Russia Sits on the Edge of an Epidemic

Out of work and separated from his wife, Yuri takes the only job he can find--chauffeuring prostitutes in this provincial city. The women are all using heroin. He becomes close to one, has an affair with her, and one evening while drunk accepts her challenge to shoot up “just once.”

In a matter of days, Yuri is addicted. Months later, he learns he is HIV-positive. He contemplates suicide.

Yet the shock of realizing he might die of AIDS gets him off drugs. He goes through two weeks of gut-wrenching withdrawal and stays off the stuff.

And his wife, in an act of love and pity he considers miraculous, agrees to take him back even knowing of his infection. It would be a happy ending, if not for the ticking time bomb in his system--and Russia’s.

Dismissed by the former Communist authorities barely a decade ago as a phenomenon of Western decadence that would never spread widely here, AIDS is making its mark on the new Russia. Disturbingly, it arrived virtually overnight, with the number of people with the human immunodeficiency virus exploding in just the last three years.

The coming together of a poor economy, a burgeoning plague of intravenous drug use, an overreaction to the country’s new freedoms and Slavic fatalism has landed Russia on the cusp of an epidemic.

The face of HIV infection today in Russia is a young man, unemployed, who is using or has used intravenous drugs--and who has caught the disease from injecting himself with a dirty needle. So far, comparatively few people seem to have been infected by homosexual or heterosexual contact. Assuming, however, that the young man is sexually active, officials fear that this will inevitably change.

At least 201,000 Russians are HIV-positive, and the country’s top AIDS fighter warns that the number of people infected but not registered with authorities could be four to six times higher.

Across the former Soviet Union, there are more than 1 million cases of HIV infection, participants at the International AIDS Conference in Barcelona, Spain, were told this summer. From a very small number of HIV/AIDS cases in 1995, the former Soviet states have zoomed ahead of the United States, which is roughly equal in population but has endured the epidemic for far longer.

The former Soviet states now face the fastest-growing AIDS epidemic in the world, the United Nations says, and international AIDS officials consider it vital that more resources go to oppose the disease here.

The epidemic in Russia is so young that cases of AIDS are rare. And it is still unclear whether there is a chance to staunch Russia’s HIV crisis before it mushrooms into a human and demographic catastrophe.

There is one glimmer of hope: The number of newly registered cases of HIV infection has actually been dropping in the last year.

But Vadim Pokrovsky, director of Russia’s federal AIDS center, argues that the recent drop-off makes the situation no less alarming. “Last year, about 88,000 new cases were registered. In the first six months of this year, we registered about 26,000 new cases--which may seem to some analysts as a slowdown,” he said. “But the number of new cases in which the virus was transmitted heterosexually rose to 7% compared with 4.3% last year, which demonstrates the epidemic is spreading over the majority sector of the population.

“And thus it begins to develop according to the African scenario, where the majority of the HIV patients contracted it heterosexually.”

In Pokrovsky’s view, if just half of the HIV-infected population spreads the virus to one sexual partner per year--which he considers conservative based on the African experience--Russia could have as many as 5 million HIV cases by 2010 and will have suffered 500,000 AIDS deaths.

“This will be very grave for the country’s demographics, because 80% of the infected people are between 15 and 30. They will die, and they will not produce children. And this is very frightening indeed for Russia,” he said.

Already troubled by their country’s declining influence since the dissolution of the Soviet Union, many Russians tend to look with dread on demographic projections that show their population declining from its current level of 144 million to around 110 million by 2050.

AIDS could accelerate that decline, and discussion of the epidemic often is seen here almost as a matter of long-term national survival.

The HIV/AIDS crisis in Russia has been a slow train wreck. Experts saw it coming but found themselves powerless to stop it. Tatyana N. Nikitina, the director of the Kaliningrad regional AIDS center, said the scenarios for the spread of AIDS in Russia turned out to be all wrong.

Officials who were concerned about the disease as early as the 1980s and early 1990s expected it to be primarily a sexually transmitted illness that would build gradually over a long period. They were caught by surprise when it instead soared in 1999 and 2000 among intravenous drug users.

Nikitina gave her clinic as an example. Until 1996, it had handled only 21 HIV cases and needed only two small rooms in a former kindergarten to function. Suddenly, it was meeting 180 clients a day, with people lining up outside the doors waiting for blood tests and HIV counseling.

“It became clear that the amount of work ahead of us was immense,” she recalled.

As in other parts of Russia, the rate of new infections in Kaliningrad--a region of about 950,000 people--is falling off. “Each month we have 30 to 40 fresh cases,” Nikitina said. “We call it a stabilization, but of course, in reality, we understand it is a tragedy.

“We also see a growth in the disease in people over 30, even over 50. Normal people, not addicts. So it means that it is now spreading by sex.”

In Russia, HIV is striking hardest in communities of intravenous drug abusers--young people taking the Afghan-grown heroin that in recent years has flooded the country via Central Asia.

Now, Pokrovsky expects a slower rise in the disease as it begins to be spread through heterosexual sex.

Few visitors to Russia fail to notice the presence and ubiquity of prostitution--women stand day and night along the road from Moscow’s main Sheremetyevo Airport and on other busy thoroughfares.

For young women desperate to escape village life and remote provincial towns, working for sex clubs and escort agencies, or dispensing “erotic” massages in their apartments by appointment, may seem the only path to economic advancement.

Research shows there is a strong link between prostitution and drug abuse, and the prostitutes themselves pose a major risk factor for HIV. In the Moscow region, a survey three years ago indicated that 14% of prostitutes were already infected.

Despite the danger of contracting HIV, prostitutes say many male clients are willing to pay more to have unprotected sex--creating an economic incentive for the women to be more careless.

Asked why anyone would put themselves at such risk, Yuri had this reply: “There is a certain element of haphazardness in the Russian mentality,” he said, citing his own misfortune. “We are always looking for a stroke of luck, but it seldom comes.”

Pokrovsky said prostitutes will play a key role in spreading the virus to the heterosexual population. “A huge number of women are among infected drug users--20% to 30%--and most of these make money for drugs through prostitution,” he noted.

Nikitina said she wouldn’t expect drug abusers to be responsible in their sexual practices, but there are exceptions.

Soon after Yuri received the news of his illness a year and a half ago, he made a resolution: “I will do everything to make sure I do not ever infect anyone else.”

“For me,” he said, “it is an ironclad rule: I will never again have sex without a condom. I make about $100 a month, and buying good-quality condoms leaves a breach in my family budget. I could buy cheaper ones, but I would never do that.”

Even so, he said, he can sense his wife’s tension whenever they have sexual relations. “I can’t blame her,” he says. Pokrovsky sees some positive signs that people are beginning to take the threat of AIDS seriously by using more condoms.

“We can see that the rates of syphilis and gonorrhea have dropped a bit. We note that the use of condoms is up somewhat,” he said. “But the biggest problem is when we have evolved to a period of toleration--meaning that the population is no longer afraid enough of AIDS.”

For example, “in June, a poll in Vlast magazine measured what issues concerned the public. Out of several thousand respondents, there were 30 concerns listed, and AIDS was not one of them.”

Pokrovsky said he sees a similar level of indifference on the part of the nation’s authorities. The expected federal budget to combat AIDS was small enough--180 million rubles, or about $6 million--he said, and then that was reduced to $5 million.

In Ryazan, the city about 136 miles south of Moscow where Yuri lives, the epidemic started slowly. There was not a single case detected in the city until 1991, and through 1998 there were one to five cases each year.

But then the drug epidemic hit, and in one year, 1999, the number of reported HIV cases mushroomed to about 300. The next year there were 508 cases, and in 2001 the number of new cases started to decline, to 307 cases. So far in 2002, it appears that the annual increase will be about 200 cases.

Anton S. Dimashov, head of the Ryazan Regional AIDS Center, thinks part of the decline is attributable to the more active prevention efforts by public health authorities. But mainly he sees a change in mentality in the town’s young people.

“In the past, the young would have contacts with the disease only by hearsay and not by direct exposure. Today, they have started to bury their own friends. And this is having a major influence on their thinking,” Dimashov said.

Yuri, who asked that his last name be omitted because he fears he will be fired from his job at a local factory, caught the virus in 2000--the news confirmed by a blood test at the regional AIDS center four months after his relationship with the prostitute began.

“I had always thought of HIV and AIDS very remotely, not as something that would ever affect me,” he says. “I had never taken any special interest in finding out more about it--just a glance at the literature out of curiosity.”

Now, he says, “I lead a group--Youth Against Narcotics--and in my spare time, I am an AIDS and HIV counselor.”

His 40-year-old wife, Tatyana, who works as a tram conductor, looks at Yuri with pity and affection as he discusses his disease, and she recalls her shock when he told her.

“At first, I thought he was just saying it to make me angry. He said: ‘It is up to you to decide if you want me to leave. If you do, I will leave.’ I finally said I would give it some thought and decide.

“And later, I thought if he has reacted this way [getting off drugs] and analyzed everything, we should leave it to God. If he wants us to stay together, we will. If not, not. I did not shout. I did not smash up the kitchen. I just felt extremely sorry for him.”

Holding her hand, Yuri chimes in: “It is the classic question, ‘To be, or not to be?’ And we decided to be.”