April 28, 2004

I. SUMMARY

AIDS cannot be conquered through the sort of 'command and control' approaches that have traditionally shaped public policy in [eastern Europe].Instead the creation of open, democratic, inclusive environments where comprehensive, multisectoral policies and innovative partnerships build trust and reduce stigma is essential to turning back the epidemic.
-U.N. Development Programme, Reversing the Epidemic: Facts and Policy Options, February 2004.
They treat us like dirt.I just want to be treated like a normal human being.
-Yevgeny X., injection drug user, Saint Petersburg, February 2004

The Russian Federation is facing a deadly epidemic of acquired immune deficiency syndrome (AIDS).It is driven in part by abuses of the human rights of those most at risk to get the disease and of the over 1 million Russians already living with the human immunodeficiency virus (HIV).The principal means of HIV transmission in Russia has been and remains injection drug use.But the Russian state has done little to support low-cost measures that would enable drug users to realize their right to be protected from this incurable disease.Instead, Russia has been a model of repression of drug users and stigmatization of HIV-positive people, putting the country squarely on the path of very high AIDS mortality and continued abuse of people affected by HIV/AIDS.

An active AIDS epidemic did not begin in Russia until fifteen years into the global history of this destructive disease.This gave Russia the opportunity to profit from the experiences of other countries in confronting it.Instead, Russia has systematically rejected well established lessons.The government has allowed police to disrupt syringe exchange and other services drug users need for HIV prevention.It has permitted drug control policies to undermine their access to health services.It has refused to allow drug users in some parts of the country to be treated for AIDS.It has allowed drug users and HIV-positive persons to be marginalized by stigma and social disdain.It has given little priority to HIV prevention more broadly, including to the right of the Russian people to basic information on HIV transmission and AIDS care.It has marshaled few resources to face an enemy that threatens to kill millions of its people before it is through.

In Saint Petersburg, the second largest city in Russia, good policies have removed some barriers to fighting HIV/AIDS.Unlike their counterparts in Moscow, the Saint Petersburg city authorities have for years operated and allowed others to offer HIV prevention services for injection drug users, including syringe exchange-an activity with a long and successful track record around the world that allows drug users to exchange their used syringes for sterile ones.Syringe exchange brings marginalized drug users into contact with educators and counselors and enables them to be referred to other health and social services.In permitting syringe exchange, Saint Petersburg has recognized the importance of "harm reduction" approaches-actions that limit the individual and social harm of drug use without requiring the cessation of drug use.[1]Saint Petersburg has also made efforts to remove discrimination in health services for people with AIDS.The specialized AIDSCenter in the city is praised by HIV-positive people as a place where they can get information and care.

Even in this environment, however, the police have been allowed to create a climate of fear for drug users and to impede directly their access to the tools of HIV prevention.Many injection drug users purchase sterile syringes in drug stores, and numerous drug users told Human Rights Watch that police patrol drug stores, especially at night, and target those who purchase syringes for harassment or detainment.Fear of encountering police around syringe exchange points similarly deters some drug users from utilizing these services.Drug injectors are detained because of possession of syringes, which is not illegal in Russia.Drug users in Saint Petersburg recounted stories of having been forced by police on the street to show their arms and if they have needle marks to be subjected to extortion and threats of detention or to having narcotics planted on them.For police, drug users represent an easy and welcome target for filling arrest quotas and extortion of money-and society is unlikely to raise a voice objecting to these abuses.

Drug users and former drug users who are or are suspected to be HIV-positive are doubly burdened by abuse and discrimination.HIV-positive people in Saint Petersburg face discrimination in access to jobs and government services and deep stigma and abuse if they are courageous enough to reveal their HIV status.Even health professionals can be abusive and are often apparently fearful of HIV-positive people.Discrimination and stigma are related to the widely held misperception that HIV is spread by casual contact.The government has done little to combat this misunderstanding, allocating paltry sums for measures to raise awareness of the basic facts of HIV/AIDS.

Because of drug laws that have historically criminalized the possession of very small amounts of narcotics, drug users in Russia face a high probability of spending time in prison or pretrial detention at some time in their lives.Injection drug use is widespread in prisons.But basic HIV prevention measures, including condoms and materials for sterilization of syringes, are largely lacking in Russian correctional facilities, making prisons across the country high-risk environments for AIDS.The vast numbers of prisoners released every year thus represent a public health challenge for the general population.Both in and outside of prison, the virtual absence of humane services to treat drug addiction and the illegality in Russia of methadone and other drugs used elsewhere to treat heroin addiction further compromise HIV prevention among drug users.

The importance of prevention measures is especially great given the paucity of antiretroviral treatment for people with HIV/AIDS in Russia.Unlike many other countries in the former Soviet sphere, Russia has neither taken advantage of discounts offered by multinational drug companies nor registered generic versions of anti-AIDS medicines.At this writing, the World Health Organization and the World Bank are pushing for registration of generic antiretroviral drugs to enable 50,000 persons with AIDS in Russia to be treated for their illness by December 2005.The government, resting on estimates of HIV prevalence that have long been questioned by international observers, asserts that only 4000 to 5000 Russians are in need of treatment.

State action that impedes people from protecting themselves from a deadly epidemic is blatant interference with the right of Russians to the highest obtainable standard of health.There is no dispute as to the effectiveness of sterile syringes for preventing HIV, hepatitis C and other blood-borne infections.Public health experts are virtually unanimous in the view that providing access to sterile syringes neither encourages drug use nor dissuades drug users from entering drug treatment programs.In reality, the near absence of humane treatment programs for drug addiction in Russia and the very nature of drug use guarantee that there will always be people who either cannot or will not stop using drugs.Impeding this population from obtaining or using sterile syringes amounts to prescribing death as a punishment for illicit drug use.

In December 2003, the State Duma (Russian parliament) took promising steps to undo some of the elements of Russia's drug laws that pose barriers to effective responses to HIV/AIDS.Its amendment to the Criminal Code of the Russian Federation opened the door, for example, to lifting of criminal sanctions for users who possess extremely small amounts of narcotics, as well as to reexamination of the important question of the legal status of syringe exchange programs and measures to regulate them.Since the amendment was passed, however, the State Drug Control Committee (SDCC) has pushed for even harsher penalties than before-seeking, for example, to criminalize possession of doses of heroine as small as 0.0001 grams, a far smaller amount than is set by most countries.In addition, SDCC officials have pushed for strict regulation of syringe exchange, including the possibility of compromising the anonymity of persons using syringe exchanges and of banning current and former drug users from working as educators, which would greatly undermine these services.

With these policy measures now being actively discussed at the federal level, this is a key moment for the new government of Vladimir Putin to make a strong commitment to fight HIV/AIDS and to respect the human rights of people already living with the disease and those most at risk.President Putin should speak out forcefully about HIV/AIDS in Russia, and he should ensure that his government follow his words with resources commensurate to the AIDS crisis.Programs that reflect lessons learned globally are urgently needed.The lives of millions of Russians depend on a new and bold commitment.

[1] Harm reduction programs include needle and syringe exchanges, replacement therapy treatment, health and drug education, HIV and sexually transmitted disease (STD) screening, psychological counseling, and medical referrals.For more information on harm reduction, see Open Society Institute, International Harm Reduction Development (IHRD) Program, "Drugs, AIDS and harm reduction: How to slow the HIV epidemic in eastern Europe and the former Soviet Union," 2001, and the web site of the IHRD Program at http://www.soros.org/initiatives/ihrd.