Millions of unnecessary deaths may result from Russia's refusal to implement accepted AIDS prevention and harm-reduction measures.

Misha Friedman

Polina, 37, has just been brought into the Botkin Infectious Diseases Hospital in St. Petersburg severely malnourished and suffering from numerous diseases, including tuberculosis, hepatitis C and HIV.

Russia is dying. Much has been written about the country's demographic crisis—the declining population, the low birth rate, the life expectancy that puts the country on par with the world's poorest—but bleak as those figures are, they don't yet include masses of people dying as a result of the country's HIV/AIDS epidemic. The World Bank estimates that in 2020, Russia will lose 20,000 people per month to AIDS.

Russia has experienced the fastest-spreading HIV/AIDS epidemics in any one country in history, but there remains a lack of effective preventative measures to slow it down—in large measure because the people most affected are also the country's most reviled.

In a country of 143 million people, roughly one million are HIV-positive. That means Russia has one of the highest percentages of HIV-infected people in the world outside sub-Saharan Africa. Robert Heimer, an epidemiologist at Yale who has spent years studying the intersection of drug use in Russia and its HIV/AIDS epidemic, says as many as five percent of all young people are infected. The Joint United Nations Programme on HIV/AIDS, also known UNAIDS, reports that 1.8 million Russians are current injection drug users.

"Unscientific" is the kindest word one can use to describe the few drug treatment options that are available, and public education about HIV and AIDS is almost nonexistent. A man named Eugeny Roisman became a media hero several years ago for practicing this form of drug therapy: kidnapping addicts, beating them, and chaining them to their beds while they go through withdrawal. Opiate substitution therapies such as methadone maintenance—the gold standard of heroin addiction treatment and the only method that demonstrably works—are illegal.

Russia was once a recipient of funds from the Global Fund to Fight AIDS, Tuberculosis and Malaria—the world's premiere non-governmental organization in the fight against the spread of HIV and AIDS—but it now rejects that assistance, largely because it doesn't want to follow international protocols for fighting the disease, such as distributing clean needles to injection drug users. Nongovernmental organizations that advocate harm-reduction strategies—needle exchanges, providing condoms to sex workers—face police harassment and criminal penalties.

Russia's major response to the crisis has been to make anti-retroviral (ARV) drug therapy available to people with full-blown AIDS—but eligibility for heroin users, the main population group with HIV, is spotty. There is anecdotal evidence, some of it reported in the medical journal The Lancet, that even non-heroin addicts must cope with ARV drug shortages.

Anya Sarang is a Moscow-based public health activist, and an outspoken critic of Russia's record when it comes HIV/AIDS and heroin use. "The Russian government's strategy of treating drug use and tackling its HIV problem is neglect and denial," says Sarang. "It is totally opposing all the effective interventions that are commanded by international organizations, while not offering anything to prevent the spread of HIV among injection drug users."

This dual failure—against intravenous drug use and against the spread of HIV—is at first glance hard to fathom. How could an ambitious first-world country allow potentially millions of its own citizens to die needlessly?

Russian leaders don't want to be told what do by the West, whether the issue is military assistance to Syria or how to treat drug addiction. But this is about more than recalcitrance toward old enemies. HIV and AIDS haven't struck all segments of the population equally—their victims are members of groups the country views as undesirables: heroin users, sex workers, prisoners, and gay men. Not everyone thinks these undesirables are worth saving.

"Some people in the Russian government actually believe that these people are not redeemable and not worthwhile human beings," says Robert Heimer, who has worked extensively in St. Petersburg.

AIDS came to Russia later than it did to other parts of the world. Perhaps that explains why one lesson remains unlearned to the Russian public: that what begins with at the margins of society spreads quickly to core. It's already underway: the HIV epidemic started among male intravenous drug users; it is now spreading in large numbers through sexual contact to heterosexual women.

The national reaction, however, remains a massive shrug. This goal of this project is to give, in small measure, a voice to those who have none.