink Russia’s HDI by over seven percent, all else being equal. To place this analysis in perspective, the HDI in Russia fell by 5.8 percent from 1985 to 1995 during a period that witnessed both the collapse of the Soviet economy and political system and the astonishing “Russian mortality crisis” of the early to mid-1990s (UNDP, 2001, p. 146). Given the demonstrated association of approximately eight percent between each additional year of male life expectancy and gross national income, falling life expectancy could also diminish economic growth, reducing the HDI even farther (Eberstadt, 2004, p. 25).

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Indeed, the “long wave event of transition is now superimposed by another long wave event—an HIV/AIDS epidemic” (Barnett, 2003, p. 417).

Conclusion This chapter has examined a range of issues related to the potential economic impact of HIV/AIDS in Russia. From households to firms, industries, and the macroeconomy, no level will be spared if urgent and effective responses do not materialize. We must keep in mind that while mathematical modeling is an imperfect exercise in which the value of outcomes depends greatly on the quality of inputs and assumptions made, policy decisions benefit greatly from the discipline imposed by the modeling process. In Russia, models have helped gain the attention of decision makers, free the discussion of HIV/AIDS from emotive, value-laden language in favor of objective and disciplined analysis, and demonstrate that HIV/AIDS is a cross-cutting development issue that cannot be limited only to concerns of health policy (Sharp, 2004b, p. 1). It is often said that Russia still enjoys a “window of opportunity,” given the long-wave nature of HIV/AIDS. While prevalence is low relative to potential, preventive action can alter the future course of the epidemic and avoid the large-scale disaster currently experienced in a number of countries. While it is now too late to speak of avoiding a crisis entirely, our investigation demonstrates that the case for decisive action remains as clear and as urgent as ever. Figure 4.11, applying a standard cost-benefit analysis, demonstrates just how profitable early preventive action still could be. Evidence-based approaches, including harm reduction programs, provide high returns on resource investment. A comprehensive study of needle and syringe exchange programs in Russia suggests that such approaches require just $564 per HIV case averted (Rhodes et al., 2004, p. 11), as opposed to $7,000 per patient per year for ART alone. But with each year that passes, this window of opportunity fades and the terms become more stark. Had Russia made, for example, a $90 million one-time investment in the early 1990s, followed by annual expenditures of some $9–10 million, HIV incidence may have been reduced by up to 70 percent, with ART available to all those in need (ILO, 2004, p. 12). A Russian proverb gives straightforward advice in such a situation: “Strike while the iron is hot.” Clearly the time to strike is now.3

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$10.0

$5.0

Millions of Current Dollars

$15.0

$0.0

3

200

5

200

007

2

9 200

Year Annual Cost

Net Benefit

Annual Benefit

Figure 4.11 Cost-Benefit Analysis of HIV/AIDS Prevention Programs in the Russian Federation Source: Author-constructed from World Bank, 2003, p. 76.

Future Research The modeling efforts discussed in this chapter have made important contributions toward establishing a framework for understanding the potential implications of HIV/AIDS in Russia and placing the issue in perspective among other competing policy objectives. Nonetheless, this generation of modeling has relied to a great extent on assumptions rather than on empirical evidence for parameter construction. Further, linkages between behavior, epidemiology, and economic implications at micro levels have been stipulated exogenously due to a lack of data on these complex relationships. One effort underway to address this gap is the “Knowledge for Action in HIV/AIDS in the Russian Federation” project. The Imperial College London is developing a system that will bring an enhanced level of rigor to the advocacy potential of modeling. A survey-based behavioral model, an epidemiological HIV transmission model, and a microeconomic model will be linked for a more realistic expression of endogeneity and inferences about the effectiveness of policy interventions for advocacy. This program represents the first comprehensive integrated modeling system to inform policy and advocacy efforts

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in Russia (Imperial College London, 2005). With these tools, Russia can take advantage of a rigorous evidence base sufficient to identify and communicate the most effective policy responses to HIV/AIDS.

Notes 1. The ILO reporting format does not facilitate calculating changes in long-term annual growth rates. 2. These are defined (ILO, 2004, p.24) as follows: the “short-term disability benefit cost” refers to Russian government compensation to workers with “temporary disability” associated with HIV/AIDS (assumed to be a 20% reduction in the ability to work); “pension dependency ratio” is the ratio of the number of employed persons to the number of people receiving pension benefits (age and disability categories); the “affordable replacement ratio” is the ratio of the pension contribution rate to the pension dependency rate, characterizing the viability of a “pay-as-you-go” pension system. 3. Since the time of this writing, the Russian government has announced welcome plans for dramatic growth in federal HIV/AIDS budgets, beginning with a twenty-fold rise in 2006 to $104 million from some $4.5 million in 2005 (RIA Novosti, 2005). Efforts to reduce ARV prices and promote evidence-based health approaches will remain critical to ensuring effective outreach and efficient use of these additional resources.

References Barnett, T. (2003) “HIV/AIDS, Human Development and the Coming Epidemic in the Balkans, Baltic, Russian Federation and the CIS,” chapter 8 in Economics of AIDS and Access to HIV/AIDS Care in Developing Countries, Issues and Challenges (ANRS [Agence Nationale de Recherches sur le Sida]). Barnett, T., and A. Whiteside (2002) AIDS in the Twenty-first Century: Disease and Globalisation (London: Palgrave). Bell, C., S. Devarajan, and H. Gersbach (2003) “The Long-Run Economic Costs of AIDS: Theory and an Application to South Africa,” World Bank Policy Research Working Paper 3152, June. Eberstadt, N. (2004) “The Russian Federation at the Dawn of the Twenty-first Century: Trapped in a Demographic Straightjacket,” NBR Analysis, 15(2). Feshbach, M., and C. Galvin (2005) “HIV/AIDS in Russia—An Analysis of Statistics,” working paper, Woodrow Wilson International Center for Scholars, January. Gorshkov, N. (2003) “Putin’s Vision of ‘Great Russia,’ ” BBC News, May 16, news.bbc.co.uk/1/hi/world/europe/3034911.stm. ILO [International Labour Organization] (2004) Social Policy Costs and Consequences of HIV/AIDS in the Russian Federation: an ILO Model (Moscow: ILO).

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Imperial College London (2005) Knowledge for Action in HIV/AIDS in the Russian Federation, Programme Framework, www.imperial.ac.uk/medicine/ about/divisions/pcphs/pcsm/research/iphd/kfa_russia/default.html. Kennedy, B., I. Kawachi, and E. Brainerd (1998) “The Role of Social Capital in the Russian Mortality Crisis,” World Development, 26(11):2029–2043. Mikkelsen, Henning (2003) “UNAIDS Presentation at the Annual National Conference on HIV/AIDS and Viral Hepatitis,” Suzdal, Russia, October 14–16. National Intelligence Council (2002) “The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China,” Intelligence Community Assessment (ICA), September, www.cia.gov/nic/special-nextwaveHIV.html. Nicholls, S., R. M. McLean, K. Theodore, R. Henry, and B. Camara (2000) “Modelling the Macroeconomic Impact of HIV/AIDS in the English Speaking Caribbean,” Journal of South African Economics, 68(5):916–932. Onishenko, G. (2005) “HIV and AIDS in the Russian Federation,” presentation at the Ministerial Meeting and CCO of UNAIDS Co-sponsors, March 31. Over, M. (1992) The Macroeconomic Impact of AIDS in Sub-Saharan Africa (Washington, DC: World Bank, Population and Human Resources Department). Pitayanon, S., S. Kongsin, and W. S. Janjareaon (1997) “The Economic Impact of HIV/AIDS Mortality on Households in Thailand,” in D. Bloom and P. Godwin, eds., The Economics of HIV and AIDS: The Case of South and Southeast Asia (Delhi: Oxford University Press). Pokrovsky, V. (2003) “AIDS: Let’s Face the Problem,” Meditsinskaya Gazeta, October 31. Renton, A., D. Gzirishvili, R. Gotsadze, and J. Godinho (2004) “Epidemics and Drivers—Regional Challenge, Regional Response,” summary report, Central Asia HIV/AIDS Project (Washington, DC: World Bank). Rhodes, T., A. Sarang, A. Bobrik, E. Bobkov, and L. Platt (2004) “HIV Transmission and HIV Prevention Associated With Injecting Drug Use in the Russian Federation,” International Journal of Drug Policy Review, 15(1):1–16. RIA Novosti (2005) “Russian Government to Boost HIV/AIDS Spending,” November 21, 2005, http://en.rian.ru/russia/20051121/42166458.html. Rosen, S., J. Simon, J. Vincent, W. MacLeod, M. Fox, and D. Thea (2003) “AIDS Is Your Business,” Harvard Business Review, February. Rühl, C., V. Pokrovsky, and V. Vinogradov (2002) “The Economic Consequences of HIV in Russia,” World Bank, Moscow, May 15, www.worldbank.org.ru. Russian Federal AIDS Center (2004) HIV Infection Information Bulletin No.26 (Moscow: Russian Federal AIDS Center). Sharp, S. (2002) “Modelling the Macroeconomic Implications of a Generalized AIDS Epidemic in the Russian Federation,” Master’s thesis, Department of Economics, University of Colorado, Boulder, May. ——— (2004a) “Modelling the Macroeconomic Implications of a Generalised AIDS Epidemic in the Russian Federation,” annex 1 in Reversing the Epidemic: Facts and Policy Options (Bratislava: UNDP). ——— (2004b) “Informing Policy through Modeling—A Case Study of the SocioEconomic Implications of AIDS in Russia,” presentation abstract, Seventh European Health Forum Gastein, Austria, October 6–9.

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Stover, J., and L. Bollinger (1999) “The Economic Impact of AIDS,” prepared for the Futures Group International, Policy Project, June 16, www.policyproject. com/puns/SEImpact/SEImpact-Africa.pdf. TPAA (Transatlantic Partners Against AIDS) (2005a) “HIV/AIDS as a Business Issue in the Russian Federation: Understanding Why and What Should Be Done,” Policy Brief 2(1), February (Moscow: TPAA). ——— (2005b) Russian Business Summit on AIDS, March, www.tpaa.net/events. UNAIDS [Joint United Nations Programme on HIV/AIDS] (2004) AIDS Epidemic Update—December 2004 (Geneva: UNAIDS/WHO). UNDP [United Nations Development Programme] (2001) Human Development Report—Making New Technologies Work for Human Development (New York: UNDP). ——— (2004a) Reversing the Epidemic: Facts and Policy Options (Bratislava: UNDP). ——— (2004b) Human Development Report—Cultural Liberty in Today’s Diverse World (New York: UNDP). Vandemoortele, J. and E. Delamonica (2000) “The ‘Education Vaccine’ against HIV,” Current Issues in Comparative Education, 3(1):6–13. WHO [World Health Organization] (2004) “Estimated ART Need in Russia,” presentation by S. Matic and P. de Colombani at WHO Regional Office for Europe, September 20–21. ——— (2006) Statistics by Country—Russian Federation, www.who.int/ countries/ rus/en/. World Bank (2003) Averting AIDS Crises in Eastern Europe and Central Asia (Washington, DC: World Bank). ——— (2004) Russian Economic Report, no.7, February (Moscow: World Bank). ——— (2005a) Combating HIV/AIDS in Europe and Central Asia, April (Washington, DC: World Bank). ——— (2005b) From Transition to Development—A Country Economic Memorandum for the Russian Federation, report no. 32308-RU, March (Moscow: World Bank). ——— (2005c) World Development Indicators, www.worldbank.org/ data/wdi2005 (Washington, DC: World Bank).

5 Has the Window of Opportunity Closed? The Contributions of Bilateral Donors Supporting HIV/AIDS Activities in Russia and Eurasia Vinay P. Saldanha

Bilateral donors working in the countries of the Commonwealth of Independent States (CIS) have been faced with a variety of challenges related to the region’s rapidly growing AIDS epidemic. The most definitive of these was whether or not they should even support programs and activities related to HIV/AIDS. When the question is asked, “When the AIDS epidemic was growing in this region where we have been working for over a decade, did our agency neglect the epidemic, thus facilitating its unchecked growth, or did we contribute to its response?” ’ the answer has been neither uniform nor disheartening. Some argue that it would have been easier and more politically expedient not to focus on the significant and growing needs for technical assistance in the field of HIV/AIDS, and instead to attend to other priority areas such as democratization, governance, and overall support for the ongoing process of reform. Some critics have even argued that the contributions of donor agencies would not have a decisive influence on the epidemics in this region, particularly if interventions in this field were not at the invitation of the governments in these countries. For the majority of bilateral donors that have an established commitment to providing significant aid and technical assistance in this region, however, it has been impossible to neglect the imperative to commit at least a portion of their resources to support HIV/AIDS

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programs and activities. Moreover, many of the most committed bilateral donors recognize that the spread of HIV and the impact AIDS will have on the economies and societies of the region are inextricably linked to the larger processes of reform and democratization. Thankfully, bilateral donors do not focus only on what is politically expedient. In the case of HIV/AIDS in the countries of the CIS, the majority of the most innovative and robust HIV/AIDS programs have been supported by contributions from bilateral donor agencies. Many of these programs, however, are still plagued by myriad challenges and shortcomings, some of which are a product of the challenging nature of HIV/AIDS activities in this region, while others are a result of the complicated and formal dynamics of funding through bilateral agencies. This chapter examines some of the imperatives and challenges that have influenced the contributions of bilateral donor agencies to the HIV/AIDS response in the CIS region. The first key question explored here is what motivates bilateral donor agencies to support HIV/AIDS activities in this region. Second, the chapter examines some of the key achievements of bilateral donors in this field. Third, the chapter highlights some of the challenges and shortcomings facing the contributions of bilateral donors and draws tentative conclusions on the issues these agencies will have to confront in the near future if they consider curtailing their involvement at the same time that the HIV/AIDS epidemics in this region continue to develop rapidly. While the examples in this chapter are examined in the context of bilateral donor support to the countries of the CIS, many of the issues discussed here relate more generally to the challenges and imperatives facing bilateral donor agencies on a global scale in the fight against HIV/AIDS. Similarly, the issues explored in this chapter are inextricably linked to the role and contributions of international organizations such as UNAIDS and its UN cosponsor agencies, and multilateral donors, most importantly the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has established itself as the single most crucial source of donor funding for HIV/AIDS activities. These and other aspects of the role of international donor organizations are addressed in chapter six of this volume. This chapter focuses chiefly on the role and contributions of bilateral donor agencies to HIV/AIDS programs and activities in the Russian Federation and Ukraine. These two countries have the largest HIV/ AIDS epidemic in all of Europe, bilateral agencies have been more active here than in any of the other countries in the CIS region, and

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they have been active for the longest period of time. Even between the Russian Federation and Ukraine, there are important distinctions between the contributions of bilateral donors, and sometimes these distinctions are evident between the same donors and their differing approaches to these two countries. It is acknowledged that the role of bilateral donors is also substantially different in the republics of Central Asia, where bilateral donors are also key supporters of the response to HIV/AIDS. The dynamics of bilateral donor support in that region are not the focus of this chapter, but the topic is addressed in another chapter (volume 2, chapter 3) of this set. Similarly, this chapter does not analyze the role of bilateral donors in the Caucasian republics of Armenia, Azerbaijan, and Georgia, nor the Baltic states of Estonia, Latvia, and Lithuania. The rapid integration of the latter countries into the European Union has concluded an intensive period of interaction with bilateral donors that is covered in chapters 7, 8, and 9 of volume 2. Finally, the regrettably small role of bilateral donors in the countries of Moldova and Belarus is not covered in this chapter, although both of these states deserve greater donor attention and support to respond to their growing HIV/AIDS epidemics.

Motivation for Engagement The key bilateral donors have been driven by a variety of factors in opting to engage and subsequently sustain their commitment to HIV/AIDS in the countries of the CIS. These factors include the inclusion of HIV/AIDS in their global programming cycle, the growing political imperative to address HIV/AIDS in this region, and their responsiveness to support programs on HIV/AIDS that were initiated by constituencies in their own countries. Interestingly, the same factors have influenced bilateral donors in different ways, with some donors heavily influenced by regional political considerations, and others driven largely by their agencies’ imperatives to focus more on HIV/AIDS at the global level. There are currently eight key bilateral technical assistance agencies that have supported the majority of HIV/AIDS activities in the Russian Federation and many of the other countries of the CIS region, or that serve as divisions of their national governments that provide aid and technical assistance throughout the world. These agencies include the Canadian

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International Development Agency (CIDA), the European Commission (EC/Tacis), the German Agency for Technical Cooperation (GTZ), the government of Finland, the government of the Netherlands (MATRA), the Swedish International Development Agency (SIDA), the United Kingdom’s Department for International Development (DFID), and the U.S. Agency for International Development (USAID).1 Not surprisingly, these agencies represent countries that are among the global leaders in the provision of overseas development assistance. As members of the Development Assistance Committee of the Organization for Economic Cooperation and Development, these countries have contributed large and growing sums of donor assistance for HIV/AIDS on the global level (OECD, 2004; Kates, 2005). While these agencies are also currently providing the majority of bilateral donor assistance for HIV/AIDS programs and activities in CIS countries, only a few of these agencies are specifically cited in this chapter as examples of bilateral aid for HIV/AIDS. The individual contributions of these agencies to HIV/AIDS in this region have been neither uniform nor consistent. For example, the most significant contributions to the fight against HIV/AIDS of any bilateral agency working in the countries of the CIS have been made by USAID. USAID was one of the first agencies to undertake support for HIV/AIDS activities in the Russian Federation, and since 1996 USAID has consistently increased its commitment to HIV/AIDS throughout the CIS region.2 The motivation for USAID’s support for HIV/AIDS has been closely linked to the U.S. government’s overall commitment to democratization, reform, and support for protection of public health in this region. According to its country profile for Russia, “USAID is providing financial and technical assistance [to Russia] to promote economic growth, strengthen democratic institutions, and address critical health and social issues. The US, in partnership with the international community, has an interest in ensuring Russia’s effective response to issues of global importance including human health concerns such as the HIV/AIDS pandemic” (USAID, 2005b). Particularly in the case of HIV/AIDS, the U.S. government has been increasingly outspoken in its commitment to emphasize the importance of HIV/AIDS beyond the scope of its bilateral assistance to the Russian Federation. The U.S. government has consistently used a variety of channels to encourage the Russian government to give greater attention to HIV/AIDS. The history of this advocacy begins in the late 1990s under the Clinton administration, when key bilateral issues between the United States and Russian Federation, including HIV/AIDS, were

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addressed through the U.S.-Russia Commission on Economic and Technological Cooperation3 (USIA, 1998). More recently under the current Bush administration, the importance of HIV/AIDS in Russia and other “strategically significant” countries has been assessed in the context of global security. In 2002, the U.S. National Intelligence Council, a center for intelligence analysis within the U.S. government, prepared a bold analysis of the potential impact of the AIDS epidemic in “next wave” countries, with a specific focus on Russia. According to the report, [T]he rise in HIV/AIDS [in Russia] will exacerbate the population decline and severe health problems already plaguing the country, creating even greater difficulty for Russia to rebound economically. These trends may spark tensions over spending priorities and sharpen military manpower shortages. . . . Driven by widespread drug use, inadequate health care infrastructure, and the government’s limited capability to respond, the number of HIV positive people probably will rise to 5 to 8 million by 2010. (National Intelligence Council, 2002)

It may seem unusual for a foreign intelligence agency to generate epidemiological estimates for the Russian Federation that far exceed the prognoses of Russia’s leading AIDS experts. In the context of the growing U.S. commitment to support Russia’s response to AIDS, however, the report demonstrated that HIV/AIDS in Russia had transcended its status as an issue for U.S. assistance and established itself as a strategic priority in America’s bilateral relations with the Russian Federation. Reinforcing this analysis with on-site diplomacy, even the former U.S. ambassador in Moscow frequently engaged his Russian counterparts on the need to exercise greater leadership and attention to AIDS: Whenever I meet with mayors and governors and polpreds [presidential representatives], I almost always ask them about their perceptions of the HIV/AIDS problem and how their administrations are working with medical authorities and NGOs to deal with this disease. This epidemic has the ability to devastate Russia’s economy, in addition to taking an awful human toll on the population. Some officials understand the grave nature of this threat, and others sadly do not. But this is a key area that requires continued cooperation. . . . We do not want to see Russia, which has the highest rate in the spread of HIV/AIDS in the world, suffer the same human, social and economic catastrophe as many nations of sub-Saharan Africa. The United States waited too long to deal with HIV/AIDS. Russia can learn from our mistakes. (Vershbow, 2003)

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While the leadership of former U.S. Ambassador Vershbow on HIV/AIDS was a vivid example for the diplomatic community in Moscow, U.S. concern over HIV/AIDS in Russia was not limited to the personal interventions of the American ambassador. Since 2003, the HIV/AIDS issue has been increasingly visible on the U.S. agenda for its relations with Moscow. According to Paula Dobriansky, U.S. undersecretary of state for global affairs, We hope to see more said and done on the battle against AIDS in Russia. President Putin has discussed HIV/AIDS in public very rarely, if at all. The Russian Minister of Health has stated that the Russian government and people do not comprehend the danger of HIV, and the health system is unprepared to fight the pandemic. . . . Indeed, our task is to help the Russian government and social leadership mobilize and begin to work against AIDS. . . . We can and must convince people in Russia—and everywhere around the world, for that matter—of the urgency and gravity of this global problem. We should bring it up in every one of our contacts with our Russian friends in every part of the country. (Dobriansky, 2003)

Indeed, the U.S. government demonstrated most vividly its commitment to focus on AIDS in Russia when the issue was officially included on the agenda of the Bush-Putin summit hosted at Camp David in September 2003. While the summit’s joint statement on HIV/AIDS suggested that “deepening cooperation in the battle against HIV/AIDS . . . will benefit the United States and Russia,” the statement clearly helped to justify greater U.S. support and technical assistance for AIDS in Russia. As noted by the deputy chief of mission at the U.S. Embassy in Moscow, “At the Camp David summit last fall, Presidents Bush and Putin agreed to intensify our cooperation on HIV/AIDS. We are now implementing this commitment” (Beyrly, 2004). Since 2003, the U.S. government has continued to demonstrate that AIDS in Russia is a leading concern, one that will require continued U.S. attention and resources for years to come. The U.S. government’s enhanced attention to HIV/AIDS in Russia and other countries in the CIS has been matched by its growing commitment of financial and technical resources (figure 5.1). The funding that USAID has committed annually for HIV/AIDS in the Russian Federation has increased almost ninefold in fewer than five years, from $1.65 million in 2000 to $9.5 million in 2004, (USAID, 2005a). In 2005, HIV/AIDS was identified as one of the

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$20.00 $15.00

Russia Ukraine Other FSU

$10.00 $5.00 $0.00 FY2000

FY2001

FY2002

FY2003

Figure 5.1 Amount of USAID Funding for HIV/AIDS for Countries in the Former Soviet Union, 2000–2003 (Millions of USD) Note: Other FSU includes funding for Eurasia regional activites. Source: www.usaid.gov.

leading components of USAID’s health assistance for Russia, and it currently represents over 15 percent of USAID’s overall assistance for the Russian Federation (USAID, 2005b). Similarly, in Ukraine, the scope of USAID funding has increased rapidly from $0.5 million in 2000 to over $3.7 million in 2005 (USAID, 2005c). In some of the other CIS countries, while the overall amount of funding has decreased slightly since 2002, USAID continues to be the leading source of bilateral technical assistance (including the Caucausus and Central Asia). The volume and visibility of USAID’s support for HIV/AIDS in Eastern Europe has even been the subject of attention and praise by other donor countries. According to AIDS Action Europe, a consortium of European AIDS NGOs, “the work done specifically on AIDS by USAID is quite visible throughout the region (far more so, obviously, than the non-existent EC programme)” (AIDS Action Europe, 2003). USAID has consolidated its position as the largest bilateral donor to HIV/AIDS activities in the CIS region. Not only does the value of these annual budgetary allocations in Russia and Ukraine often exceed the combined contributions of all other bilateral donors, but the USAID contributions have also exceeded the budgetary allocations for HIV/AIDS of the national governments in the majority of these countries. The second key bilateral donor agency in this region is the European Commission (EC). Some argue that the EC is not a bilateral agency, as its diverse European constituencies qualify it as a multilateral donor. Indeed, many of the EC’s contributions are from the same bilateral donor agencies, such as the United Kingdom’s DFID, that are also working in the area. Insofar as the EC

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maintains a distinct and growing program of donor assistance to CIS countries, it is rapidly establishing itself as one of the most important bilateral donors for HIV/AIDS. Throughout the 1990s, the EC’s support for global HIV/AIDS assistance grew substantially. However, the majority of the EC’s support was directed at developing countries through its development agency, EuropeAid, or at HIV/AIDS activities in the European Union through its “Europe against AIDS Programme.” The EC’s successor to this program, the “Programme of Community Action in the Field of Public Health (2003–2008),” is not focused on AIDS, but it does provide support for HIV/AIDSrelated activities for both EU members and EU candidate countries in Eastern Europe (EC, 2002). Since 2001, the majority of the EC’s funding specifically for global HIV/AIDS activities has been provided through its contributions to the Global Fund, to which the EC has been the largest single European contributor to date (GFATM, 2005c). Until the end of 2003, however, the EC provided remarkably little direct funding for HIV/AIDS activities in CIS countries. As noted by European AIDS organizations, “the European Commission does not have any instruments dedicated to supporting HIV/AIDS or health programmes in Eastern Europe. . . . Considering the scope of the HIV epidemic developing in Eastern Europe and the major negative impacts this epidemic will have upon the economic and political stability of the region, it has now become urgent for the European Union to set up its specific response” (AIDS Action Europe, 2003). The wake-up call for Europe’s lack of attention and commitment to HIV/AIDS came in February 2004, when the members of the European Union united with ministerial representatives from the states of Eastern Europe and the CIS in Dublin to focus on the growing HIV/AIDS epidemic in this region. The resulting “Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia” provided an ambitious framework for all the countries of Europe, including Russia and Ukraine, to “provide universal access to effective, affordable and equitable prevention, treatment and care” by 2005 (EC, 2004a). In the aftermath of the Dublin conference, the European Council called for “vigorous follow up by the Union and relevant regional bodies on the outcome of the Ministerial Conference on HIV/AIDS in Europe and Central Asia hosted by the Presidency in Dublin” (Council of the European Union, 2004). As of 2004, the portfolio of HIV/AIDS activities supported by the EC in Russia was estimated to exceed €9.7 million (UNAIDS Russia,

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2005), making the EC the second largest bilateral to support HIV/AIDS programs in the Russian Federation. Similarly, the EC increased its support for HIV/AIDS programs in Ukraine in 2004–2005, and is considering plans to increase assistance further. Supported by the Dublin Declaration and the subsequent “Vilnius Declaration on Measures to Strengthen Responses to HIV/AIDS in the European Union and in Neighbouring Countries,” the EC has also developed a strengthened policy framework covering all of its external action on confronting HIV/AIDS as well as tuberculosis and malaria (EC, 2004b). This strategy specifically recognizes the urgency of the AIDS epidemics in the Russian Federation, Ukraine, and other countries that are covered by the EC’s European Neighbourhood Policy. Of the €13.9 billion that has been committed by the EC to support all programs and projects in this region under the European Neighbourhood and Partnership Instrument (ENPI) for the period of 2007–2011, it remains to be seen what proportion of these funds will be specifically committed to HIV/AIDS. Another key bilateral donor supporting HIV/AIDS activities in this region is the United Kingdom’s Department for International Development (DFID). The United Kingdom has provided the second largest amount of funding among bilateral donors to the global effort on HIV/AIDS (Summers and Kates, 2003). Prior to 2001, DFID was only marginally involved in HIV/AIDS activities in CIS countries. In that year, DFID adopted an ambitious program to commit £25 million to Russia over five to seven years specifically for HIV/AIDS with the aim of contributing to the containment of its epidemic (DFID, 2001). This program was intended to establish DFID as the single largest bilateral donor to HIV/AIDS programs in Russia. Regrettably, the majority of these funds were later redirected to other commitments in Afghanistan and Iraq, leaving Russia with only a small portion of DFID’s planned funding. However, the process of developing such a program helped to establish DFID’s continued interest and commitment to the fight against HIV/AIDS in Eastern Europe and Central Asia. In subsequent years, DFID has maintained active support for HIV/AIDS activities in this region, with a significant and growing proportion of its assistance being delivered through international organizations such as UNAIDS. In 2004, the U.K. government adopted a new strategy for “[t]ackling HIV and AIDS in the developing world.” According to this strategy, the U.K. government committed itself to providing the majority of its funding for HIV/AIDS to developing countries (DFID, 2004). In this context, the growing epidemics in

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Eastern Europe and Central Asia will receive proportionally less support, with DFID considering a complete withdrawal from this region by 2008. Just at the time when it has established itself as one of the most active and committed bilateral donors in the region, DFID will be undertaking few, if any, new commitments on HIV/AIDS. The Canadian International Development Agency (CIDA) has also made a substantial contribution to HIV/AIDS in Russia and Ukraine. While the overall amount of CIDA funding for HIV/AIDS in this region is relatively small, CIDA has been able to mobilize considerable Canadian expertise and resources in support of HIV/AIDS activities in this region. The Canada Fund at the Canadian Embassy in Moscow began supporting HIV/AIDS initiatives in Russia as early as 1992, even before CIDA had recognized the newly independent states of the former Soviet Union as recipients of Canadian development assistance. The first substantial CIDA funding for HIV/AIDS in this part of the world came in 1998 in Russia, with subsequent support for larger AIDS projects in Russia and Ukraine in 2001, and more recently in Ukraine in 2005. In all of these cases, CIDA supported projects that had been initiated by constituencies within Canada. In its global HIV/AIDS Action Plan, CIDA committed “to increase quality, quantity, and cost-effectiveness of HIV/AIDS interventions funded by CIDA” (CIDA, 2000). As of mid-2005, however, CIDA had yet to develop a formal HIV/AIDS strategy for CIS countries, nor had it earmarked specific funds in its programming cycle for HIV/AIDS activities in this region. Like some other bilateral donors, CIDA is also making plans to withdraw entirely from Russia, thus enhancing the risk that yet another key donor may depart at a time when more substantial resources and assistance will be required to confront the region’s growing HIV/AIDS epidemic. Like other bilateral donor countries, the government of Canada has also exercised political leverage to engage the Russian government on the need to increase attention and resources for HIV/AIDS programs. While visiting Moscow in February 2002, Canadian Prime Minister Jean Chrétien made a formal address on AIDS (Associated Press, 2002), and various Canadian ambassadors in Moscow have frequently been involved in HIV/AIDS-related events.

Key Contributions of Bilateral Donor Agencies The most important contributions made by bilateral agencies in this region have been their consistent and growing commitment to support

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innovative HIV/AIDS programs and activities at the national and regional levels. In many cases, bilateral donors have addressed issues that were otherwise neglected by national and local governments. Many activities supported by bilateral agencies have focused on populations most at risk for HIV, particularly injection drug users, commercial sex workers, and men having sex with men—populations that continue to be underserved by governmental programs and services in this region. In many cases, the bilateral donor support for programs implemented by nongovernmental organizations has also produced invaluable secondary results, such as enhancing the professionalism of local NGOs and local governmental agencies working on HIV/AIDS, or has served as a catalyst for the mobilization of additional funds from multilateral donors. These and other results supported by bilateral donor agencies have helped to make their collective contributions to HIV/AIDS in the countries of the CIS far greater than merely the value of the funding they have committed to HIV/AIDS activities. One of the most important contributions of bilateral donors in the HIV/AIDS field has been their emphasis on prevention and support activities for most-at-risk populations. According to UNAIDS, the majority of the CIS countries are still facing “concentrated epidemics” (UNAIDS, 2004) in which the majority of resources should be focused on prevention, treatment, and care among those populations that are most at risk for HIV/AIDS (UNAIDS, 2005a). Since 1997, the majority of newly reported cases of HIV infection in this region have been among injection drug users (UNAIDS, 2004). The bulk of governmental resources for HIV/AIDS, however, are spent on epidemiological surveillance, with limited resources for the provision of treatment and care, and for general awareness campaigns. There are few examples in the region of government programs that are specifically focused on the prevention of HIV among IDUs. In contrast, some bilateral donors have consistently provided significant support for programs that focus on this vulnerable population. The most vivid example here is DFID’s contribution to prevention and support programs for IDUs in 30 regions of the Russian Federation (UNAIDS Russia, 2005). Since 1999, DFID’s consistent funding of this program has established it as the most important bilateral donor to harm reduction efforts in the Russian Federation. Even the U.S. government, which has been widely criticized for its global ban on support for needle exchange programs (Wall Street Journal, 2005), has demonstrated a focus in some CIS countries on addressing the prevention and support needs of vulnerable

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populations, including IDUs. In Ukraine, USAID’s social and health strategy specifically calls for the provision of information and support services “to at least 60% of high-risk groups in select highprevalence oblasts. International best practice dictates that 60% coverage of high-risk populations must be met in order to keep a concentrated epidemic from becoming a generalized epidemic” (USAID, 2005c). Similarly, USAID’s HIV/AIDS strategy for Russia “focuses on improving service delivery to vulnerable populations” (USAID, 2005a). In several cases in the region, IDU-oriented harm reduction programs that are chiefly supported by other donors have been complemented by USAID assistance to information and support services for this same target population, thus keeping within the limits of the U.S. government’s global restrictions on support for needle exchange programs. Other key prevention programs focused on most-at-risk populations have also largely been supported by bilateral donor agencies. Commercial sex workers have been a priority for prevention programs in Russia and Ukraine supported by USAID, DFID, and SIDA, among others. Research and prevention interventions related to HIV/AIDS and STIs among men having sex with men have also been supported by USAID, DFID, and CIDA. In Russia and Ukraine, SIDA, USAID, and the EC have been among the few donors that have supported programs to provide prisoners with access to HIV/AIDS-related information, prevention, and support in some low and medium security prisons. Support from bilateral donors has also been crucial in drawing attention to emerging issues beyond the scope of prevention and support, such as behavioral surveillance and socioeconomic research. Several bilateral donors have provided support for behavioral surveillance studies in the Russian Federation—a key source of trends and behavioral data that has been largely neglected by the standard system of epidemiological surveillance. From 2001 to 2004, DFID and USAID supported a series of behavioral surveillance studies in several Russian regions that helped to explain the alarmingly high rates of HIV among IDUs (Rhodes, et al., 2004) and HIV/STIs among commercial sex workers, homeless persons, and street youth (Shakarishvili et al., 2005). CIDA also supported a behavioral surveillance study in four Russian regions that in 2003 identified trends in unsafe sexual practices among IDUs that were already driving the epidemic beyond its concentration in that population (Calzavara et al., 2004). One of the shortcomings of

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bilateral support for such research activities, however, has been the lack of domestic support to sustain and enhance these efforts and integrate them with existing systems for epidemiological surveillance. There has been only a limited commitment to continue and scale up these and other research activities using domestic resources, despite the fact that in the majority of cases, local partners were trained and supported in the studies’ design and implementation. Even more worrisome, in few if any cases have the results of this research been systematically assessed and used by AIDS experts and policymakers in the region for the purpose of program development and evaluation. While bilateral donors have supported much of the seminal research that has successfully identified some of the emerging trends in the region’s epidemic, they have been less successful in building mechanisms to ensure that the results of this research are translated into strengthened national policies and programs that address these trends. In contrast to HIV/AIDS prevention and policy, the area of HIV/AIDS treatment and care has been a lesser priority for the donor community. Of the few successful interventions in the region that have addressed issues of laboratory diagnosis, clinical treatment and management, and treatment adherence, however, the majority have been supported by bilateral donors. Through a partnership between American and Ukrainian health institutions, USAID has supported a pilot project on the prevention of mother-to-child transmission of HIV in Odessa that has helped to reduce the rate to less than ten percent, one of the lowest in the CIS region. The main project supported by CIDA in this field helped to establish a Russian network of four regional centers of excellence for the comprehensive treatment and care of patients living with HIV/AIDS. This project was also one of the first in Russia to advocate for cost-effective strategies that would lower the cost of antiretroviral medications (Saldanha, 2003), and it also supported clinical trials that demonstrated the cost-effectiveness of cheaper combinations of antiretroviral medications (Webster, 2003). After two years of negotiations led by Russian officials and advocates, supported by pressure from the Global Fund and other international organizations, the annual cost of first-line antiretroviral medication in Russia dropped to about $1,200 per patient in 2005, from over $7,800 per patient in 2004 (WHO, 2005), with even greater price reductions expected in the near future. More importantly, these and other projects supported by USAID, the government of Finland, and the EC have helped to draw the much-needed attention of the

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Russian government and other multilateral donors, such as the Global Fund, to the growing need to provide effective and sustainable treatment and care for hundreds of thousands of Russians diagnosed with HIV/AIDS. One of the unique contributions of bilateral donor agencies in the CIS region has been their consistent support for nongovernmental organizations working in the HIV/AIDS field. In many Western countries, NGOs have been at the forefront of the response to AIDS. Often seeking to encourage a similar grassroots response, many bilateral donors have frequently sought to support and enhance the stature and role of NGOs in the Eurasia region as key partners in the response to HIV/AIDS. USAID, CIDA, the EC, and others have supported the majority of training programs and capacity-building initiatives in Russia and Ukraine that have aimed to enhance the potential and involvement of NGOs. Of the dozens of nongovernmental organizations currently working in the HIV/AIDS sector in Russia, the majority have at some point been recipients of training, small grants, or other forms of technical assistance from bilateral agencies. In many regions of Russia, these organizations have been a key source of information, prevention, and support services, particularly for populations most at risk for HIV. Beyond their contributions to HIV prevention and support services, these organizations have also been critical to mobilizing additional resources for HIV/AIDS activities in their regions. In 2001, when CIDA searched for pilot regions in Russia to implement a multisectoral AIDS project, it selected four regions with professional and established NGOs. More recently, when GTZ provided assistance in support of the implementation of the first of two Global Fund grants to Russia, it chose nongovernmental organizations in Moscow and Novosibirsk as implementing partners. In these and other cases, it can be argued that the bilateral donors were in need of NGOs to serve as implementing agencies for their programs almost as much as the NGOs themselves needed access to funding to support and enhance their activities. In many cases, bilateral donors’ contributions to NGOs have underscored the need to balance support for foreign and domestic nongovernmental organizations working on HIV/AIDS in the same countries. According to the EC’s regulations, for example, the implementation of technical assistance projects must be led by European organizations or specialists, thus giving European organizations a

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means of establishing their presence in HIV/AIDS activities in the region. The Ministry of Foreign Affairs of the Netherlands, also a key donor to global HIV/AIDS activities, provides a significant portion of its support for AIDS activities in this region to AIDS Foundation East West, a Dutch NGO with its head office in Moscow. Similarly, many of USAID’s HIV/AIDS projects in Russia and Ukraine have been implemented by large, U.S.-based agencies that are themselves nongovernmental organizations. Often the appearance on the local landscape of large, foreign NGOs with substantial funding from bilateral donors is viewed with considerable skepticism by many domestic organizations, which see them as potential competitors for scarce resources. A notable exception was USAID’s decision to implement its largest prevention and support programs in Ukraine through the International HIV/AIDS Alliance, a U.K.-based international NGO. With USAID support, the International HIV/AIDS Alliance in Ukraine has established itself as a leading Ukrainian NGO, managed exclusively by a team of highly qualified Ukrainian nationals. The only bilateral donor agency that has fully implemented a policy of “untied” assistance for HIV/AIDS in this region is DFID. Following up on a policy to untie all of its aid and technical assistance in 2002 (Morrisey, 2002), DFID has increasingly focused on the implementation of its assistance for HIV/AIDS through international and/or domestic NGOs, with no preference shown for organizations based in the United Kingdom. Some of the most valuable contributions of bilateral donors have been in support of small, local NGOs. Of the numerous harm reduction projects that DFID supported in 30 Russian regions, the majority were implemented by small, locally focused nongovernmental organizations. The leading roles of these organizations have helped to consolidate their influence at the forefront of prevention activities among IDUs in Russia. Similarly, a large number of local Ukrainian NGOs are key partners in the implementation of prevention and support activities in the USAID-supported “SUNRISE” project in eight Ukrainian regions. In a three-year, CIDA-supported project in Russia, more than 20 local and regional NGOs were united through regional networking and training activities. While all of these local organizations received minor grants, the project was able to help many of them establish themselves as important and sustainable partners in the local response to HIV/AIDS. While it may still be too early to assess the impact of bilateral donor contributions to NGOs at the national level, smaller and more targeted assistance provided by bilateral donors for nascent

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NGOs has helped to develop more effective local responses to HIV/AIDS, at least in some regions of Russia and Ukraine. The widespread support of bilateral donors for NGOs in this region has not been without critics. Government officials in the region have often been highly ambivalent toward the preference of bilateral donors to support NGOs in the HIV/AIDS field. Few governments at the national or regional level have the capacity to monitor resource flows to the HIV/AIDS activities within their territories (Opuni et al., 2002). When a significant portion of these resources are provided directly from bilateral donor agencies to nongovernmental organizations, sometimes without the involvement or endorsement of local or national governments, the government is often unaware and unaccountable for the results of these programs and activities. In some cases, the lack of involvement of local authorities in these programs has led to accusations that the bilateral donors are supporting initiatives that undermine “national interests.” While there has never been credible evidence in support of such charges, the countries and regions where bilateral support for NGOs has been explicitly endorsed and supported by local governments have consistently received greater support from donor agencies and organizations. Another challenge highlighted by the increasing involvement of bilateral donors to HIV/AIDS programs in this region has been the lack of coordination between the priorities of these donors and their national counterparts. Few bilateral donors have formal strategies for HIV/AIDS. Those that do exist are infrequently developed in partnership with national governments, and rarely, if ever, is the formal endorsement of national authorities sought before these strategies are formally approved. So-called sectorwide approaches, or SWAPs, that are being implemented in some developing countries, are still unheard of in the countries of the CIS. In order to consider seriously the implementation of a SWAP for HIV/AIDS, there must be a strong national AIDS authority that has the capacity and authority to coordinate and even guide the contributions of external donors. In this region, however, projects are often developed and even approved by bilateral donors as a result of their own tender or review processes, with little or no input or feedback from national authorities. As a result, national authorities feel only limited responsibility and ownership for the successful implementation of these programs, and the programs are rarely, if ever, reflected in the national or regional strategic plans for HIV/AIDS. While this pattern has been a serious barrier to the sustainability and scale-up of donor-supported activities, the lack of

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national involvement has also encouraged bilateral donors to support more innovative projects. Harm reduction programs in Russia and prevention programs for other most-at-risk populations such as MSM and commercial sex workers in Ukraine would have otherwise been difficult to implement if national authorities were involved in implementation of these programs at every step. As a result, many bilateral donors continue to struggle to maintain a delicate balance between the formal requirement for implementing projects that are consistent with national priorities and the urgency of supporting innovative programs, such as harm reduction, that are largely neglected by national authorities. The lack of coordination between many of the key objectives of bilateral donors and the national AIDS authorities has also led to charges that some donors are monopolizing precious national resources for their own programs and projects. According to Peter Piot, executive director of UNAIDS, AIDS program managers are spending obscene amounts of time trying to satisfy dozens of duplicative reporting requirements, and hosting repetitive review missions month after month. Donor-driven agendas are raising transaction costs and reducing programme effectiveness. There has been much discussion of late of the “absorptive capacity” in countries, but little action to address the fact that it is donors who are absorbing much of the overstretched capacity that presently exists. (Piot, 2003)

With the growing volume and intensity of bilateral support for HIV/AIDS in this region, the lack of coordination between an increasing number of projects has intensified these problems. In some regions of Russia and Ukraine where bilateral agency involvement is extensive, the HIV/AIDS priorities of regional governments are driven more by the imperatives of donors than by national or local AIDS authorities. Similarly, many of the most experienced HIV/AIDS personnel in the areas of prevention and project management in Russia and Ukraine work for NGOs that are funded by bilateral organizations. Throughout the region, governmental AIDS authorities lack adequate resources to attract the leading national expertise. Such specialists are often engaged by organizations that are implementing projects for bilateral donors at salaries that are beyond the scale of national budgets; in some cases, they have even left governmental AIDS programs to work for organizations that are implementing projects for bilateral donors. Many of the same organizations are also focused on serving as implementing

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partners for the bilateral agencies, leaving them with little time and capacity to implement programs and activities under the national AIDS program. Despite these challenges, bilateral donors to HIV/AIDS in this region have also made important, albeit less visible contributions through their support for the Global Fund. Launched in January 2002, the Global Fund to Fight AIDS, Tuberculosis and Malaria is a uniquely independent, performance-based funding mechanism designed both to attract new resources and to direct resources to these diseases, in a coordinated way, to where they are needed most. Since the beginning of 2003, the Global Fund has provided over $80 million in funding for HIV/AIDS activities in the countries of the Commonwealth of Independent States (GFATM, 2005a). The Global Fund’s contributions represent substantial increases of funding for HIV/AIDS in this region and already dwarf the combined scope and pace of funding provided by all the bilateral donor agencies. Despite its independent status and transparent procedures for reviewing and funding proposals, key bilateral agencies continue to play an important role in facilitating and advocating for the growing involvement and commitment of the Global Fund in three key areas. First, many NGOs in the region that have previously implemented grants from some of the key bilateral donor agencies are now actively involved in the implementation of grants supported by the Global Fund. In 2003, the Global Fund decided to provide a grant of up to $90 million to a consortium of five nongovernmental organizations to scale up HIV/AIDS prevention and support activities among vulnerable groups in priority regions of the Russian Federation. Not surprisingly, many of these organizations had previously served as key recipients of grants from some of the leading bilateral agencies in Russia and thus had a proven track record and capacity to implement large technical assistance projects for HIV/AIDS. In Ukraine, USAID began to provide funding to the International HIV/AIDS Alliance in 2000 to support prevention and information services. If the Alliance had not demonstrated its capacity as a capable implementing agency under these auspices, it is unlikely to have been appointed by the Global Fund initially as grant steward and later as principal recipient of the $92 million GFATM-funded program. In both Russia and Ukraine, the earlier support and funding that these organizations received from bilateral donors enabled them to build their organizational capacity and professionalism to the extent that they were subsequently able to perform the role of principal recipient for significantly more substantial funding from the Global Fund.

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The second area of interaction between bilateral donors and the Global Fund has been in the latter’s support for projects and initiatives that were initially supported by bilateral donors. In Russia, many of the current activities being supported on a large scale by the Global Fund’s Round Three grant were earlier supported by bilateral donors in selected regions. In the Global Fund Round Four grant to Russia, some of the strategies and approaches for the rapid scale-up of treatment in up to 57 regions were earlier supported by a CIDA-funded project in four pilot regions. In such cases, the initial investments made by the bilateral donors in support of ambitious pilot projects were vindicated when funding was mobilized by the Global Fund to scale up and sustain these and other programs on a national scale. The third area of interaction between bilateral donors and the Global Fund has been the role performed by some donors in guiding the implementation of the Global Fund’s grants through their involvement in Country Coordination Mechanisms (CCMs). In Russia, key bilateral donors, including USAID and the EC, are members of the CCM (GFATM, 2005b). Similarly, USAID has also been or is still a member of the majority of the CCMs in the region, including in Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Tajikistan, Ukraine, and Uzbekistan. In Ukraine, USAID was a member of the original CCM that submitted a Round One proposal to the Global Fund. The active role of USAID in these CCMs is in contrast to that of other bilateral donors, who are largely supportive of activities supported by the Global Fund in this region but are generally not members of these CCMs.

Key Challenges Facing Bilateral Donor Agencies In light of the significant contributions of bilateral donor agencies to HIV/AIDS in the CIS region, it is important to assess these contributions in the context of current and emerging challenges. The most significant of these challenges is the difficulty of sustaining their commitments to HIV/AIDS when many of these agencies are planning to exit from the region in the coming years. The second challenge is their limited ability to support and enhance HIV/AIDS activities in a manner that is consistent with the countries’ overall strategies for HIV/AIDS, thus moving beyond support for individual projects to supporting longterm strategic programs. The third challenge is to identify and support future areas where they can indeed continue to make measurable

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contributions that can complement, if not exceed, the support that will be provided by the Global Fund. As mentioned earlier, many of the key bilateral donor agencies are developing or even implementing strategies to exit from the region. Increasingly, bilateral donors are beginning to focus their activities on the least developed parts of the world that face the most acute needs for assistance, particularly in the field of HIV/AIDS, where the magnitude of needs is greater than in the countries of the CIS. In this context, the choices are difficult. While many of the CIS countries are now boasting robust and sustained economic growth, the AIDS epidemics in these countries are rapidly growing. This problem is manifested most acutely in the Russian Federation, which has amassed foreign reserves in excess of $180 billion, a sum more than adequate to cover the cost of scaling up HIV/AIDS prevention and treatment programs throughout the world. Yet the current scope of prevention programs in Russia still reaches only a fraction of most-at-risk populations, and the majority of people with HIV/AIDS in Russia lack even basic access to treatment, care, and support. How can bilateral donors justify their commitment to sustain funding for HIV/AIDS activities in the Russian Federation when the Russian government has more than adequate domestic resources to address these needs? While there is no consensus on this matter among the key bilateral donors, an exit from some if not all countries in this region may serve as a wake-up call for governments. In the case of DFID, CIDA, and other leading bilateral donors that have announced plans to withdraw partially or entirely from the region in coming years, the top priority should be to ensure that the programs they have supported are sustained, scaled up, and owned by national or regional authorities. In some cases, donors have already addressed these challenges, with some measurable success. As described earlier, programs that have been supported by DFID and CIDA are now being scaled up through funding from the Global Fund’s grants to Russia. While these represent some of the few examples of model HIV/AIDS projects initially supported by bilateral donors and now scaled up in a systematic manner, it can be argued that the responsibility for maintaining these projects has simply been transferred from one external donor to another. In fall 2005, the Russian government announced new federal funding for HIV/AIDS in excess of $100 million per year, indicating that domestic resources for HIV/AIDS in Russia are at last being rapidly increased to unprecedented levels. It is still unclear how these new resources from the Russian government

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will be coordinated with existing and planned donor resources to ensure an effective federal response. Rather than advocating for extending their involvement in this region, or increasing their commitment to HIV/AIDS, some bilateral agencies would benefit from a strategic reassessment of how HIV/AIDS may affect their existing portfolio of programs. So-called “mainstreaming” of HIV/AIDS has been advocated by UNAIDS and other development agencies as a key approach for countries to address the multidimensional threats of HIV/AIDS beyond the health sector, but these approaches are also directly relevant to the strategies of donor agencies. Many of the key achievements that have been supported by bilateral agencies in the areas of employment generation, administrative and legal reform, security and defense, and other sectors may be seriously undermined by the unabated spread of HIV/AIDS. The existing portfolio of programs supported by bilateral donors could be substantially strengthened if they were revised to address the growing impact of HIV/AIDS. This is particularly important for the EC, which is emerging as one of the key bilateral donors to HIV/AIDS programs in this region. Of the €13.9 billion that has been committed by the EC to support all programs and projects under the European Neighbourhood and Partnership Instrument (ENPI) for 2007–2011, it is likely that only a small portion will be committed to HIV/AIDS. The beneficial results of the EC’s contribution to HIV/AIDS programs could be greatly enhanced if the EC were to introduce mainstreaming of HIV/AIDS into all spheres of its support and partnership. The second key challenge facing bilateral agencies is to continue their support for HIV/AIDS activities in a manner that is consistent with national HIV/AIDS strategies. In the 1990s, when few countries in this region had developed national AIDS strategies or programs that reflected the full spectrum of needs and priorities, bilateral agencies could identify areas of involvement with little or no consultation or guidance from national authorities. Today, many of the countries in the region are working to develop and implement national HIV/AIDS frameworks that are consistent with the Three Ones principles for effective national responses to HIV/AIDS. The successful adaptation and implementation of the Three Ones at the national level requires a “consultative and iterative process between donors, multilateral and country-level partners” (UNAIDS, 2005b). However, the majority of support from bilateral donors is still focused on the implementation of regional pilot projects or on supporting NGOs. As described earlier,

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some bilateral donors have deliberately bypassed national governments and/or national AIDS authorities in order to support initiatives such as harm reduction or capacity building for NGOs that were otherwise not being supported by the national AIDS program. This strategy has led to certain sectors or subnational regions receiving a disproportionate amount of donor assistance, to the neglect of other sectors or regions that are also in urgent need of donor support. The extent to which bilateral donors will be open and willing to coordinate their future activities with the priorities of national AIDS programs will largely be determined by the leadership exercised by the national AIDS authorities in these countries. As has been noted by several analysts, there is still a dearth of political leadership on HIV/AIDS in Russia (Gerber and Mendelson, 2005) and other countries in the region. The attention given by bilateral donor agencies to HIV/AIDS in these countries may embarrass national governments that are not giving the issue the same recognition of urgency or public importance. In countries like Ukraine, however, where key bilateral donors have been actively engaged by the newly established National Coordination Council for HIV/AIDS, there is greater incentive to ensure that bilateral donors will respond to needs as defined by national authorities, and to commit their aid and technical assistance accordingly. This is also a critical area for bilateral donors to engage national AIDS authorities in the process of developing and implementing national AIDS strategies and programs. In countries where bilateral donors have provided a significant proportion of the resources for HIV/AIDS activities, they command the legitimacy and the stature to ensure that their contributions are considered by national authorities. The third key challenge facing bilateral donor agencies is to determine how, in the face of the rapidly evolving AIDS epidemics in the region, they can continue to identify and support future areas for maintaining effective involvement. The majority of HIV/AIDS prevention and support activities either were launched with the support of bilateral donors or are currently being supported by bilateral donors. Particularly in countries like Russia and Ukraine, where these agencies have been most actively involved, HIV/AIDS epidemics continue to progress at an alarming rate. Even in sectors where bilateral donors have been most actively involved, such as prevention activities for most-at-risk populations or public awareness campaigns, the levels of awareness and safe behaviors are still inadequate to suggest that countries in the region have turned the corner in their responses to HIV/AIDS (UNAIDS, 2004). In the subnational regions that have received a disproportionate

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amount of donor attention and support, such as St. Petersburg or Altai Krai in the Russian Federation or Odessa Oblast in Ukraine, there are no indications that the epidemic has stabilized, even among those populations that have been the focus of donor activities. In this context, bilateral donor agencies are faced with difficult choices. They can argue that they have made their most valuable contributions, and that the time has now come for national and local governments to take responsibility for responding to HIV/AIDS. While this statement may indeed be true, it should not provide a rationale for bilateral donors’ departure from this region, or at least from the HIV/AIDS sector. On the contrary, the continued progression of the HIV/AIDS epidemics underscores the increasing need for key bilateral donors to maintain and even increase their commitment. However, this task is further complicated by the need for these same bilateral agencies to make measurable contributions that can complement, if not exceed, the Global Fund’s significant and growing support. One of the most promising developments in this region has been the rapid increase of funding for HIV/AIDS programs from the Global Fund. It can even be argued that the growing contributions of the Global Fund in the region are a direct result of the enhanced commitments that bilateral donors have made to the Global Fund at the global level. However, with the majority of the Global Fund’s support being used to expand access to prevention and treatment services rapidly and at the national level, the scope for bilateral donor involvement is being dramatically transformed. In past years, the rationale for bilateral donor involvement was to provide catalytic funding for HIV/AIDS activities. The resources contributed by bilateral donors— only recently the key external source of funding for HIV/ AIDS activities in this region—are now being dwarfed by the growing contributions of the Global Fund. The Global Fund does not aim to compete with the contributions of bilateral donors but rather to complement them. Nevertheless, the growth of HIV/AIDS programs and activities covered by grants from the Global Fund will further threaten the rationale for bilateral donors to maintain and increase their commitment to HIV/AIDS. There are at least four possible solutions to address these challenges, the first of which is for bilateral donors to focus on those areas that are not covered by the Global Fund. Insofar as Global Fund grants provide a clear and transparent framework for key objectives and indicators, bilateral donors should develop their future strategies in ever closer collaboration with national partners to ensure that they

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will cover at least some of the gaps in national strategic frameworks that are not addressed by the Global Fund. Similarly, bilateral donors should curtail their support for small, regionally disparate, and nonstrategic interventions in favor of larger and more sustainable programs that reinforce the contributions of the Global Fund and other partners in support of national strategic objectives. Third, bilateral donors should earmark increased funding for strategically important “operational research,” to ensure that future programs and activities are evidence-based. Currently there is a dearth of scientifically rigorous operational research in this region. For example, most countries in the region lack scientifically valid estimates of the size of most-at-risk populations such as IDUs and commercial sex workers. Without such reliable estimates, updated on a regular basis, it is impossible to know whether current prevention programs are covering a majority of the target population or only a small fraction of the population, with the latter more likely the case. These and other aspects of operational research are being covered only partially by the Global Fund, and yet they are critical contributions to the national response to HIV/AIDS that could be covered by bilateral donors. Finally, bilateral donors should also increasingly exercise their “soft power,” through highlevel partnerships between ministries and technical experts to advocate for increased attention to specific issues. A majority of the key bilateral donors represent governments that are members of the G8. These governments could use their participation in the G8 and other bilateral diplomatic fora to enhance greatly the political focus on HIV/AIDS, particularly in this region. As described earlier in this chapter, U.S. diplomats have consistently raised the issue of HIV/AIDS as a priority in their dealings with Russian officials. Such multilateral and bilateral AIDS diplomacy should be intensified and expanded by all bilateral donors and their governments until HIV/AIDS prevention, treatment, and care services are available on a universal basis in all of the countries of the CIS.

Conclusion At the turn of the millennium, the key argument for urgent and enhanced bilateral involvement in HIV/AIDS activities in the countries of the CIS was to “seize the window of opportunity” to contain the AIDS epidemic (WHO, 2000). Since 2000, the AIDS epidemic in this region has more than doubled in size, from an estimated 700,000 people living with HIV/AIDS to over 1.6 million (UNAIDS/WHO,

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2005). Despite the efforts of national and regional governments and nongovernmental organizations, supported by significant contributions from bilateral donors, HIV continues to spread relatively unchecked among and beyond populations that are most at risk. This situation is exacerbated by the large and growing gap between the funding needs and the resources currently available for HIV/AIDS programs in the CIS region. According to expert estimates, the annual cost of effective scale-up of essential programs for HIV/AIDS prevention, care, and treatment programs in this region will reach as much as $1.5 billion by 2007 (Futures Group, 2003). Of this amount, three-fifths will be required in the three countries with the largest epidemics—the Russian Federation, Ukraine, and Kazakhstan, the countries that have received the majority of bilateral donor assistance for HIV/AIDS. In light of the growing resource needs for HIV/AIDS in the region, the financial contributions of even the largest bilateral donor agencies seem almost insignificant. In this context, the question persists as to how best to evaluate the impact of bilateral donors’ contributions. This chapter has argued that the ultimate value of these contributions to HIV/AIDS programs in the countries of the CIS far exceeds their monetary value. Bilateral agencies and the governments they represent have consistently added immeasurable value to the policy debate over the urgent need to give more attention and resources to HIV/AIDS in CIS countries. Bilateral donor agencies have also supported key pilot projects and programs, particularly in high prevalence regions and through provision of services by nongovernmental organizations that have demonstrated the efficacy and the acceptability of interventions in many countries throughout the region. Similarly, bilateral donors have supported much of the limited scientific and operational research that has been conducted to date on HIV/AIDS in this region, the results of which should be used more strategically to inform and encourage the use of sound research and program methodologies, and evidence-based approaches. Finally, bilateral donors have leveraged their commitments to advocate for and facilitate larger contributions from international agencies such as the United Nations and, more notably, the Global Fund. Support from bilateral donors has also helped to raise the stature and attention of HIV/AIDS activities and has provided effective mechanisms to sustain and scale up initiatives. In light of additional funding from the Global Fund and continued guidance from UNAIDS, many of the governments in this region now have growing resources and strengthened leadership to focus on HIV/AIDS. Perhaps

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the final litmus test for the contributions of the bilateral donors will be the extent to which the initiatives they supported are maintained and scaled up by governments at the national level. Increasingly, this challenge will be determined less by these bilateral donors and their contributions to HIV/AIDS, but rather by the national authorities in the majority of these countries, which have yet to demonstrate a national response that is commensurate with the scope of their HIV/AIDS epidemics.

Notes The views expressed in this chapter reflect the personal views of the author and should not be taken to reflect the official policy or position of UNAIDS. 1. This does not purport to be an exhaustive or authoritative list, but rather indicates the main bilateral agencies working on HIV/AIDS in this region, listed in alphabetical order. 2. Currently, USAID is supporting HIV/AIDS programs in Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Russian Federation, Tajikistan, Ukraine, and Uzbekistan. Source: www.usaid.org. 3. Formerly known as the Gore-Chernomyrdin Commission, the Commission was established in 1993 to promote cooperation between the United States and the Russian Federation across a spectrum of sectors.

References AIDS Action Europe (2003) “Situation Analysis and Action Plan on HIV/AIDS in Central, Eastern Europe and Central Asia in the Context of EU Enlargement, ver. 3.2,” December 2003, http://www.integration-projects.org/keydocs/Draft_ ActionPlanHIVcee.pdf (accessed September 3, 2005). Associated Press (2002) “Canadian Prime Minister Jean Chretien Visited an AIDS Research Center and Pledged to Help Russia Fight the Disease,” February 15. Beyrle (2004) “Deputy Chief of Mission John Beyrle, Transatlantic Partnership against AIDS Remarks,” Moscow, March 30, http://moscow.usembassy. gov/embassy/transcript.php?record_id⫽74 (accessed September 3, 2005). Calzavara, L. et al. (2004) “Is the HIV Epidemic in the Russian Federation Shifting into the Heterosexual Population: Preliminary Results of the Russian Polaris HIV Cohort,” Canadian Association for HIV Research, http://cahr-acrv.ca/ english/resources/abstracts_2004/abs/abs305.htm (accessed September 3, 2005). CIDA [Canadian International Development Agency] (2000) HIV/AIDS Action Plan. (Quebec: CIDA). Council of the European Union (2004) “Presidency Conclusions—Brussels, 17 and 18 June 2004,” http://europa-eu-un.org/articles/mt/article_3602_mt.htm (accessed September 3, 2005).

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DFID (2001) “Russian Federation: HIV/AIDS Programme: Programme Concept Note,” http://www.dfid.gov.uk/aboutdfid/dev-committee/dcmeeting18oct01.asp (accessed September 3, 2005). ——— (2004) Taking Action: The UK’s Strategy for Tackling HIV and AIDS in the Developing World, www.dfid.gov.uk/Pubs/files/HIVAIDStakingactionsummary. pdf (London: DFID). Dobriansky, Paula J. (2003) “The Emerging Security Threat of HIV/AIDS: Russia,” remarks at East-West Institute Conference, February 28, http:// www.state.gov/g/rls/rm/2003/18480.htm (online September 3, 2005). EC [European Commission] (2002) “Programme of Community Action in the Field of Public Health (2003–2008),” European Commission, DG Health and Consumer Protection, September, http://europa.eu.int/comm/health/ph_programme/ programme_en.htm (accessed September 3, 2005). ——— (2004a) “Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia,” February 24, http://www.eu2004.ie/templates/ document_file.asp?id⫽7000 (accessed September 3, 2005). ——— (2004b) “A Coherent European Policy Framework for External Action to Confront HIV/AIDS, Malaria and Tuberculosis,” October 26, http://europa. eu.int/eur-lex/en/com/cnc/2004/com2004_0726en01.pdf (accessed September 3, 2005). Futures Group (2003) “Funding Required for the Response to HIV/AIDS in Eastern Europe and Central Asia,” July, prepared by Futures Group and Instituto Nacional de Salud Publica, Cuernavaca, Morelos, Mexico. Gerber T., and S. Mendelson (2005) “Crisis among Crises among Crises: Public and Professional Views of the HIV/AIDS Crisis in Russia,” April, http://www. wcfia.harvard.edu/conferences/demography/papers/Gerber_Mendelson.pdf (accessed September 3, 2005). GFATM (2005a) “Global Fund Grants—Progress Details, Eastern Europe and Central Asia, HIV/AIDS Component,” report, http://www.theglobalfund.org/ en/funds_raised/ reports/(accessed September 14, 2005). ——— (2005b) “List of CCM Members in the Russian Federation,” http://www.theglobalfund.org/search/memberlist.aspx?countryID⫽RUS (accessed September 3, 2005). GFATM (2005c) “The Global Fund to Fight AIDS, Tuberculosis and Malaria: Pledges,” www.theglobalfund.org/en/funds-raised/pledges/ (accessed September 3, 2005). Kates, J. (2005) “Financing the Response to HIV/AIDS in Low and Middle Income Countries: Funding for HIV/AIDS from the G7 and the European Commission,” by Jennifer Kates, Kaiser Family Foundation, July. Morrissey, O. (2002) “British Aid Policy Since 1997: Is DFID the Standard Bearer for Donors?” Centre for Research in Economic Development and International Trade, University of Nottingham, http://www.nottingham.ac.uk/economics/ credit/research/papers/CP.02.23.pdf (accessed September 3, 2005). National Intelligence Council (2002) “The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and China: Intelligence Community Assessment,” September, http://www.cia.gov/nic/special_nextwaveHIV.html (accessed September 3, 2005).

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Piot, P. (2003) “AIDS: The Need for an Exceptional Response to an Unprecedented Crisis,” A Presidential Fellows Lecture by Dr Peter Piot, executive director of UNAIDS and under secretary-General of the United Nations, November 20, Preston Auditorium, World Bank. OECD (2004) “Analysis of Aid in Support of HIV/AIDS Control, 2000–2002,” Organization for Economic Cooperation and Development, 16, www.oecd.org/ dataoecd/57/60/32159448.pdf. Opuni, M., S. Bertozzi, J-A Izazola, J-P Gutierrez, and W. McGreevey (2002) “Resources for HIV/AIDS Prevention and Care,” AIDS, 16(supplement 4): S53–S60. Rhodes, T. et al. (2004) “HIV Transmission and HIV Prevention Associated with Injecting Drug Use in the Russian Federation,” International Journal of Drug Policy, 15:1–16. Saldanha, V. (2003) “Vacuum of Leadership,” Financial Times, November 28. Shakarishvili, A. et al. (2005) “Sex Work, Drug Use, HIV Infection, and Spread of Sexually Transmitted Infections in Moscow, Russian Federation,” Lancet, 366(9479):57–60. Summers, T., and J. Kates (2003) “Global Funding for HIV/AIDS in Resource Poor Settings,” Kaiser Family Foundation, December, Metro Park, California, and Washington, DC, www.kiff.org/hivaids/loader.cfm?url⫽/commonspot/security/ getfile.cfm&PageID⫽28514. UNAIDS (2004) “AIDS Epidemic Update: December 2004,” Geneva. ——— (2005a) “Intensifying HIV Prevention: A UNAIDS Policy Position Paper,” Geneva, data.unaids.org/publications/irc-pub06/jc1165-intensiv_hiv-newstyle_ en.pdf (accessed September 3, 2005). ——— (2005b) “The Global Response to AIDS: ‘Making the Money Work’— The Three Ones in Action,” communiqué from the High-Level Meeting, March 9. UNAIDS/WHO (2005) “AIDS Epidemic Update: December 2005,” 45, Geneva, www.unaids.org/epi/2005/doc/report_ pdf.asp. UNAIDS Russia (2005) “Internationally Funded HIV-Related Activities in the Russian Federation,” http://www.unaids.ru/site_admin_predpr/f/Inventory_2005_En.pdf (accessed September 3, 2005). USAID (2005a) “USAID Health Profile Russia: HIV/AIDS,” http://www. usaid.gov/our_work/global_health/aids/Countries/eande/russia_05.pdf (accessed September 3, 2005). ——— (2005b) “USAID Country Profile: Russia (June 2005),” http://www. usaid.gov/locations/europe_eurasia/countries/ru/russia.pdf (accessed September 3, 2005). ——— (2005c) “USAID Ukraine Data Sheet: 121–0325: Social Protection and Health,” http://www.usaid.gov/policy/budget/cbj2005/ee/pdf/1210325.pdf (accessed September 3, 2005). USIA (1998) “GCC10 Text: Press Statement on Gore-Chernomyrdin Commission,” March, http://www.fas.org/news/russia/1998/98031201_wpo.html (accessed September 3, 2005). Versbow, A. (2003) “Vershbow on U.S.-Russian Social, Humanitarian Cooperation, July 25, 2003,” http://www.usembassy.it/file2003_07/ alia/a3072803.htm (accessed September 3, 2005).

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Wall Street Journal (2005) “Bush Ties Money for AIDS Work to a Policy Pledge,” February 28, http://www.aegis.com/news/wsj/2005/WJ050212. html (accessed September 3, 2005). Webster P. (2003) “HIV/AIDS Explosion in Russia Triggers Research Boom: Several Studies Now Underway Aim to Offer Solutions to the HIV/AIDS Crisis for Russian Policy Makers,” Lancet, June 21, 361(9375). World Health Organization (2000) “HIV in Eastern Europe—A Rapidly Closing Window of Opportunity,” press release EURO 18/00, Copenhagen, Geneva and Brussels, December 5, http://www.euro.who.int/mediacentre/PR/ 2000/ 20010909_12 (accessed September 3, 2005). ——— (2005) “Summary Profile for HIV/AIDS Treatment Scale-up: Russian Federation,” June, http://www.who.int/3by5/support/june2005_rus.pdf (accessed September 3, 2005).

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6 International Donor Support to the Eastern Europe and Central Asia Region: Opportunities and Challenges Bertil Lindblad

During the last few years, there has been a sharp increase in international donor aid and financial assistance to help contain the HIV/AIDS epidemic in Eastern Europe and Central Asia. Funds are substantially greater than what has hitherto been administered through national budgets or any other single source of funding targeted at tackling the growing epidemic in the region.

Programs in Russia In the Russian Federation, recent funding for HIV/AIDS support programs and activities includes a $150 million World Bank loan approved in 2003 aimed at combating TB and HIV/AIDS. Of the total amount, $47 million is earmarked for HIV/ AIDS activities that include policy development, strategies and public information for HIV/AIDS control, strengthening of surveillance and monitoring, and prevention with an emphasis on high-risk populations and mother-to-child transmission. Counterpart financing is being provided by the Russian government in the amount of $18.4 million. The institutional scope is multisectoral, including but not limited to the Ministry of Health and the Ministry of Justice. Project activities will be implemented at the federal, regional, and local levels, with the latter playing a primary role. All administrative regions in the Russian Federation were invited to submit proposals for both the TB and the HIV/AIDS components. Proposals outlining specific HIV/AIDS activities were received from 82 of the 89 regions.

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The Global Fund to Fight AIDS, Tuberculosis, and Malaria has also given the Russian Federation two separate grants. A proposal submitted by a consortium of five NGOs, “Stimulating an Effective National Response to HIV/AIDS in the Russian Federation,” was approved in the amount of $88.7 million. These NGO consortium programs— currently being implemented in ten of Russia’s 89 regions—focus on HIV/AIDS prevention and awareness among youth and the general population. They also address the specific needs of vulnerable populations, including injection drug users (IDUs), sex workers, street children, men having sex with men (MSM), and prisoners. These programs promote treatment, care, and health, include a social support module, and are structured to address the needs of people living with HIV/AIDS. The proposal also has an advocacy module focused on improvement of the HIV/AIDS policy environment, especially with regard to national and regional HIV/AIDS policies. The goal is to stimulate an adequate national response to the epidemic, primarily via a focus on legislative reform, reduction of ARV prices, and improved coordination among various institutions and levels of government. Within the fourth round of the Global Fund, a proposal submitted by the Russian Federation, “Promoting a Strategic Response to HIV/AIDS and TB Treatment and Care for Vulnerable Populations in the Russian Federation,” was approved in late June of 2004 in the amount of $120.5 million. This proposal focuses on vulnerable population groups that represent over 85 percent of diagnosed cases of HIV/AIDS in Russia: IDUs, sex workers, MSM, prisoners, and orphans. Slated projects aim to improve the identification and referral of individuals from these population groups and to expand and improve their access to comprehensive HIV/AIDS treatment, care, and support. These objectives will require high levels of outreach services, integration of HIV/AIDS treatment and care with drug-dependence services, and the use of peer education systems to involve IDUs in the implementation of key aspects of care, support, and adherence counseling. The conditions set by the Global Fund for disbursement of the approved funds—most notably a price level of $1,700 per person per year for ARV treatment, as well as treatment protocols and guidelines—have been met. The funds were earmarked to be made available during the second half of 2005. The United Nations, primarily through the Joint United Nations Programme on HIV/AIDS (UNAIDS), has expanded its support and activities in recent years by bringing together ten cosponsoring agencies and the UNAIDS Secretariat.1 Together, UNAIDS cosponsoring

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agencies and the secretariat have strengthened country-level capacity with specific emphasis on technical support in relevant areas such as access to treatment, monitoring, and evaluation. Staff capacity has been added in order to provide enhanced technical support to national partners. In financial terms, United Nations support amounted to approximately $57.6 million in 2005. UNAIDS and its cosponsoring agencies work closely with bilateral donors, most notably DFID (United Kingdom), SIDA (Sweden), USAID, and the European Commission. The recent significant increase of international funding through the Global Fund, the World Bank loan, the United Nations, and various other donors—amounting to more than $250 million over five to ten years— represents an unprecedented opportunity to bring improved HIV/AIDS prevention and care to the Russian Federation. For the various programs and projects to achieve a sustainable and significant impact, they will rely to a large extent on enhancing the capacity of individuals, institutions, and systems through multipartner involvement and cross-sectoral commitment and expertise—elements that all require stronger and improved cooperation and coordination (UNAIDS, 2004a).

Programs in the Caucasus In 2002, the Armenian government, with the assistance of UN agencies, submitted a successful proposal to the Global Fund. As a result, Armenia will receive $7.2 million over the next 5 years. Funded projects will address a number of issues outlined in its National Program but will focus mostly on prevention among IDUs, providing care and support for people living with HIV/AIDS, and educating sex workers, MSM, mobile populations, and young people. Georgia and Azerbaijan are also recipients of Global Fund grants. A proposal submitted by Georgia was approved in February 2003, and a proposal by Azerbaijan was approved in 2004. Georgia will receive $12.1 million over five years. The Azerbaijan proposal included a budget of approximately $12 million, with a total of $6.5 million approved.

Programs in Central Asia Since January 2004, Kazakhstan has been the beneficiary of a grant from the Global Fund amounting to $22.4 million over five years. By the end of 2004, this grant had been used to implement HIV/AIDS

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educational programs in all secondary schools, establish 16 friendly STI clinics for vulnerable population groups (in addition to the regular STI service institutions), assist about 20 percent of IDUs by providing harm reduction interventions, and supply ARV combination therapy to five percent of the people with advanced HIV disease. The country receives technical, consultation, managerial, material, and financial support from UN agencies as well as from bilateral donors and international NGOs. There has been a significant increase in international donor support to HIV/AIDS programs and projects in Kyrgyzstan over the past two years. The Global Fund has provided a $4.9 million grant. The Soros Foundation is continuing its support of harm reduction programs, and USAID has supplied Kyrgystan’s National AIDS Center and three provincial centers with laboratory equipment. Other technical, managerial, financial, and in-kind support is being provided by other donors and UNAIDS cosponsoring agencies. In Tajikistan, a Country Coordination Mechanism (CCM) for the implementation of projects supported by the Global Fund was established in 2002. There are a number of NGOs implementing HIV/AIDS prevention interventions in the country, and some of these are full members of the CCM. In November 2004, more than ten NGOs created a network of Harm Reduction Associations. In April 2004, the first NGO comprised of people living with HIV/AIDS was registered in Tajikistan. Over the last several years, the government, UN agencies, and other donors have undertaken a major effort to mobilize resources. To date, Tajikistan has received two grants from the Global Fund. The second grant, amounting to $8.1 million, was approved in 2004. Other international donors include USAID, DFID, the World Bank, and the Dutch government. There has recently been a dramatic increase in available HIV/AIDS funding to Tajikistan. Currently, there is more than $20 million committed for HIV/AIDS activities through 2008–2009. The increase in funds has resulted in a heightened national response, but challenges remain in terms of insufficient capacity to implement programs at the national and subnational levels. An urgent need remains to improve national response coordination and to synchronize existing systems among various partners. In Turkmenistan, the national Red Crescent Society, Youth Union, and Women’s Union are the major nongovernmental organizations involved in HIV/AIDS awareness activities specifically targeting the general public as well as vulnerable population groups. USAID is

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another major donor, providing direct support to the government as well as undertaking joint projects with UN agencies. Interventions supported by international and bilateral organizations are coordinated by the United Nations Theme Group on HIV/AIDS. Though Turkmenistan still claims to be HIV-free (there has only been one officially registered case of HIV infection), experts estimate at least 300 cases of HIV infection. This discrepancy indicates a potential deterioration of the HIV situation. The lack of citizen awareness coupled with prevailing unsafe sexual behavior and injection drug use increase the risk of an emerging HIV epidemic in the country. These problems are especially common among young people. Recently, the government has decided to apply for a grant through the Global Fund and has requested technical support from WHO for preparing the project proposal. The interest of donors in providing support to Uzbekistan for HIV/AIDS prevention programs has recently increased considerably. The United Nations system, primarily through UNAIDS, its cosponsoring agencies (including UNFPA, UNDP, UNESCO, UNICEF, UNODC, WHO, and the World Bank), bilateral donors such as DFID (United Kingdom) and USAID (United States), and international NGOs have assisted Uzbekistan in increasing awareness of HIV/AIDS and providing support to programs that focus on vulnerable population groups including injection drug users and sex workers. The Global Fund has approved Uzbekistan’s proposal ($24.5 million for five years) and has already provided the first tranche. A notable increase in Uzbek HIV infection rates has attracted the attention of high-level officials, resulting in a stronger recent commitment by the government to address the spread of HIV/AIDS. The approach to harm reduction programs targeted at injection drug users and other vulnerable population groups is therefore slowly changing, and overall, HIV/AIDS awareness is growing. The main challenge now is to ensure that the various national partners will be able to absorb the rapid influx of resources made available by the Global Fund, the UN system, and other donors. To this end, additional technical support is needed (UNAIDS, 2004b; UNAIDS/WHO, 2004).

Programs in Ukraine International donor support to Ukraine has increased notably in recent years. In early 2004, the Global Fund appointed the International HIV/AIDS Alliance—an international NGO in Kiev and

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previously a subrecipient—as the temporary principal recipient providing stewardship of Global Fund-supported activities (initially for a one-year period). By the end of 2004, Global Fund-supported projects had enabled an increase of ARV treatment to over 1,400 patients living with HIV in Ukraine. Other key initiatives are being supported by USAID, the European Commission, and other donors, and are primarily focused on prevention, capacity building of public organizations, and initiatives in regions most heavily affected by the epidemic. In 2004, the government of Ukraine also began the implementation of a comprehensive project on HIV/AIDS prevention and support as part of a $62 million loan provided by the World Bank. The World Bank has also commenced a study on the socio-economic impact of HIV/AIDS in Ukraine. In 2004, the scope and coverage of national HIV/AIDS programs and services in Ukraine remained limited, while the epidemiological situation deteriorated as HIV continued to spread, particularly through heterosexual transmission.

Commitment and Coordination With the remarkable and rapid increase in available funding for HIV/AIDS programs in the region, there is an urgent need for solid political commitment to absorb and use the funds effectively. The challenges include a lack of coordination among international supporters, multiple monitoring and cumbersome evaluation and reporting systems imposed by different donors, insufficient management capacity, and poor coordination among concerned ministries and other government bodies. In countries receiving financial resources through the Global Fund as well as the World Bank, including the Russian Federation and Ukraine, implementation capacity is a concern and will require additional technical and administrative support. In the case of Russia, the fact that Global Fund grants have been provided to both the NGO Consortium as well as the government requires careful coordination; the Russian CCM was established only for the fourth round and relates only to the government grant. An added challenge in Russia is that implementation of a large number of activities funded through the Global Fund as well as the World Bank loan began around the same time, thus demanding careful coordination. Along these lines, Ukraine has substantially improved its implementation history with regard to funding provided by the Global Fund. In January 2004, the Global Fund suspended its funding to

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Ukraine due to concerns about slow implementation and overall governance. Since then, grant arrangements have been reinstated under the leadership of the International HIV/AIDS Alliance, which has developed strong ties with the National AIDS Center and other national partners. In July 2005, the Global Fund approved a continuation of its support to Ukraine until September 2008 based on an application that was jointly prepared by the new government, local nongovernmental organizations, and the All-Ukrainian Network of People Living with HIV. The application of the “Three Ones” principles—as developed by the United Kingdom, United States, and UNAIDS—provided a platform for efforts to improve coordination and efficiency of national responses to the epidemic. The Three Ones principles call for: ●

●

●

one agreed AIDS action framework that provides the basis for coordinating the work of all partners; one national AIDS coordinating authority, with a broad-based multisectoral mandate; and one agreed country-level monitoring and evaluation system.

Achieving full application of the Three Ones principles is a key priority of the United Nations system. UNAIDS and its cosponsors, along with other international stakeholders, have made it a top priority to support countries in the region in applying the Three Ones. The United Nations Theme Groups on HIV/AIDS, bringing together the UNAIDS cosponsoring agencies and the Secretariat, are the main vehicles through which agencies coordinate activities at the country level. During 2004–2005, the Three Ones principles were firmly established globally by governments, the United Nations, and civil society partners. UNAIDS acts as a facilitator at the country level for processes aimed at the consistent application of these principles, while also providing technical support in conjunction with cosponsoring agencies. In the Russian Federation and Ukraine, two major joint UN initiatives along these lines are underway with additional support from DFID and Sida Sweden. In both countries, UNAIDS and its cosponsors— in close consultation with national partners—have developed a set of activities related to policy and strategy development. Additionally, they supply technical support to key institutions and organizations while assisting in the development of a common monitoring and evaluation system. All activities have been developed and structured along each of the

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Three Ones principles, and the preparatory phases have included broad-based consultations with all relevant government and civil society partners. There is also active recruitment of people living with HIV/AIDS into the decision-making process. Other countries in the region are engaged in efforts to streamline national programs and improve coordination, including harmonization and alignment of donor support. To this end, UNAIDS is facilitating regionwide exchanges and technical consultations, as well as encouraging regional representatives to participate at international meetings and workshops that focus on applying the Three Ones principles. The Three Ones provide a conceptual framework for all countries in Eastern Europe and the Central Asia region geared toward expanding the response to the epidemic while the window of opportunity remains open. It is hoped that, if urgent action is taken, the epidemic can be curtailed. This will depend on firm political commitment and consistent efforts to expand collaboration and improve coordination.

Note 1. The Joint United Nations Programme on HIV/AIDS (UNAIDS) brings together the UNAIDS Secretariat and ten UN system organizations in a common effort to fight the epidemic: the Office of the United Nations High Commissioner for Refugees (UNHCR), the United Nations Children’s Fund (UNICEF), the World Food Programme (WFP), the United Nations Development Programme (UNDP), the United Nations Population Fund (UNFPA), the United Nations Office on Drugs and Crime (UNODC), the International Labour Organization (ILO), the United Nations Educational, Scientific and Cultural Organization (UNESCO), the World Health Organization (WHO), and the World Bank.

References UNAIDS (2004a) “Coordination in Action: Application of the Three Ones Principles in the Russian Federation,” project document, Moscow. UNAIDS (2004b) Report on the Global AIDS Epidemic (Geneva: United Nations). UNAIDS/WHO (2004) AIDS Epidemic Update, December (Geneva: United Nations).

7 HIV and Drug Use in Eurasia Robert Heimer, Robert E . Booth, Kevin Irwin, and Michael Merson

The twin epidemics of drug addiction and HIV simultaneously emerged in the Eurasia region in the late 1990s. Both were unanticipated by health establishments. Failure to act slowed the collection of detailed data and effective responses. In this chapter, we report on our observations and on those of our colleagues. To provide a proper sense of the problem created by the slow response of most of the governments in the region, this chapter combines a description of our experiences with the limited data available from scholarly sources.

Introduction and Context: Personal Observations In May of 2004, two of us (Heimer and Irwin) traveled to Irkutsk in Siberia and to Khabarovsk in the Russian Pacific region. The latter city is on the Amur River, 120 kilometers from the Chinese border and thousands of miles from major heroin trade routes. It is a handsome, prosperous city of 650,000 people and capital of the eponymous province, which stretches 1,200 miles north from the city along the Sea of Okhotsk. During our visit we were invited by the regional AIDS Center to travel with its staff to conduct HIV testing in a village, Mukhen, that was experiencing a newly detected HIV outbreak among injection drug users. To get from Khabarovsk to Mukhen, we took the major road north out of town and drove for about 45 minutes along the Amur River. We turned southeast for fifteen minutes and then left the

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paved highway. We drove east for an hour before we arrived at the end of the dirt road. Mukhen defines remote. It was once a prosperous lumbering village, but the mills that fabricated boards from the surrounding stands of timber are crumbling, and few remain in operation. The village amenities—the cinema, communal bathhouse, dispensary, and central market, all dating from the Soviet era—are in disrepair. The village’s 5,000 residents live either in single-story wooden houses or in three-story drab brick apartment blocks. Parts of town resemble the Appalachian houses that were photographed during the Depression. Despite being poor and isolated, Mukhen has discovered heroin. With its arrival came addiction and syringe-borne viruses like HIV. Testing of local residents who made their way to Khabarovsk seeking help for their addictions revealed an outbreak of HIV. So the staff of the AIDS Center had been making trips to Mukhen to offer voluntary HIV counseling and testing to villagers. Among the individuals who were visiting the village’s outpatient clinic for testing while we were there were a handful of curious young adults at little risk for infection, and seven or eight active injection drug users. The latter individuals reported little trouble obtaining their drugs, even in remote Mukhen. The drug they obtained was different from that being purchased by drug injectors in Irkutsk, 2,500 kilometers to the west. Injectors in Irkutsk, like those in Moscow, St. Petersburg, and some other parts of the former Soviet Union, were able to purchase commercially prepared heroin that would seem familiar to drug injectors in the western United States. This resinous product can be directly dissolved and injected. From Mukhen and Khabarovsk in the Far East to Tomsk on the West Siberian plain, all the way west to Novorossiysk on the Black Sea, and throughout Ukraine, the predominant form of drug is, by contrast, a form of morphine gum that is chemically modified into heroin by injectors before it is dissolved and injected. In Ukraine, it is known colloquially as “himiya” (chemistry) when it is prepared from the upper part of the stem and capsule of the poppy plant. In Russia, this same material is called “chornaya” (black) because of its color. The dried plant material is first mixed with baking soda and boiling water. The mixture is then heated and solvent added. To help remove dust and dirt, the solution is then strained through a cloth filter, more solvent added, and strained again. Vinegar and boiling water are then added, and the aqueous phase of the mixture is collected and evaporated by heating to concentrate the opiate alkaloids. It is possible to

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obtain the concentrated alkaloid as the opium gum from the poppy heads, called “mak” or “hanka.” At this point, all that is left is to convert the morphine into heroin by chemical acetylation. The final liquid product is drawn through a cotton filter on the tip of a needle into a syringe. Depending on the starting material and the inclusion of optional steps, the process can produce four milliliters of drug in 30 minutes to two hours, and its potency can vary enormously. In Ukraine, himiya is not self-made, but instead almost always purchased from gypsies or “drug dealers.” When purchasing from gypsies, users will typically go to one of the open-air markets in their cities and purchase two milliliters of the solution in a preloaded syringe, at a cost of six to eight hryvnia ($1.20–$1.60) per milliliter, that they often share with another user. Injectors report the advantages of buying from gypsies over dealers: gypsies are more likely to have drugs, are more conveniently located, are cheaper, and are seen as lower-risk in terms of selling HIV-contaminated drugs. The disadvantages are that gypsies generally have lower-potency drugs, and buying in the markets brings with it a greater likelihood of arrest. Consultation with himiya “dealers” revealed that they usually prepared enough solution for six to ten customers each day, which they sold out of a common container for 10–12 hryvnia ($2.00–$2.40) per milliliter. The solution is transferred to the buyer through one of several means: dealers take the user’s syringe and return with the solution in it; they have the solution in a cup and the user is instructed how much to draw up into his syringe; they “back load” the solution, squirting the buyer’s dose from a ten-milliliter syringe into the open end of the user’s syringe; or they provide it in solution in a condom. While the quality of the drug obtained from dealers was seen as better than that obtained from the gypsies, dealers “prepare” less often and thus are more likely not to have drugs to sell. In addition, since most dealers are users too, there is a greater risk of contracting HIV from infected dealers who might have put a dirty needle in the jar or who might give back a contaminated syringe. Regardless of whether the predominant form of heroin is commercial grade or homemade himiya, chornaya, mak, or hanka, older injectors in all cities who have used heroin since at least the mid-1990s report using the homemade variety first. Our conversations with these older injectors revealed that the popularity of preparation and injection of homemade opiates occasionally resurfaces, either when commercial heroin grows scarce or when poppies are in season. Users report that homemade

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drugs are often cheaper, and that homemade drugs allow more control over the quality (purity and potency) of the product. Many injectors also report experience injecting homemade methamphetamine, called “vint” in Russia and “shirka” in Ukraine. Vint making retains an almost mythical status in Russian drug culture, spawning numerous books and even a popular internet website about its production and users’ experiences. When heroin was scarce in the spring of 2002 in the aftermath of the U.S. invasion of Afghanistan, we found that the reagents for making methamphetamine were readily and openly available. At the Lubyanka metro station in Moscow, in the shadow of the old KGB headquarters, we descended a flight of stairs and encountered an older woman selling blue bottles of solutan, an ephedrine-based cold remedy. We walked to the next staircase and encountered a one-legged Russian-Afghan War veteran selling the chemicals needed to convert the ephedrine into methamphetamine. Neither was directly engaged in illegal activity. In fact, the police patrolling the station were more interested in the young drug user who approached the veteran, detaining him and questioning him about why he was carrying syringes. In free-market Russia, the lesson seems to be that it is acceptable to sell the raw materials for drugs, but not acceptable to use them. In Ukraine as well, methamphetamine use is common, although not quite as popular as heroin. While himiya was typically injected two to three times a day, shirka was usually injected only once a day. There is a second homemade stimulant often injected. Called “jeff” in Russia and “baltushka” in Ukraine, it is made by the oxidation rather than the reduction of ephedrine. This reaction produces methcathinone, the psychoactive ingredient similar to that found in khat, a plant material chewed in East Africa and the Arabian Peninsula. It is a short acting drug (30–60 minutes) that takes only a few minutes to prepare. It is also often described as a “woman’s drug” since it is reported to have aphrodisiacal properties.

Increasing Drug Use Follows the Fall of the Soviet Union Many attribute the expansion of psychoactive drug use and injection to the freedoms that came with the fall of the Soviet system (Atlani et al., 2000). While older Russians were disconcerted by the termination of the old political and economic order, younger Russians rushed

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to embrace Western ideas and products that had been previously forbidden to them. This inevitably included drugs. While opiate use was not uncommon, especially among Soviet soldiers who had fought in Afghanistan in the late 1980s, it was only with the opening of trade and the relaxation of state controls that widespread experimentation with injection drug use began. This dynamic is revealed by the official statistics from government-funded narcology (addiction) clinics, which register those individuals who seek treatment. In Russia in 1992, there were fewer than 50,000 registered drug users (Max Planck Institute for Foreign and International Criminal Law, 2000; Rhodes et al., 2004). By 1995, this number had tripled to 150,000, and by 2002 the number had again more than tripled to more than 500,000 (Rhodes et al., 2004). Convictions for narcotics increased eightfold between 1991 and 1997 to more than 70,000 (Radchenko, 2001). Similarly in Ukraine, the number of new reported cases of drug dependence increased sharply, from 4,544 in 1991 to 11,443 in 2001 (Pozynyak et al., 2002). This wave of experimentation with heroin use has reached all levels of Russian youth. Our study of heroin injectors from eleven Russian cities across the country found that 41.9 percent reported having at least some postsecondary education. In some cities, that number reached 55 percent. Heroin—a drug associated with organized crime, social deviance, and the ghetto—became popular among welleducated young Russians in part because of opportunities for abuse that were created by the economic and social situation and the new freedoms that came about in the wake of the fall of the Soviet Union. Democratic, open societies always have to weigh the costs and benefits of their liberties, but Russia has no tradition to rely upon. Many reports about Russia since 1990 have focused on the excesses engendered by these new freedoms. These excesses are most evident in the economic sector, exemplified by a concentration of economic power among a handful of oligarchs and the ongoing struggle of the Putin administration to discourage the oligarchs from meddling in politics (Goldman, 2003). They are also obvious in the consumer sector. Russia quickly went from a country of queues to a country where all consumer goods were available, from a country of dowdily dressed women to one that was at the global center of sex trade. It was only a matter of time before black market goods were as readily available as their open market counterparts. In the context of a thriving shadow economy, the emerging drug trade would find a well-prepared infrastructure.

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The situation is similar throughout the countries that comprised the Soviet Union. Rapid and extraordinary changes were brought on by its collapse in 1991. None may have undergone greater transformation, and greater social and economic disruption, than Ukraine. High unemployment led to increased poverty throughout the country. By 1999, nearly two-thirds of the population had earnings below the poverty level (UNDP, 1999). Economic disparity, together with a decline in state-supported services, reduced the quality of life for most Ukrainians and left many economically, psychologically, and physically vulnerable (UN Economic Commission for Europe, 1997; The Monee Project CSS/CIS, 1999). Into this vacuum illicit activities entered, most notably the black market in illegal psychoactive drugs. In the first five years following the demise of the Soviet Union, the magnitude of the illicit economy in Ukraine was estimated to have tripled, reaching more than 40 percent of the gross national product in 1994–1995 (Schneider, 2000). In a relatively brief period of time, domestically produced opiates and amphetamines proliferated throughout the country (United Nations International Drug Control Programme, 1997; Rhodes et al., 1999). Conversations with Russian drug users have reinforced the economic descriptions of a proliferating black market in drugs. With little history to guide an understanding of the impending impact of large-scale experimentation with addictive drugs, getting high on heroin at first seemed the chic, Western alternative to getting drunk on vodka. Take, for example, the case of Svetlana, a 21-year-old biophysics student whom we encountered through her participation in HIV research among drug users in St. Petersburg. She was in her first year of university when she and her boyfriend first used heroin. Like many Russian university students, both lived at home with their parents. Svetlana was planning to obtain her degree in chemistry and participate in biochemical research. Her boyfriend was pursuing a degree in law. As addiction took over their lives, Svetlana’s boyfriend first stopped his studies, then was expelled from his home by his family. He tried several time to quit on his own, with the help of friends, or by undergoing detoxification in a municipal narcology clinic. Each time he quickly relapsed, especially since many of his friends were still using. Foremost among these was Svetlana. Somehow Svetlana had managed to keep her use under control. She continued to study and to live at home. She admits that she made life hell for her boyfriend by continuing to use heroin, even in his presence, when he was trying to quit.

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They quarreled bitterly. He wanted her to stop; she told him to stop trying to control her life since he could not even control his own. She did not fully understand the power of addiction. Eventually, Svetlana rejected her boyfriend altogether. Today, she thinks that he still may be an addict, but she also knows that he did leave their home city to live with relatives in a smaller town. There, just possibly, it might be harder to get heroin and he might have overcome his addiction. Svetlana proved to be one of the fortunate ones. She decided to stop after learning that she was infected with HIV. She enlisted the help of some friends from a local support group of people living with HIV and their families. This support group provided her with what she needed to get through the rough detoxification period and with the ongoing encouragement to remain drug-free. All the while, Svetlana continued her studies at the university and expects to complete her doctorate in physical biochemistry within the next year. We will return to Svetlana’s story later, but it is not uncommon. Millions of young Russians have experimented with heroin since the late 1990s.

Current Trends in Injection Drug Use and Addiction Treatment The first few years of the twenty-first century are considered by many to be the years in Russia when experimentation with and addiction to hard drugs like heroin and methamphetamine peaked. This belief is supported by statistics from official government clinics and from anecdotal reports. In the major cities, we were told about the establishment in the early years of the decade of private narcology clinics that have since closed due to insufficient demand. In many places narcologists, who also treat those with alcoholism, are reporting an upsurge in the number of former heroin users who are being treated for alcoholism. Taking these three factors together, it seems that the wave of experimentation with heroin is over but that Russia is still burdened with large numbers of heroin addicts, a situation that resembles that seen in the United States after the first large epidemic of heroin use in the late 1960s and early 1970s. Providing adequate care to the large residual population of addicts in Russia seems an impossible task under present conditions. Addiction treatment is hampered by Russian law and Russian policies (Butler, 2003; Csete, 2004). Confidential treatment services are available, but these services are expensive. In order to receive free or inexpensive

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treatment, individuals must become registered addicts. This designation places them on a list for five years, resulting in a loss of privileges including certain forms of employment and suspension of driving licenses. If treatment were effective, many addicts might be disposed to make these sacrifices. Current care consists of palliated detoxification programs, usually five to ten days of inpatient care. There are few long-term abstinence-based recovery programs. Talking to the physicians who run the detoxification programs in several of the cities we visited, we conclude that a successful transition from detoxification to after-care is a rarity. First, the Russian system has no medical care programs that cover the long recovery period that follows successful detoxification. Second, the physicians and clinical staff responsible for running the detoxification do not engage in thorough discharge planning. Sometimes the narcology clinic will have made arrangements for their patients, upon discharge, to return to their families, but little or no counseling is provided to the families to prepare them for the difficulties of living with people in recovery. Narcotics Anonymous programs exist in many locations for those in recovery, but most narcologists we talked with were unlikely to refer their patients to these services. We are not sure why, but their reluctance seems to be based on the idea that these programs are not “medical.” Thus, it is not surprising that the success rate for detoxification is routinely estimated, even by the narcologists who run the programs, to be dismal. Physicians in St. Petersburg, Ekaterinburg, Kazan, and Khabarovsk have all confided that they expect that no more than five percent of patients who complete detoxification will remain abstinent for six months. To make matters worse, Russian law precludes the use of substitution therapy with methadone, buprenorphine, or any other opiate for the treatment of addiction (Butler 2003). Outside of Russia, the use of substitution therapy is widely acknowledged to be the most effective and cost-efficient way to manage opiate addiction and to prevent negative medical consequences of injection drug use such as HIV infection or drug overdose. The use of substitution therapy is expanding in much of the world. Inside Russia, substitution therapy is forbidden. Part of the reason may have a cultural basis in linguistics. The Russian language does not have words that distinguish treatments that palliate the negative effects of illness from those that cure. With this limitation, it is easy to view substitution therapy as a false medical treatment, since treated individuals remain dependent on some form

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of opiate medication. When abstinence is the sole acceptable goal of treatment for addiction, more rational approaches, such as substitution therapy, become unacceptable even in the face of overwhelming evidence that the abstinence-only based approach is all but universally unsuccessful. Over the past few years, coalitions of progressive Russian narcologists, regional AIDS Center directors, AIDS activists, and international treatment experts and advocates have tried to identify strategies that will change this calculus and allow the establishment, at least, of demonstration substitution therapy programs. To date, there has been little progress, but our observation is that more Russians seem open to expanding treatment options. Other countries in the Eurasian region do not seem to have taken such a regressive stance when it comes to substitution therapy. As of the fall of 2004, methadone programs were operating throughout the Baltics, in five cities in Lithuania, two in Estonia, and one in Latvia. In Central Asia, there were two programs in Kyrgyzstan. Movements to liberalize access to methadone are taking hold in Ukraine, Moldova, and Belarus. These steps have been accompanied by the establishment of national treatment guidelines, training of treatment providers, and availability of funding for eight pilot programs, including five in Ukraine. Buprenorphine is registered in these three countries as well, and small pilot projects have begun. The higher price of buprenorphine relative to methadone and the absence of national treatment guidelines, however, may slow expansion of its use.

HIV among Injection Drug Users Addiction is not the only negative consequence of heroin’s spread throughout the countries of Eurasia. The first place in the region where HIV/AIDS established itself in epidemic form was among young drug injectors who had extensive contact with the West. In Ukraine, the first outbreaks were reported in 1995 in the southern cities of Odessa and Nikolaev, with Odessa, in all probability, the port of entry. In the naïve population of IDUs who were unaware of the potential dangers from syringe-borne transmission of HIV and other viruses, prevalence increased rapidly. It has been estimated that within a year, 30 percent of all IDUs had become infected. The first Russian city to register an upsurge of HIV infections among IDUs was Kaliningrad (Mashkilleyson and Leinikki, 1999),

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Russia’s westernmost city and an unconnected enclave on the Baltic sandwiched between Poland and Lithuania. As a port city not directly connected to Russia, the end of Soviet control meant easier entry for both legal and illegal goods. In 1996, the first reports of HIV infection among the city’s growing IDU population surfaced, and by 2000, some estimates indicated that half of them were already infected. This pattern has been repeated throughout the region. For example, a mid-1999 rapid assessment of the situation in the city of Irkutsk found extensive injection drug use but little HIV infection, placing the number of IDUs at 50,000. This information was used to support the development of a harm reduction program centered on syringe exchange. But it was 13 months before the program could find funding and begin, even in a limited capacity. Over the five years since the assessment, the number of IDUs does not appear to have increased. Sometime in the 13-month interval, however, HIV arrived from Moscow, either in a Muscovite IDU visiting Irkutsk or in an Irkutsk IDU who returned home infected (Bobkov et al., 2001). By the time the exchange started, there were already 1,300 people who were registered as infected with HIV (Burrows and Weber, 2001). Almost all were IDUs. Despite this explosion of infections, the exchange was allowed to operate inefficiently, without adequate funding or support from the local AIDS Center or municipal health establishment. Syringe exchange was viewed with suspicion as a foreign idea. As a result, near the end of 2004, there were more than 17,500 people registered as HIV-infected in the Irkutsk region; nearly all were IDUs, and nearly all lived in the city of Irkutsk. This was a preventable epidemic. A mechanism to prevent it was elaborated, but failures at the local and federal levels resulted in a failure to implement targeted prevention activities.

Law Enforcement and Stigma May Hamper Prevention Efforts There are other aspects of the situation in Irkutsk that shed some light on why it is home to the highest population prevalence of registered HIV infections of any territory in Russia (652 per 100,000 people as of November, 2004). Many of these enabling factors were described to us by Vladimir, a veteran heroin injector and Metallica fan who unofficially presides over harm reduction in Third Village, a run-down neighborhood of one-story wooden shacks on fenced-off small lots located across the Angara River about a half hour by bus from the center of Irkutsk.

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Third Village is one of the few places in Russia where we have witnessed an open drug scene. IDUs throughout the city know this place. And the police know it as well. The sellers are encountered on the pitted roads that run through the area, and they sell heroin for as little as 100 rubles ($3.30) per dose. This is the usual price, but when the heroin gets scarce or the police launch one of their periodic crackdowns, the price can double. Vladimir explained that the local heroin dealers and the police are in cahoots. Police routinely shake down the users for money or for drugs. Police let the IDUs keep their drugs if bribes are offered. Bribes can net 30,000 rubles per month per precinct. If drugs are confiscated from IDUs in Third Village, they often wind up for sale in other neighborhoods of the city. On occasion the police authorities have tried to stem this corruption, but their efforts have been only briefly effective. The former, allegedly corrupt precinct commander, who was ousted in 2002, was returned to his post within two years. Heroin is a problem for many young persons in Irkutsk, including some who seek to join the police force. It seems that even police cadets from the nearby training academy come to Third Village to buy their heroin. The quality is routinely high and the likelihood of arrest remains low if injectors follow the “rules.” In Ukraine, injectors report a similar kind of accommodation by corrupt police officials. We were told that gypsies paid a monthly fee to the police in order to continue illegal operations. Since the police had a monthly quota of arrests to make, when they needed to arrest users they notified the gypsies, who would not go to the market that day. Users who did not know this would show up and get arrested. There was also an allegation that drug selling at one of the markets in Odessa ceased for several months as the gypsies and the new director of the market could not agree on the price of the bribe. Whatever the accommodation between the dealers and the authorities, users are less protected. Police harassment, arrest, and incarceration are the norm. We heard many stories when we visited Irkutsk in May of 2004 of police arresting users, taking them to the police station, beating them, and then releasing them. Of the 826 drug users that we interviewed in eleven cities in Russia between 2002 and 2004, 45 percent had been to prison at least once. The police were also known to take preloaded syringes from users or confiscate ephedrine as users left pharmacies, and then demand payment for their return. Such aggressive police practices throughout Russia have discouraged drug users from obtaining new syringes at pharmacies, an otherwise legal and

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affordable resource. Drug injectors reported that the police presence at the central drug distribution points led them to seek a safe place to inject immediately after buying drugs. This urgency has prevented safer injection hygiene from becoming routine, despite the educational efforts of harm reduction programs. In Irkutsk, harm reduction programs face additional hurdles. Despite regular harm reduction outreach to Third Village, the resources available to the city’s harm reduction program are often insufficient. Its services have varied with changes in program resources and in the political climate (Meyer, 2000). An Irkutsk Harm Reduction Project began in 1999 with money granted by the George Soros-funded Open Society Institute. It has received funding from UNICEF, the U.S. Red Cross, and more recently, Pfizer. The program operates out of the local office of the Red Cross, as well as in an informational center for people living with HIV or AIDS and their families. This part of the project was receiving 15–20 calls a day when we visited in May of 2004. UNICEF funds have been used mostly for informational campaigns that target the general population. When the project started, it was originally designed to operate out of a fixed site. Not one hospital, polyclinic, or narcology center, however, was willing to accept the project. It was therefore obliged to switch to a street outreach-based format. The project has worked with the local AIDS Center, police, and incarceration organizations, but it does not seem to be well integrated into the health apparatus of the city. It has virtually no allies in local government. The project sends people to the AIDS Center for testing, but the AIDS Center seems to give little support in return. There is no evidence that the other arms of the public health apparatus are of much use either. The IDUs we interviewed in Irkutsk reported that the local narcologists remain all but unanimous in their belief that IDUs are recalcitrant and do not want treatment for their addictions. The project has found that IDUs’ most common question is, “How can I stop using drugs?” Unable to provide much of an answer except detoxification and abstinence, narcologists are avoided. The Irkutsk project continues today to support drug users, but the form that its services will take in the future remains an open question. When we visited, the syringe exchange part of the program had been temporarily suspended for several months. Before that, the project was exchanging about 60,000 syringes per year, with 92 percent of syringes returned. (Recall that if the rapid assessment estimate of 50,000 IDUs was even a twofold overestimation, this would barely amount to two syringes per IDU per year.)

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Three factors forced a cutback in the provision of clean syringes. First, our visit occurred shortly after parts of the Russian federal government sought to restrict syringe exchange programs. This effort originated with the State Drug Control Committee (SDCC), which has central offices in Moscow and agents in each Russian territory. Its authority to restrict was felt to reside in Article 230 of the Russian Criminal Code, which makes it a crime to “incline” anyone toward the use of illegal drugs. The SDCC had interpreted inclining to include any activity that does not prevent individuals from using illegal drugs. Since syringe exchange does not castigate drug users, but instead seeks to meet them on their own terms to prevent the negative consequences of their drug use, it was objectionable to the SDCC. Scientific evidence that syringe exchange has never been associated with increases in drug use in a community in which an exchange was situated was irrelevant. The SDCC framed the issue in narrow moralistic terms that were not open to rational discussion. In many parts of Russia, syringe exchange activities were curtailed after the SDCC instructed its regional agents to act, and as a result all local harm reduction activities targeted at drug injectors must be reported to the SDCC and the federal public health ministry. In some locations, where the exchange program was financially stronger or better connected to the local health establishments than was the case in Irkutsk, the impact of the SDCC actions was mitigated. In Irkutsk, however, the program chose not to oppose the local SDCC. The financial plight of the Irkutsk harm reduction project, the second of three hurdles, may have influenced its decision not to oppose the SDCC. Funding from the Open Society Institute for syringe exchange had ended, and there were no resources to keep up the purchases of the 5,000 syringes needed each month. A 300,000 ruble ($10,000) grant from Pfizer Pharmaceuticals was going to be used to purchase, operate, and maintain a van for the mobile delivery of services. It is unclear whether these services will include syringe exchange at any time in the near future. The third hurdle encountered by the harm reduction program in Irkutsk results from the stigma associated with HIV/AIDS. Normal kindergartens and primary schools still refuse entry to the more than 20 HIV-infected children in the city. The project has had to create an orphanage for children abandoned by their mothers, as well as a maternal program that provides the 150 HIV-positive mothers who keep their children with supplemental food and vitamins. Antiretroviral treatment is not yet an option for the

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mothers, although the local AIDS Center claims to have the resources to provide combination therapy to reduce mother-to-child transmissions. The stigma is not restricted to the general public. Based on their findings of widespread HIV/AIDS stigma and discrimination in a study of local health care institutions, the project has begun an anti-stigma campaign targeting medical professionals, but still many prejudices remain. Such prejudices are often actively voiced by government officials. In Ukraine, for example, when one of us (Booth) met with a highranking member of the Ministry of Health to explain HIV prevention and our project, his radio was playing so loudly that it was impossible to hear the translator. At our request he turned the radio down, but his disinterest was evident. Another example of official prejudice was failed efforts to obtain permission for project outreach workers to distribute bleach to disinfect syringes. Despite Western research and U.S. government letters attesting to the effectiveness of bleach in reducing the transmission of HIV, the Ministry of Health adamantly maintained that it did not trust U.S. researchers. The chairman of the Disinfection Committee, under the Ministry of Health, told us that only if their laboratory scientists found bleach to be 100 percent effective in eliminating HIV would it be approved, but that the ministry would conduct such tests only if our project paid for them. The final, insurmountable barrier was being informed that transferring products such as bleach from large containers into smaller (2 oz.) bottles that could be distributed to drug injectors was not permitted in Ukraine. It is one thing for local officials who do not have evidence that their local harm reduction efforts are a success to remain skeptical. It is another for places with proven success to disparage those efforts. This has occurred quite recently in Lithuania.This Baltic country sits adjacent to the Russian oblast of Kaliningrad, which as noted above was the first location in the Russian Federation where HIV was found to be spreading at epidemic rates among drug injectors. In Lithuania, HIV prevalence in adults is estimated to be 0.1 percent, the lowest HIV rate of the three Baltic nations, only a tenth of that in Estonia and the Kaliningrad oblast. Lithuania was among the first former Soviet countries to adopt a harm reduction strategy (Subata and Tsukanov, 1999). It combined syringe exchange, methadone maintenance, and outreach to and education of drug injectors, a three-pronged strategy felt to be important in keeping HIV prevalence low (Des Jarlais et al., 1995). Harm reduction has been an official policy of Lithuania for many years, a fact confirmed by Lithuania’s support for international documents

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that call for harm reduction, including the UNGASS Declaration of Commitment, the Dublin Declaration on partnership for effective responses to HIV and the EU drug strategy for 2005–2012. Nevertheless, in March 2005 Lithuanian parliamentarians individually and in two committees called for the EU Drug Horizontal Group to delete harm reduction from its action plan for 2005–2008. Supporters of harm reduction from the Ministry of Health and the NGO sector were ignored as the parliamentarians argued, erroneously on both counts, that Western support for harm reduction was flagging in response to the absence of scientific data in its support. Lithuania thus became the only European country to oppose harm reduction at the Group meeting. It remains to be seen whether this action will have long-lasting consequences for Lithuanian public health policy, but it does not augur well for harm reduction that opposition came from both the Labor Party and more conservative politicians.

A Failure of Surveillance? As other chapters in this volume have speculated, the Russian government may be undergoing a slow and long overdue change in attitude, from viewing the epidemic as a troubling but peripheral problem concentrated in undesirables like drug addicts and sex workers to a threat to national security. This evolution in perspective suggests that the government may finally be poised to respond. The question remains: to what will they be responding? One might expect that, with a large, nationwide program that has HIV-tested at-risk populations often without their explicit permission, the Ministry of Health could provide reliable statistics, but to date no suitable sentinel surveillance strategy has been enacted. It is therefore hard to take the official epidemic statistics at face value. In Russia, this becomes especially true when one looks at the reporting of new HIV infections since they reached their peak in 2001. Only 52,000 new cases were reported in 2002, 40,000 in 2003, and just under 33,000 in 2004. During this time, the percentage of cases attributable to injection drug use also declined. In St. Petersburg, the percentage of infection due to injecting drug use declined from around 80 percent in 2000 and 2001 to 60 percent in 2003, while the percentage attributable to heterosexual transmission increased from less than five percent to 15 percent. The difficulty in drawing a conclusion from these statistics is that the percentage of infections with unknown attribution during this same time frame more than doubled from eight percent to 20 percent. If these unattributed infections were divided in the

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same proportion as the attributed cases, then 75 percent of the cases were among injectors. This is not a significant decline from the 80 percent reported in the preceding years. The surveillance system has other limitations. Before one can understand what the number of registered Russian cases means, one has to know the denominator from which the cases are identified. In this situation, the appropriate denominator is the number of injectors tested for HIV infection. Injectors known as such to the surveillance system are those tested at narcology centers or following detention by the criminal justice system. Between 2001, the ostensible height of the epidemic, and 2002, the number of injectors tested declined from 524,300 to 331,100. This 37 percent decrease is only slightly less than the percentage decline in the total number of cases detected, which fell from 88,000 to 52,000. Thus, the ratio of positive persons to all injectors tested in the two years remained about the same, with a prevalence of 16.8 percent in 2001 and of 15.7 percent in 2002. If the number of injectors coming into contact with the surveillance system had remained the same, then little or no drop in the number of newly reported cases would have been observed. An important question is therefore what factors accounted for the drop in the actual number of injectors coming into contact with elements that contribute to the country’s surveillance system. The several possibilities include a decrease in the actual number of injectors as injection drug use became less socially acceptable, a decrease in the use of narcology services by injectors, lower rates of incarceration of drug users, or decreased rates of testing among those injectors newly registering at narcology centers or newly incarcerated. There is circumstantial evidence that all of these hypotheses are correct, which does little to resolve the mystery behind the decline in newly registered HIV infections. On the other hand, there is evidence that in some high prevalence regions of Russia, HIV prevalence among injectors is continuing to increase. In St. Petersburg, convenience samples of injectors (meaning that no attempt was made to determine if the individuals questioned and tested were representative of the entire population of injectors) found HIV prevalences rising from two to four percent in 1998, to 11–18 percent in 2000, and to 30–38 percent in 2002 (Abdala et al., 2003; Krupitsky et al., 2004; Ostrovsky, 2000, 2002; Shaboltas et al., 2004). Yet official HIV incidence among this population in 2003 remained at four percent (Kozlov et al., 2004). These conflicting findings demonstrate the limitations of an inadequate surveillance system. The situation in Ukraine is similar, where it is also widely held that the official statistics grossly underestimate the true scope of the

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epidemic. Ukrainian legislation requires that only those who have undergone clinical and laboratory testing by a government-approved laboratory, and who are identified by name, be included in the HIV register. The country’s declining economic situation has led to a severe decrease in testing since a peak in 1993. Moreover, we have been told repeatedly since 2000 by several Ukrainian colleagues that one firm, with ties to the Ministry of Health of Ukraine, has a monopoly on manufacturing test kits, which are of questionable quality. In spite of fewer opportunities for testing and a reluctance to get tested, official HIV prevalence nearly doubled from 1999 to 2003 (“Eastern Europe and Central Asia,” 2005). The inadequate surveillance systems throughout countries of the former Soviet Union also make it difficult to predict the future course of the epidemic. (This is exacerbated by the increased freedom of movement of people across borders.) A question that weighs heavily on the minds of many of those concerned about the Russian HIV epidemic is to what extent the concentrated epidemic of HIV/AIDS in drug injectors will expand into the general population. Heterosexual transmission does seem to be increasing. Several estimates predicting the growth of the epidemic are quite bleak (Lowndes et al., 2003). For example, Grassly et al. (2003) estimate that once HIV enters the injector community in an urban population, there is a greater than 90 percent likelihood that between 15 and 70 percent of all urban sexually active adults will become infected within ten years, given the best data on risky injection and unsafe sexual practice. Of course, this is a prediction, based on mathematical modeling informed by behavioral surveys, but it does indicate why a better surveillance system is imperative. Without such a system to know where the epidemic is growing most swiftly, it will be impossible to allocate appropriately the scarce resources available for HIV prevention. It is like fighting a growing fire with a small extinguisher—one needs to be extremely accurate with one’s aim. Miss the target and the blaze could get completely out of hand.

Reasons for Optimism? We have spent much time in this chapter sounding dire warnings. Given the poor financial, medical, and social responses to date and the stigmas associated with the two interrelated epidemics of drug use and HIV, it is hard to be optimistic. There are, however, some bright spots in the response to the epidemic in Eurasia that should be recognized.

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These highlights include the development of some well-designed and demonstrably successful HIV prevention programs focusing on drug injector education and syringe exchange, the appearance of support groups of and for people living with HIV and AIDS, and the emergence of social advocacy to reduce stigma and promote a sane, scientifically valid public health policy. Among the most successful HIV prevention programs implemented to date is Project Renewal in Kazan, the capital of Tatarstan in the Russian Federation. Kazan is a city of 1.1 million inhabitants located on the central stretch of the Volga River. Project Renewal is unusual among Russian harm reduction projects. It is run directly out of the Ministry of Health, has collected and analyzed data to demonstrate its effectiveness, and has produced training materials to teach other Russian harm reduction programs how to replicate its successes. The project is built on a tripartite approach to provide injectors with access to clean syringes that has proven especially effective in the Russian legal and economic context. The first approach relies on fixed-site exchange point services in dispensaries throughout the city. The second employs mobile exchange vans that visit locations of open, street-based commercial sex solicitation. The third approach is based on the fact that, unlike the open scenes for commercial sex work, the drug markets are not open areas at which injectors can be contacted (Badrieva and Karchevsky, 2001). Instead, the project relies on outreach workers who visit apartments that attract large or regular gatherings of drug injectors. The outreach workers train the inhabitants of these apartments in the elements of harm reduction and provide them with the supplies needed to create venues for high-volume secondary syringe exchange. The interactions of the outreach workers and the provision of supplies are monitored to keep the most productive secondary sites functioning. Project Renewal has demonstrated that participants who interacted with the program were less likely than newly encountered injectors to give away or use previously used syringes, more likely to have used a new syringe the last time they injected with others, and more likely to be able to anticipate their need to acquire new syringes (Badrieva et al., 2006). Furthermore, their data indicate that the secondary exchange sites have proven more productive than the mobile and fixed-site syringe exchanges (Irwin et al., 2006). Since 2001, Project Renewal has trained other harm reduction programs in the Russian Federation to employ this model of reaching injectors, identifying and training volunteers, and monitoring results of secondary syringe exchange.

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If there is hope for Ukraine it is in the recent change of government. Viktor Yushchenko, the new president, has declared that he wants closer ties with the West, including becoming a part of the European Union. The final election was held in December 2004, and there is some evidence that change is already occurring. Because of the vast corruption, the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2003 temporarily withdrew funds given to the Ministry of Health. The new government responded by firing a number of high-ranking officials, and the funds have since been restored, based in large measure on Yushchenko’s vow to end corruption. The fate of Ukraine may rest on his success or failure. When the AIDS epidemic surfaced in the United States, the Reagan government was slow to respond. Early promises of a vaccine-based cure were made and broken. Stigma against those infected was widespread, even among those treating the infected (Shilts, 1987; Gerbert et al., 1991). The response in the United States has remained suboptimal, but much of what has happened to improve the situation was the work of AIDS activists. Their combative tactics and firm commitment to increasing AIDS awareness and scientific knowledge have proven to be an effective, even if sometimes rebarbative, strategy. The early activists such as ACT-UP and the AIDS Brigade were first ignored and then denigrated by those in power. A generation later, the activists’ agenda seems mainstream even when it is rejected (Souder, 2005). The stirrings of a similar trajectory seem to be underway in Russia. The most obvious evidence along these lines in the Russian Federation is the award of nearly $90 million from the Global Fund to Fight AIDS, Tuberculosis and Malaria to Globus, a consortium of Moscow NGOs that previously were viewed with disdain by most in the Russian government. The money from the Fund will be used to support prevention programs, demonstration treatment efforts, and anti-stigma public awareness campaigns. This single action makes insiders of the NGOs that had previously been all but ignored by the Russian government. In spite of the widespread absence of a civil society legacy in postSoviet Russia, there has been a recent expansion of grassroots efforts to increase prevention efforts targeted at injectors, expand their access to antiretroviral care, and change the laws that hamper proper treatment of drug addiction. Organizations like AIDSFront and Kolodets are devising “in-your-face” activities reminiscent of ACT-UP. They have had moderate success in focusing attention on governmental neglect of the situation and in spearheading international support for

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changes within Russia and with the international agencies that perhaps can influence policies within Russia. Among the recent notable efforts of this kind has been a discussion at WHO about placing substitution medications to treat opiate addiction on the agency’s list of essential medicines. The success of this effort may go a long way toward overturning the Russian prohibition on substitution therapy and speeding the expansion of treatment in the other countries in Eurasia where such therapies are in their infancy. These coordinated advocacy efforts recently helped to prompt revisions to Article 228 of the Russian Penal Code, easing the penalties for drug possession (Levinson, 2004). This change may reduce the number of drug users in Russian prisons, which have served as incubators for HIV and tuberculosis (Bobrik, 2004; Frost and Tchertkov, 2002). Some in government have complained that the revised code is too lenient, and a new compromise may have to be reached. Another direction that the enhanced advocacy has taken is the organization of support groups for those infected and affected with HIV. These groups are the front lines in the struggles to reduce stigma, ensure antiretroviral and associated medical care for injectors and others infected with HIV, and increase the government’s commitment to controlling the HIV epidemic. This brings us back to Svetlana. She is a member of Svecha, a support group in her home town, St. Petersburg. In addition to completing her studies, Svetlana takes time to promote Svecha’s activities through meetings, political actions, interacting with other PLWHAs not yet involved with Svecha, and talking to interested strangers, including foreigners like us. For Svetlana and Svecha, the battle is still an uphill one against prejudice, limited resources, competing priorities, and inertia. The Svecha meeting that Svetlana invited us to attend was filled with passionate activists willing to take on this struggle. They remain the best hope for preventing dire epidemic predictions from becoming the reality of the future for Russia, Ukraine, and elsewhere in Eurasia.

References Abdala, N., J. M. Carney, A. J. Durante, N. Klimov, D. Ostrovski, A. M. Somlai, A. P. Kozlov, and R. Heimer (2003) “Estimating the Prevalence of SyringeBorne and Sexually Transmitted Diseases among Injection Drug Users in St. Petersburg, Russia,” International Journal of STD & AIDS, 14:697–703. Atlani, L., M. Carael, J. B. Brunet, T. Frasca, and N. Chalka (2000) “Social Change and HIV in the Former USSR: The Making of a New Epidemic,” Social Science & Medicine, 50:1547–1556.

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Badrieva, L., and E. Karchevsky (2001) Building Volunteer Networks: Secondary Needle Exchange, Peer Education (Kazan, Russia: Project Renewal). Badrieva, L., E. Karchevsky, K. Irwin, and R. Heimer (2006) “Reduced Injection-Related HIV-1 Risk Associated with Participation in a Harm Reduction Project in Kazan, Russia,” submitted to AIDS Education and Prevention. Barnett, T., A. Whiteside, L. Khodakevich, Y. Kruglov, and S. Steshenko (2000) “The HIV/AIDS Epidemic in Ukraine: Its Potential and Social Impact,” Social Science & Medicine, 51:1387–1403. Bobkov, A., E. Kazennova, T. Khanina, M. Bobkova, L. Selimova, A. Kravchenko, V. Pokrovsky, and J. Weber (2001) “An HIV 1 Subtype A Strain of Low Genetic Diversity Continues to Spread among Injecting Drug Users in Russia: Study of the New Local Outbreaks in Moscow and Irkutsk,” AIDS Research and Human Retroviruses, 17:257–261. Bobrik, A. (2004) “Health and Health-Related Factors in the Penal System of Russia,” report prepared for the World Bank, Moscow, January 2004. Bobrik, A., K. Danishevski, K. Eroshina, and M. McKee (2005) “Prison Health in Russia: The Larger Picture,” Journal of Public Health Policy, 26:30–59. Burrows, D., and U. Weber (2001) “The Time it Takes: When to Start Harm Reduction Programmes for HIV Prevention among IDUs,” paper presented at the Twelfth International Conference on the Reduction of Drug Related Harm, New Dehli, India, April. Butler, W. E. (2003) HIV/AIDS and Drug Misuse in Russia: Harm Reduction Programmes and the Russian Legal System (London, UK: International Family Health). Csete, J. (2004) Lessons Not Learned: Human Rights Abuses and HIV/AIDS in the Russian Federation (New York: Human Rights Watch). D’Adesky, A. (2003) HIV Erupts in Russia (Washington, DC: American Foundation for AIDS Reaearch). Des Jarlais, D. C., H. Hagan, S. R. Friedman, P. Friedmann, D. Goldberg, M. Frischer, S. Green, K. Tunving, B. Ljungberg, A. Wodak, M. Ross, D. Purchase, M. E. Millson, and T. Myers (1995) “Maintaining Low HIV Seroprevalence in Populations of Injecting Drug Users,” JAMA, 274:1226–1231. “Eastern Europe and Central Asia,” UNAIDS/WHO, AIDS Epidemic Update, December 2005, www.unaids.org/epi/2005/doc/EPIupdate-html-en/ epi05-07-en.htm. Frost, L., and V. Tchertkov (2002) “Prisoner Risk-Taking in the Russian Federation,” AIDS Education and Prevention, 14(supplement B):7–23. Gardner, K. J. (1996) “HIV Testing and the Law in Russia,” report published by AESOP Center, Moscow, http://www.openweb.ru/aesop/eng/hiv-hr/hiv.html (accessed May 25, 2005). Gerbert, B., B. T. Maguire, T. Bleecker, T. J. Coates, and S. J. McPhee (1991) “Attitudinal and Structural Barriers to Care,” JAMA, 266:2837–2842. Goldman, M. I. (2003) The Piratization of Russia: Russian Reforms Go Awry (New York: Routledge, Taylor and Francis Group). Grassly, N. C., C. M. Lowndes, T. Rhodes, A. Judd, A. Renton, and G. Garnett (2003) “Modeling Emerging HIV Epidemics: The Role of Injecting Drug Use

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and Sexual Transmission in the Russian Federation, China, and India,” International Journal of Drug Policy, 14:25–43. Irwin, K., E. Karchevsky, R. Heimer, and L. Badrieva (2006) “Secondary Syringe Exchange as a Model for HIV Prevention Programs in the Russian Federation,” Substance Use and Misuse, 41(6–7):979–999. Khodakevich, L., and K. L. Dehne (1998) HIV Epidemics in Drug-Using Populations and Increasing Drug Use in Central and Eastern Europe (Geneva: Global Research Network on HIV Prevention in Drug-Using Populations). Kozlov, A. P., A. V. Shaboltas, O. V. Toussova, S. V. Verevochkin, T. Perdue, B. Masse, and I. F. Hoffman (2004) “HIV Incidence among Injection Drug Users in St. Petersburg, Russia,” abstract presented at the Fifteenth International AIDS Conference, Bangkok, Thailand, July. Krupitsky, E., E. Zvartau, G. Karandashova, N. J. Horton, K. R. Schoolwerth, K. Bryant, and J. H. Samet (2004) “The Onset of HIV Infection in the Leningrad Region of Russia: A Focus on Drug and Alcohol Dependence,” HIV Medicine, 5:30–33. Levinson, L. (2004) New Revision of the Criminal Code: Anti-drug Articles (Moscow: Institute of Human Rights). Lowndes, C. M., M. Renton, M. Alary, T. Rhodes, G. Garnett, and G. Stimson (2003) “Conditions for Widespread Heterosexual Spread of HIV in the Russian Federation: Implications for Research, Monitoring and Prevention,” International Journal of Drug Policy, 14:45–62. Mashkilleyson, N., and P. Leinikki (1999) “Evolution of HIV Epidemic in Kaliningrad, Russia,” Journal of Clinical Virology, 12:37–42. Max Planck Institute for Foreign and International Criminal Law (2000) Illegal Drug Trade in Russia (Freiberg, Germany: Max Planck Institute). Meyer, H. (2000) “Siberian City Faces Threat of Full-Blown AIDS Epidemic,” Agence France Presse, December 12. Ostrovsky, D. V. (2002) “WHO Drug Injecting Study in St. Petersburg, Phase Two,” abstract presented at the Fourteenth International AIDS Conference, Barcelona, Spain, July. ——— (2000) “Injection Drug Use, HIV, Hepatitis, and Overdose in St. Petersburg,” paper presented at the Eighth International Conference on AIDS, Cancer, and Related Problems, St. Petersburg, Russia. Pozynyak, V. B., V. E. Pelipas, A. N. Vievski, and L. Miroshnichenko (2002) “Illicit Drug Use and its Health Consequences in Belarus, Russian Federation and Ukraine: Impact of Transition,” European Addiction Research, 8:184–189. Radchenko, V. I. (2001). Commentary on the Decrees of the Plenum of the Supreme Court of the Russian Federation with Regard to Criminal Cases, V. V. Lebedev and B. N. Topomin, eds. (Moscow: Russian Federation), 223. Rhodes, T., A. Sarang, A. Bobrik, A. Bobkov, and L. Platt (2004) “HIV Transmission and HIV Prevention associated with Injecting Drug Use in the Russian Federation,” International Journal of Drug Policy, 15:1–16. Rhodes, T., G. V. Stimson, A. Ball, N. Crofts, K. L. Dehne, and L. Khodalevich (1999) “Drug Injecting, Rapid HIV Spread, and the ‘Risk Environment’: Implications for Assessment and Response,” AIDS, 13(supplement 1): 259–269.

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Schneider, F. (2000) “Illegal Activities and the Generation of Value Added: Size, Causes and Measurement of Shadow Economics,” Bulletin on Narcotics, 52:102–104. Shaboltas, A. V., O. V. Toussova, I. F. Hoffman, R. Heimer, S. V. Verevochkin, R. W. Ryder, K. Khoshnood, T. Perdue, T. Masse, and A. P. Kozlov (2004) “HIV Prevalence, Sociodemographic, and Behavioral Correlates and Recruitment Methods Among Injection Drug Users in St. Petersburg, Russia,” Journal of Acquired Immune Deficiency Syndromes, 41(5):657–663. Shilts, R. (1987) And the Band Played On: Politics, People, and the AIDS Epidemic (New York: St. Martin’s Press). Souder, M. (2005) Testimony before the Committee on House Government Reform, Subcommittee on Criminal Justice, Drug Policy, and Human Resources, United States Congress, February 16. Subata, E., and J. Tsukanov (1999) “The Work of General Practitioners among Lithuanian Roma in Vilnius: Incorporating Harm Reduction into Primary Medical Practice,” Journal of Drug Issues, 29:805–810. The Monee Project CSS/CIS (1999) After the Fall: The Human Impact of Ten Years of Transition (Florence, Italy: UNICEF International Child Development Centre). UN Economic Commission for Europe (1997) Trends in Europe and North America 1996/1997. The Statistical Yearbook (Geneva: United Nations). UNAIDS/WHO [Joint United Nations Programme on HIV/AIDS / World Health Organization] (2002) AIDS Epidemic Update (Geneva: Joint United Nations Programme on HIV/AIDS). UNDP [United Nations Development Programme] (1999) Human Development Report (New York: Oxford University Press). United Nations International Drug Control Programme (1997) World Drug Report (New York: Oxford University Press).

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8 Rights and Lessons Scorned: Human Rights and HIV/AIDS in Russia and Eurasia Joanne Csete

Across the globe, HIV/AIDS has affected first, and most profoundly, persons who were socially marginalized and subjected to human rights abuse before the epidemic appeared. This is nowhere truer than in Russia and Eurasia, where drug users have been the most affected population. Drug laws and social disdain for narcotic drug users in the region have been harsh since Soviet times. A long-held lesson from the global experience of combating HIV/AIDS is that working respectfully with drug users, especially through peer-run programs, produces better results than repressive measures that are likely to drive them further to the margins of society and beyond the reach of health services. Unfortunately, this lesson has been scorned by some countries in the region, including Russia. The precarious state of the protection of human rights in general in the Soviet Union set a dangerous stage for this new epidemic. The first HIV/AIDS “programs” of the Soviet authorities beginning in the late 1980s set a tone of repression rather than respect of rights. These consisted of massive mandatory HIV testing of “high-risk” persons such as drug users, men who have sex with men (MSM), sex workers, and prisoners. From 1987 to 1994, the Russian government is estimated to have conducted over 140 million HIV tests on an involuntary basis (Stachowiak, 1996). The fall of the Soviet Union and the attendant increase in unemployment and poverty coincided with an increase in the availability in Russia and Eurasia of opium and heroin from Afghanistan. Narcotic drug use and heroin use in particular have risen meteorically since

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1990 and show no signs of abating (“Illegal Drug Trade in Russia,” 2000, p. 3). There are an estimated four million injection drug users in Russia alone, and some estimates run higher (HRW, 2004a, pp. 15–16). Injection drug users in Russia and Eurasia have rarely known human rights protections in the law. Rather, drug laws in the region and the manner in which they are enforced invite human rights abuse of users. The widespread stigma and social disdain they face allow abuses to persist with impunity. The rampant AIDS problem in the region is in many ways the logical conclusion of policies that cause drug users’ decisions to be governed by fear of abuse more than a desire to protect themselves and those around them from HIV. Among international public health authorities, there is a consensus that HIV prevention among drug users should be based on the idea that many persons who inject drugs are unable, for whatever reason, to stop using drugs, at least in the short to medium term. Ensuring that they have access to clean syringes for injection is a central element of HIV prevention in many countries. Assessing programs to provide sterile syringes in a recent review, the World Health Organization concluded that the effectiveness of such programs in reducing HIV transmission “must be regarded as overwhelming” (WHO, 2005, p. 28). In many countries, sterile syringes are furnished through syringe exchange programs in which used syringes are exchanged for sterile ones, usually at no cost to the user. For persons who inject heroin and other opiates, WHO and other UN agencies have recognized the importance of therapy with opiate substitutes such as methadone and buprenorphine, which can be ingested without injection and can stabilize cravings and enable drug users to live and work normally (WHO, 2005, p. 30; WHO/ UNODC/UNAIDS, 2004, pp. 2ff). As noted below, the human right to health is understood by international authorities to encompass access to a range of HIV prevention measures, including sterile syringe services. This chapter seeks to describe the link between systematic abuse of the human rights of drug users in the former Soviet bloc and the rapid spread of HIV/AIDS. With a focus on Russia and Central Asia, it suggests that human rights abuses associated with application of repressive drug laws and police abuse of drug users have directly undermined the realization of the right of drug users to health and particularly to protect themselves from HIV/AIDS. Recent changes in the drug laws in Russia are described and constitute some grounds for hope for a more rights-respecting approach to HIV/AIDS among drug users, but a long history of repression as the preferred official approach to drug control tempers that hope. This chapter relies heavily on the

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author’s field work and publications for the HIV/AIDS Program of Human Rights Watch.

Impediments to HIV Prevention for Injection Drug Users Injected heroin is the drug of choice in much of Russia and Eurasia. In many parts of the region, communal preparation of opiates for injection is one factor leading to high rates of sharing of syringes. A 2004 review noted that in Russia, for example, from 36 to 82 percent of IDUs shared syringes regularly, depending on the city, as did 22–65 percent of drug users in Russian prisons (Rhodes et al., 2004, pp. 5–6). There is clearly an urgent need for ensuring access of drug users to sterile syringes for prevention of HIV as well as hepatitis C and other diseases transmitted intravenously. In Russia and Eurasia, virtually all countries have at least a few functioning syringe exchanges, but in most the coverage is very low compared to the need. Some experts estimate coverage of as little as three to five percent of need in Russia and 10–11 percent in Eastern Europe and Central Asia (Global HIV Prevention Working Group, 2003, p. 19; 2004, p. 13). Moreover, none of the countries in the region provide national government funds for syringe exchange services, sometimes citing the fact that syringes can be purchased in drug stores in most countries (Wolfe and Malinowska-Sempruch, 2004, p. 56). Drug stores are undoubtedly the most important source of syringes for many drug users in Russia and Eurasia. Nonetheless, syringe exchanges are important because information, referral to other services, and other support can be provided along with sterile syringes. In Russia, significant reductions in risky behavior (including syringe sharing) linked to participation in syringe exchanges have been demonstrated repeatedly, but they have not been linked to drug store purchases of syringes. There is also some evidence of higher rates of condom use among drug users who have contact with syringe exchange services compared to those whose have other principal sources of syringes (Rhodes et al., 2004, pp. 6, 8). Studies in the region have shown that police abuse and other human rights violations impede drug users’ access to both syringe exchanges and drug stores. Police harassment is one of the most important factors that exacerbate risky behavior among drug users in the region. In a 2002 study of drug use in five Russian cities, 44 percent

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of drug users said that they had been stopped by the police in the month prior to being interviewed, and two-thirds of these said that their injecting equipment had been confiscated by the police (Rhodes et al., 2003, p. 41). More than 40 percent added that they rarely carried syringes for fear of encountering the police while possessing them. Drug users who fear carrying syringes are unlikely to use syringe exchange services or make sufficient syringe purchases in drug stores to keep up with their needs. In a detailed qualitative study in Togliatti, Russia, fear of being arrested or detained by the police was found to be the most important factor behind the decision of drug users not to carry syringes, which in turn was an important determinant of sharing syringes during injection (Rhodes et al., 2003, pp. 39, 45–46). Drug users who had been arrested or detained by the police were over four times more likely than other users to have shared syringes in the previous four weeks. Drug users who feared the police in Togliatti tended to avoid not only syringe exchange services but also drug stores, because police frequently targeted people buying syringes, a result also found in a 2003 study in Moscow (Trubnikov et al., 2003, p. 454). A 2004 Human Rights Watch (HRW) report drew on testimony of numerous drug users in St. Petersburg who feared purchasing syringes because of police patrols of drug stores, and other users who avoided needle exchange services out of fear of police abuse. One 36-year-old man who characterized himself as an experienced drug user noted, A lot of users will think it’s better to use old needles than to have contact with the police. Police can hang out where the [needle exchange] bus stops or near the drug stores. If they catch you with syringes, even if you have no heroin, you can be arrested or have to pay $500. Some drug stores even signal the police [when someone buys needles]. (HRW, 2004a, p. 29)

In the same report, health workers who managed syringe exchanges in the city asserted that syringe possession, while not illegal in Russia per se, nonetheless was a frequent trigger for extortion and other police abuse of drug users. “The central authorities of the police understand the [syringe exchange] services and they normally support the idea, but sometimes they need to fill their detention quotas,” said one service provider (HRW, 2004a, p. 30). Numerous drug users told HRW that police checked the arms of people they suspected of injecting drugs, and if they found injection marks, then harassment, extortion, or unlawful detainment would frequently follow. These actions on the

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part of state authorities most certainly contribute to reluctance on the part of drug users to seek public services. Humanitarian Action in St. Petersburg, an NGO with one of the longest experiences of HIV prevention in the region, made overtures to the city police to try to reduce harassment of drug users. Alexander Tsekhanovitch, the group’s president, told HRW, “[The police chiefs are] very smart and well educated, and they absolutely understand what we’re doing. But, they say, remember we get medals for arresting drug users. We can’t say to our people ‘stop arresting drug users’; this is how their performance is evaluated” (HRW, 2004a, p. 31). Alexander Rumantsyev, director of the NGO Delo in St. Petersburg, followed the disposition of the court cases of numerous drug users and noted that the acquittal rates were near zero, mirroring patterns previously reported in Russia (HRW, 1999, p. 118, 2004a, p. 35). Opiate substitution therapy using methadone is widely credited with controlling HIV transmission among heroin users in many countries, but it is illegal in Russia and illegal or not offered in Central Asia (except Kyrgyzstan), as well as in Albania, Armenia, Azerbaijan, and Belarus (Central and Eastern European Harm Reduction Network, 2002, p. 4). A long promised pilot program in Kazakhstan had not materialized as of late 2004 (Nurali Amanzholov, personal communication). Ukraine registered methadone for substitution therapy use in 2002 but at this writing has yet to authorize any programs. Since the fall of the Soviet Union, commercial sex work, like drug use, has by many accounts become much more widespread in Russia and Eurasia, and several studies have estimated that a high percentage of sex workers are also injecting drug users (Rhodes et al., 2004; Webster, 2003, p. 2133). Sex workers, whether they inject drugs or not, are especially vulnerable to HIV and other sexually transmitted diseases, particularly if they are unable to enforce condom use among their clients or if they are required to pay off the police with unprotected sexual acts. If they do inject drugs, they are often very likely to have to inject quickly—that is, in an unsafe manner—and may avoid syringe exchanges because of fear of police harassment or arrest based on their sex work or their drug use or both. In both Kazakhstan and Russia, Human Rights Watch documented numerous cases of police extortion of sex workers for either money or sex (HRW, 2003, pp. 25–29, 2004a, pp. 36–37). In many of these incidents, sex workers were required to have unsafe sex with police to avoid arrest or to be released from detention, or they were discouraged from seeking health services for fear of police abuse. “Sex workers and drug users are a big source of income for the police,” noted Anna Chikhacheva, a social worker with Humanitarian

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Action in St. Petersburg (HRW, 2004a, p. 36). Since drug users and sex workers are widely regarded in society as undesirable elements, the police face little risk of social censure for their harassment of these persons. In addition to human rights abuses suffered by drug users serving prison sentences, discussed below, Human Rights Watch has documented numerous abuses of the rights of drug users in temporary detention or awaiting trial (HRW, 2003, pp. 19–23, 2004a, pp. 34–37). These include abuse amounting to torture in which drug users’ addiction is used against them as an instrument of coercion in police interrogations. Many drug users also recounted violations of their due process rights—including the right to be charged and tried promptly and the right to competent legal counsel. All of these factors contribute to a climate of fear among drug users that undermines their motivation and capacity to seek HIV prevention services and other health care.

Human Rights Law, Other International Commitments, and HIV Prevention for Drug Users Under international law, all persons have a right to obtain lifesaving health services without fear of punishment or discrimination. The International Covenant on Economic, Social and Cultural Rights (ICESCR), which has been ratified by the Russian Federation and most Eurasian countries, guarantees this right and requires state parties to provide all the steps necessary for “the prevention, treatment and control of epidemic . . . diseases.” The UN committee that oversees the application of this covenant has stated that the duties of states with respect to this right should be understood to include “the establishment of prevention and education programs for behavior-related health concerns such as sexually transmitted diseases, in particular HIV/AIDS” (Committee on Economic, Social and Cultural Rights, 2000, para. 16). The right to health is also guaranteed in the Russian Constitution and in the laws of most Eurasian countries (Russian Federation, 1993, art. 41[1]). State action to impede people from attempting to protect themselves from a deadly epidemic is blatant interference with the right to health. The effectiveness of sterile syringes in preventing HIV and other blood-borne infections is clear (WHO, 2005, p. 28). Many studies have demonstrated that providing access to sterile syringes neither

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encourages drug use nor dissuades current users from entering drug treatment programs (WHO, 2005, p. 28). The near absence of humane drug treatment programs in Russia and Eurasia virtually guarantees that there will always be people who cannot stop using drugs. By preventing this population from obtaining or using sterile syringes, the state has effectively imposed a death sentence for illicit drug use. Other nonbinding international agreements or UN recommendations address the importance of syringe exchange and opiate substitution therapy as essential components of effective HIV prevention services. In 2001, member states of the UN General Assembly agreed to an HIV/AIDS declaration that endorsed “a wide range of prevention programs” including “sterile injecting equipment” and “harm-reduction efforts related to drug use” (UN General Assembly, 2001, para. 52). The 1998 UNAIDS/Office of the High Commissioner for Human Rights (OHCHR) International Guidelines on HIV/AIDS and Human Rights, which represent the consensus of governmental and nongovernmental experts but are not legally binding, also enjoin countries to ensure that there are no legal barriers to syringe exchange programs (OHCHR/ UNAIDS, 1998, para. 29d). WHO, UNAIDS, and the UN Office on Drugs and Crime stress that opioid substitution therapy reduces HIV risk and other harmful effects of heroin use, such as criminal activity, and say that this therapy “should be considered as an important treatment option in communities with a high prevalence of opioid dependency,” which is certainly the case in Russia and Eurasia (WHO/ UNODC/UNAIDS, 2004, p. 2).

Prisoners and HIV Prevention Being in prison or other state detention centers is an important risk factor for HIV in Russia and Eurasia. Because drug laws in the region generally allow incarceration of users who possess even very small amounts of narcotics, a high percentage of drug users find themselves in state custody at some point. About half the inmates in the prison system of St. Petersburg and its surrounding region, for example, were estimated in 2004 to be imprisoned because of drug-related crimes (HRW, 2004a, p. 39). From 1996 to 2003, HIV prevalence in Russian prisons rose more than thirtyfold (Roshchupkin, 2003, p. 213; UNDP, 2004, pp. 33–34). A 2000 survey of 9,727 inmates in St. Petersburg found that 46 percent were HIV-positive and 58 percent had injected drugs in the previous year (Rhodes et al., 2004, p. 4). Injection drug use is

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reportedly widespread in prisons in most countries in the region, while HIV prevention services such as provision of sterile syringes, opiate substitution, and even condoms are rare (Holley, 2003, pp. A1ff; UNDP, 2004, pp. 33–34). Some 300,000 prisoners are released each year from penal institutions in Russia alone, representing a public health challenge for the whole population (“Disease control . . .,” 2003, p. 6). Prison medical officers in the region have acknowledged the problem of drug use in prisons, and some seem frustrated by the official policy of denying drug use in prisons, which prevents putting programs in place to address HIV and other drug-related harms (HRW, 2004a, p. 40). Kyrgyzstan, Belarus, and Moldova are the only countries in the region that provide syringe exchange services in prisons (Lines et al., 2004, pp. 36–43). Prisons in most countries in the region also lack services for detoxification or rehabilitation of drug users other than simple withdrawal. Even condoms are not available in many prisons in the region, though condoms for conjugal visits— sometimes the only officially approved sex in prisons—are sometimes provided (HRW, 2004a, p. 41). Although the separation of HIV-positive and HIV-negative prisoners has been abolished as official policy in Russia and several other countries in the region, this separation still occurs in practice (HRW, 2004a, pp. 40–42; Roshchupkin, 2003, p. 213). Segregation of prisoners by HIV status not only contributes to the stigma faced by inmates living with HIV/AIDS but may also create a false sense of security around the idea that HIV transmission is absent or unlikely in the officially HIV-negative parts of the prison. Former prisoners living with HIV/AIDS in St. Petersburg reported that when they had the chance to move out of the “HIV-positive” part of the prison, they sometimes chose to remain segregated because they feared that they would be stigmatized or blamed for any new infection if they were integrated with others (HRW, 2004a, p. 42). Prisoners have the same right to health enjoyed by other persons, and they are completely reliant on the state for access to services essential to realizing this right. The WHO Guidelines on HIV Infection and AIDS in Prisons note that HIV prevention measures in prisons should be comparable to those in the surrounding community and should be based on “risk behaviors actually occurring in prisons, notably needle-sharing among injecting drug users and unprotected sexual intercourse” (WHO, 1993, art. A. 4). Regarding injection drug users in particular, WHO recommends that authorities consider provision of clean syringes where

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that service is available to the general public and recommends provision of condoms in all cases. Russia and most Eurasian countries are far from abiding by these international guidelines.

Discrimination and the Right to Information Human rights abuses faced by drug users in Russia and Eurasia are probably partly linked to the public association of drug use with HIV/AIDS, a highly stigmatized disease. Stigma and discrimination associated with HIV/AIDS are in turn linked to a gross deficit of basic knowledge about the epidemic in the region. A 2001 telephone survey of adults in St. Petersburg, for example, indicated that one-third of respondents believed that condoms did not protect against HIV, 48 percent believed that HIV could be transmitted through kissing, and 56 percent believed that it spreads from mosquito bites (Amirkhanian, Kelly, and Issayer, 2001, p. 50). A survey of 5,000 Russians found in 2001 that about 40 percent of respondents thought that a teacher who became HIV positive should not be allowed to continue teaching (Vanappagar and Ryder, 2002, pp. 1, 10). Discrimination thrives amidst such attitudes. A 2003 study of 470 HIV-positive persons in St. Petersburg found that 30 percent of respondents said that they had been refused health care because of their HIV status. About ten percent had been fired from their jobs or forced by family members to leave their homes (Amirkhanian, Kelly, and McAuliffe, 2003, pp. 2367–2368, 2370). In Russia, at least, the public’s lack of understanding of HIV/AIDS is attributable largely to the government’s limited investment in HIV/AIDS awareness programs. Given the size and potential destructive power of the AIDS epidemic on its territory, the Russian government has devoted comparatively little money and personnel to fighting HIV/AIDS. The annual federal budget for HIV/AIDS for the fiscal years 2002 through 2004 was about $4–5 million for an epidemic that is estimated to have infected over one million people and to be growing rapidly in the population of approximately 145 million (HRW, 2004a, p. 56; “Russia is running . . . ,” 2003, p. 43). By comparison, the government of Poland, with a population of 39 million people and an estimated 13,000 persons living with HIV/AIDS, allocated $11.7 million in the fiscal year 2003–2004 (UNAIDS, 2004a). Romania, with its population of 22 million and a very small number of people with AIDS, allocated $48 million over the last three years, including over $25 million for antiretroviral treatment (UNAIDS, 2004b).

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Discriminatory refusal of health care, as reported by many drug users to Human Rights Watch in its 2004 studies in Russia and Kazakhstan, extends in many settings to exclusion from treatment for HIV/AIDS. In St. Petersburg, where the Federal AIDS Center has some excellent policies on confidentiality of counseling and testing, the city health authorities have nonetheless refused to include active drug users in antiretroviral (ARV) treatment programs, citing the inability of active users to keep to a treatment schedule (HRW, 2004a, p. 45). This conclusion runs counter to studies conducted by the Federal AIDS Center in Moscow, in which active drug users complied well with ARV regimens (HRW, 2004a, p. 45), and with similar positive outcomes in numerous countries (Open Society Institute, 2004, pp. 9–11ff).1 Excluding drug users from ARV therapy, aside from being a selfdefeating public health policy in an epidemic so centrally driven by injecting drug use, is a violation of the human rights of drug users and a clear case of discrimination by the state. ARV treatment for drug users and all persons with HIV/AIDS who need it is further constrained in Russia by the government’s refusal to register general antiretroviral medicines for use in the country (HRW, 2004a, p. 14), the reasons for which are unclear.

Recent Developments in Narcotic Drug Policy in Russia HIV/AIDS and drug policy in Russia are important as they can be highly influential on the direction of policy in the entire Eurasian region. In December 2003, the Criminal Code of the Russian Federation was amended to include language that was interpreted by many experts as exempting syringe exchange programs from criminal prosecution under the drug laws. Before this change, the legal status of syringe exchanges was in question as the law seemed to allow such programs to be understood as potentially encouraging drug use (Butler, 2003, pp. 11–13). Along with this amendment, the Ministry of Health and the federal drug control office were authorized to review the standards for criminal possession of narcotics, which previously allowed possession of virtually any amount of illicit drugs to be punishable with long prison terms (Wolfe and Malinowska-Sempruch, 2004, pp. 39–40). The new standards issued in May 2004 liberalized the law considerably so that, for example, possession of less than one gram of heroin or less than 20 grams of cannibis would be administrative offenses punishable by

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a fine but not by imprisonment—still a strict standard, but an important change (Levinson, 2004a, p. 4). As a result, at least 30,000 inmates have been released, relieving a crisis situation of overcrowding in Russian prisons, which activists noted was the main motivation for the amendment in the first place (Levinson, 2004b). Nonetheless, at various times in 2003 and 2004, the federal drug control office in Russia made various threats against syringe exchange services in particular, saying that they should all be run by the government and not by NGOs, that they should always be in government hospitals and not in mobile units (the latter often being more convenient and less stigmatizing for drug users), that all persons using them should be tested for HIV, and that the services should not be anonymous—all ideas that run counter to what is known about best practices of HIV prevention among drug users (Mikhailov, 2003; HRW, 2004a, p. 20). In addition, the deputy director of the drug control office, Alexander Mikhailov, asserted that drug users and former drug users should not be permitted to work in HIV prevention services for injection drug users, a suggestion that runs counter to the conclusion of UNAIDS and HIV service providers all over the world that peer-led education can be most effective for HIV prevention among drug users and other marginalized persons (UNAIDS, 1999, pp. 20–25). For drug users, especially in places such as Russia where they are highly stigmatized, peer education and outreach are especially crucial. It will be important to follow the practical application of the new drug standards in Russia as much as their evolution on paper. After all, Russia has, on paper, one of the most advanced laws in the world to protect people living with HIV/AIDS from limitation of their human rights (Russian Federation, 1995). This law even provides that the state will guarantee “regular information of the population, including through the mass media, about accessible measures for the prevention of HIV infection.” But the ideal described in this law is unrecognizable in the lived experience of many drug users and people with HIV/AIDS in Russia.

Conclusion An active HIV/AIDS epidemic did not begin in Russia and Eurasia until fifteen years into the global history of this uniquely destructive disease. This gave the region the opportunity to profit from the experiences of other countries in confronting HIV/AIDS. Instead,

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Russia and other states in the region have systematically rejected lessons learned by hard experience in other parts of the world. They have treated drug users as though they are expendable commodities rather than human beings with the right to life and the right to health. They have failed to respect the right of their people to basic information on HIV transmission and AIDS care. Many countries, Russia most notably, have applied few resources to combat an enemy that threatens to kill millions in the region before it is through. The HIV/AIDS epidemic in Russia and Eurasia would have been, and would in the future be, dramatically less lethal if the region’s HIV/AIDS policies and programs were based on respect for the human rights of drug users and people living with HIV/AIDS. Instead, drug users, having little hope of access to humane treatment for their addiction, are put in a position of having to struggle for the right to health services that enable them to protect themselves from HIV and other life-threatening consequences of their addiction. Although not directly related to HIV/AIDS, the tragedy in the schoolyard of Beslan, Russia in September 2004, when more than 300 persons were killed by alleged Chechen separatists, may turn out to be important in the history of HIV/AIDS in the region. Some weeks after the event, Russian officials put out the word that some of the alleged terrorists were “drug addicts” led to violence by their addiction (“Drug addiction . . . ,” 2004). Whatever the merits of the accusation—and it was also noted that no injection equipment was found at the site—this accusation could not but harden public opinion against drug users in the country, potentially undermining HIV/AIDS programs for drug users. In the aftermath of Beslan, the Putin government in the name of counterterrorism also restricted civil liberties in a number of ways, including new restrictions on civil society organizations that may make it more difficult for them to receive independent support from overseas (see, e.g., Diederik Lohman, personal communication with the author; HRW, 2004b; and the text of the most recent legislation signed into law on January 10, 2006, available at http://www.icnl. org/ press/Articles/2006/20060119.htm). This move is significant because one of the great hopes for turning around the HIV/AIDS epidemic in Russia and Eurasia is an emerging civil society movement to fight the disease. Russia is one of only two countries in the world where the Global Fund to Fight AIDS, Tuberculosis and Malaria made a large grant to a group of nongovernmental organizations on the grounds that they were excluded from the government-led proposal to the Fund.

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This grant, made in 2004, has the potential to support groundbreaking efforts in HIV prevention and AIDS care and treatment for marginalized persons. Strong civil society organizations focused on HIV/AIDS and drug policy are growing in Russia, Central Asia, and throughout the region. Organizations such as the Central and Eastern European Harm Reduction Network, based in Lithuania, help provide a research base for this new movement. As in many other countries, the most important thing that governments in Russia and Eurasia can do to fight HIV/AIDS may be to ensure that civil society organizations are unencumbered in their efforts to reach out to drug users, sex workers, and prisoners in ways that governments in the region have largely failed to do.

Note 1. Research on this subject confirms unsurprisingly that active drug users face some challenges in ARV compliance not faced by non-drug users but that, with some simple and low-cost measures to tailor programs to drug users, compliance can be equivalent among drug users and other patients. The best results on compliance of heroin users to ARV regimens have been reported in settings where methadone or other opiate substitution therapy is readily available, unlike in Russia and much of Eurasia. See Moatti et al., 2000; Mocroft et al., 1999; Roca et al., 1999.

References Amirkhanian, Y. A., J. A. Kelly, and D. Issayev (2001) “AIDS Knowledge, Attitudes and Behaviour in Russia: Results of a Population-Based, RandomDigit Telephone Survey in Saint Petersburg,” International Journal of STD and AIDS, 12(1):50–57. Amirkhanian, Y. A., J. A. Kelly, and T. L. McAuliffe (2003) “Psychosocial Needs, Mental Health and HIV Transmission Risk Behavior among People Living with HIV/AIDS in Saint Petersburg, Russia,” AIDS, 17(16):2367–2374. Butler, W. E. (2003) HIV/AIDS and Drug Misuse in Russia: Harm Reduction Programmes and the Russian Legal System (London: International Family Health). Central and Eastern European Harm Reduction Network (2002) Injecting Drug Users, HIV/AIDS Treatment and Primary Care in Central and Eastern Europe and the Former Soviet Union (Vilnius, Lithuania: Central and Eastern European Harm Reduction Network). Committee on Economic, Social and Cultural Rights of the United Nations (2000) General Comment No. 14: The Right to the Highest Attainable Standard of Health (Geneva: United Nations). “Disease Control in North West Russia” (2003) Prison Healthcare News, (4):6, www.kcl.ac.uk/depsta/rel/icps/prison_healthcare_news_4.pdf.

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“Drug Addiction among the Beslan Terrorists” (2004) Pravda, October 19, 2004, newsfromrussia.com/main/2004/10/19/56680.html. Global HIV Prevention Working Group (2003) Access to HIV Prevention: Closing the Gap (New York: Henry J. Kaiser Family Foundation). ——— (2004) HIV Prevention in the Era of Expanded Treatment Access (New York: Henry J. Kaiser Family Foundation). Holley, D. (2003) “Up to 1.5 Million Russians Have HIV, Government Says,” Los Angeles Times, April 18, A1, www.aegis.com/news/lt/2003/LT030409.html. HRW [Human Rights Watch] (1999) Confessions at Any Cost: Police Torture in Russia (New York: Human Rights Watch). ——— (2003) Fanning the Flames: How Human Rights Abuses Are Fuelling the AIDS Epidemic in Kazakhstan (New York: Human Rights Watch). ——— (2004a) Lessons Not Learned: Human Rights Abuses and HIV/AIDS in the Russian Federation (New York: Human Rights Watch). ——— (2004b) Q&A: The Beslan Massacre and Its Aftermath, hrw.org/ english/docs/2004/09/22/russia9377.htm. “Illegal Drug Trade in Russia: Final Report” (2000) Freiburg, Germany, Max Planck Institute for Foreign and International Criminal Law, October. Levinson, L. (2004a) Russian Drug Policy: Time of Changes (New York: Open Society Institute). ——— (2004b) “Zakonodatelstva RF o narkotikah: Opit lobbirovanya grazhdanskovo interesa,” paper presented at the International Conference on Building Effective National HIV/AIDS and Drug Policy, Dushanbe, Tajikistan, November 22–23. Lines, R., R. Jürgens, G. Betteridge, H. Stover, D. Laticevschi, and J. Nelles (2004) Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience (Montreal: Canadian HIV/AIDS Legal Network). Mikhailov, A. G. (2003) “State Drug Control Committee of Russia,” letter no. 509, November 19, made available in English by the New Drug Policy Project, Moscow. Moatti, J. P., M. P. Carrieri, B. Spire et al. (2000) “Adherence to HAART in French HIV-Infected Injecting Drug Users: The Contribution of Buprenorphine Drug Maintenance Treatment,” AIDS, 14(2):151–155. Mocroft, A., S. Madge, A. M. Johnson et al. (1999) “A Comparison of Exposure Groups in the EuroSIDA Study: Starting Highly Active Retroviral Therapy (HAART), Response to HAART and Survival,” Journal of Acquired Immune Deficiency Syndromes, 22(4):369–378. OHCHR/UNAIDS [Office of the United Nations High Commissioner for Human Rights/Joint United Nations Programme on HIV/AIDS] (1998) HIV/AIDS and Human Rights: International Guidelines (Geneva: United Nations). Open Society Institute (2004) Breaking Down Barriers: Lessons on Providing HIV Treatment to Injection Drug Users (New York: Open Society Institute). Rhodes, T., L. Mikhailova, A. Sarang, C. M. Lowndes, A. Rylkov, M. Khutorskoy, and A. Renton (2003) “Situational Factors Influencing Drug Injecting, Risk Reduction and Syringe Exchange in Togliatti City, Russian Federation: A Qualitative Study of Micro Risk Environment,” Social Science and Medicine, 57(1):39–54.

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Rhodes, T., A. Sarang, A. Bobrik, E. Bobkov, and L. Platt (2004) “HIV Transmission and HIV Prevention Associated with Injection Drug Use in the Russian Federation,” International Journal of Drug Policy, 15(1):1–16. Roca, B., C. J. Gomez, and A. Armedo (1999) “Stavudine, Lamuvudine and Indinavir in Drug Abusing and Non-Drug Abusing HIV-Infected Patients: Adherence, Side Effects and Efficacy,” Journal of Infection, 39(2):141–145. Roshchupkin, G. (2003) “HIV/AIDS Prevention in Prisons in Russia,” in T. Lokshina, ed., Situation of Prisoners in Contemporary Russia (Moscow: Moscow Helsinki Group). Russian Federation (1993) Constitution of the Russian Federation, as amended in 1996, 2001, and 2003, Moscow. ——— (1995) Federal Law on Prevention of the Dissemination in the Russian Federation of the Disease Caused by the Human Immunodeficiency Virus, as amended in 1996, 1997, and 2000, Moscow. “Russia is Running Out of Time to Curb AIDS before it Devastates the Country” (2003) Economist, June 21. Stachowiak, J. (1996) “Systematic—Forced—HIV Testing in Russia,” Women Alive, Summer 1996, www.thebody.com/wa/summer96/russian.html. Trubnikov, M. N., L. N. Khodakevich, D. A. Barkov, and D. V. Blagovo (2003) “Sources of Injecting Equipment for Drug Users in Moscow, Russia,” International Journal of Drug Policy, 14(5–6):453–455. UN General Assembly (2001) Declaration of Commitment on HIV/AIDS, www.un.org/ga/aids/coverage/FinalDeclarationHIVAIDS.html. UNAIDS [Joint United Nations Programme on HIV/AIDS] (1999) Peer Education and HIV/AIDS: Concepts, Uses and Challenges (Geneva: UNAIDS). ——— (2004a) “National Response Brief—Poland,” www.unaids.org/en/ Regions_Countries/ Countries/poland.asp. ——— (2004b) “National Response Brief—Romania,” www.unaids.org/en/ Regions_Countries/ Countries/romania.asp. ——— (2004c) Reversing the Epidemic: Facts and Policy Options (New York: UNDP). Vannappagar, V., and R. Ryder (2002) “Monitoring Sexual Behavior in the Russian Federation: The Russia Longitudinal Monitoring Survey 2001,” report submitted to the U.S. Agency for International Development, Chapel Hill, NC, University of North Carolina, April. Webster, P. (2003) “HIV/AIDS Explosion in Russia Triggers Research Boom,” Lancet, 361(9375):2132–2133. Wolfe, D., and K. Malinowska-Sempruch (2004) Illicit Drug Policies and the Global HIV Epidemic: Effects of UN and National Government Approaches (New York: Open Society Institute). WHO [World Health Organization] (1993) Guidelines on HIV Infection and AIDS in Prisons (WHO/GPA/DIR/93.3, reissued as UNAIDS/99.47/E) (Geneva: United Nations). ——— (2005) Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS among Injecting Drug Users (Geneva: WHO). WHO/UNODC/UNAIDS (2004) Substitution Maintenance Therapy in the Management of Opioid Dependence and HIV/AIDS Prevention: Position Paper (Geneva: United Nations).

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9 AIDS and Security in Russia Harley Balzer

In Russia, as in many other countries, AIDS has been the “Nuremberg disease”: no one has it; people who are HIV positive deserve their fates due to immoral lifestyles; and Russian authorities are just following the practices in other countries where leaders refuse to acknowledge the problem until lots of people die. While Russian leaders replicate the behavior of rulers elsewhere, dismissing evidence of a growing HIV-positive population and focusing their attention on other pressing needs, AIDS has become a serious security issue in Eurasia. The Russian Federation faces a daunting challenge in staffing its military and security services. In the years 2015–2020, even with no losses due to HIV/AIDS, there will not be enough young men in the draft-age cohort to meet personnel needs. In this context, the impact of a moderate-scale epidemic of a disease like AIDS would turn an impossible situation into a disaster requiring unprecedented solutions. The puzzle of AIDS and Russian security is this: why with a strong commitment to restoring Russia’s role in global affairs has a government evinced so little concern about a threat that could seriously undermine Russia’s military and economic capabilities? Do Russia’s leaders perhaps know something more than outside observers about the nature of the problem in Russia, justifying their complacency? Is HIV/AIDS somehow different in Russia? Or are Russian elites behaving like leaders in many other countries who resist addressing the problem until faced with a serious crisis and strong demand from the affected communities? The answers to these questions are important not only to Russia but also to the security of the entire Eurasian region. If Russia does face declining security capacity due to HIV/AIDS, the country will be

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unable to exert a stabilizing influence in a territory extending from the EU border across the Caspian and Central Asia to China and India. If the most extreme negative projections of Russia’s demographic and health trajectory turn out to be correct, massive social dislocation could occur on a vast territory with thousands of nuclear weapons, dozens of facilities housing radioactive material, and chemical and biological weapons detritus. The issues are hardly of concern solely to Russia. The preceding chapters demonstrate that HIV/AIDS represents a major challenge to Russia’s health care system, administrative capacity, and stock of human capital. The argument in this chapter is that given Russia’s already daunting demographic situation and the current incidence of infection, HIV/AIDS represents a significant threat to both traditional and new Russian security concerns. It is a much more serious problem than in many countries with similar infection rates. Unlike China, India, or Indonesia, Russia’s population is already declining in numbers, making the impact of any additional population losses more severe. While the Russian government is hardly unique in ignoring the problem, the trajectory of Russian politics—narrowing opportunities for expression and limiting mobilization to groups approved by the regime—cuts off the possibility of collective action by affected communities that might alter government policy.

Demographic Demise Even if Russia experiences zero population losses from HIV/AIDS, the country faces a severe demographic decline. While some Russian leaders and policy analysts now recognize this to be a major problem, even most of these individuals continue to believe that some combination of rhetoric, inducements, and natural “self-correction” mechanisms will produce a change in birth rates. Few appreciate either the timespan within which the problems have been developing or the magnitude of the challenges (Feshbach, 2003; Obukhova, 2001). Russia’s demographic catastrophe involves multiple components, including a declining birth rate, exacerbated by smaller numbers of women in age cohorts who normally engage in reproduction and poor health among women of child-bearing age; unusually high mortality rates among males between the ages of 30 and 60; and increasingly poor health indicators for young men. Estimates from both Russian and Western sources suggest that Russia’s population of 144 million in 2004 will decline to somewhere between 110 million and 70 million by 2050. A smaller population is not necessarily in and of itself an

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insurmountable challenge. The overwhelming majority of Russia’s productive industries are in the natural resource sector, and hydrocarbons in particular. The oil and gas industries and related services employ perhaps three million people. About 70 percent of the Russian population lives in a condition of dependency on the state or on family and friends. Like Kuwait, Russia could rely on foreign labor in the service sector. Like Japan, small and medium businesses could draw on immigrant labor. Despite the political and social problems posed by large-scale labor immigration (Balzer, 2003), it might alleviate the labor force problem. The declining population does, however, represent a serious challenge to Russia’s human capital and security equation. There are not enough young people to staff the military forces that Russia’s leaders claim to need (table 9.1). These declining numbers, as shown in the table, will force a stark choice between maintaining military force Table 9.1 Estimate of Share of 18-Year-Olds Entering Higher Education Year

Male Births

Males Aged 18

Higher Full-Time Males Males Admitted Education Higher Admitted as % of Males Admitted Education Aged 18

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

1,028,204 929,394 829,276 722,584 734,721 700,084 666,570 643,146 655,944 621,807 649,608 673,515 719,511 760,934

1,039,000 1,056,000 1,031,000 1,041,000 1,056,000 1,083,000 1,066,000 1,088,000 1,122,000 1,128,000 1,190,542 1,265,483 1,241,000 1,224,000 1,275,000 1,269,000 1,195,000 1,101,000 1,025,500 927,000 826,500 720,000 732,000

583,900 565,900 520,700 590,700 626,500 681,000 729,000 814,600 912,900 1,059,000 1,292,500 1,461,600 1,504,000 1,644,000

360,800 368,800 359,100 392,400 396,100 423,100 445,800 488,300 532,300 589,000 687,500 745,700 774,700 803,800

233,580 266,360 208,280 236,280 250,600 272,400 291,600 325,840 365,160 423,600 517,000 584,640 601,600 657,600

22.48 25.22 20.20 22.70 23.73 25.15 27.35 29.95 32.55 37.55 43.43 46.20 48.48 53.73

Continued

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Table 9.1 Continued Year

2013 2014 2015 2016 2017 2018 2019

Male Births

Males Aged 18

Higher Full-Time Males Males Admitted Education Higher Admitted as % of Males Admitted Education Aged 18

697,500 664,000 641,500 653,500 619,000 647,000 671,000

Source: Compiled by author from Russian official data sources.

levels and offering young men opportunities to get a higher education. For the foreseeable future, and quite likely for the entire twenty-first century, Russia will have a smaller pool of conscripts. Despite efforts to raise the prestige of the military through public relations campaigns, most young men continue to view military service as something to avoid, even at high cost. The young men available for military service in the 1990s were increasingly less physically fit, less well educated, and more likely to engage in criminal and high-risk behavior than previous cohorts. If in the Yeltsin era discussions of Russian military reform were driven by political and economic considerations, under Vladimir Putin demography has become a major concern (Arbatov, 2004; Shilov, 2005). Little can be done to alter significantly the number of men available for the draft in the next two decades. Everyone who will reach draft age by 2022 had been born by 2004.1 The number of males reaching age 18 will peak in 2005–2006 and will decline by about 100,000 per year starting in 2007, for a total decline of some 400,000 by 2010. The reduction in numbers will reach 200,000 per year in some years. By 2015 the number reaching draft age each year will be 600–650,000, or about half the number in 2005 (table 9.1). Declining numbers of young men are exacerbating the already extreme problem of the military being unable to induce young men to serve. Surveys by the Ministry of Education in late 2003 found that 37 percent of young men would rather not serve in the military. About 70 percent had a negative view of the military, while only one in six was willing to consider contract service (Krasnaia zvezda, 2004).

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In Moscow only three percent of draft-age males serve in the military; in Moscow Oblast the figure is five percent (Galkin and Mukhin, 2004). Russian law provides two dozen categories of draft deferments, allowing between 80 and 90 percent of eligible young men to avoid service each year (Ulitskaia, 2004). Abetting draft avoidance has become a profitable business, with the cost of particular types of deferments reflecting both their reliability and the impact the diagnosis will have on an individual’s subsequent career prospects.2 The Ministry of Defense has waged a long-running campaign against Russia’s extensive list of deferments. Proposals to curb student deferments in early 2005 were postponed in the face of widespread protests over monetization of social benefits, but this was almost certainly a tactical retreat. Paralleling the shortage of suitable conscripts, the officer corps finds it increasingly difficult to recruit and retain personnel. The Russian military does not have a large cadre of noncommissioned officers (NCOs). Many of the duties performed by NCOs in the U.S. military are carried out by officers. Their number and quality has become a serious concern. During the 1990s, many officers remained in the military because it seemed to promise relative security. With improvement in the economy since 1998, military service has become less attractive. In the first two and a half years of the new century, more than 15,000 officers under age 30 left military service, along with about one-third of the lieutenants and about 30 percent of cadets (Gavrilov, 2002). Sociologist Sergei Solov’ev found that fewer than half (40–45 percent) of those subject to the draft would be willing to serve as officers under contract, and then only if adequate salaries and housing were provided (Solov’ev, 2003). Military concern about the declining pool of recruits is evident in increased campaigns to snare young men before they can legally establish exemptions (Galkin and Mukhin, 2004). The personnel shortage has given added impetus to discussions of military reform, generally predicated on a shift to a professional military (Arbatov, 1998 and 2004; Busza, 2000; “Aktual’nye zadachi . . .” 2003; Armeiskii Sbornik, 2004). Some Russian political and military leaders are seeking a combination of more realistic legislation and stricter enforcement, along with a program to staff at least part of the armed forces with professional contract personnel. Others favor a shorter period of universal service with no exemptions. A Federal Program adopted in 2003 mandated creating 80 contract service formations during 2004–2007 (72 in regular forces, three in

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Border Guards, and five in Interior Ministry Troops), with 147,500 men serving in these units. The contract personnel are to be enticed with higher salaries, guaranteed housing on retirement, funded pensions, and high quality medical care. Even if this program were to be 100 percent successful, 150,000 professional soldiers represent only 15 percent of Russia’s armed forces, not to mention the other “power ministries” that have their own militarized formations (such as the Border Guards, Interior Ministry, Ministry of Emergency Situations, Railroad Troops). It will be difficult to achieve even these modest goals. Reports in mid-2005 indicated that about one-third of the contract personnel recruited by local draft boards were dismissed as unsuitable or refused to sign their contracts when they arrived at military bases (Savenkov, 2005). Russia has also initiated a program encouraging young men of draft age from the CIS to migrate to Russia, with special arrangements to grant citizenship after they complete three years of service. In 2004, plans called for 500 soldiers to be recruited under these arrangements, but the supporting legislation was contradictory. It was not possible to invite young men from abroad to participate in the program, thereby limiting it to those already in Russia visiting relatives, working, or studying. But the decree implementing the program stipulated that after submitting an application an individual had three months to either enter the army or leave Russia (Moskovskii komsomolets, 2004). This politically contentious project would have to be improved and massively expanded to have a significant impact on recruitment. During 2003–2004 specialists at the Institute for the Economy in Transition prepared material in support of a proposed six-month term of service for all 18-year-olds. The concept was to establish a compulsory term of service at a level where fulfilling one’s military obligation would be perceived as less costly than paying for an exemption. According to one account, President Putin was prepared to endorse this proposal when Boris Nemtsov leaked it to the press, thereby making it impossible for it to be regarded as the president’s initiative (personal communication, Moscow, July 2004). In early 2005 Defense Minister Sergei Ivanov spoke several times about reducing the term of service to one year, an arrangement less objectionable to the military. In mid-2005 plans were announced to shift to a one-year term of service as of January 1, 2008, with about 500,000 men to be inducted each year. Students will be allowed to defer service, but will be required to serve after graduation. The state could pay for higher education and preparatory study for those who serve three years on a contract basis

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(Argumenty i fakty, 2005). While this may work in the short term, it will not solve the problems a decade from now. If 30 percent of young men are not fit for any type of military service, by 2012 the army would have to enlist all the able-bodied 18-year-olds to meet its conscription goals. Numbers alone do not convey the full nature of the challenges involved in staffing the Russian military. The physical condition and educational background of young men represents a serious concern for Russian recruiters. The smaller number of potential conscripts in future years will not be healthier than those now available. The most unfavorable health trends in the country are found among young people ages 15–17. Overall, illness rose by one-third among this group in the 1990s. Approximately 50 percent of young males finish secondary school with some chronic ailment. The number of teenagers infected with syphilis increased 70-fold between 1990 and 1997 (Malakhova, 1999). Even given a low base, the rates of STIs are alarming and generally are a reliable indicator of HIV trends (Eberstadt, 2004). Diverse sources report on the declining physical, intellectual, and moral quality of military personnel and the weak economic and technical base for the Russian military (Balzer, 2002 and 2003; Eberstadt, 1999 and 2004; Feshbach, 2003 and 2005; Oliker and Charlick-Paley, 2002; Trenin, 2001; Trenin and Malashenko, 2004; Vakhrameev, 2001). Nicholas Eberstadt (1999) has provided an excellent summary of the Russian health crisis and its implications for military recruitment, suggesting that Russia’s “relative economic and political decline” could continue for another generation. Eberstadt’s assessment may be overly optimistic. Without serious changes in policies and priorities on the part of Russia’s leadership, the “networked” problems of population decline, health, labor force, and education suggest that it would require dramatic changes to reverse the trajectory. The Russian military’s own assessment is that the social portrait of the army changed significantly between 1993 and 2003. Those entering military service in the twenty-first century have lower educational levels, poorer physical and psychological health, and manifest pacifist and antimilitary attitudes. They are more likely to be orphans or “unsupervised” and are more likely to use alcohol and narcotics. A growing number have criminal records (“Aktual’nye zadachi . . . ,” 2003).3 The Military Medical Administration reported that 300,000 of the young men conscripted into the military in 1999 were underweight and unfit for military service. The average child in Russia in

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1999 was shorter by 5–8 centimeters than children a decade earlier. Average chest size had decreased by 5–6 centimeters. Where conscripts in 1990 were generally capable of 50 push-ups, in 1999 many found it difficult to do even ten (Malakhova, 1999). Fewer than one in five conscripts is considered “healthy.” If in 1994 27 percent of draft age Russians could be inducted, in 2002 the figure was only eleven percent (Armeiskii Sbornik, 2004). The intellectual as well as the physical quality of those serving in the military is a serious and growing problem. During the 1990s enrollments in higher education in the Russian Federation reached record levels, both in absolute numbers and as a proportion of the age cohort. This impressive achievement was accompanied by a sharp decline in enrollments in preschool and kindergarten programs and decreased coverage in elementary and secondary schools. Russia has become a sharply stratified society, where roughly half of the young men enroll in higher education and avoid the draft, while the military must find personnel among the physically fit individuals in the other half. Only two percent of those conscripted in 2003 had a higher education (Konstantinovskii, 2003). Often Russia must draft secondary school dropouts, and in some cases individuals who are functionally illiterate. The number of recruits who had not completed high school increased fivefold in 2003 over the previous year, leading some to joke about revival of a “workers’ and peasants’ army” (Mukhin, 2004).4 Criminals and misfits might be a more apt characterization. The conscript pool increasingly consists of young men with criminal records, adjustment problems, and an inclination to engage in highrisk behavior. The number of recruits who admitted having used narcotics increased from eight percent in 2002 to ten percent in 2003. Some five percent of those drafted had been convicted of a juvenile offense, and in 2005 ten percent had a criminal record. Drug addiction increased tenfold, and drug abuse among teenagers accounts for 75 percent of that age group infected with HIV/AIDS (Feshbach, 2005). Russian security specialists have been discussing issues of force size, modernization, and a shift to contract service (Aldis and McDermott, 2003; Arbatov, 2004; SVOP, 2004). Many hoped the size of Russia’s military would be scaled back in the face of the demographic situation and changing security requirements. The debate was resolved at least temporarily in October 2003 with President Putin’s statement that the military “had been reformed enough” and that the number in military service would remain between one and 1.1 million. Defense Minister Sergei Ivanov cited this figure repeatedly in 2004–2005. Maintaining

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these numbers would constitute a significant challenge even if Russia experienced no additional population losses. Factoring HIV/AIDS into the equation produces scenarios requiring even harsher choices among military force requirements, higher education, and participation in the labor force. Examining the impact of HIV/AIDS on security in other regions of the world may help us to appreciate the sorts of challenges that Russia is likely to face.

HIV/AIDS and Security in Other World Regions The burgeoning literature on HIV/AIDS as a security issue has focused overwhelmingly on the most extreme example of the problem, sub-Saharan Africa (SSA) (ICG, 2004; Price-Smith, Tubin, and Ostergard, 2005; Pharoah and Schönteich, 2003; Altman, 2003; Heinecken, 2003; Ostergard, 2002; Elbe, 2002; Henk, 2001). Both in terms of the extent of HIV infection and its relation to armed conflict, this region has illustrated what can happen when the disease spreads unchecked in a region prone to conflict. While providing important lessons, sub-Saharan Africa is not necessarily a forecast of what will happen elsewhere. It is not even characteristic of all of Africa. But it does offer important cautionary examples. The African experience has demonstrated the five- to eight-year gap between HIV infection and the onset of AIDS. This region has also provided data on some of the ways military forces are particularly vulnerable to HIV: large concentrations of young men living away from home, not closely supervised, and therefore inclined (and sometimes encouraged) to engage in high-risk behavior, with pocket money to pay for alcohol, drugs, and commercial sex, and in some cases sharing partners. These attributes describe the Russian military as well as most African militaries (Frolov, 2004, p. 94). Other aspects of the African situation are not replicated in other regions. Sub-Saharan Africa moved to heterosexual transmission more quickly and with a more devastating impact than other world regions. While SSA is hardly the only place where men resist using condoms and women find it difficult to reject noncompliant partners, the problem seems to be particularly acute there. Cultural practices involving the “cleansing” of widows may be overrepresented in the Western media, but their existence has increased the spread of HIV infection. Some African leaders have been among the most recalcitrant deniers of the link between HIV and AIDS. While women everywhere have

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difficulty verifying whether their partners have engaged in unprotected sex with others, the problem appears to be particularly severe in this region. Combined with a low quality of health care, these practices have resulted in an epidemic of staggering proportions. Estimates suggest that as many as half the population in the 25–45 age group is infected. About 25 percent of the total South African population is projected to be HIV positive by 2010, but the rate will approach 50 percent among those aged 30–35. The impact varies geographically within SSA and even within individual countries, with some locales remaining relatively unaffected. Areas bordering states with high levels of infections have been among the hardest hit. In South Africa, the most affected areas are those bordering Zimbabwe and Botswana, and surrounding Lesotho and Swaziland (Price-Smith, Tubin, and Ostergard, 2005). Africa has also demonstrated that HIV is not simply a product of poverty; Botswana, once among the wealthiest and most stable countries on the continent, has the world’s highest infection rate, nearly 40 percent (Heineken, 2003, p. 283). A Nigerian commentator cited six factors causing the high prevalence of HIV in that country: rapes committed by soldiers, uncontrollable population movements, refugee camps with conditions for unprotected or forced sex, poverty resulting in a high incidence of commercial sex, declining literacy that limits access to information about protection, and the collapse of health services (Altman, 2003, p. 421). Not all of these factors are present in Russia. Reports of rape camps in Chechnya have not been accompanied by the sorts of horror stories recounted in Africa, where HIV-positive soldiers have been intentionally assigned to “rape duty” (Elbe, 2002). Population movements and refugee flows are now a common feature of life in some Russian border regions, but they have not reached the levels seen in SSA. On the other hand, Russia has definitely experienced a significant increase in poverty and commercial sex. Information about HIV/AIDS and the protection provided by condoms seems to correlate directly with education levels, and the Russian health care system has improved for those who can afford to pay but deteriorated for most others. Price-Smith, Tubin, and Ostergard (2005) make a compelling case for the linkage between HIV/AIDS and security in southern Africa, focusing in particular on the strain AIDS places on economic and human resources. Most pandemics strike particularly hard at the weak, the young, and the old in a society. AIDS, by contrast, most severely impacts young adults—the portion of the population in their prime years of reproduction, education, career development, and

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military service. In southern Africa, AIDS has had a devastating impact on medical and education personnel and increasingly on the civil service. In other words, it is eliminating the very people who play an important role in combating its spread. In a conclusion with direct parallels to Eurasia, Price-Smith and his coauthors (2005) found that “South Africa’s ability to be the bedrock of regional stability will continue to diminish as resources and manpower are drained from the foreign policy and military institutions needed to carry out such expectations.”

HIV/AIDS and Russian Security Previous chapters document the Russian government’s failure to respond to the threat posed by HIV/AIDS. Unless Russia truly is unlike all the other countries in Eurasia, a large number of people are going to die in the decade 2005–2015, and an already overburdened health care system will face overwhelming challenges. All calculations of birth rates and other changes in the Russian population, including some (temporary) positive trends, are likely to be dramatically altered. Despite these daunting challenges, the policy response has been late and tepid. The official Russian position, repeated by some researchers, is that Russia inherited the Soviet Union’s excellent system of tracking diseases, and therefore it has been possible to isolate HIV among the injection drug-using population. This group includes some women, mainly sex workers, which explains the data on increased incidence of HIV among females and newborns (Denisov and Sakevich, 2004). Despite these assertions, the gender distribution of Russia’s HIVpositive population has been changing as the disease spreads from men who have sex with men and drug users to the general population—the same pattern observed in other countries. Women constituted 24 percent of the officially registered HIV-positive population in 2001; in 2002, this figure was 33 percent. The number of children born with HIV is also increasing. In 2001, HIV-infected women bore 1,139 children, and in 2002 the number more than doubled to 2,777 (Pleven, 2003). Overall in Russia in 2004 about 30 percent of new cases of HIV infection were the result of heterosexual transmission, but in some regions, such as Krasnodar, heterosexual transmission accounted for more than half of new cases reported (Mcdetsky, 2004). There were some indications beginning in spring 2005 that the leadership may have finally recognized the importance of addressing the issue and accepting advice based on international experience. In April 2005,

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Deputy Prime Minister Alexander Zhukov addressed an AIDS conference in Moscow and acknowledged that Russia has a serious problem and needs to enlist the business community to help combat the disease. Both Zhukov and Health Minister Mikhail Zurabov stated that AIDS now represents a threat to Russia’s security (Bransten, 2005). As in many other countries, this acknowledgment comes tragically late, and the health care system is far from prepared. Despite the scattered comments by high-level officials, almost all in international meetings devoted to the subject, the policy response continues to be painfully slow. Some local NGOs and regional governments have adopted promising programs, but strong leadership at the national level began to emerge only in late 2005.5 Beyond the economic impact of lost revenues and the cost of treating those with AIDS (Rühl, Pokrovsky, and Vinogradov, 2002), the security conundrum for Russia involves the impact of HIV/AIDS on the already shrinking cohorts available for higher education, the labor force, and military service. Eberstadt (2002) calculated three scenarios for the incidence of HIV in Russia during the period up to 2025: a mild epidemic resulting in four million cases and three million deaths; an intermediate epidemic, with thirteen million cases and nine million deaths; and a severe epidemic that would infect nineteen million people and kill twelve million. While the impact of these additional deaths on total population is more difficult to predict, experience elsewhere suggests that increased mortality would occur overwhelmingly among Russians of reproductive age. This would have a cumulative impact on future birth rates. By 2050, a mild epidemic would result in a reduction of the total population by some ten million, whereas an intermediate epidemic would reduce the population by up to twenty million. Projections of the size of Russia’s working age population in 2025 under these scenarios are daunting: 89 million absent HIV; 86 million with a mild HIV epidemic; 81 million with an intermediate epidemic; and 78 million with a severe epidemic. World Bank estimates range from an “optimistic” variant of 5.3 million deaths from AIDS by 2020 to a “pessimistic” projection of 14.5 million. The optimistic scenario would represent 1.3 million additional deaths in the period 2010–2015, at a time when the student (and draft age) population will shrink by 2.8 million from other causes. In the years of greatest decline, 2015–2020, when the student age population is projected to be around 6.5 million, the optimistic scenario projects 1.8 million additional deaths. The pessimistic scenario would be an almost unthinkable 4.9 million (Rühl, Pokrovsky, and Vinogradov, 2002).

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The most serious impact, at least in the short term, will be less on the size of the military recruitment pool than in other areas. As mentioned earlier, the worst health indicators in Russia are among young people in the 15–17 age bracket. Given the five- to ten-year lag between contracting HIV and manifesting symptoms of AIDS, children would have to contract the disease at ages 8–13 for symptoms to be visible at the induction age of 18. In 2004 the military did reject about 5,000 HIVpositive recruits. As they become more desperate for personnel, this practice may change.6 Local draft boards, in part due to disputes over who should pay for HIV tests, tend to ignore problems and fail to test recruits, thereby meeting their quotas, but these young men are subsequently dismissed from service at significant expense to the military (Feshbach, 2005). The most serious immediate effects are likely to be in the officer corps, where retaining personnel is already a significant problem, and in the professional/contract units that are supposed to be responsible for combat operations. These older groups aged 25–39 are more likely to manifest AIDS symptoms and are also more likely to be exposed to risks during their military service. The stark choices among military service, higher education, and work in the civilian sector represent a second immediate dilemma. Plans to introduce a one-year term of service in 2008 coincide with a shrinking pool of 18-year-olds (table 9.1). This scheme will require inducting a much larger share of the cohort; the number most often cited in 2005 was 500,000. It will also necessitate curtailing exemptions and maintaining a more active reserve. While there are potential creative solutions to this problem, such as funding educational opportunities for those who complete military service or introducing an expanded officer training track at higher education institutions, these policies require resources and competent and honest administration. The potential for errors and abuse is enormous. If young men are permitted to complete their higher education before being conscripted, one result will be an older cohort of soldiers and inevitably a higher incidence of both HIV and AIDS. Allowing young men to complete their five-year higher education before requiring them to serve in the military will provide an older cadre of recruits, and could furnish good officer material. However, it also means a break between higher education and graduate study that could seriously impair the “pipeline” of scientific and technical personnel. A top student in physics, chemistry, or information technology who interrupts his study for a year or two might not return, or might

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find it difficult to get back up to speed on current scientific literature. An older draft pool will also raise the issue of exemptions for those with children or financial support for their families. Over the longer term (a decade), even a limited AIDS impact will reduce the size of the economically active population in the prime employment years and will also negatively affect any pro-natal policies that the government adopts. The combination of lower economic growth and continuing low birth rates will exacerbate the challenges of providing economic and human resources for the military. HIV/AIDS also complicates potential solutions to population decline. At current birth and death rates, Russia will need 700,000 immigrants per year for the next 40 years just to maintain its current population size. If one percent of the Russian population is HIV positive, even if incidence is halted at this level, that would mean an additional two to three million deaths, raising the immigration numbers needed to stabilize the population to more than one million per year for at least the next two decades. Given that Russia will be competing with Europe, North America, and Japan for educated and highly skilled immigrants, the danger of any population influx representing not just a decline in human capital but also a new public health problem is quite real. One of the most thorough analyses of the potential economic impact of HIV/AIDS in Russia was carried out by the World Bank (Rühl, Pokrovsky, and Vinogradov, 2002). The potential variation in outcomes is quite large. But the conclusion from these models is that even a mild epidemic of HIV will have serious consequences for Russia’s economic performance. Increasing oil prices may mask the effects for a period of time, but this is also likely to diminish the sense of urgency needed to address the problem. While it may be the case that Russia’s resource-based economy could function with a limited pool of labor, the experience in African countries dependent on mining and oil, such as South Africa and Nigeria, has been that rates of HIV infection are particularly high among the labor force in these industries. Large concentrations of relatively well-paid males engaged in physical labor away from home have created conditions exacerbating the AIDS epidemic (Pharoah and Schönteich, 2003). Increased rail and truck traffic, exemplified by the Asia-Europe highway project, creates major paths for HIV infection.

Possible Amelioration? Are there ways Russia’s population decline might be reduced or offset? Population decline has been ameliorated in a few countries by a concerted

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policy response including immigration, pro-natalist policies, and raising the retirement age. While none of these approaches alone is sufficient, in concert they can produce positive results. The more extreme cases posed by gender imbalance in China, India, and Pakistan, or AIDS in Africa, are of a different magnitude (Hudson and Den Boer, 2002). While Russia’s declining birth rate is not unusual in industrial societies, the high mortality rate among working age males represents a stark difference from other world regions. Russian adults in all age cohorts die at rates utterly unprecedented for the country’s levels of education and economic development. If Russian fertility rates are comparable to Italy (1.25 births per female), the death rates diverge radically: 103 deaths per 100 live births in Italy compared to 170 in Russia. The effects of negative population growth in Italy could be ameliorated by a connected policy response including immigration, pronatalist policies, and raising the retirement age (Keely, 2000, 2003). Russia’s situation would require far more. The Russian government should certainly pursue pro-natalist policies. But failure to understand the demographic data is leading a growing number of government officials to argue that social programs to offset the population decline are succeeding. This will make it even more difficult to adopt less popular measures to cope with the drop in births after 2005, and particularly after 2010. Successful demographic policy requires a multipronged and consistent effort across multiple sectors. In responding both to demographic decline and to HIV/AIDS, Russian officials have exhibited a depressingly familiar (if understandable) preference to grasp at indications that the problems might simply go away. In an article in Russia’s premier economics journal, former deputy minister of Education L. Grebnev (2003), for example, claims that population decline has been reversed. The increase in births since 2000, however, is more likely due to a larger cohort of women in the prime child-bearing age groups (20–29) than to psychology, stability, the economy, or government programs (Feshbach, 2003). Nevertheless, Elizarov (2002, p. 154) contends that social influences are more important than the number of women aged 20–29. A similar emphasis on the social and economic dimensions was expressed by former deputy premier Galina Karelova, emphasizing housing for young families as one of the most important measures to stimulate more births (Krasnaya zvezda, 2003 ). Housing is also a key element in strategies to attract Russian-speaking immigrants. The state program for contract military service includes increasing the military housing fund from 98,000 to 450,000 apartments over the coming decade. This would seem to be in direct competition with any program to provide housing for families with newborn children.

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Even a massive rise in the birth rate would not have an impact on the conscription pool for 18 years. Are there other sources of personnel? The draft age could be raised (or lowered), but this would have implications for combat effectiveness, the economy, and education. Measures to curtail significantly student draft exemptions are likely to provoke social protests. More women could be recruited for the military. When Defense Minister Sergei Ivanov visited Washington in April 2004, his public relations packet included a copy of a glossy English-language edition of the magazine Russian Military Review (no. 3, March 2004), featuring a cover story on women in the military. The cover features a female commando with a Kalashnikov assault rifle, treading through kneedeep snow.7 The number of women in the armed forces stood at 90,000 in 2004. About 4,500 female officers serve. The overwhelming majority, over 70 percent, are in the military medical service. Most of the rest are in signal troops, financial services, and translation and interpreting jobs. Some 60,000 women serve on a contract basis, primarily in communications, clerical and medical jobs. Some do serve in combat and in special operations: 1,600 women have been awarded special honors for courage in battle or counterterrorist operations. On International Women’s Day (March 8) 2004, ITAR-TASS issued a press release stating that the number of women in the military would not be altered by personnel cuts; TASS made the same statement on March 8, 2005. Drafting or otherwise attracting more women to military service raises all the problems the U.S. military is experiencing with rape and assault. In a country where 15,000 women die from physical abuse by their spouses or male partners each year—and 3,000 men are killed by their wives—it will not be a minor problem (Naryshkina, 2004; RFE/RL Newsline, April 4, 2004). It might be possible to increase the catchment rate. The Russian military has already begun to take stronger measures to enforce conscription. Where in the past recruiters employed a “fish net” approach, rounding up young men of draft age in the metro and even on the street, in 2004 they shifted to a “hook and line” strategy, having local draft boards monitor young men of military age, visiting them in their homes, and “encouraging” them to report for duty (Galkin and Mukhin, 2004). In Moscow, where only three percent of the young men eligible for conscription actually serve, this may well improve the induction rate. In April 2005, Defense Minister Sergei Ivanov pointedly noted that Vologda, with a population of two million,

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sends as many men to the army as Moscow with its ten million residents (ITAR-TASS, April 13, 2005). His comments came in the context of the need to double the number of draftees when the one-year term of service is introduced. However, even 100 percent success in recruitment would not alleviate the impending shortage of young males. A variation on the human capital theme has been proposed by analysts who focus on the Revolution in Military Affairs (RMA), and by Russians who still invoke the country’s “scientific-technical revolution” and “science-intensive industry.” Adherents of this view suggest that the increasing technologization of warfare could play to Russian strengths in science and technology. As military power becomes more and more a function of smart weapons, automation, and advanced communications, the combination of a large cadre of highly educated specialists and the proven ability to focus resources on priority projects could enable Russia to field an ultra-modern military requiring significantly less raw manpower. The Soviet Union was able to develop and maintain its superpower arsenal only by devoting an enormous share of resources to the project. Soviet science and technology were not superior to American or European competitors; rather, the Soviet Union devoted a much larger share of its available resources to the competition (that is, if the United States spent one-third of GDP, the Soviet Union spent two-thirds). There is no untapped reservoir of high technology capacity on which Russia can draw to develop a modern military establishment. And it certainly cannot be done on the cheap. Russia has never managed serial production of a personal computer. To believe that it could achieve low-cost production of the hardware for an automated and computerized battlefield is, at minimum, a stretch. Cyber-weapons for the battlefield of the future require money, production facilities, and scientific talent. Yet Russia’s economic difficulties remain significant. Russians are learning to operate modern plants, but they are still far away from reliable production of high technology products, much less on an economically competitive basis. Much of the scientific talent is gone. Of the 1–1.5 million scientists in the Soviet Union, perhaps one in ten remain active. Many top people have left the country, either as emigrants or to work temporarily in other nations. Among the younger generation, going abroad is almost obligatory.8 Even if Russia could overcome these economic, technological, logistical, and human capital challenges and manage to create the postmodern military envisioned by proponents of the RMA, it is far

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from clear that this would enable the nation to meet its real security challenges. The premise of the RMA is conflict between major powers equipped with roughly similar modern weapons. The most serious threats to Russian security, however, are from terrorists and insurgents, particularly along Russia’s southern tier.9 Nuclear weapons and high technology are far from the most effective way to confront these challenges. Quite the opposite is the case—these offer terrorists attractive targets. The former communist country that has made the greatest progress in modernizing its military forces is China (Bickford, 2005). The trajectory of changes in the People’s Liberation Army (PLA) provides a striking contrast to developments in the Russian military. The Chinese military is abandoning many of the patrimonial and corrupt practices that now pervade Russia’s armed forces. China’s emergence represents a long-term security challenge that is making it impossible for Russia to choose between maintaining a large standing army and modernizing its nuclear arsenal. But Russia has neither the personnel nor the resources to do both, and the economic and population losses from AIDS will make this dilemma even more problematic.

Conclusion In responding to HIV/AIDS, the Russian government and most of its policy elite have behaved like ostriches. The most common refrain is that people die of lots of other things (cancer, heart attacks), while no one is dying of AIDS, and scientists will find a vaccine or a cure before AIDS becomes a serious problem in Russia.10 Russian leaders are not unusual. No country’s leadership has been particularly enlightened in the early stages of the disease. As Judy Twigg notes in the introduction to this volume, it has generally required mobilization by the communities most affected to get political attention. In this context, the retreat from open expression and growing government efforts to “manage” civil society in Russia become more than a question of whether political scientists label Russia as “democratic” or “authoritarian.” Limiting discourse is a life-and-death issue for hundreds of thousands of people. Inhibiting public discussion and mobilization precludes the bottom-up pressures that produced changes in other places where leaders were unwilling to recognize the problem. The way Russia is truly unique is in the demographic context. Outside of sub-Saharan Africa, AIDS is a major concern in countries where the population is growing but will grow more slowly due to

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AIDS. In most of these countries the leadership has been no more farsighted in taking steps to address the challenges, creating a tragedy for those who will suffer needlessly. In Russia, the population is already shrinking, even with immigration, and the only question is how much more it will decline as a result of the impending AIDS casualties. What in other countries represents a human tragedy could in Russia become a national catastrophe with significant security implications for the entire region.

Notes The author is grateful for Murray Feshbach’s suggestions and relentless supply of information; to Nick Eberstadt, Judy Twigg, Marjorie Mandelstam Balzer, and Andrew Kuchins for ongoing discussions and comments on earlier versions of this work; and to Sarah Wilhelm and Maria Repnikova for invaluable research assistance. The remaining errors are the author’s responsibility. 1. Russia’s population will continue to be augmented by immigration, including of children. The influx of Slavic and Russian-speaking young people in the decade 1991–2001 was about equal to the number of Russians under age 18 who die from illness and accidents each year (Elizarov, 2002). 2. In the spring of 2002, false certification of a lung or stomach ailment cost $2,000–$5,000. A less reliable psychological deferment was priced at $1,000. Certification as a alcoholic or drug addict, which could have a negative impact on future earnings potential, was priced at $300–$500 (Cottrell, 2002). During the summer of 2004, NTV reported that a medical certificate was priced at 1,700 to 2,700 Euros; a registration certificate identifying someone as a university student in the reserves cost 1,200 Euros; certification of a mental deficiency was a mere 350 Euros; and a (temporary) deferment from a current conscription campaign was 500 Euros. Certification as a homosexual (from a psychiatric hospital) was priced at $1,500. Proof of paternity cost 2,500 “currency units” (meaning Euros or dollars, or an average of the two). See NTV, August 12, 2004. Between 2001 and 2005, the amount spent to avoid military service rose from $12.6 million to $353.6 million (INDEM, 2005). 3. The same article notes that the army has managed to remain “one of the most law-abiding institutions in Russia,” stating that the level of crime among military service personnel is half the rate in the country as a whole. In 2005, however, military officials reported an alarming increase in crime, providing data that incidence is now 75% of the civilian rate (Savenkov, 2005). 4. Minister of Defense Sergei Ivanov has attempted to co-opt the joke, using it to demand a reduction in draft deferments for students so that the military ceases to be the province of lower-class Russians (Argumenty i fakti, 2005). 5. See the chapter by Celeste Wallander in this volume. 6. Public statements by Minister of Defense Ivanov and Chief of the General Staff Yurii Baluevskii in spring 2005 seemed to herald either a new campaign to

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8.

9.

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Harley Balzer improve compliance with recruitment notices, or another round in the ongoing battle between the Army and the medical and educational establishments over deferments. The article inside was not about female commandos, but rather about a female officer in the technology acquisition office who was deemed a good candidate for a “Mrs. Russia” beauty context. The title: “Woman First, Colonel Later: Some Commissioned Officers Make Serving in the Russian Army Irresistible.” The Dean of Science at one leading St. Petersburg higher education institution told the author in 1997 that 24 of his 27 recent gradate students were employed abroad. In 2003, he stated that the picture had not changed significantly. A number of Russian officials and official documents recognize that the “southern tier” and terrorism, crime, trafficking, and the rest of the “new wars” issues are the major threat facing Russia. But even many of the best analysts still devote considerable energy to NATO expansion. For early treatments of the nontraditional security issues in Eurasia, see Arbatov, Kaiser, and Legvold, 1999; Menon, Fedorov, and Nodia, 1999; Rozman, Nosov, and Watanabe, 1999; and Galeotti, 2002. The author has heard versions of this explanation from at least six individuals at the rank of Deputy Minister or Minister in the Russian government. The prevalence of this view is confirmed by Gerber and Mendelson, 2005. For comparative perspective, see the World Bank, 2003a, p. 5. HIV has manifested a capacity to mutate over time, and in countries like Thailand and South Africa that thought they had “gotten a handle” on the disease, it has emerged in new forms or among different population groups. The United States has not been immune to this phenomenon. Russian leaders’ failure to acknowledge the severity of the problem means that, even if their insistence that the statistical practices inherited from Soviet medical work prove their current view that the disease is limited to specific populations, there is no reason to believe that this will always be the case.

References “Aktual’nye zadachi razvitiia vooruzhennykh sil Rossiiskoi Federatsii” (2003) Krasnaia zvezda, October 11. Aldis, A.C., and R. N. McDermott, eds. (2003) Russian Military Reform, 1992–2002 (London and Portland, OR: Frank Cass). Allison, R. (2004) “Russia, Regional Conflict, and the Use of Military Power,” in S. E. Miller. and D. V. Trenin, eds., The Russian Military: Power and Policy (Cambridge, MA: American Academy of Arts and Sciences), 121–155. Altman, D. (2003) “AIDS and Security,” International Relations, 17(4):417–427. Arbatov, A. G. (2004) “Military Reform: From Crisis to Stagnation,” in S. E. Miller and D. V. Trenin, eds., The Russian Military: Power and Policy (Cambridge, MA: American Academy of Arts and Sciences), 95–119. ——— (1998) “Military Reform in Russia: Dilemmas, Obstacles, and Prospects,” International Security, 22(4):83–134.

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Arbatov, A., K. Kaiser, and R. Legvold, eds. (1999) Russia and the West: The 21st Century Security Environment, volume I, Eurasia in the 21st Century: The Total Security Environment, D. Hatelius and A. G. Arbatov, eds. (Armonk, NY and London: M. E. Sharpe). Argumenty i fakty (2005) “ ‘Lichnost,’ Ministr Oborony Sergei Ivanov. U nas rabochaia i krest’ ianskaia armiia,” 13:3, March 3. Armeiskii sbornik (2004) “Krugly stol,” January 4, 11–25. Baev, P. K. (2001) “The Russian Army and Chechnya: Victory Instead of Reform?” in S. J. Cimbala, ed., The Russian Military into the Twenty-First Century (London and Portland, OR: Frank Cass), 75–93. Balzer, H. (2003) “Demography and Democracy in Russia: Human Capital Challenges to Democratic Consolidation,” Demokratizatsiya, 11(1):95–109. ——— (2002) “Human Capital and Russian Security in the 21st Century,” in A. Kuchins, ed., Russia After the Fall (Washington, DC: Carnegie Endowment for International Peace), 163–184. Bickford, T. (2005) “The Role of the Military in Post-Communist Politics: A Study of the Chinese PLA, With Comparisons to the Russian Armed Forces,” paper presented at the Annual Meeting of the International Studies Association, Honolulu, HI, March 1–5. Bloom, D. E., D. Canning, and J. Sevilla (2003) The Demographic Dividend: A New Perspective on the Economic Consequences of Population Change (Santa Monica, CA: Rand). Bransten, J. (2005) “Government Shows Signs of Acknowledging AIDS Epidemic,” RFE/RL Russian Political Weekly, 5(14), April 8. Brown, M. E., ed. (2003) Grave New World: Security Challenges in the 21st Century (Washington, DC: Georgetown University Press). Busza, E. (2000) “State Dysfunctionality, Institutional Decay, and the Russian Military,” in V. Sperling, ed., Building the Russian State: Institutional Crisis and the Quest for Democratic Governance (Boulder, CO: Westview Press), 113–136. Cimbala, S. J., ed. (2001) The Russian Military into the Twenty-First Century (London and Portland, OR: Frank Cass). Cottrell, R. (2002) “Russian Army Starts Spring Draft,” Financial Times, April 2. Degtiarev, A. K., and E. I. Litvinenko (2003) “Kursanty vvyzov: zhiznennye strategii i innovatsionnyi potentsial,” Sotsiologicheskie issledovaniia, 12(236):69–75. Demin, P. S. (2003) “O prestizhe voennogo obrazovaniia,” Sotsiologicheskie issledovaniia, 12(236):66–69. Denisov, B. P., and V. I. Sakevich (2004) “Dinamika epidemii VICh/SPID,” Sotsiologicheskie issledovaniia, 1:75–85. Dubrogai, E. V. (2003) “Sem’ia i sotsial’noe polozhenie ofitsera,” Sotsiologicheskie issledovaniia, 12(236):80–82. Eberstadt, N. (2004) “The Demographic Factor as a Constraint on Russian Development: Prospects at the Dawn of the Twenty First Century,” National Bureau of Asia Research, NBR Analysis, 15(2), September. ——— (2002) “The Future of AIDS,” Foreign Affairs, 81(6):22–45. ——— (1999) “Too Sick To Matter?” Heritage Policy Review, 95, June/July, www.policyreview.org/jun99/eberstadt.html.

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Elbe, Stefan (2002) “HIV/AIDS and the Changing Landscape of War in Africa,” International Security, 27(2):159–177. Elizarov, V. (2002) “Demograficheskoe polozhenie Rossii: tendentsii i posledstviia,” Federalizm, 1(25):151–182. Feshbach, M. (2005) “HIV/AIDS in the Russian Military—Update,” paper prepared for UNAIDS meeting, Copenhagen, Denmark, February 22–23. ——— (2003) Russia’s Health and Demographic Crises: Policy Implications and Consequences (Washington, DC: Chemical and Biological Arms Control Institute). Feshbach, M., and C. M. Galvin (2005) HIV/AIDS in Russia—An Analysis of Statistics (Washington, DC: Woodrow Wilson International Center for Scholars). Frolov, V. (2004) “The National Security Implications of the HIV/AIDS Epidemic in Russia,” Annex 2 of UNDP (2004). Galkin, M., and V. Mukhin (2004) “Minoborony na bol’shoi okhote. Voennoe vedomstvo gotovit ocherednye radikal’nye mery dlia popolneniia armeiskikh riadov,” Nezavisimaia Gazeta, May 31. Galeotti, M. (2002) “The Challenge of ‘Soft Security’: Crime, Corruption and Chaos,” in A. Cottey and D. Averre, eds., New Security Challenges in Postcommunist Europe: Securing Europe’s East (Manchester and New York: Manchester University Press), 151–171. Gavrilov, Y. (2002) “Okhota za leitenantom,” Moskovskii komsomolets, 114, May 30:2. Gerber, T. and S. Mendelson (2005) “Crisis among Crises among Crises: HIV/AIDS in the Eyes of Russian Health Care Experts,” Problems of PostCommunism, 52(4), July/August:28–41. Grebnev, L. (2003) “Rossiiskoe obrazovanie v zerkale demografii,” Voprosy ekonomiki, 5:4–25. Heinecken, L. (2003) “Facing a Merciless Enemy: HIV/AIDS and the South African Armed Forces,” Armed Forces and Society, 29(2):281–300. Henk, D. (2001) “Security: A New African Paradigm,” University of Zimbabwe, Center for Defense Studies, Occasional Paper No. 1, www.uz.ac.zw/units/cds/ occasional/paper1/index.html. Hudson, V. M., and A. Den Boer (2002) “A Surplus of Men, A Deficit of Peace: Security and Sex Ratios in Asia’s Largest States,” International Security, 26(4):5–38. Hunter, S. (2005) Aids in Asia: A Continent in Peril (New York: Palgrave MacMillan). International Crisis Group (2001) HIV/AIDS As A Security Issue (ICG: Washington and Brussels). ——— (2004) “HIV/AIDS as a Security Issue in Africa: Lessons from Uganda,” Issues Report No. 3, April 16, www.icg.org/home/index.cfm?id ⫽ 2606&1 ⫽ 1. INDEM (2005) “Vo skol’ko raz uvelichilas’ korruptsiia za 4 goda: rezul’taty novogo issledovaniia Fonda INDEM,”www.anti-corr.ru/index.htm. Keely, C. B. (2000) “Demography and International Migration,” in C. B. Brettell, and J. F. Hollifield, eds., Migration Theory: Talking Across Disciplines (New York and London: Routledge), 43–60.

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——— (2003) “Demographic Development and Security,” in M. E. Brown, ed., Grave New World: Security Challenges in the 21st Century (Washington, DC: Georgetown University Press), 197–212. Konstantinovski, D. (2003) “Education in Transition Society: Growing Inequality (Study of the Situation in Russia),” in The International Handbook on the Sociology of Education: An International Assessment of New Research and Theory (Lanham, MD: Rowman and Littlefield), 232–255. Krasnaia zvezda (2003) “Ia vse propuskaiu cherez serdtse,” interview with Galina N. Karelova, (202):1, October 29. ——— (2004) “Vozvrashchenie patriotov,” (34):1, February 27. Malakhova, A. (1999) “Tsvety zhizni vianut na glazakh,” Novye izvestiia, January 21. Medetsky, A. (2004) “AIDS Just Beats Out Books in Budget,” Moscow Times, December 1, 1. Menon, R., Y. E. Fedorov, and G. Nodia, eds. (1999) Russia, the Caucasus and Central Asia: The 21st Century Security Environment, volume II, Eurasia in the 21st Century: The Total Security Environment, D. Hatelius and A. G. Arbatov, eds. (Armonk, NY and London: M. E. Sharpe). Miyamoto, N., Y. Want, and H. J. Park (1999) “New Threats: Dangers and Vulnerabilities of Russia’s Far East,” in G. Rozman, M. G. Nosov, and K. Watanabe, eds., Russia and East Asia: The 21st Century Security Environment (Armonk, NY and London: M. E. Sharpe), 200–211. Moskovskii komsomolets (2004) “Srochno v nomer! Inostrantsy budut zhdat’ zachisteniia v armiiu ne bol’she trekh mesiatsev,” (98):3, May 7. Naryshkina, A. (2004) “Domashnee nasilie—osnovnaia prichina smerti i invalidnosti zhenshchin v vozraste ot 16 do 44 let,” Izvestiia, (77):2, April 28. Obukhova, O. V. (2001) “Demograficheskie faktory i politika,” Sotsial’nogumanitarnoe znaniia, 4:303–310. Oliker, O., and T. Charlick-Paley (2002) Assessing Russia’s Decline: Trends and Implications for the United States and the U.S. Air Force (Santa Monica, CA: Rand). Ostergard, R. (2002) “Politics in the Hot Zone: AIDS and National Security in Africa,” Third World Quarterly, 23(2):333–350. Peven, L. V. (2003) “Osobennosti perekhoda k professional’noi forme organizatsii vooruzhennykh sil,” Sotsiologicheskie issledovaniia, 12(236):62–66. Pharoah, R., and M. Schönteich (2003) “AIDS, Security and Governance in Southern Africa: Exploring the Impact,” Institute for Strategic Studies, Pretoria, South Africa, Occasional Paper No. 65, January, www.iss.co.za/Pubs/Papers/ 65/Paper65.html. Pikayev, A. A., E. N. Nikitina, and V. Kotov (1999) “Harmful Legacies and Dangerous Weaknesses,” in Arbatov (2004), 210–238. Pleven, L. (2003) “HIV Spreads Quickly in Russia, Particularly among the Young,” Newsday, August 4. Price-Smith, A. T., M. Tubin, and R. L. Ostergard (2006) “The Decay of State Capacity: HIV/AIDS and South Africa’s National Security,” in R. L. Ostergard, Jr., ed. HIV/AIDS and the Threat to National and International Security (Basingstoke: Palgrave MacMillan).

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Rozman, G., N. G. Nosov, and K. Watanabe, eds. (1999) Russia and East Asia: The 21st Century Security Environment, volume III, Eurasia in the 21st Century: The Total Security Environment, Hatelius, D., and A. G. Arbatov, eds. (Armonk, NY and London: M. E. Sharpe). Rühl, C., V. Pokrovsky, and V. Vinogradov (2002) “The Economic Consequences of HIV in Russia,” World Bank, May 15, www.worldbank.org.ru/eng/ group/hiv/. Savenkov, A. (2005) “Press-Konferentsiia glavnogo voennogo prokurora Aleksandra Savenkova,” RIA Novosti, May 24. Sharp, S. (2004) “Modelling the Macroeconomic Implications of a Generalized AIDS Epidemic in the Russian Federation,” Annex I of UNDP (2004). Shilov, M. (2005) “Vymiranie ili migratsiia?” Politcom.ru, July 22. Solov’ev, S. S. (2003) “Mentalitet Rossiiskogo ofitsera: vyzovy XXI veka,” Sotsiologicheskie issledovaniia, 12(236):50–61. SVOP [Sovet po vneshnei i oboronnoi politike] (2004) Voennoe stroitel’stvo i modernizatsiia vooruzhennykh sil Rossii, March 30, www.svop.ru/live/ materials.asp?m_id ⫽ 8481&r_i . . . 1. Trenin, D. (2001) The End of Eurasia: Russia on the Border Between Geopolitics and Globalization (Moscow and Washington: Carnegie Endowment for International Peace). Trenin, D. V., and A. V. Malashenko, with A. Lieven (2004) Russia’s Restless Frontier: The Chechnya Factor in Post-Soviet Russia (Washington, DC: Carnegie Endowment for International Peace). Twigg, J. L. (2002) “What Has Happened to Russian Society,” in A. C. Kuchins, ed., Russia After the Fall (Washington, DC: Carnegie Endowment for International Peace), 147–162. Twigg, J. L., and K. Schecter, eds. (2003) Social Capital and Social Cohesion in Post-Soviet Russia (Armonk, NY and London: M. E. Sharpe). Ulitskaia, E. (2004) “Izbezhat’ prizyva mozhno na zakonnykh osnovaniiakh,” Moskovskaia pravda, April 26. Ullman, R.H. (1999) “Russia, the West, and the Redefinition of Security,” in A. Arbatov, K. Kaiser, and R. Legvold, eds. Russia and the West: The 21st Century Security Environment volume I, Eurasia in the 21st Century: The Total Security Environment, D. Hatelius and A. G. Arbatov, eds. (Armonk, NY and London: M. E. Sharpe), 189–209. UNDP (2004) HIV/AIDS in Eastern Europe and the Commonwealth of Independent States. Reversing the Epidemic: Facts and Policy Options (Bratislava: UNDP). Vakhrameev, A. V. (2001) “Natsional’naia bezopasnost’ Rossiiskoi Federatsii (deklaratsii i real’nost’),” Sotsial’no-gumanitarnye znaniia, 1, 2, and 3. Vishnevskii, A. (2005) “Demograficheskii krizis v stranakh SNG,” Demoskop Weekly, April 4–17, 197–198, Demoscope.ru/weekly/2005/0197. Vitkovskaia, G. S. (1999) “Lawlessness, Environmental Damage, and Other New Threats in the Russian Far East,” in G. Rozman, M. G. Nosov, and K. Watanabe, eds., Russia and East Asia: The 21st Century Security Environment (Armonk, NY and London: M. E. Sharpe), 179–199.

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World Bank (2003a) HIV/AIDS in Southeastern Europe: Case Studies from Bulgaria, Croatia and Romania (Washington, DC: World Bank). ——— (2003b) HIV/AIDS and Tuberculosis in Central Asia: Country Profiles (Washington, DC: World Bank). ——— (2003c) HIV/AIDS in the Middle East and North Africa: The Costs of Inaction (Washington, DC: World Bank).

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Notes on Contributors

Judyth L. Twigg is Interim Director of the L. Douglas Wilder School of Government and Public Affairs at Virginia Commonwealth University, and Adjunct Associate Professor at Georgetown University. She received a PhD in Political Science and Security Studies from MIT, an MA in Political Science and Soviet Studies from the University of Pittsburgh, and a BS in Physics from Carnegie Mellon University. Her current research focuses on the security implications of health and demographic trends in Russia as well as the evolution of Russian health and social policy. Her work has been published in several leading medical and social science journals, and she has edited two books on Russia’s health and social sectors. Twigg is currently writing Critical Condition: The Politics of Health Care Reform in Russia for the University of Pittsburgh Press. She has been a consultant for the U.S. government and the World Bank, and she was a member of the 2005 Council on Foreign Relations Task Force on U.S.-Russia Relations. In February 2005, she was given one of twelve Distinguished Faculty awards by the State Council on Higher Education in Virginia. Strobe Talbott is President of the Brookings Institution. He served as Deputy Secretary of State from 1994 to 2001, and Ambassador-atLarge and Special Advisor to the Secretary of State for the former Soviet Union (1993–1994). Prior to his service in government, he worked at Time magazine for 21 years, as a reporter, Washington Bureau Chief, Foreign Affairs Columnist, and Editor-at-Large. He is the author of nine books, most recently Engaging India, a memoir of U.S. diplomacy toward South Asia after the 1998 Indian and Pakistani nuclear tests. He has a BA from Yale university and an M Litt from Oxford University. Harley Balzer is Associate Professor of Government and International Affairs and an Associate Faculty Member of the Department of History at Georgetown University, where from 1987 to 1991 he

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served as Director of the Center for Eurasian, Russian, and East European Studies. During 1993, Balzer served as Executive Director and Chairman of the Board of the International Science Foundation, established by George Soros to disburse $100 million to support basic science in the countries of the former Soviet Union. Balzer’s research interests include Russian and Soviet social history, science and technology, education, Russian politics, and U.S.-Russian relations. He is currently completing two book projects. One, on current Russian political conditions, is tentatively titled Russia’s Democratic Dilemmas: Putin, Population, and Petroleum. The second, dealing with financing higher education in the Russian Empire, the USSR, and the Russian Federation, is called Public-Private Partnerships in Russian Higher Education: Historical Models and Current Policy. Robert E. Booth, a social psychologist, is a Professor of Psychiatry at the University of Colorado School of Medicine. For more than 30 years, Booth has devoted his career to evaluating the effectiveness of interventions designed to address various social problems. For the last 18 years, this work has focused on interventions to prevent the spread of HIV among drug users. He has published widely in this area. Currently, Booth has a National Institute on Drug Abuse (NIDA)-sponsored grant focusing on interventions designed to increase treatment entry and retention among injection drug users. He has served on NIDA review study sections for more than 17 years, and from 1998 to 2002 was a member of the Office of AIDS Research Advisory Council. Since 1999, he has worked with injection drug users in Ukraine, where he currently has a five-year award from NIDA designed to prevent the spread of HIV among drug injectors in Kiev, Donetsk, and Odessa. Joanne Csete is Executive Director of the Canadian HIV/AIDS Legal Network. She founded and directed the HIV/AIDS Program at Human Rights Watch, where she worked until 2004, supervising the documentation of human rights violations linked to HIV/AIDS around the world, including in several countries of the former Soviet Union. Before that, she was a senior technical program advisor for UNICEF, including in the regional office for Eastern and Southern Africa in Nairobi. She worked for eleven years in sub-Saharan Africa on a range of health and nutrition programs. She was on the faculty of the Nutritional Sciences Department at the University of WisconsinMadison for five years. She has a PhD in International Nutrition from Cornell University, a Master’s Degree in Public Health from Columbia

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University, and a Bachelor’s Degree in Economics from Princeton University. Murray Feshbach is a Senior Scholar at the Woodrow Wilson International Center for Scholars and Research Professor Emeritus at Georgetown University. He served as Chief of the USSR Population, Employment, and Research and Development Branch of the Foreign Demographic Analysis Division of the U.S. Bureau of the Census, retired from the U.S. government in 1981, and became a Research Professor at Georgetown University. In addition, at the request of the U.S. Department of State, he served in 1986–1987 as the first (experimental) Sovietologist-in-Residence, in the Office of the Secretary General of NATO, Lord Carrington, in Brussels, Belgium. During 1972–1982, he was a member of five different Working Groups under the U.S.-USSR Agreement on Science and Technology. During 1974–1984, he was an expert for OECD on science and technology in the USSR. He is a past President of the American Association for the Advancement of Slavic Studies, as well as a past president of the Association for Comparative Economic Studies. Feshbach has published a number of books and over 100 articles and book chapters, and he has presented papers at numerous conferences, as well as testimony for the U.S. Congress. His most recent book, Russia’s Health and Demographic Crises, was published in April 2003, and he completed two reports in 2005 (with Cristina Galvin) on HIV/AIDS in Russia and in Ukraine. In May 2004, Feshbach received the Annual Award of the 12th International Conference on HIV/AIDS, Cancer and Related Problems, sponsored by the Biomedical Research Center and held at St. Petersburg State University. Robert Heimer is Associate Professor of Epidemiology and Public Health and of Pharmacology at the Yale School of Medicine. He has been working on HIV prevention for drug users since 1990 when he began studies of the effectiveness of the New Haven syringe exchange program. In 1998, the scope of his work expanded from the United States to Russia at just the same moment that the epidemic of HIV, overwhelmingly associated with injection drug use, struck Russia and other countries of the former Soviet Union. This work, begun as an NIH/Fogarty-funded training program in HIV prevention science in St. Petersburg, has expanded to a large portfolio of research projects in St. Petersburg and beyond. Heimer is interested in the intersection of Russian drug preparation and injection practices with the implementation of harm reduction strategies. His recent efforts include

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participation in the first HIV incidence study of Russian drug users, in the evaluation of syringe exchange programs in Kazan and St. Petersburg, and in the virological assessment of the potential for HIV transmission through home-made preparations of heroin and methamphetamine. Kevin Irwin is a Public Health Sociologist and a Research Associate at the Yale School of Public Health and the Center for Interdisciplinary Research on AIDS (CIRA). His work focuses on disease prevention and health improvement for drug users and sex workers in the United States, Russia, and India. This work spans both clinical and field settings, from investigating the impact of AIDS-related stigma and discrimination in hospitals, to assessing provider and consumer satisfaction with office-based buprenorphine treatment, to evaluation of syringe exchange programs, and to ethnographic research with injection drug users. In Russia this work has been centered on understanding the relationships between home-made drug manufacturing and risk for HIV in several cities, as well as the evaluation of secondary syringe exchange in Kazan. As an outgrowth of this work, he is also actively involved in developing capacities and resources for the ethical conduct of research with drug users. Bertil Lindblad is Representative of the Joint United Nations Programme on HIV/AIDS (UNAIDS) to the Russian Federation. Prior to moving to Moscow, he served as Deputy Director of the UNAIDS New York Office. His duties included provision of technical guidance and support to the Office of the United Nations Secretary General in the planning of AIDS-related advocacy activities. In 2000–2001, Lindblad coordinated the initial planning for the groundbreaking 2001 General Assembly Special Session on HIV/AIDS. From 1994 to 1999, he was Senior Advisor for Child Protection at UNICEF Headquarters in New York. He has also held several positions with Radda Barnen/Swedish Save the Children, and he served in Moscow as Third Secretary in the Commercial Section of the Swedish Embassy. He holds a degree in International Relations, Russian, and French from Pomona College, a certificate in International Relations from Institut d’Etudes Politiques, Paris, and a certificate in French from the Sorbonne. Michael Merson is the Director and Principal Investigator of the Center for Interdiscplinary Research on AIDS (CIRA) at Yale University, and Director of the Administrative and International Research Cores.

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Previously he worked for 17 years with the World Health Organization (WHO), serving first as Director of the Diarrheal Diseases Control and Acute Respiratory Control programs and subsequently as Executive Director of the WHO Global Program on AIDS. More recently he has written on global AIDS policy issues, which is his current major area of interest. He has served on various NIH review panels and advisory committees, is a consultant to the World Bank for its HIV/AIDS projects in various countries, and has received the Surgeon General’s Exemplary Service Medal and the Arthur S. Flemming Award for distinguished government service. He has been elected to the Institute of Medicine (IOM) of the National Academy of Sciences and invited as a member of the IOM’s Board on Global Health. He is also the Principal Investigator of Yale’s AIDS International Training and Research Program (AITRP) in St. Petersburg, Russia, and its extension activities in China and South Africa, as well as the International Clinical, Operational and Health Services Research and Training Award (ICOHRTA) Program in Pretoria, South Africa. He is a coinvestigator on the Bill & Melinda Gates Foundation, Global Health Program grant to implement structural interventions for HIV prevention among high-risk groups in Andhra Pradesh, Karnataka, Tamil Nadu, and Maharashtra, India. He has authored more than 175 articles and is the senior editor of International Public Health, the first textbook prepared on the subject. Alena Peryshkina is a cofounder and the Director of AIDS infoshare. The organization currently has 40 full-time staff members and works in the areas of HIV prevention, especially among sex workers; support and care of people with AIDS; capacity building of NGOs; and advocacy and policy. AIDS infoshare is also part of the NGO consortium that received a third round grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria. Peryshkina is the European NGO representative to the Programme Coordinating Board of UNAIDS. She was instrumental in the creation of the Federal Coordinating Council on HIV/AIDS of the Russian Ministry of Health, and currently serves as a member. As AIDS infoshare was the local host organization, Peryshkina led the effort to launch the Eastern European and Central Asia AIDS Conference with the Russian government, International AIDS Society and UNAIDS in 2006. Vinay P. Saldanha works as Monitoring and Evaluation Adviser for the Joint United Nations Programme on HIV/AIDS (UNAIDS) in Kyiv, Ukraine. From 1998 to 2004, he served as the Project Coordinator for

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the Canada AIDS Russia Project, which was financially supported by the Canadian International Development Agency (CIDA). With over ten years of experience in the management of HIV/AIDS programs in the former Soviet Union, he has consistently called attention to the growing HIV/AIDS epidemic in this region, and supported efforts of governmental and nongovernmental organizations and affected communities in responding to HIV/AIDS. Shombi Sharp is the United Nations Development Programme (UNDP) Focal Point for HIV/AIDS in Europe and the CIS. Formerly head of the UNDP HIV/AIDS Programme in the Russian Federation, he has published economic models on the impact of HIV/AIDS in Russia. Prior to joining UNDP, Sharp worked in the private sector in the United States and Africa. He holds a Master’s Degree in Economics from the University of Colorado and a postgraduate diploma in AIDS Management from the University of Stellenbosch. Julie Stachowiak is a cofounder and the current President of AIDS infoshare. She and two Russian colleagues founded the organization in 1993 with the mission of lessening the harm caused by the AIDS epidemic in Russia. Stachowiak received her PhD in Public Health from the Johns Hopkins University Bloomberg School of Public Health, where she now holds a faculty position in the Department of Epidemiology. Her current research includes a long-term study of sexual and drug-related risks for HIV and STIs among male and female sex workers in Moscow and a study of HIV and hepatitis C risks among injection drug users in Dushanbe, Tajikistan. She also holds a Master’s of International Affairs Degree in Human Rights and a Master’s of Public Health, both from Columbia University. She served on the Board of Directors of the AIDS Memorial Quilt for eight years, and on the Board of Mobilization Against AIDS for two years. Celeste A. Wallander is a Visiting Associate Professor in the School of Foreign Service at Georgetown University, and a Senior Associate in the Russia and Eurasia Program at the Center for Strategic and International Studies. Previously, she was director of the Russia and Eurasia Program and CSIS Trustee Fellow. Before joining CSIS, she was Senior Fellow at the Council on Foreign Relations in Washington, DC and Associate Professor of Government at Harvard University. She is the founder and Executive Director of the Program on New Approaches to Russian Security. Her recent projects include work on U.S.-Russia security cooperation, the history of Russia and globalization,

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HIV/AIDS in Russia, and the 2004 Ukrainian presidential election. Among her books are Swords and Sustenance: The Economics of Security in Belarus and Ukraine (MIT, 2003), and Mortal Friends, Best Enemies: German-Russian Cooperation after the Cold War (Cornell, 1999). She is currently writing Global Russia: Economics, Politics, and Security. Wallander received her BA from Northwestern University summa cum laude and her PhD from Yale University. She is a member of the Council on Foreign Relations.

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Index

Aarhus Conference, 26 Abuse alcohol and tobacco, 5 police, 167 ACT-UP, 159 Activism, 60–61, 159 Advocacy, 49 Afghanistan, 145 Africa, 41 Aleksandr Zhukov, 35 All-Ukrainian Network of People Living with HIV, 139 AIDS Brigade, 159 AIDS Foundation East West, 69 AIDS Front, 159 AIDS Infoshare, 57, 61–62 AIDS Research Group, 8 Anti-AIDS Campaign, 27 Antiretroviral medications (ARVs), xii, 5, 45, 49, 91, 115, 174 Arabian Peninsula, 144 Armenia, 105, 135 AvtoVaz, 95 Azerbaijan, 105, 135 Baltic and Nordic States, xiv Belarus, 105 Beslan, 176 Birth rates, 182 Bisexual, 9, 11, 15 Blood donor, 11, 26 transfusion, 9

Botkin Infectious Diseases Hospital, xi Botswana, 190 Breastfeeding, 26 Bridge populations, 78 Bubonic plague, 81 Burgasov, Pyotr Nikolayevich, 7 Bush Administration, 107 Bush-Putin Summit, 109 Camp David Summit, 109 Canada AIDS Russia Project, 6 Canadian International Development Agency (CIDA), 106, 112 Cardiovascular disease, 5 Central Epidemiology Research Institute, 8 Challenges faced by bilateral donors, 118 Chechnya, 40, 71 Childhood morbidity, 5 Chornaya, 142 Chretia, Jean, 112 Clinton Administration, 106 Committee of Soldiers’ Mothers, 59 Commonwealth of Independent States (CIS), 103 Communism, xiv Communist Party, 35, 36 Condom demand, 17 use, 15, 189

216

Index

Confidentiality, 20 Coordinating Council on HIV/AIDS, 43 integration among other government ministries, 46 Corruption, xiv Country Coordinating Mechanism (CCM), 4, 70, 121, 137 Criminal Code of the Russian Federation, 174 amendment of, 174–175 Delo, 169 Democracy, 5, 38, 106, 145 Demographic change, 84 Demonstration, 2 Detoxification programs, 148 Development Assistance Program Organization for Economic Cooperation and Development, 106 Diagnosis reluctance to diagnose HIV, 12 Diagnostic test kits (HIV), 25 Discrimination, xiii, 7, 8, 49, 173, during the Soviet Union, 17, 19 in health care, 20, 23, 174 Disinformation campaign, 13 Doctors Without Borders, 4 Draft avoidance, 185 Draft population, 194 Drug addicts, 8 homemade, 143 trafficking, 2 Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia, 110, 155 Duma, 46 East Africa, 144 Eberstadt, Nicholas, 187 Economy breakup of the Soviet Union, 62 cost of HIV in Russia, 4

growth, 79 health and social protection sectors, 91 impact of HIV, 50, 83 models of HIV/AIDS implication, 84–96 wealth vs. health of the population, 5 Elista, 22 Enrollment in higher education, 189 EU Drug Horizontal Group, 155 Europe against AIDS Programme, 110 EuropeAid, 110 European Commission (EC), 106, 109 European Neighborhood and Partnership Instrument (ENPI), 111 European Union, 105 Education disinformation campaign, 17 sex, 17, 19 Estonia, 105, 154 Federal AIDS Center, 8, 33, 43, 79, 174 Finland, 106, 115 FOCUS Media, 69 Future effective campaigns against HIV/AIDS, xiii population projections, 79 projections for HIV/AIDS infections in the Russian Federation, 27–28, 192 Funding medical supplies and equipment, 23 treatment efforts, 91–95, 133 Gameleya Institute, 27 Generalization, 78 Geopolitical dimension HIV/AIDS, xiv Geographic distribution of PLWHA, 30 Georgia, 105, 135

Index German Agency for Technical Cooperation (GTZ), 106 Glasnost, 15, 59 Global Fund to Fight AIDS, Tuberculosis and Malaria and the Caucasus, 134 and collaboration with other NGOs, 69 and corruption, 159 and the Country Coordinating Mechanism, 47, 69 and Kazakhstan, 135 and Russia, 1, 42, 48, 134 and Ukraine, 4, 138–139 and the European Union, 110 support for bilateral donors, 120, 126 Gross Domestic Product (GDP), 96 Growth Rates of HIV in Russia, 33 Government and civil activism, 36 and municipalities, 37, 46 coordination between agencies, 36 financial support for HIV prevention programs, 44, 133, 173 fiscal budget, 40 narcology clinics, 145 surveillance, 36 Gorbachev, 59 Group of Eight (G8), xv, 33 Gypsies, 143 Hanka, 143 Haq, Mahbubul, 96 Harm Reduction Programs, 2, 44, 67, 113–114, 152, 158 Hepatitis C, 24, 167 Heroin, 142, 145 Himiya, 142 Homosexuality, 15, 28 behavior and stigmatization, 7 in the Soviet Union, 15 Hospitals and the spread of HIV, 22 Households impacted by HIV, 95

217

HTLV-1, 14 Human Development Index (HDI), 96 Human Rights Watch (HRW), 168, 174 Humanitarian Action in St. Petersburg, 169 Infant mortality, 24 Infections oo-infection HIV/TB, 44 global, 1 rate of, 1 Inflation, 63 Infosvyaz, 64 Injection Drug Users (IDUs), 1, 3, 16, 34, 149 and breakup of the Soviet Union, 67 and human rights, 166 HIV cases in Russia, 28 Injection hygiene, 152 Institute for the Economy in Transition, 186 International aid cooperative aid programs, 4 International AIDS Alliance, 137 International Covenant on Economic Social and Cultural Rights (ICESCR), 170 International Labour Organization (ILO), 86 International law, 170 International Monetary Fund (IMF) loans to Russia, 42 Involuntary testing, 165 Irkutsk Harm reduction Program, 152 Ivanov, Sergei, 186, 187 Ivanovsky Insitute, 14 Kalmyk Autonomous Soviet Republic, 22, 30 Kaposi’s Sarcoma (KS), 26

218

Index

Kazakhstan, 135 Komsomol’skaya Pravda, 16 Kremlin, xv Kyrgystan’s National AIDS Center, 135 Labor morbidity and mortality, 90 Labor Party, 155 Latvia, 105 Law enforcement and cooperation with the Ministry of Justice (MOJ), 44 and drug abuse, 143, 151 and harm reduction programs, 45 police abuse, 2, 151, 167–170 Legislation and drug laws, 44, 153, 160, 174–175 and homosexuality, 60 rehabilitation programs, 147 substitution therapy, 148 surveillance, 46 syringe exchange, 171 Lenmedpolimer, 25 Life expectancies, 96 Lithuania, 105, 154 Mainstreaming of HIV/AIDS, 123 Mak, 143 Malaria, 111 Marx, Karl, 58 Medecins du Monde-France, 4 Men who have sex with men (MSM), 15, 34 Microbicides, xii Military draft population, 185, 194 education and health trends among recruits, 187, 193 Medical Administration, 187 recruitment, 185–186 service, 184 Ministry of Defense (MOD), 45, 185

Education (MOE), 184 Health (MOH), 43, 133, 154, 174 Health and Social Development (MOHSD), 44 Justice (MOJ), 44, 133 Moldova, 105 Mukhen, 137 Narcotics Anonymous, 148 Nemtsov, Boris, 186 Netherlands, 106, 117 Nigeria, 190 Noncommissioned officers (NCOs), 185 Non-governmental organizations (NGOs), 2 and bilateral donors, 116 and municipalities, 117 awareness programs, 49 consortium, 48, 134, 137 cooperating with the Ministry of Justice, 44 Coordinating Council on HIV/AIDS, 43 future recommendations, 72 harm reduction programs, 47, 135 independence in Russia’s political environment, 48 pilot programs for prevention of HIV/AIDS, 33 Quasi-governmental “QuaNGOs”, 63 support for bilateral donors, 116 Official statistics and credibility, 50, 51, 155 HIV epidemic figures, 51, 69, 155 registered cases of drug abuse, 145 registered cases of HIV, 34, 78 Ogonyok, 27 Olga Gayevskaya, 25 Oligarchs, 38, 50 Onishchenko, Gennadi, 43 Open Health Institute, 69 Open Society Institute, 4

Index Orange Revolution, 4 Organizations, intergovernmental, 4 international, xii Patriot, 13 Perestroika, 7, 59 Pokrovski, Vladimir, 17 Poland, 173 Politburo, 36 Political Parties, 38, 59 Population (see also demographic change) decline, xiv, 79, 182, 195 future projection, 80 Population Services International, 69 Prevention Caucasus region, 135 Central Asia, 135 Cost-benefit analysis, 98 law enforcement, 150 national programs, 42 programs, 4, 171 public policy, 42 work and service, 47 Prisons HIV prevention measures, 171–172 injection drug use, 171–173 reported HIV infections, 44 Privatization, xiv Project Renewal, Kazan, 158 Propaganda, 8, 12 Prostitution, 16, 20 Putin, Vladimir and civil activism, 5, 36 and counterterrorism, 176 and the G8, xv and government reform, 40 and HIV prevention policies, 34, 40–41 and the military, 186, 187 and population decline, 79 leadership, 38–40 State of Nation address, 69

219

Radio Liberty, 7 Red Crescent Society, 135 Revolution in Military Affairs (RMA), 197 Romania, 173 Russia AIDS Relief (RAR), 66 Russian Business Summit on AIDS, 95 Federation of Family Planning (RFFP), 66 Health system at the onset of the HIV epidemic, 67 Security Council, 35 Union of Industrialists and Entrepreneurs (RSPP), 95 Second International Conference on AIDS, 9 Sector wide approaches (SWAPs), 118 Sex behavior, 14 commercial, 2, 7, 11, 17, 68, 169 education, 17, 18 Shirka, 144 Single use hypodermic needle, 21 Socioeconomic influence on the spread of HIV, 81 Soros Foundation, 135 South Africa, 190 Soviet Union and AIDS mortality, 25 and blood donations, 25 and civil society, 58 and health care, xiv, 2, 4, 13, 20 and HIV cases reported, 26 and the impact of its political system on Russia, 35, 58 and sterilization practices in hospitals, 24 period and collapse, 2, 58–59, 61, 144 SPIDNET, 65 Stabilization Fund, 40

220

Index

State Drug Control Committee (SDCC), 153 State Program for the Prevention of the Spread of AIDS, 16 Stavropol kraj, 30 Stigmatization (see also discrimination), 153, 173 Sub-Saharan Africa, 3, 189 Substitution therapy, 2, 67, 148, 166, 169 Supreme Soviet, 62 Surveillance of HIV/AIDS, 50, 156 Swedish International Development Agency (SIDA), 106 Syphilis, 187 Syringe exchange programs, 67, 150, 153, 167–169 private demand, 25 reuse, 16, 21 sterilization, 23 Tajikistan, 136 Tanzania, 9 Testing for HIV among blood donors, 26 and diagnostic equipment, 11, 25 mandatory, 12, 60, 165 voluntary, 142 The Futures Group, 78 Three Ones, 124, 139 Transmission and drug use, 28, 149–150 and foreigners, 30 and the general population, 69, 78 and heterosexuality, 30, 78, 189 and homosexuality, 28, 60 and medical mistakes, 29 Treatment, HIV/AIDS detoxification programs, 147–149 donor community, 115 costs, 91 programs in post-soviet Russia, 4

Tuberculosis, 4, 111, 133 Turkmenistan, 2, 136 Ukraine, 1, 137–138, 143, 145, 155 UN Security Council, 33 UN Population Division, 79 United Kingdom’s Department for International Development (DFID), 106, 108, 111 United Nations Programme on HIV/AIDS (UNAIDS), 1, 6, 111, 134 collaboration with other NGOs, 69, 135 Program Coordinating Board, 69 estimates of HIV infections, 78 United Nations Theme Group on HIV/AIDS, 137, 139 Urals, xiv U.S. Agency for International Development (USAID), 106, 108 U.S. Bureau of the Census, 79 U.S. Centers for Disease Control and Prevention, 13 U.S. Department of State’s Foreign Affairs, 13 U.S. National Intelligence Council, 1, 107 U.S. – Russia Commission on Economic and Technological Cooperation, 107 USSR Academy of Medicine, 7 Uzbekistan, 137 Vint, 144 Volgograd Oblast, 30 Wimm-Bill-Dann, 95 Women health trends, 182 HIV positive, 11, 78, 191 and the military, 195 Women’s Union, 136

Index World Bank AIDS mortalities, 192 economic cost of HIV in Russia, 4 loans to Russia, 42, 133 World Health Organization (WHO) HIV/AIDS in prisons, 172 syringe exchange programs, 166

World Trade Organization (WTO) Russia’s joining conditions, 39 Yeltsin, Boris, xiv, 37 Youth Union, 135 Zhukov, Alexander, 95, 192 Zimbabwe, 190 Zurabov, Mikhail, 192

221