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IV. BACKGROUND

HIV/AIDS in the Russian Federation

Until the mid-1990s, it was widely thought that Russia would be spared the destruction of HIV/AIDS. Beginning in the late 1990s, however, the United Nations system’s annual reports on the state of the global HIV/AIDS epidemic estimated that eastern Europe and central Asia—the United Nations region that includes Russia and the former Soviet Union (FSU)—was the region with the fastest growing epidemic in the world.4 The rapidity of the spread of the epidemic in Russia and some surrounding countries was unprecedented in the history of HIV/AIDS at least partly because injection drug use, an efficient means of spreading HIV, has been the most important cause of new transmission in the region. In Russia from 1995 to 2001, the rate of new infection doubled every six to twelve months.5

The government’s official estimate of the number of persons living with HIV/AIDS in the country is 800,000 to 1.2 million.6 United Nations reports have consistently noted that prevalence figures from Russia and other eastern European countries have underestimated the extent of the epidemic.7 The United Nations annual report on HIV/AIDS in December 2003 cited estimates of up to 1.5 million people living with HIV/AIDS in the country.8 A report by the research arm of the U.S. Central Intelligence Agency in 2002 suggested at that time that 2 million Russians might be HIV-positive and projected that as many as 8 million would be living with HIV/AIDS by 2010.9 The projection of the Federal AIDS Center in Moscow is that there may be as many as 5 million Russians living with HIV/AIDS by 2007.10Russia was estimated in 2003 to account for 76 percent of all HIV infection in central and eastern Europe.11

After having reported sharp and steady increases in new HIV transmission for several years, Russia reported a significant decline in the rate of new transmission in 2002. Dr. Vadim Pokrovsky, head of the Federal AIDS Center that supervises many aspects of AIDS surveillance and research in the country, was cited in a February 2004 United Nations Development Programme (UNDP) report as concluding that this decline was “not a true reflection of changes in HIV incidence,” but rather resulted from a 38 percent decline in 2002 in the number of drug users tested for HIV.12 Pokrovsky told the press in November 2002 that this decline in testing was caused by the federal Ministry of Health’s having stopped paying for HIV tests, forcing regions and cities to pick up the slack.13 The UNDP report is critical of eastern European countries that rely for their AIDS surveillance on case reporting—that is, surveillance based not on representative sample surveys of at-risk populations but on recording of each case identified by the health system.14 Pokrovsky said that Russia relies for its estimates both on results from the millions of HIV tests that are performed each year—approximately 24 million in 2003—and increasingly on small-scale surveys.15

In 2002, an estimated 93 percent of persons registered by the government as HIV-positive since the beginning of the epidemic were injection drug users.16 In contrast, in 2002 an estimated 12 percent of new HIV transmission was sexual—that figure climbed to 17.5 percent in the first half of 2003—indicating the foothold that the epidemic is gaining in the general population.17 The European Centre for the Epidemiological Monitoring of AIDS (EuroHIV), a center affiliated with the World Health Organization, noted that HIV prevalence may have “reached saturation levels in at least some of the currently affected drug user populations” in eastern Europe, including in Russia, but cautioned against complacency “as new outbreaks could still emerge among injection drug users…, particularly within the vast expanse of the Russian Federation.”18 Rhodes and colleagues in a February 2004 article echo this conclusion, noting evidence of recent examples of severe HIV outbreaks among drug users in Russia.19

Risk factors and government action

Beginning in about 1987, Russia and other Soviet states began establishing AIDS centers to address the disease. Unfortunately, the mission of these centers was not to provide information and preventive services to the population but rather to carry out a massive program of mandatory testing and official registration of persons with AIDS.20 It is estimated that from 1987 to 1993 the Russian government conducted over 120 million HIV tests, largely on an involuntary basis, of “high-risk” persons, including drug users, gay and bisexual men, persons diagnosed with other sexually transmitted diseases, persons who had traveled abroad, and the sex partners of persons in these categories.21 Virtually none of these persons received counseling about HIV testing or HIV disease.

In Russia today, blood donors, health workers who work regularly with HIV-positive patients, and persons presenting with a long list of diseases that are considered to be possible opportunistic infections linked to AIDS are required to be tested for HIV,22 though involuntary HIV testing has also been reported to continue for most inmates in prisons and pretrial detention facilities.23 In March 2003, the Russian Ministry of Defense said it would ban HIV-positive persons from active military service, suggesting that new recruits would be tested for HIV.24 In late 2002, the director of one of the biggest AIDS NGOs in Russia criticized the government for continuing to spend so much of the “meager” federal AIDS budget on testing.25 By law, a person seeking a voluntary HIV test may do so anonymously; the law does not address the anonymity or confidentiality of HIV tests conducted under other circumstances.26

Being in prison or other state detention is an important risk factor for HIV in Russia. A very high percentage of drug users in the FSU find themselves in state custody at some time in their lives. Injection drug use is reportedly widespread in Russian prisons, and HIV prevention services such as provision of sterile syringes, disinfectant materials for syringes and condoms are virtually absent.27 Official statistics indicate that from 1996 to 2003, HIV prevalence in Russian prisons rose more than thirty-fold from less than one per 1000 inmates to 42.1 per 1000 inmates.28 According to a 2002 report, about 34,000 HIV-positive persons—over 15 percent of the persons officially counted as HIV-positive in the country—were in state custody, of which the large majority found out about their HIV status in prison.29 The Kresty pretrial detention facility in Saint Petersburg was reported in 2002 to have about 1000 HIV-positive persons among its 7800 inmates.30 Some 300,000 prisoners are released each year from penal institutions in Russia,31 representing an important public health challenge.

Although a 2001 federal directive eliminated the previously obligatory practice of segregation of HIV-positive prisoners in Russian correctional facilities, many facilities still maintain separation of HIV-positive and HIV-negative prisoners.32 Such practices not only contribute to the stigma faced by inmates living with HIV/AIDS, but also may create a false sense of security around the idea that HIV transmission is absent or unlikely in the non-HIV-positive parts of the prison.33

Commercial sex work in the region has become much more widespread since the fall of the Soviet Union. As in many parts of the world, in the FSU the exchange of sex for drugs and the use of sex work to support drug habits provide important links between injection drug use and commercial sex.34 Dr. Chris Beyrer of Johns Hopkins University estimated in 2003 that some 40 percent of sex workers in Moscow were regular injectors of heroin.35 Rhodes and colleagues note that studies from several locations in Russia estimate that between 15 and 50 percent of women injection drug users engage in sex work with some regularity. They also note that in some cities there are few HIV prevention or information services available, particularly for workers in the sex trade.

Surveys reveal a worrying deficit of knowledge in the Russian population about the basic facts of HIV and AIDS. A 2001 telephone survey of adults in Saint Petersburg indicated that one third of respondents believed that condoms did not protect against HIV, and 48 percent believed that HIV could be transmitted through kissing, 30 percent through cigarette-sharing, and 56 percent from mosquito bites.36 A survey of 5000 Russians funded by the U.S. Agency for International Development found in 2001 that about 40 percent of respondents thought that a teacher who became HIV-positive should not be allowed to continue teaching. Less than 10 percent said they would patronize a grocery store run by an HIV-positive person.37 Dr. Mikko Vienonen, the WHO special representative for Russia, said: “AIDS is linked to sin, sex and drugs, and it is difficult to talk about these taboos,”38 a problem hardly unique to Russia and one that many countries have overcome with well funded educational campaigns. The director of EuroHIV is one of many experts to have criticized Russia for allocating very little money to public awareness programs and HIV prevention more generally.39 Dr. Pakrovsky echoed this conclusion, noting that the entire annual HIV prevention budget for the federal government in 2004 was less than U.S. $1 million.40

The low level of awareness of the basic facts of HIV/AIDS is probably an important determinant of discrimination and stigma suffered by people with AIDS, which has been shown by many accounts to be widespread in Russia. A 2003 study of 470 HIV-positive persons in Saint Petersburg, for example, found that 30 percent of respondents said they had been refused health care because of their HIV status. About 10 percent had been fired from their jobs or forced by family members to leave their homes. Almost half had been required by the police or by health professionals to sign documents acknowledging their HIV status, and 44 percent said they were required by physicians to give information about their sex partners or others they knew who took drugs.41

There is very little access to antiretroviral (ARV) treatment for persons with HIV/AIDS in Russia and the FSU, and there is even more limited access for injection drug users than for the rest of the population.42 The ARV drugs commercially available in Russia as of this writing are the brand-name products of multinational pharmaceutical companies. The Russian Federation has yet to register any generic ARV drugs for sale in the country. Federal officials told Human Rights Watch that a process was in place to register four generic ARVs, but they did not say when they thought those medicines would be available to the public.43 Ukraine, Russia’s neighbor, which is estimated to have a somewhat higher HIV prevalence than Russia, has registered a number of generic antiretrovirals, and treatment is now available there for about U.S. $700 per year, compared to the approximately U.S. $12,000 annual cost of ARV treatment available in Russia.44

HIV/AIDS has reached Russia in the midst of what many observers have characterized as more than a decade of severe deterioration of health services following the fall of the Soviet Union. Since 1992, health spending by the Russian state has fallen by an estimated 75 percent, and life expectancy for men has tumbled below sixty years.45 Tuberculosis is a long-standing problem in the country and has also become the most important opportunistic infection linked to HIV/AIDS. An estimated 30,000 persons die of tuberculosis each year in Russia.46 In 2003, about 10 percent of inmates in the Russian penitentiary system were estimated to have active tuberculosis,47 and as many as one third of these may have had the multi-drug-resistant variant.48

The explosive increase in injection drug use is linked to a severe epidemic of hepatitis C,49 a viral disease that is a major risk factor for fatal liver cirrhosis. In addition, Russia and its neighbors from the former Soviet bloc have experienced very large increases in the incidence of sexually transmitted diseases other than HIV (such as syphilis, gonorrhea and chlamydia), which are in turn risk factors for HIV transmission.50 Treatment for sexually transmitted infections (STI) in Russia has often included registering patients as STI “carriers” and requiring them to identify their sexual partners.51 Drug users and sex workers are understandably not eager to seek treatment with these requirements.

Narcotic drug use in Russia

There is some controversy over the number of narcotic drug users in Russia. Dr. Vadim Pokrovsky of the Federal AIDS Center said that estimates of the number of active drug users in Russia in February 2004 ranged from 1 to 4 million, and he believed the high end of that range reflected the reality. On February 20, 2004, Alexander Mikhailov, the deputy director of the State Drug Control Committee (SDCC), a federal body, was cited in Pravda as saying that Russia had over 4 million drug users, and that the “gloomy prediction” of his office was that Russia could have over 35 million drug users by 2014.52 In early January 2004, the executive secretary of the Commonwealth of Independent States, which includes twelve former Soviet states, predicted that in 2010 the twelve countries would have 25 million drug users of whom 10 million would be living with HIV/AIDS,53 the vast majority in Russia.

There is no doubt that drug use and heroin use particularly have risen meteorically in Russia since 1990. Mikhailov said the total number of drug users had risen 900 percent in the decade ending in early 2004.54 A Max Planck Institute study of the drug trade in Russia concluded that drug-related crimes increased twelve-fold from 1990 to 1999.55 Many analysts have traced the dramatic rise in use of injected heroin since the fall of the Soviet Union to economic collapse and attendant rises in unemployment, poverty and desperation and to increased availability of cheap heroin trafficked through central Asia and across the former Soviet states.56 Some observers have suggested that the aftermath of the events of September 11, 2001 in Afghanistan and central Asia has done nothing to stem the flow of heroin through the region and may even exacerbate it in the long run.57 Mikhailov of the SDCC has told the press on numerous occasions that the United States military intervention in Afghanistan has contributed to heroin consumption in Russia because the Taliban had been able to suppress opium production before they were overthrown.58 In 2003, Victor Cherkesov, head of the SDCC, said the drug trade in Russia was valued at about U.S. $8 billion a year.59

Drug-using practices are not uniform across the many regions of the vast Russian Federation, but some patterns have been described by researchers. The dominant drug of choice overall in Russia remains injected heroin, but homemade preparations of ephedrine, including methamphetamine in a liquid form known as vint (meaning “screw”) are also widely injected.60 Use of powdered or refined heroin builds on a longer tradition of consumption of home-produced opiates of various kinds. The reliance on drug preparations made in the home also established a tradition of group injecting. As Grund notes, it often happens that one person will provide some of the ingredients, one will provide the cooker and filters61 or other equipment, and so on, and the overall process is much cheaper when carried out in groups than by individuals.62

Unfortunately, this tradition can also be associated with high risk of transmission of HIV and other pathogens. Group situations such as this lead frequently to the collective use of injecting equipment in Russia.63 The 2004 review by Rhodes and colleagues noted that studies from all over Russia indicate a high prevalence of sharing needles—from 36 percent to 82 percent, depending on the city, and from 22 percent to 65 percent among drug users surveyed in Russian prisons.64 In addition, researchers have recorded frequent use of practices that entail squirting drug preparations from one user’s syringe into another by “front-loading” (into a syringe from which the needle has been removed) or “back-loading” (into a syringe from which the plunger has been removed), both of which increase the risk of infectious disease transmission.65

As of early 2004, there were an estimated seventy-five syringe exchange programs across the Russian Federation, of which forty-two were run by government institutions and thirty-three by NGOs.66 Most of these provide drug users with sterile syringes as well as with counseling and information, condoms, and referrals to other health and social services. Fifty-six of the eighty-nine regions report having at least one functioning syringe exchange.67 It is also legal in Russia to purchase syringes at a drug store. Studies in several locations in Russia have shown that drug stores are the most important source of syringes for most drug users.68

The range of services and especially the counseling and information that are provided at syringe exchange points can make the utilization of these services a more promising avenue for HIV prevention than the purchase of syringes in drug stores. Significant reductions in risky behavior, including sharing of syringes, linked to participation in syringe exchange programs have been demonstrated repeatedly in Russia,69 but such results have generally not been associated with drug store purchases of syringes. In an in-depth 2003 study of behaviors associated with drug use in the city of Togliatti, it was found that injection drug users who had syringe exchange programs as their main source of syringes were less than one third as likely to share syringes as those who reported drug stores as their major source.70 There is also some evidence of higher rates of condom use among drug users who have contact with syringe exchange services compared to those whose have another principal source of syringes.71

Researchers have found that police harassment is one of the most important factors that exacerbate risky behavior among drug users in Russia. In a 2002 study of drug use in five Russian cities, 44 percent of drug users said they had been stopped by the police in the month prior to being interviewed, and two third of these said that their injecting equipment had been confiscated by the police.72 Over 40 percent added that they rarely carried syringes for fear of encountering the police with them. In the Togliatti study, Rhodes and colleagues found that fear of being arrested or detained by the police was the most important factor behind the decision of drug users not to carry syringes, which in turn was an important determinant of sharing syringes during injection.73 This study concluded that drug users who had been arrested or detained by the police for drug-related offenses were over four times more likely than other users to have shared syringes in the previous four weeks. Drug users who feared the police in Togliatti tended to avoid not only syringe exchange services but also drug stores that sold syringes because police frequently targeted people buying syringes at such locations, a result also highlighted in a 2003 study of drug users in Moscow.74

Narcotic drug policy in Russia: Recent developments

Harm reduction programs, particularly needle exchange, have had unclear legal status in Russia. The 1996 Criminal Code of the Russian Federation defined as crimes the manufacture, acquisition, keeping, carriage, sending, or sale of illegal narcotics (article 228) and the “inclining to consumption” of illegal drugs (article 230), interpreted by most observers to refer both to consumption and to inducing another person to consume illicit drugs.75 The 1998 Federal Law on Drugs and Psychotropic Substances similarly defines crimes related to the manufacture, use, and sale of illicit drugs and does not address harm reduction activities explicitly.76 Expert observers noted in recent years that the lack of explicit treatment of harm reduction activities in the law has enabled law enforcement officials to interpret the law as prohibiting activities such as syringe exchange and particularly to charge that harm reduction activities can have the effect of promoting drug use.77

In December 2003, article 230 of the Criminal Code on consumption of illicit drugs was amended to add the following commentary:

The given article does not cover promotion of use of relevant tools and equipment necessary for the use of narcotic and psychoactive substances, aimed at prevention of HIV infection and other dangerous diseases, when it is implemented with the consent of health and narcotic and psychotropic substances traffic control authorities.78

This amendment was immediately hailed by some observers as a breakthrough for legal protection of harm reduction services. A press statement by the NGO International Family Health, which had funded Butler’s analysis of Russian drug law in 2003, was headlined “Harm reduction programs gain legal basis in Russian law” and pronounced the future of needle exchange programs in Russia to be “more secure.”79

The amendment, however, also specified that the federal Ministry of Health and the Russian State Drug Control Committee (SDCC) should together formulate regulations for the operation of harm reduction services for drug users. The SDCC is a relatively new body, formed pursuant to a March 2003 edict of the State Duma and constituted in June 2003.80 Its mandate is the coordination of the work of all federal departments whose work touches upon illicit consumption and trafficking of narcotics.81 In 2003, Butler estimated that the SDCC was given control over about 40,000 law enforcement agents, most of them transferred from the federal tax police force.

The new regulations for harm reduction programs were meant to be in place by March 2004 but had not been issued as of this writing. Since late 2003, the deputy chief of the SDCC, Alexander Mikhailov, has issued a number of statements that have caused concern among defenders of harm reduction and particularly syringe exchange programs. On November 19, 2003, Mikhailov issued an edict to regional drug control officials saying that programs that “exchange disposable syringes for drug abusers” constitute “open promotion of illegal drugs” and suggesting that regional authorities should consider whether there were grounds for invoking criminal law against operators of these services.82 The letter also suggested that authorities in countries such as the Netherlands, Switzerland, and Canada had disavowed harm reduction and particularly syringe exchange programs as erroneous policy leading to promotion of drug use, a patently untrue statement. There was a swift international reaction to this letter, denouncing the analysis and defending the HIV prevention record of syringe exchange services.83

On February 16, 2004, Mikhailov issued another public statement on the subject, this time asserting that the SDCC would not ban syringe exchange programs, but rather sought to license them and ensure that they are carried out in government health facilities.84 He said it was his personal view that syringe exchange services serve both a prevention and a treatment function, which some observers have taken to mean that he was suggesting HIV testing of drug users who seek sterile syringes at exchange services.85 Lev Levinson, director of the New Drug Policy Project in Moscow, said that through this suggestion and in other ways, the SDCC had made it clear that it thought users of syringe exchange services should not be able to keep their anonymity.86 Mikhailov noted further that syringes should not be exchanged in mobile units such as buses, a measure that would hit NGOs especially hard since government-run needle exchange services tend to be in fixed health facilities whereas numerous NGOs run mobile units.

Mikhailov of the SDCC also asserted that drug users and former drug users should not be permitted to work in HIV prevention services for injection drug users, a suggestion that runs counter to the conclusion of UNAIDS and HIV service providers all over the world that peer-led education can be most effective for HIV prevention among drug users and other marginalized persons.87 Kasia Malinowska-Sempruch, director of the International Harm Reduction Development Program of the Open Society Institute, which has supported syringe exchange and other harm reduction activities extensively in Russia and other former Soviet states, told Human Rights Watch:

It is a clear lesson of harm reduction programs since the earliest days that drug users and former drug users are among the most effective educators for reaching other drug users. It only makes sense—non-users will have a much harder time understanding the day-to-day challenges faced by drug users and persuading them of the importance of HIV prevention.88

She also noted that there is that there is “an across-the-board global agreement that HIV prevention services need to be offered in a way to respect people's privacy and confidentiality—and this is especially crucial for drug users who are marginalized.”

A Ministry of Health statement in February 2004 expressed general support for HIV prevention activities among persons at risk of HIV/AIDS but did not address needle exchange specifically.89 Dr. Alexander Golyusov, director of the HIV/AIDS unit in the Ministry of Health, emphasized to Human Rights Watch in February 2004 that no decision had been taken to shut down or curtail needle exchange, and he called the international and national reaction to Mikhailov’s earlier letter “strong and appropriate.” He said the ministry saw it as very important to work respectfully with drug users on HIV prevention, “to treat them with humanity, and this will bring more benefits.”90 He said the SDCC tends to see syringe exchange in a negative light but said that any decisions about regulation of needle exchange programs will be subject to interministerial approval. Golyusov also noted that he is opposed to needle exchange services that judge their own success simply by the number of syringes they distribute. “The main point is not in giving away needles, but the main thing is to work with people to change their mentality and understanding because giving away needles without consultation only brings harm,” he said.

The State Duma’s December 2003 amendment of the Criminal Code was also hailed as an opportunity to revise the criminal drug possession laws in Russia, which have historically defined harsh penalties for very small levels of individual possession of narcotics.91 In the late 1990s, Russia reduced by a factor of fifty the amount of heroin and other drugs the possession of which would entail mandatory imprisonment.92 Activists noted that the main motivation for the 2003 changes may have been to reduce the severe overcrowding of prisons.93 The Duma’s amendments expressed the view that individual possession of “less than ten average doses” should not be a criminal offense but mandated the Ministry of Health and the SDCC to review by March 16, 2004 the definition of an individual dose.94 The SDCC circulated a proposal that would have defined the minimum dose for criminal possession of heroin at 0.0001 grams, a dose smaller than any that Human Rights Watch could find on record among countries that define legal minimum amounts for criminal prosecution.95 It also recommended corresponding minimum doses of 0.015 grams for cannabis and 0.0005 for methamphetamines.

Reacting to this proposal, on March 11, Ella Pamfilova, chair of the Human Rights Commission at the Presidency of the Russian Federation, issued a statement to the prime minister denouncing the SDCC proposal. She noted that it would “distort the will of legislators who introduced a strictly differentiating approach between drug users and those who deal drugs.” Pamfilova offered the assistance of her commission in establishing more reasonable doses.96 The Duma extended the deadline for a decision on the minimum doses until May 16, 2004.

Substitution (or replacement) therapy such as methadone maintenance therapy, which has been widely credited with controlling HIV transmission among injection drug users in many countries, is illegal in Russia, and the 2003 amendments to the drug law did not change this. Methadone is classified as “illicit” by the terms of the three United Nations conventions on drug control,97 though most countries that are signatories to the conventions have methadone programs that are successful in substituting injected heroin with noninjected methadone. In this case, neither the SDCC nor the Ministry of Health seems necessarily disposed to review the status quo. Dr. Golyusov of the Ministry of Health said that he is concerned by first-hand accounts from drug users that methadone is more addictive or “harder to get off” than heroin and that other countries’ experiences have been “contradictory.”98

The refusal of Russia to legalize methadone and support substitution therapy has been widely criticized by international experts. The Open Society Institute has noted that in criminalizing use of methadone, Russia is denying itself one of the potentially most effective tools at its disposal to stem the AIDS juggernaut it faces.99 Dr. Robert Newman, an internationally renowned expert on substitution therapy, told Human Rights Watch:

It is unconscionable to have a condition as deadly as heroin addiction, and refuse to make available a medical treatment that has been found to be both safe and effective. A commitment to treating HIV/AIDS and curtailing its further spread to the general community is contingent upon treatment of intravenous substance use, and that treatment demands a key reliance on methadone maintenance if it is to reach a significant number of people. Refusal by the Russian authorities to permit the treatment of opiate addiction with methadone would be understandable if there were an alternative—any alternative; the fact is, however, there is none.100

Substitution therapy with methadone or buphrenorphine, another opiate substitute, has been available in most of the other former Soviet states for some years.101


4 Joint United Nations Programme on HIV/AIDS (UNAIDS)/and World Health Organization (WHO), “AIDS Epidemic Update” (UNAIDS/02.58E), December 2002, p. 12; and UNAIDS/WHO, AIDS Epidemic Update (UNAIDS/01.74E), December 2001, p. 6.

5 United Nations Development Programme, “Reversing the Epidemic: Facts and Policy Options (HIV/AIDS in Eastern Europe and the Commonwealth of Independent States),” UNDP-Bratislava, 2004, p. 16.

6 Human Rights Watch interview with Dr. Vadim Pokrovsky, chief of the Federal AIDS Center, Moscow, February 26, 2004.

7 “AIDS Epidemic Update 2002,” p. 12, and “AIDS Epidemic Update 2003,” p. 15.

8 “AIDS Epidemic Update 2003,” p.14.

9 National Intelligence Council, “The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China,” September 2002, p. 12.

10 Anna Badkhen, “Russia on brink on AIDS explosion—Ignorance and inaction threaten catastrophe,” San Francisco Chronicle, July 28, 2002. Available at www.aegis.com/news/sc/2002/SC020726.html (retrieved March 5, 2004).

11 Françoise F. Hamers and Angela M. Downs, “HIV in central and eastern Europe,” Lancet online review, February 18, 2003, available at http://image.thelancet.com/extras/02art6024web.pdf (retrieved March 12, 2004).

12 United Nations Development Programme, “Reversing the Epidemic: Facts and Policy Options (HIV/AIDS in Eastern Europe and the Commonwealth of Independent States),” Bratislava: UNDP, 2004, pp. 17.

13 Irina Titova, “AIDS workers struggle to get message out,” Saint Petersburg Times, November 29, 2002, p. 1.

14 UNDP, Reversing the Epidemic, pp. 12-13.

15 Human Rights Watch interview with Dr. Vadim Pokrovsky, Moscow, February 26, 2004.

16 Central and Eastern European Harm Reduction Network (CEEHRN), “Injecting Drug Users, HIV/AIDS Treatment and Primary Care in Central and Eastern Europe and the Former Soviet Union,” July 2002, p. 6.

17 UNDP, “Reversing the Epidemic,” p. 16, and Tim Rhodes, Anya Sarang, Alexei Bobrik, Eugene Bobkov and Lucy Platt, “HIV transmission and HIV prevention associated with injecting drug use in the Russian Federation,” International Journal of Drug Policy, vol. 15, no. 1, February 2004, pp. 2.

18 European Centre for the Epidemiological Monitoring of AIDS (EuroHIV), “HIV/AIDS Surveillance in Europe: Mid-Year Report 2003 (no. 69),” 2003, p. 7.

19 Rhodes et al., 2004, pp. 2-3.

20Julie Stachowiak, “Systematic—forced—testing in Russia,” Women Alive, Summer 1996. Available at http://www.thebody.com/wa/summer96/russian.html. Retrieved December 10, 2002.

21 Kevin J. Gardner (AESOP Center), “HIV Testing and the Law in Russia,” 1995-96, [online], http://www.openweb.ru/aesop/eng/hiv-hr/hiv.html, (retrieved February 28, 2004); Stachowiak, “Systematic-Forced-HIV Testing in Russia.” By 1996, official statistics held that there were only 1150 HIV/AIDS cases.

22 Russian Federation, Federal Law on Prevention of the Dissemination in the Russian Federation of the Disease Caused by the Human Immunodeficiency Virus, March 30, 1995, as amended in 1996, 1997 and 2000, article 9.

23 Dr. Tatjana Smolskaya, Pasteur Institute of Saint Petersburg, “Impact of HIV/AIDS on Society,” presentation at the Northern Dimension Forum, Lappeenranta, Finland, October 22, 2001, p.1.

24 “Russia to bar people living with HIV/AIDS, drug users from military service,” Kaiser Daily HIV/AIDS Report, March 17, 2003. The same announcement said that drug users and persons “of untraditional sexual orientation” would also be barred from service.

25 Rian van de Braak, “Slaying the AIDS monster: No time to lose” (opinion), Saint Petersburg Times, November 29, 2002, p. 5. In February 2004, the Saint Petersburg health authorities estimated that 36 million rubles (U.S.$1.24 million) was needed to cover HIV testing of the 65.5 million rubles (U.S.$2.24 million) allocated for HIV/AIDS in 2001 to 2003.

26 Federal Law on Prevention of the Dissemination in the Russian Federation of the Disease Caused by the Human Immunodeficiency Virus, article 8(2).

27 See, e.g., David Holley, “Up to 1.5 million Russians have HIV, government says,” Los Angeles Times, April 18, 2003, at A1. Available at http://www.aegis.com/news/lt/2003/LT030409.html (retrieved March 10, 2004).

28 G. Roshchupkin, “HIV/AIDS Prevention in Prisons in Russia,” in T. Lokshina, ed. Situation of Prisoners in Contemporary Russia (Moscow: Moscow Helsinki Group, 2003), p. 213; UNDP, Reversing the Epidemic, p.33.

29 “Some facts about HIV in prisons,” Prison Healthcare News, issue no. 2, Summer 2002, p. 4.

30 Mark Schoofs, “Jailed Drug Users Are at Epicenter Of Russia's Growing AIDS Scourge,” Wall Street Journal, June 25, 2002, p. A1.

31 “Disease control in North West Russia,” Prison Healthcare News, no. 4, Spring 2003, p. 6.

32 Roshchupkin, p. 213 ; “First published report of a visit to the Russian Federation highlights healthcare concerns,” Prison Healthcare News, no. 5, Summer 2003, p. 6.

33 Schoofs, 2002.

34 Godinho et al., p. 3.

35 Paul Webster, “HIV/AIDS explosion in Russia triggers research boom,” Lancet, vol. 361, June 21, 2003, p. 2133.

36 Yuri A. Amirkhanian, Jeffrey A. Kelly and Dmitri Issayev, “AIDS knowledge, attitudes and behaviour in Russia: Results of a population-based, random-digit telephone survey in Saint Petersburg,” International Journal of STD and AIDS, vol. 12, no. 1, p. 50.

37 The same survey showed low levels of condom use among adults and young people, including among those who had engaged commercial sex workers. Vani Vannappagar and Robin Ryder, “Monitoring sexual behavior in the Russian Federation: The Russia Longitudinal Monitoring Survey 2001,” report submitted to the U.S. Agency for International Development, Carolina Population Center, University of North Carolina, April 2002, pp. 1, 10.

38 “Russian must lift taboo on AIDS, say health NGOs,” Agence France-Presse, November 27, 2002.

39 Hamers and Downs, “HIV in central and eastern Europe.”

40 Human Rights Watch interview, Dr. Vadim Pokrovsky, Moscow, February 26, 2004.

41 Yuri A. Amirkhanian, Jeffrey A. Kelly, and Timothy L. McAuliffe. “Psychosocial needs, mental health and HIV transmission risk behavior among people living with HIV/AIDS in Saint Petersburg, Russia,” AIDS, vol. 17, no. 16, November 7, 2003, pp. 2367-2368, 2370.

42 Central and Eastern European Harm Reduction Network, p.3.

43 Human Rights Watch interviews with Dr. Vadim Pokrovsky and Dr. Alexander Golyusov, Moscow, February 26, 2004.

44 Konstantin Lezhentsev, policy director, International Harm Reduction Development Program, Open Society Institute, paper presented at World Bank meeting on access to treatment in Russia, Moscow, February 25, 2004.

45 Paul Webster, “Russia hunts for funds for ailing health service,” Lancet, vol. 361, February 8, 2003, p. 498.

46 Nina Schwalbe and Persephone Harrington, “HIV and tuberculosis in the former Soviet Union,” Lancet, supplement to vol. 360, December 2002, p. S19.

47 “Overcrowding in Russian prison system facilitates spread of tuberculosis, HIV, report says,” Kaiser Daily HIV/AIDS Report, July 24, 2003.

48 Schwalbe and Harrington, p. S20.

49 See, e.g., Dr. Tatjana Smolskaya, Pasteur Institute of Saint Petersburg, “Impact of HIV/AIDS on Society,” presentation at the Northern Dimension Forum, Lappeenranta, Finland, October 22, 2001, p. 5.

50 See, e.g., United States Centers for Disease Control and Prevention, “Fact Sheet: Prevention and Treatment of Sexually Transmitted Diseases as an HIV Prevention Strategy,” available at http://www.cdc.gov/hiv/pubs/facts/hivstd.htm (retrieved March 10, 2004).

51 Ibid.

52 “In sad tally, Russia counts more than 4 million addicts,” Pravda, February 20, 2004 [online], available at http://newsfromrussia.com/main/2004/02/20/52421.html (retrieved March 9, 2004).

53 “CIS 2010: 25 million drug addicts, 10 million of them living with HIV,” NewsInfo.ru, January 2, 2004 [online], available at http://www.tpaa.net/articles/reg_010504_cis_drugs.html (retrieved March 9, 2004).

54 In sad tally, 2004.

55 Max Planck Institute for Foreign and International Criminal Law, “Illegal Drug Trade in Russia: Final Report,” Freiburg, Germany, October 2000, p. 3.

56 See, e.g., Karl L. Dehne, Jean-Paul C. Grund, Lev Khodakevich, and Yuri Kobyshcha, “The HIV/AIDS Epidemic among Drug Injectors in Eastern Europe: Patterns, Trends and Determinants,” Journal of Drug Issues 29 (4), 1999; Julie Stachowiak and Chris Beyrer, John Hopkins Bloomberg School of Public Health, “HIV Follows Heroin Trafficking Routes,” October 14, 2002 [online] http://www.eurasianet.org/health.security/presentations/hiv_trafficking.shtml (retrieved January 25, 2003).

57 Nancy Lubin, Alex Klaits, and Igor Barsegian, “Narcotics interdiction in Afghanistan and Central Asia: Challenges for international assistance” (report to the Open Society Institute), 2002.

58 See, e.g., Vladimir Isachenkov, “Drugs from Afghanistan flood Russia,” Associated Press, August 27, 2003 [online]. Available at www.cdi.org/russia/271-9.cfm (retrieved March 11, 2004). A similar conclusion regarding the post-Taliban opium industry in Afghanistan is found in “The Afghan plague: The rising tide of heroin feeds social ills and undermines the state,” Economist, July 26, 2003, p. 14. This article says that good quality processed heroin as opposed to less processed opiates has been the export of choice from Afghanistan since 2002.

59 “Russian drug trade valued at USD 8 billion a year,” Pravda, April 17, 2003 [online]. Available at http://english.pravda.ru/accidents/2003/04/17/46021.html (retrieved March 10, 2004).

60 Rhodes et al., 2004, p.4.

61 Cookers are bottle caps, spoons or any other item in which injectable drugs are heated to transform them from powder or other nonliquid form into an injectable solution. Filter refers to cotton, cigarette filters or other fibers that are used to remove solids from injectable liquid drug preparations.

62 Jean-Paul Grund, “A Candle Lit from Both Sides: The HIV Epidemic in Russia,” in Karen NcElrath, ed. HIV and AIDS: A Global View (Westport, Connecticut: Greenwood Press, 2001). Excerpt available at http://johnranard.com/fire_within/candle_text_body.html (retrieved March 22, 2004).

63 Tim Rhodes, Larissa Mikhailova, Anya Sarang, Catherine M. Lowndes, Andrey Rylkov, Mikhail Khutorskoy, Adrian Renton, “Situational factors influencing drug injecting, risk reduction and syringe exchange in Togliatti City, Russian Federation: A qualitative study of micro risk environment,” Social Science and Medicine vol. 57, 2003, p. 40.

64 Rhodes et al., 2004, pp. 5-6.

65 Rhodes et al., 2003, p.40; Grund, p. xx.

66 Rhodes et al., 2004, p. 7.

67 Human Rights Watch interview with Dr. Alexander Golyusov, director, HIV/AIDS Unit, Ministry of Health, Moscow, February 26, 2004.

68 See, e.g., Maxim N. Trubnikov, Lev N. Khodakevich, Dmitry A. Barkov, Dmitry V. Blagovo, “Sources of injecting equipment for drug users in Moscow, Russia,” International Journal of Drug Policy, vol. 14, 2003, p.454.

69 See review in Rhodes et al., 2004, p. 6.

70 Ibid.

71 See review in Rhodes et al., 2004, p.8.

72 Cited in Rhodes et al., 2003, p.41.

73 Rhodes et al., 2003, pp. 39, 45-46.

74 Trubnikov et al., 2003, p.454.

75 Russian Federation, Criminal Code of the Russian Federation, June 13, 1996, as amended on May 27, 1998, Chapter 25, Crimes Against Health of the Populace and Social Morality.

76 Russian Federation, Federal Law on Narcotic Drugs and Psychotropic Substances, Federal Law no. 3-03, January 8, 1998, as amended by Federal Law no. 116-03, July 25, 2002.

77 See, e.g., William E. Butler, “HIV/AIDS and Drug Misuse in Russia: Harm Reduction Programmes and the Russian Legal System,” London, Family Health International, 2003, p. 11-13; and Transatlantic Partners Against AIDS, “On the Frontline of an Epidemic: The Need for Urgency in Russia’s Fight Against AIDS,” New York, 2003, p. 14.

78 Federal Law no. 162, About amendments and additions to the Criminal Code of the Russian Federation, December 2003. The authors of these revisions were members of parliament Mikhail Zadornov of Yabloko and Alexander Barannikov of the Union of Right Forces. See Lev Levinson, “Novaia redaktsiia ugolovnogo kodeksa soputstvuiushchie izmeniia zokonodatel’stva (New version of Criminal Code and accompanying legislative changes),” available at www.drugpolicy.ru (retrieved March 15, 2004).

79 International Family Health, “Harm reduction programmes gain legal basis in Russian law” (press release), London, January 26, 2004 [online], www.ifh.org.uk/HR_legal.htm (retrieved March 5, 2004).

80 Isachenkov, 2003.

81 Butler, pp. 55-56.

82 Alexander G. Mikhailov, State Drug Control Committee of Russia, letter no. 509, November 19, 2003, made available in English by the New Drug Policy Project, Moscow.

83 Human Rights Watch interview with Lev Levinson, director, New Drug Policy Project, Moscow, February 24, 2004. Human Rights Watch also wrote to the State Drug Control Committee in response to its statement.

84 Interview with Deputy Director of Narcotics Control Committee Alexander Mikhailov: “We intend to shield Russia against narco-aggression (My namereny postavit zaslon narkoagresii protiv Rossii), Interfax, February 16, 2004. As of this writing, syringe exchange services are not required to be licensed.

85 Human Rights Watch interview with Lev Levinson, Moscow, February 24, 2004.

86 Ibid.

87 See, e.g., Yuri A. Amirkhanian, Jeffrey A. Kelly, Elena Kabakshieva, Timothy L. McAuliffe, and Sylvia Vassileva, “Evaluation of a social network HIV prevention intervention program for young men who have sex with men in Russia and Bulgaria,” AIDS Education and Prevention, vol. 15, no. 3, pp. 205-207 for an example of a successful peer-driven HIV outreach program and a review of other peer education efforts in Russia. For an analysis of peer education in HIV/AIDS programs globally, see UNAIDS, “Peer education and HIV/AIDS: Concepts, uses and challenges” (Best Practice Collection monograph), Geneva: UNAIDS, 1999.

88 Human Rights Watch interview with Kasia Malinowska-Sempruch, director, International Harm Reduction Program, Open Society Institute, New York, March 11, 2004.

89 Gennady Onishchenko, chief sanitary inspector of the Russian Federation, Ministry of Health, “On the Implementation of Measures to Counter the Spread of HIV Infection in the Russian Federation,” Directive No. 2, January 14, 2004.

90 Human Rights Watch interview with Dr. Alexander Golyusov, director, HIV/AIDS Unit, Ministry of Health, Moscow, February 26, 2004.

91 See, e.g., “Russia’s new drug law in effect: No jail for drug users, greater penalties for traffickers,” Drug War Chronicle, no. 328, March 12, 2004. Available at http://stopthedrugwar.org/chronicle/328/russia.shtml (retrieved March 13, 2004).

92 Purchase of 0.005 grams of heroin was punishable by five to seven years in prison. See Daniel Wolfe and Kasia Malinowska-Sempruch, “Illicit Drug Policies and the Global HIV Epidemic: Effects of UN and National Government Approaches,” New York: Open Society Institute, 2004, p. 39. Activists have noted that a chart with this and minimum standards for other drugs was widely used in the judicial system but never formally codified into law. See Lev Levinson, “Russian drug policy: Need for a change,” presentation at conference on “Mobilizing Allies in Fight for Human Rights and Harm Reduction,” Budapest, July 1, 2003.

93 Ibid.

94 Russian Harm Reduction Network, Update on the Russian State Drug Control Committee and its position toward harm reduction (letter to Network members), March 12, 2004.

95 The Czech Republic, for example, issued a prosecutorial instruction indicating that possession for personal use of amounts under 1 gram of heroin and the equivalent of less than 20 cigarettes worth of marijuana should not trigger criminal prosecution but rather administrative sanction. The laws of the fifty states of the U.S. vary considerably and depend in most cases on whether the infraction is a first-time offense. In Texas, for instance, which is considered to have strict laws, a first-time conviction of possession of up to 1 pound (453 grams) of marijuana by law results in a sentence of probation with mandatory drug treatment and a fine. In Portugal, as in many countries, possession of up to ten doses of drugs is handled as an administrative rather than criminal infraction. Portuguese drug law defines ten doses of heroin as 1 gram and ten doses of marijuana as 25 grams. See European Monitoring Centre for Drugs and Drug Addiction, “European Legal Database on Drugs,” at http://eldd.emcdda.eu.int/home.shtml (retrieved March 20, 2004), and National Organization for the Reform of Marijuana Laws, state information, at http://www.norml.org/index.dfm?wtm_view=&Group_ID=4575 (retrieved March 20, 2004). Many states that do not define minimal criminalizable amounts for personal possession have very harsh punishments for any amount of narcotics.

96 Ibid. The Harm Reduction Network noted that the NAN Foundation of Russia, a private group that works on drug treatment and rehabilitation, convened an independent group of experts who recommended alternatives to the SDCC proposal for each category of drugs. That group’s recommendation for the minimum criminalizable dose for possession of heroin was 0.1 gram and for cannabis 1 gram.

97 The three U.N. drug control conventions are the Single Convention on Narcotic Drugs of 1961, the Convention on Psychotropic Substances of 1971, and the Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances of 1988, and all are available at http://www.incb.org/e/index.htm (retrieved March 22, 2004).

98 Human Rights Watch interview with Dr. Alexander Golyusov, February 26, 2004.

99 Kasia Malinowska-Sempruch, Jeff Hoover, and Anna Alexandrova, “Unintended Consequences: Drug Policies Fuel the HIV Epidemic in Russia and Ukraine,” 2003, New York: Open Society Institute, p. 6.

100 Human Rights Watch interview with Dr. Robert Newman, director, Baron Edmond de Rothschild Chemical Dependency Institute, New York, March 18, 2004.

101 Central and Eastern European Harm Reduction Network (CEEHRN), “Injecting Drug Users, HIV/AIDS Treatment and Primary Care in Central and Eastern Europe and the Former Soviet Union” (report of a survey), Vilnius, July 2002.


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