AIDS experts say Russia needs new HIV strategy

MOSCOW - AIDS experts urged Russian officials on Wednesday to scrap their abstinence-based strategy for curbing the spread of HIV, saying the country's fast-growing epidemic could be entering a dangerous new phase.

AIDS specialists meeting here urged Russia to adopt successful strategies like needle-exchange programs and heroin substitutes such as methadone for drug addicts.

The number of HIV infections in Russia has doubled in the past eight years and there is evidence that in this region the virus is increasingly being spread by heterosexual sex.

The rapid growth of the epidemic in Russia is in contrast to sub-Saharan Africa and South and Southeast Asia, where prevalence of the virus fell during the same eight-year period, according to UNAIDS, the United Nations AIDS agency.

Russia's chief public health officer, Gennady Onishchenko, told a regional AIDS conference Wednesday that Russia is "emphatically against" the use of drug replacement therapy. Meanwhile, he criticized programs that exchange clean needles for used ones, saying such programs may promote illicit drug sales and HIV transmission.

Both are part of a so-called harm reduction strategy, in contrast to the just-say-no programs that urge abstinence from drugs and risky sex. Russian health officials say they are committed overall to a "healthy lifestyles" rather than a harm reduction approach to improving public health.

That isn't good enough, a number of foreign experts say.

"International studies show that an abstinence-based message on drug use or sex simply doesn't work," said Robin Gorna, executive director of the International AIDS Society. In Russia, she said, "it does appear that ideology is getting in the way of public health care policy."

Russia has increased spending on AIDS programs by 33 times since 2006, making it a central part of an ambitious new national health care strategy. It has expanded drug treatment dramatically for AIDS sufferers and is among the leaders worldwide in reducing the incidence of transmission of the disease between mothers and their babies.

But many Russian officials view harm reduction efforts as encouraging criminal or shameful behavior. The position has left it increasingly isolated, as China recently embraced such programs, foreign AIDS experts here said.

Russia has some highly successful needle exchange programs and free condom programs, several foreign specialists said, but many have been paid for through grants from the international Global Fund to Fight AIDS, TB and Malaria.

Now those grants are being terminated under Global Fund rules, the specialists said, because Russia is too wealthy to qualify for them.

Chris Beyrer, a professor at the Johns Hopkins School of Public Health, said Russian officials "have never really embraced" needle exchange, free condom distribution and other harm reduction techniques.

"It is the reason I think that they continue to have one of the most severe epidemics in the region," said Beyrer, director of Hopkins' AIDS International Training and Research Program. He was in Moscow for the regional meeting, which runs through Friday.

Gorna of the International AIDS Society said the only needle exchange programs in Russia are some 75 funded primarily by foreign donors, 22 of which shut down in August after their grants ran out. She and other experts said the regions where those programs have operated have seen slower transmission rates than the rest of Russia.

Russian civic groups and other nongovernment organizations that have distributed millions of free condoms in Russia also lost their Global Fund grants in August, due to the eligibility issue, Gorna said. She said she was unable to determine Wednesday whether the Russian government has continued those programs.

Michel D. Kazatchkine, executive director of the Global Fund to Fight AIDS, TB and Malaria, told reporters at a news conference that he hoped the Russian government would keep the harm reduction programs going. But Onishchenko, speaking at the same event, did not say whether the Russian government would do so.

AIDS was virtually unknown in Russia and elsewhere in the Soviet Union prior to the collapse of Communism. What started as an epidemic among male injection drug users here in the late 1990s has gradually moved into the communities of sex workers. By 2007 about 44 percent of new infections in Russia were among women, according to UNAIDS, raising fears it could move into the general population.

Onishchenko blamed the increase in HIV infections to the surge in Afghan poppy production over the past decade, a trend that has flooded the former Soviet Union with heroin.

Russia, with a population less than half that of the U.S., has 13 percent of the world's heroin users and they consume about one-fifth of the drug used worldwide each year, according to an October report by the United Nations Office on Drug Control.

Though Russia has adopted federal laws forbidding discrimination against HIV-positive individuals, widespread discrimination continues, according to a December 2008 United Nations report on AIDS in Russia, Eastern Europe and the former Soviet Union.

People living in the region are routinely asked to provide health certificates that reveal their HIV status, the report found. Hospital workers often casually identify HIV-positive patients to bystanders and co-workers, U.N. researchers said, and hospitals frequently segregate HIV-positive patients, treat them with scorn or charge them extra, hidden fees.

HIV-positive children face discrimination at school, including forced disclosure of their status and segregation from other students, while in the labor sector, many employers are wary of hiring HIV-positive individuals.

AIDS activists say that discrimination drives many of those infected to avoid testing and treatment.

In addition to harm reduction, Russian and foreign health experts on Wednesday debated the size of the country's AIDS problem and the adequacy of the government's response.

While the U.N. estimates Russia has 1.1 million people with HIV, the government says it has registered just half that number - a total of 501,000 cases.

Kazatchkine of the Global Fund said Wednesday that only 23 percent of Russians who should be receiving anti-retroviral therapy for HIV are getting it. He said most nations are providing such therapy to 35 to 40 percent of those infected.

Onishchenko questioned what he called this "strange data," saying that everyone who needs it is getting the drug regimen, except for a small percentage of injection drug users who walk away from the program.

"They are receiving treatment unless they escape treatment," he asserted.