In 2010, President Dmitry Medvedev said heroin was a threat to Russia's national security. This year, Russia pledged to finance programmes to reduce the harm done by drug use, including an HIV crisis that is one of the most severe in the world.
But even though the number of new HIV infections in Russia jumped 10% over 2011, health workers and global HIV authorities say Moscow has not honoured that promise.
This is not due to a lack of cash - Russia is doubling its budget for HIV in 2012 from 2010 levels. At issue is how it will use the funds. From next year, no money will go to such internationally recognised efforts as needle exchanges. None has ever gone to heroin substitution: the Russian authorities oppose it. Moscow doesn't believe these approaches help slowly the spread of HIV/Aids.
"Working on drug dependency is more effective than needle exchange and methadone programs," said Alexei Mazus, who heads the Moscow Centre for HIV/Aids Prevention, one of around 100 such venues across the country run by the health ministry.
HIV rates fall with needle exchanges
In areas where needle exchanges have taken place, he said the health ministry had seen new HIV cases increase, not fall. Russia's health ministry said last year it had evidence that HIV rates have tripled in areas where foreign-run needle exchange programs were running.
The United Nations says so-called harm reduction programmes - needle exchanges, and using methadone as a substitute for heroin - are effective in slowing the spread of HIV. Methadone reduces the risk of infection by dirty needles because it can be swallowed, rather than injected.
A major WHO study found HIV rates fell more than 18% in cities with needle exchanges, while they rose 8 percent in areas that did not have them. The British and US governments both approved needle exchanges in recent drug policies drafted to combat HIV. But in Russia's drug strategy for 2010-20, heroin substitutes are banned.
Health workers angered by Russia’s approach
Projects such as giving drug users and sex workers clean needles, HIV awareness training and medication have been funded by the United Nations in Russia for the last seven years. Next year that funding comes to an end and with it, so will most of these schemes.
Some health workers and global HIV authorities are angered and baffled by Russia's approach, which they say will only aggravate the problem.
"When a few programs were funded and running it was then difficult to see how things could get worse. Now we know," Damon Barrett, a senior human rights analyst at Harm Reduction International in London, told Reuters.
Over a million Russians are HIV positive
Separated from world no 1 opium producer Afghanistan by former Soviet Central Asia, whose borders are porous, Russia has more heroin users than any other country. Moscow puts the total at two million, although the United Nations says there are half a million more, and local non-governmental organisations (NGOs) say there could be as many as three million.
This year, Russian health officials estimate 62 000 people were newly infected with HIV, a 10% increase on 2010 and the upper limit of a prediction made last year by the International Aids Society. Officially, Russia has had almost 637,000 cases, including over 100 000 deaths in the year to November.
The UN puts the number of people living with HIV today in Russia at over a million.
Since 2004, NGOs in Russia have received a grant from the UN's Global Fund to Fight Aids, Tuberculosis and Malaria. The Fund says the R2.8 billion it has provided has reached half a million Russians. It has supported over 70 harm reduction programmes across the country. The 20 or so that remain will stop receiving UN money at the end of this month.
This is for two reasons, says Nicolas Cantau, fund portfolio manager for Russia at the Global Fund. First, Russia has become richer, and the Fund's resources can be given to impoverished countries. For rich countries to be eligible for Global Fund resources, 10 percent of the population must be infected: South Africa is the only country in the Group of 20 richest nations to qualify.
Russia has been a donor as well as a recipient, and has given the Fund $265 million up to date. But the Fund now wants something in return: It says Russia should begin financing its own harm reduction programs.
Money put aside for HIV testing
At a United Nations meeting in New York, Russia pledged to do just that from this year. Its deputy health minister Veronika Skvortsova said Moscow also gave general support to a declaration for Zero new infections, zero discrimination, and zero Aids-related deaths.
A spokesperson for the health ministry said Russia has put aside money for free HIV testing, for the first time ever. But he declined to comment in detail on why harm reduction programs have yet to materialise. "They are not considered useful in fighting this disease," he said.
Some health workers are incensed.
"As it turns out, they were tricking us," said Anya Sarang, who heads the Andrey Rylkov Foundation for Health and Social Justice, a small Russian NGO. "Now we are in the final month of the year. Have they actually done anything? No," Sarang said.
The Global Fund's Cantau is dismayed. "All the things that we have done will be lost without further funding," he says. "It is disappointing."
Prevention by counselling
Russia has put aside around R4.9 billion for HIV in 2012 - double what it had in 2010 - but only 3% of this will go towards prevention. Some money will go to HIV tests, and Moscow says it also provides free anti-retroviral drugs for all sufferers of the disease, although the UN says only a quarter of those in need actually receive them.
No funds will go to needle exchanges. Instead, Russia's HIV/Aids Prevention Centres will try preventing HIV with anti-drug adverts, and treating HIV with psychological counselling.
Mazus, the head of the Moscow Centre, said HIV sufferers need to grieve through counselling, which will also prevent them from passing on the disease to others.
"HIV is a behavioural disease. It's not being transferred in everyday life. It is not dangerous," he told Reuters.
Such views are scorned by foreign health bodies.
Instead of making good its June promise, Russia has "ramped up repressive measures known to fuel HIV", said Harm Reduction International's Barrett. He pointed to the ban on opiate substitution therapy.
Spotlight on Russia
Concerns have spread beyond health workers. On World Aids Day, December 1, a drug-users' network organised protests at 12 Russian embassies from New York to Stockholm to Canberra.
Hundreds of protesters rallied and held candles, some holding signs accusing the state of murder for its refusal to legalize methadone, while others held large red banners heaping shame on Russia.
The protests' coordinator, Erin O'Mara, also editor of Black Poppy, a British magazine for drug users, said "the spotlight was on Russia and its shameful lack of response and indeed inappropriately aggressive, state-sponsored aggression towards... people who use drugs".
In Moscow, protesters played funeral music and held up coffins as they paraded past the health ministry. The ministry declined comment.
Russia willing to watch Aids epidemic
Some foreign health workers in Russia fear its endemic corruption could make it hard for them to access what funds are available for HIV prevention.
"It will be very tough to find money. We fear that the state's funding for HIV will be pre-awarded," said Yelena Agapova, from the Aids Foundation East-West (AFEW), a Dutch organisation set up in Russia 10 years ago.
Like dozens of NGOs in Russia combating HIV, her organisation has received the bulk of its support from the Global Fund. It runs mother-to-child HIV prevention programmes, prison HIV prevention and safe sex campaigns.
Though its Moscow office will stay in place with a skeletal staff, it says it will significantly downsize its projects from next year. Only a handful of similar organisations will continue working once flows from the Global Fund stop over coming weeks. They will be financed from Western awards and George Soros' Open Society Foundation.
Harm Reduction International's Barrett says the impact will be catastrophic: "It is a human disaster that Russian authorities are willing to watch unfold," he said.
(Reuters Health, December 2011)