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HEALTH-RUSSIA: More Funding, But HIV/AIDS on the Rise

Kester Kenn Klomegah

MOSCOW, Jun 3 2007 (IPS) - Russia’s HIV infection rate continues to rise – most notably in the heterosexual and non-drug-using populations – despite steady increases in funds to fight the disease. Experts and medical researchers say dramatic changes in sexual attitudes and behaviour are essential if the trend is to be reversed.

“Funds allocated for prevention are not enough and prevention programmes implemented in Russia are very limited in terms of coverage, sustainability and effectiveness. The disease is spreading further into the heterosexual population [beyond] drug users, and especially from men to women. And this trend will continue,” Roman Dudnik, regional adviser at AIDS Foundation East-West (AFEW), told IPS.

To change behaviour, people need a better understanding of the reasons why they have to use condoms and that condoms are an effective prevention tool, Dudnik explained.

“But unfortunately, at the moment, there are different messages that are spread via mass media (safer sex messages and messages that there is not such thing as safe sex) and this creates lots of misunderstanding and confusion in people’s heads. And this usually leads to a refusal of any preventive measures,” he added.

Women comprised 40 percent of the 39,589 news cases of HIV registered in Russia last year. In the first four months of 2007, 15,122 cases were registered, which is seven percent more than in the same period in 2006. Experts say AIDS funds are not reaching the destinations where they are most needed. The human immunodeficiency virus seemingly spreads as the funds increase.

Although surprisingly there was a sharp decline in HIV infections through the use of non-sterile equipment by injecting drug users between 2001 and 2005, there is a correspondingly steep increase in the proportions of infections due to unprotected sex, Neill McKee, a communications expert with the Bloomberg School of Public Health at John Hopkins University in the U.S. told IPS.

He noted that 40 percent of newly reported infections in 2005 were among women, and that only a minority of those women had contracted the virus through infected syringes or the like.

“Russia is a very large territory and is probably experiencing many mini-epidemics rather than one epidemic,” he said.

For instance, the HIV prevalence amongst sex workers in St. Petersburg is very high – more than 50 percent – whereas the prevalence for their peers in Moscow has been measured to be less than five percent. The reason could be that in St. Petersburg sex workers are mainly independent and many inject drugs. In Moscow, however, the crime syndicates that control sex workers also limit drug behaviour.

“In other regions the pattern may be different again, and it takes a good deal of research and planning to properly address the epidemic in each region. [There has to be] an in-depth analysis of what investment is needed to defeat HIV/AIDS. And this really will help them to focus on increasing resources for prevention, peer education for young people, counselling and social support for drug users,” he added.

Condoms, McKee said, are widely available for prevention purposes, but there are many conservative elements in Russian society that would not like to see a highly visible campaign to promote their use. It is also true that condoms don’t work well if the people involved are using drugs or alcohol, and that is often the case in risky situations – so condoms are part of the answer, but not all of it, he said.

According to experts, testing and concurrent counselling are only the first step to prevention. To reduce disease transmission requires changes in individual behaviour, social norms, laws, policies, and practices that promote risk.

For those who use injected drugs, the primary prevention measures are increased access to clean syringes, effective treatment for addiction, and antiretroviral therapy for those already infected. None of these are being adequately provided in Russia, agree health experts.

Russia’s health and development ministry said overall funding for fighting AIDS is rising but that just 200 million roubles (7.75 million dollars) would be spent on prevention in 2007 out of a total health budget of 5.3 billion roubles (205.4 million dollars). This would hardly make a dent in the problem, experts believe.

“A large portion has to be spent on the problem as it currently is focused – on drug using populations. But in fact, the opposite seems to be the case,” Robert Heimer, a public health researcher at Yale School of Medicine, told IPS.

“There is a serious need to reform drug treatment. Detoxification, abstinence-only, and other approaches failed in the vast majority of cases and cannot be considered adequate or ethical treatment. Russia will not be able to manage its addiction problem until it changes its law in this area,” he said.

While the HIV/AIDS epidemic has created a dire situation in many Russian cities, there are some places that have fared better, and should be touted as examples of successful responses, he said. Two noteworthy examples are Yaroslavl and Kazan:

In Yaroslavl, in the province of the same name, just north-east of Moscow, an HIV epidemic among injecting drug users has been averted, thanks in part to early implementation of a peer education programme and expanded syringe access through pharmacies.

In Kazan, in the Republic of Tatarstan in Russia’s central west, as the epidemic began to take root, the local health ministry committed resources to develop a republic-wide syringe exchange with a three-pronged system to ensure the syringes were distributed.

The extent of the expansion of the epidemic beyond injectors to the general population is a matter of great debate. Drug users in Russia tend to be young and sexually active. Therefore, the programmes like syringe exchange, enhanced pharmacy access, and proper drug treatment will need to promote safe sex as well as safe injection.

“For this to be successful, there will need to be behaviour change at the individual level and changes in social norms regarding the use of condoms and disclosure of HIV status to sexual partners,” McKee said, adding that there also has to be substantial investment in efforts to reduce HIV/AIDS stigma.

“On the other hand, HIV treatment and HIV prevention are synergistically linked. Resources have to be expended in both directions simultaneously,” he stressed.

The World Health Organisation representative in Moscow said prevention activities unfortunately rarely show immediate success or measurable outcomes.

“It is also not quite clear how much is ‘enough’. Canada spends approximately 10.5 percent of its total public health expenditure on prevention (and public health); and Italy 0.7 percent, France 2.1 percent and Switzerland 2.4 percent. But in the RF (Russian Federation), 7.5 million dollars were allocated for 2007 (through the national priority projects) and spending on prevention only started in 2006,” Corinna Reinicke, a coordinator of WHO’s HIV/AIDS programme for Russia, told IPS.

Citing United Nations Secretary-General Ban Ki-moon, she said that she was encouraged by recent initiatives around the world to improve the care and treatment of people living with HIV, but nevertheless the number of people with the disease has risen in every region, despite progress towards achieving universal access to treatment, prevention, care and support.

Combating HIV/AIDS in Russia, like everywhere else, needs sustained and greater investment in tools for prevention and treatment, said Reinicke, and should be targeted to the most vulnerable populations, including fighting gender inequality, stigma and discrimination.

“In the RF only about 20 percent of the entire population knows anything about HIV transmission and prevention; mass media could and should play a major role in addressing that issue,” she said.

More women in Russia, including married women, live with HIV/AIDS than ever before.

Based on a recent survey in two regions in Russia among men who have sex with other men, risky behaviour is clearly a concern in the spread of sexually transmitted disease. In a further survey in 2006 in five regions it was demonstrated that a significant proportion of women were engaged in multiple unprotected sexual relations, said Reinicke.

The researchers acknowledge that Russian has reiterated a high level of commitment in response to the AIDS epidemic. The State Council held a special meeting on AIDS in which President Vladimir Putin set goals for developing a strategy and improving coordination through a high-level government commission on AIDS, and establishing a unified monitoring and evaluation system.

Further, a new federal HIV/AIDS programme for 2007-2011 was developed and adopted.

Dave Paprocki, a Global Health Council spokesperson, told IPS in an email interview that despite increased efforts, coordination of activities in responding to the disease remains a challenge for the Russian Federation, given the size of the country, the autonomy of the regions in terms of budgeting and decision-making, as well as a wide range of competing entities.