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Monday, June 19, 2017


Russia struggles to contain HIV/AIDS epidemic as one million Russians are HIV positive - and the number keeps growing

Russia struggles to contain HIV/AIDS epidemic as one million Russians are HIV positive - and the number keeps growing

Will Ebola be outside the Africans border if HIV/AIDS epidemic is no longer an African issue?

2016 Russia's HIV/AIDS Statistics

850,000 - 1.5 million estimated people living with HIV.
0.8% - 1% adult HIV prevalence.
98,177 new HIV infections (2015)
24,000 Aids-related deaths (2014)
37% adults on antiretroviral treatment (2015)

Provided by: The Russian Federal Aids Center, the Ministry of Healthcare of the Russian Federation, WHO, UNAIDS.

The Russian Federation (Russia) has the largest HIV epidemic in Eastern Europe and Central Asia, with more than 98,000 new HIV infections reported in 2015 and a rate that is growing by between 10-15% each year.

Eastern Europe and Central Asia is the only region in the world where HIV infections are rising. In Russia, the number of people newly diagnosed with HIV has risen by 149% since 2006,  and with the country accounting for eight out of ten new HIV infections in the region, the situation there is of particular concern.

In January 2016, Russia reached its millionth case of HIV. Currently, there are around 850,000 people thought to be living with HIV, although it is estimated that at least another 500,000 cases have gone undiagnosed. An additional 220,000 people have died of AIDS-related illnesses since the mid-1980s when the virus was first reported in the country.

Although the Russian government has collected extensive epidemiological data on HIV since 1987  official data remains under reported. While a lack of data is a problem, it is clear that evidence-based policies would save many lives.

People who inject drugs (sometimes referred to as PWID) are disproportionately affected by HIV in Russia. In 2015, 54% of those newly diagnosed with HIV where the mode of transmission was known were infected through injecting drug use.

However, in the same year, 44% of new infections occurred through heterosexual sex. Some experts predict that heterosexual sex may soon overtake injecting drug use as the main means of HIV transmission. 

This means the HIV epidemic may be shifting from mainly affecting key populations including people who inject drugs, sex workers, prisoners and men who have sex with men, to affecting the general population.

Key affected populations

People who inject drugs (PWID) and HIV in Russia

Russia has the highest number of people who inject drugs in the region (1.8 million) - about 2.3% of the adult population.

Between 18% and 31% of people who inject drugs are thought to be living with HIV.  A 2015 survey of people who inject drugs conducted in five Russian cities (Abakan, Barnaul, Volgograd, Naberezhnye Chelny and Perm) found that one in three people who inject drugs were living with HIV.

Women who inject drugs are marginalised and particularly vulnerable to violence. A study released in 2016 of a group of Russian HIV-positive women who inject drugs reported that almost a quarter (24.1%) had been forced to have sex with a police officer. This significantly contributed to these women’s unwillingness to seek harm reduction services.

The sexual partners of key affected populations and HIV in Russia

An estimated 44% of new infections are associated with heterosexual sex, with the partners of sex workers and injecting drug users at increased risk.

As male-to-female sexual transmission of HIV is more efficient than female-to-male transmission, Russia’s HIV epidemic is affecting increasing numbers of women. The government reports that more than 38% of all new cases of HIV in 2015 were among women.

Younger women (aged 15-24) are at particularly high risk and are twice as likely to be living with HIV than their male counterparts.

There are 80-100 cases of HIV infection among women a day. This is no joke - a day. They are mostly young women, aged from 25 to 35 years and they are the main new risk group.

- Vadim Pokrovsky, head of the Russian Federal Aids Centre

Women, especially young women, face multiple challenges and barriers to accessing HIV services, such as stigma, discrimination, gender stereotypes, barriers to sexual and reproductive health, and violence.

Encouragingly, mother-to-child transmission (MTCT) of HIV is currently one of Russia’s success stories. In 2016, the government announced it had achieved a 98% success rate in stopping mother-to-child transmission.

Prisoners and HIV in Russia

“I was shipped to a specialty tuberculosis colony. It seemed like everyone with tuberculosis also had HIV. I survived the scariest place I had ever been. We were 36 men in a closet with only 12 beds. 

We stood, coughed on each other, while others slept in shifts. Most guys, including me, would stop or dispose of our tuberculosis medications so that we could get sick and move from our closet to the infirmary where we'd get our own bed. Many who went to the infirmary never left except in a pine box because their medications didn't work anymore.”

- Sasha, an injecting drug user from Russia

In 2015, there were around 656,600 prisoners in Russia. This is equivalent to 446 out of every 100,000 people incarcerated, the second highest rate in the region after Turkmenistan (583 per 100,000), and far in excess of the global average of 146 prisoners per 100,000. 

Harsh drug criminalisation policies have resulted in large numbers of people who use drugs being incarcerated. Nearly all drug-related convictions are for drug use rather than drug trafficking.

In Russia, 6.5% of prisoners are estimated to be living with HIV but just 5% of these are on antiretroviral treatment (ART). It is estimated that 84 out of every 100,000 prisoners have tuberculosis (TB) with high levels of multi-drug resistant TB (MDR-TB) also reported. A 2010 systematic review estimated that between 5% and 17% of Russia’s TB cases could be due to exposure within the prison.

Opioid substitution therapy (OST) and needle and syringe programmes (NSPs), which have been shown to reduce the risk of HIV, are not available in Russian prisons.
Men who have sex with men (MSM) and HIV in Russia
In Russia, data relating to men who have sex with men (sometimes referred to as MSM) is extremely limited.

Vadim Pokrovsky, the head of the Federal AIDS Centre, has estimated that around 10% of Russia’s men who have sex with men are living with HIV, with this population accounting for around 1.5% of new annual HIV infections.

The 2013 Russian ban on “propaganda of non-traditional sexual relations among minors”, has been used by authorities to block support for HIV information and support services for men who have sex with men and others from the lesbian, gay, bisexual, transgender and intersex community (LGBTI). 

One survey from St. Petersburg, conducted between 2012 and 2015 by the Russian human rights NGO Phoenix Plus, found that HIV prevalence among men who have sex with men had increased from 10% in the year before the law was enacted to 22% in 2015.

Sex workers

Data on sex workers in Russia is also limited. According to a 2011 study conducted among female sex workers in Kazan, Krasnoyarsk, and Tomsk, 3.9% had HIV. Those with a history of injecting drug use and/or experiences of physical and sexual abuse were found to have significantly higher HIV prevalence. 

Sex workers who inject drugs are particularly likely to be living with HIV. Although data on this population is limited, a 2011 study estimated that almost a third of sex workers in Russia have injected drugs at some point in their lives.

Sex workers are also at heightened risk of sexual violence. In a study of almost 900 female sex workers conducted in St. Petersburg and Orenburg, rape during sex work was reported by 64% of respondents. Those who had experienced rape were more likely to inject drugs and binge on alcohol, both of which increases vulnerability to HIV.

HIV prevention programmes in Russia

In 2016, the Russian Prime Minister approved Russia’s 2017-2020 HIV strategy. This is the first official policy to be drawn up since Russia’s 2002-2006 strategy.

The strategy’s stated aims are to reduce HIV transmission rates by focusing on prevention programmes and to decrease the number of AIDS-related deaths. However, although the “rehabilitation, social adaptation and social support” of key affected populations is discussed, no national programmes are outlined.

Harm Reduction

Russia does provide access to certain harm reduction services. However, coverage is extremely low, and where services do exist they are not comprehensive.

Most government-funded services are only in detoxification, allowing people to briefly withdraw from their addiction and then to return to their life situation. 

Private rehabilitation services have grown, where people can go after detoxification, but mostly you can only use them if you have money. If you don’t have money, there are still basically no options.

- Anya Sarang, president of the Andrey Rylkov Foundation

Needle and syringe programmes (NSPs)

The Global Fund to Fight AIDS, Malaria and Tuberculosis withdrew its grant to Russia in 2010, in large part because Russia had achieved high-income country status. The Global Fund had previously financed the majority of NSP work in Russia but, when it withdrew, the Russian government did not replace funding, and the number of needle exchanges in the country dropped from 80 to 10.

Opioid substitution therapy (OST)

In Russia OST remains illegal. The Russian government views OST as merely replacing one addiction with another. Its use is punishable by up to 20 years in prison.

This is despite the fact that UNAIDS, the World Health Organization (WHO) and other international bodies recommend OST and other evidence-informed forms of drug dependence treatment as proven methods for curbing drug use, reducing vulnerability to infectious diseases including HIV and improving people’s uptake of health and social services.

Furthermore, without an OST programme, many people with HIV who have TB fail to get treatment as this requires a lengthy stay in the hospital. Without OST, people who inject drugs are highly likely to discharge themselves or get discharged for disciplinary reasons before their TB treatment has become effective.

Other HIV prevention programming #STOPHIVAIDS

In November 2016, national HIV prevention campaign #STOPHIVAIDS was launched by Svetlana Medvedeva, spouse of the Russian Prime Minister, with the participation of the ministries of health, education and communications and the Russian agency for consumer protection, Rospotrebnadzor.

The campaign will target young people and the general population and will run on television and social media platforms, featuring Russian celebrities talking about HIV awareness, prevention and stigma, and discrimination. 

It also includes public events, film screenings and free anonymous express HIV testing and counseling (HTC). An online lesson Knowledge–Responsibility–Health, designed for young people, will also be made available to the campaign. HIV awareness events are also planned in secondary schools, military bases, and juvenile correctional facilities.

Prevention programmes for men who have sex with men

Despite Russia’s hostile environment towards men who have sex with men, studies have shown that it is possible to carry out successful HIV prevention work among this population through peer-to-peer interventions. 

For example, an LGBTI-led community education and HIV prevention project for men who have sex with men in St Petersburg and Budapest in Hungary produced significant falls in the proportion of men who have sex with men engaging in unprotected sex, especially with casual or multiple partners.

HIV testing and counselling (HTC) in Russia

In 2015, HIV screening coverage in Russia was low at 19.3% (around 30 million people). However, Russia’s 2017-2020 HIV strategy states 35% of people will be annually tested for HIV by 2020 if the correct funding is secured.

 HTC is currently carried out indiscriminately rather than being targeted towards vulnerable groups. For example, members of vulnerable groups such as people who inject drugs and sex workers accounted for less than 1% of the 24 million HIV tests carried out in Russia in 2011.

Even where testing is available, people are often diagnosed at a late stage of infection. In 2014, 40.3% of people newly diagnosed with HIV in Russia had CD4 cell counts below 350.

Antiretroviral treatment (ART) in Russia

Although access to ART has expanded significantly in Russia, new HIV infections continue to outpace enrollment onto ART, with key affected populations most likely to miss out.

Although statistics on the proportion of people living with HIV who are on ART are disputed, it is estimated to be between 17-26%, well below the global average of 46%. In 2015, the proportion of people who have been diagnosed with HIV who are on ART stood at 37.3%.

In 2016, Russia expressed its aim to implement the 2015 WHO treatment guidelines to provide ART to people living with HIV, regardless of their CD4 count.

For those on treatment, viral suppression is one of Russia’s relative success stories. Around 85% of people who are on ART have a suppressed viral load, meaning they are far less likely to pass HIV on to someone else. 

This is the highest proportion of people to be virally suppressed in any country across the region. However, as the vast majority of people living with HIV are not on treatment, the effect this will have on the rate of new HIV infections will be minimal

HIV co-infections in Russia

Hepatitis and HIV

Chronic hepatitis C virus (HCV) is the fifth leading cause of death for people living with HIV in Europe. Although research on HIV/HCV coinfection is limited, in Russia HCV prevalence among people living with HIV is estimated at above 90%. This is mainly due to the association of HCV with injecting drug use.

For example, a 2015 study in St. Petersburg of people who inject drugs found nearly all those who tested positive for HIV also tested positive for HCV but only 3.3% were receiving any HCV treatment.
Tuberculosis and HIV

Although the number of new TB infections and deaths relating to TB are falling in Russia, HIV/TB co-infection is still a serious concern. The incidence of MDR-TB is increasing, which is further complicated by increasing rates of HIV infection. In 2013, TB/HIV coinfection represented 12.5% of new TB cases.

All patients registered with coinfection are entitled to ART and TB chemotherapy. However, in 2011 only 68% of all registered HIV/TB cases underwent such treatment. In the same year, fewer than 40% of people with TB who had advanced HIV were treated.

Barriers to the HIV response in Russia

Legal barriers to HIV prevention and treatment in Russia

The new conservative legislation is placing additional restrictions on same-sex relationships, sex work and drug use, which could further prevent key populations accessing HIV services.

Although Russia decriminalised same-sex relationships in 1993 and transgender Russians have been allowed to change their legal gender on identity documents since 1997, the environment towards men who have sex with men and other LGBTI people is hostile. ILGA-Europe, the European section of the International LGBTI Association, rated Russia 48th out of 49 European countries for LGBTI equality in 2016.

In 2013, legislation prohibiting dissemination of “propaganda of non-traditional sexual relations among minors” has resulted in the arrest of those working on HIV prevention for men who have sex with men. Influenced by Russia, a wave of similar repressive laws have been passed or are being debated in former Soviet Union states.

Punitive drug laws also inhibit access to HIV testing and treatment for people who inject drugs. It has been reported that police will arrest people who inject drugs who access NSPs and confiscate drugs and syringes or extract bribes for possessing them.  

In a 2014 study from St Petersburg, 60.5% of people who inject drugs had been arrested for needle possession or had drugs planted on them by the police and were subsequently arrested.

Administrative barriers relating to harm reduction also exist. In Russia, as in many other countries in the region, official name-based registration of people who inject drugs is required to receive treatment. However, registration often results in restrictions in employment, loss of privileges (eg, driver’s license) and targeting by police.

In January 2017, Russia launched a national registry of HIV patients. Registration is not compulsory, however health ministry spokesperson Oleg Salagai told Russian news agency TASS: “Any individual diagnosed with HIV should be interested in being included in this register since he or she will receive medicine on this basis.” 

There are concerns that the registry could be used to further intimidate and police key affected populations, in particular men who have sex with men and people who inject drugs. Social barriers

Stigma and discrimination towards people living with HIV and key populations remain high. This acts as a barrier to people most affected by HIV from accessing the HIV prevention and treatment services they need.

A 2015 survey by the Russian LGBT Network found levels of violence experienced by respondents to have grown for the first time in four years; 60% had suffered psychological violence, 17% suffered physical violence and 7% suffered sexual violence. Of the 8% of survey respondents who had experienced discrimination when accessing health or medical services, 41% were transgender people.  

In October 2015, the Yuri Levada Analytical Center released the results of an opinion poll in which 37% of Russians surveyed said they wanted LGBT people to live separately from the rest of Russian society and 21% said they wanted LGBT people to be ‘liquidated’.

A 2010 survey by the People Living with HIV Stigma Index in Russia found 72% of respondents had been subjected to gossip due to their HIV status. Around half (49%) had encountered insults, victimisation or verbal threats and just under half (46%) had been subjected to physical violence.
Economic barriers

A lack of funding remains a significant barrier to the scale-up of HIV prevention and treatment programmes to tackle the epidemic effectively in Russia.

As of July 2013, the World Bank reclassified Russia as a high-income country. As a result, international support for HIV programmes in the region is decreasing, yet domestic funding for HIV prevention is not meeting the funding gap.

For example, 30 projects serving some 27,000 people who inject drugs were left without financial support after a grant from the Global Fund to Fight AIDS, Malaria and Tuberculosis ended in 2014. Although projects in 16 cities still exist, their scale is insufficient.

Russia also faces high costs for antiretroviral (ARVs) drugs, in part because ARVs are imported rather than manufactured domestically.

The head of Russia's Federal AIDS Centre, Vadim Pokrovksy has said that the Russian government's 2016 budget of RUB 21 billion (US$325 million) was about a fifth of what is needed to address the problem.  

However, there are signs that domestic HIV spending may increase. For example, in March 2016, Veronika Skvortsova, the Russian health minister, promised an extra US$315 million in funding for HIV treatment and prevention in 2017. Whether this funding promise will be implemented remains unclear.

Civil society’s role in Russia’s HIV response

In 2012, Russia passed the Foreign Agents Law, which required all NGOs who receive foreign funding and conduct ‘political activity’ to register their organisation and publicly identify themselves as a ‘foreign agent’ – a term that is widely interpreted in Russia to mean spy or traitor. 

In 2014, the law was amended to enable Russian authorities to make decisions on who to add to the ‘patriotic stop list’. Fines can be issued to anyone involved in organising activities or receiving funds from any undesirable foreign organisation and prison terms can be imposed for repeated violations.

This has interrupted the work of many community-based organisations that provide HIV services to key populations and receive international funding in the absence of domestic funding for these purposes. 

For example in 2015, the Ministry of Justice registered Russian LGBT NGO Maximum as a foreign agent. Maximum was found guilty of failure to register and fined RUB 300,000 (approx. US$5,000).

The future of the HIV response in Russia

In Russia, the number of new HIV infections continues to rise. The head of Russia's Federal AIDS Centre has warned that 2 million people will be diagnosed with HIV by 2020 if more effective programming fails to be implemented.  Yet, without addressing the needs of key affected populations, the surging HIV epidemic is only likely to worsen.

A fundamental shift in policy is needed to promote effective evidence-based prevention programming aimed at key affected populations. Policies that reduce social marginalisation, stigma and discrimination rather than exacerbate them are essential if Russia is to tackle this growing epidemic.

The scale of prevention programmes for key populations is currently grossly insufficient. The expansion of comprehensive harm reduction interventions are desperately needed as are other prevention programmes that meet the needs of key affected populations, in particular, the sexual partners of people who inject drugs, young women, sex workers and men who have sex with men.

Drastically scaling up HIV testing and counselling and the number of people living with HIV on ART to suppress viral load, in combination with expanding condom use programmes for both the general population and key affected populations, will be key to reducing the growing number of sexually transmitted HIV infections in Russia.

Despite possible increases in domestic spending, the funding gap created by a reduction in money from international donors remains a concern for prevention and treatment programmes, especially given the importance of increasing services for those most affected by HIV.

Transparent national data collection and dissemination, particularly on key affected populations, must also be prioritised.

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