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V. FINDINGS OF HUMAN RIGHTS WATCH’S INVESTIGATION

Introduction

With a population of about 5 million, Saint Petersburg (formerly Leningrad) is the second largest city in Russia. It has a major port on the Baltic Sea. In 2003, the city celebrated the three hundredth anniversary of its founding. Saint Petersburg and Moscow are the only cities in the Russian Federation that are politically autonomous units with legislative bodies independent of a regional or oblast-level government. In the area of health, for example, the city has its own Health Committee, which is able to make regulations within the bounds of federal law.

There is an active drug scene in Saint Petersburg and a historically higher rate of drug-related crime than in any other Russian city. In 1999 in Saint Petersburg, there were 315 drug-related offenses per 100,000 population, more than twice as high as Moscow’s figure of 149 per 100,000.¹⁰² Reflecting the national increase in drug use but along a much steeper curve, drug-related crimes in Saint Petersburg rose twenty-fold from 1990 to 1999.¹⁰³ A five-city study of injection drug users in 2002 found that drug users in Saint Petersburg had the highest rate of recent needle-sharing of any of the cities, with 48 percent of the 221 users in the study reporting sharing in the thirty days prior to their first use of a needle exchange program.¹⁰⁴ The number of drug users in the city is unknown; one academic researcher put the figure at 100,000 in 2001.¹⁰⁵

The evolution of HIV/AIDS in Saint Petersburg has been relatively recent and very swift. Surveys indicated that HIV prevalence among injection drug users in the city was about 4 percent in 1998, 12 percent in 1999, 19 percent in 2000, and 36 percent in 2001.¹⁰⁶ As of February 2004, there were 21,900 officially registered persons living with HIV/AIDS—that is, people who tested positive for HIV in government health facilities—in the city of Saint Petersburg. City health authorities noted that they estimate the real figure of people living with HIV/AIDS to be closer to 50,000.¹⁰⁷ The Federal AIDS Center in Moscow estimated the prevalence of HIV in Saint Petersburg as of January 2004 to be 480 per 100,000 population, more than twice as high as the national average of 182 and well in excess of Moscow’s rate of 363 per 100,000.¹⁰⁸

As in most of Russia, a high percentage of persons living with HIV/AIDS are injection drug users, though new transmission is growing among non-drug users. An estimated 91 percent of new HIV transmission in 2001 was linked to injection drug use, down to 85 percent in 2002.¹⁰⁹ HIV prevalence among pregnant women is often taken as a proxy for the spread of the disease in the general population. The Botkin Infectious Disease Hospital, which is meant to provide maternity services for HIV-positive women in Saint Petersburg, had an estimated 470 deliveries of newborns to HIV-positive women in 2003, compared to fifteen in 2000.¹¹⁰ A 2002 survey among university students in Saint Petersburg found that nearly 1 percent of them were HIV-positive,¹¹¹ an ominous result in a population not traditionally considered to be at high risk.

HIV/AIDS has affected other groups at risk in the city. The NGO Humanitarian Action, which is the descendant of another NGO that began providing HIV services for drug users in Saint Petersburg 1996, conducted a series of HIV prevalence surveys in collaboration with the United Nations Children’s Fund (UNICEF) and the State Laboratory of Sanitation and Epidemiology. They found that the HIV prevalence in a sample of about 200 street children in 2000 was 8.0 percent but in 2001 and 2002 over 10.8 percent and 10.4 percent respectively.¹¹² Prevalence of hepatitis C in this population was 19 percent in 2000 and over 25 percent in 2002. Street children, of which there are estimated to be about 15,000 to 25,000 in Saint Petersburg, are vulnerable to drug use and sexual predators.¹¹³

Humanitarian Action estimated in early 2004 that more than 90 percent of the approximately 8000 sex trade workers in the city were injection drug users, the vast majority injecting heroin.¹¹⁴ A 2000 study found that women drug users who engaged regularly in sex work in Saint Petersburg had a 65 percent prevalence of HIV.¹¹⁵

Official actions on HIV/AIDS in Saint Petersburg

The city of Saint Petersburg has taken many positive steps to combat both the AIDS epidemic and discrimination faced people living with and affected by HIV/AIDS. The AIDS Center of the city instituted a confidential system of registration of people who test positive for HIV/AIDS by which new infections are noted without using the name of the person tested.¹¹⁶ According to the experience of the people with AIDS interviewed by Human Rights Watch, the confidentiality of test results is respected by the AIDS Center. The City Duma also took the unusual step in 2002 of issuing regulations to health workers outlining their responsibilities to treat people with HIV/AIDS. This measure was, at least in part, a response to a number of incidents in which HIV-positive persons were refused care at city health facilities.¹¹⁷

The AIDS Center of Saint Petersburg has developed innovative computer-based education programs on HIV/AIDS and other sexually transmitted diseases for students in the city’s schools, a previously neglected population for such education. Numerous AIDS activists said Dr. Aza Rakhmanova, the city’s senior infectious disease physician, has been an outspoken advocate for treatment access for people with HIV/AIDS. The Botkin Infectious Disease Hospital, which along with the city AIDS Center receives persons with AIDS, including pregnant women, for treatment and care, has welcomed collaborations with nongovernmental organizations for HIV prevention and counseling of people with AIDS.¹¹⁸ Persons with HIV/AIDS and injection drug users who spoke to Human Rights Watch had many positive things to say about these initiatives and the city’s services for people with HIV/AIDS.

On World AIDS Day (December 1) 2003, civil society groups in Saint Petersburg organized a rally in favor of the rights of persons living with HIV/AIDS, including the right to antiretroviral (ARV) treatment. The event drew about a thousand people, unprecedented for an AIDS-related event in the Russian Federation. The focus of much of the rally was the need for antiretroviral treatment for people with AIDS and the activists’ contention that many people with AIDS in the city were unable to benefit from the government’s limited ARV program. On February 10, 2004, the governor (mayor) of Saint Petersburg, Valentina Matvienko, told the press: “No matter how much money has to be spent, we cannot leave those who are sick without treatment. Whatever the circumstances, money for this purpose will be allocated.”¹¹⁹ In early 2004, the city government provided the great majority of funds for AIDS programs in the city; the federal contribution accounted for a small percentage of the funds used.

In spite of the important actions taken by the city to fight HIV/AIDS, Human Rights Watch’s investigation found a number of areas in which human rights violations impede the ability of people at risk of HIV/AIDS to protect themselves from the disease and the ability of people already living with the disease to live lives free of discrimination and abuse. These include police harassment and other impediments to HIV prevention services, other harassment of drug users in the law enforcement system, the absence of HIV prevention services for drug users in prison, and discrimination linked to popular misconceptions of HIV/AIDS.

Impediments to HIV prevention for injection drug users

As of early 2004, there were officially four syringe exchange facilities in Saint Petersburg—the mobile service of the NGO Humanitarian Action, the fixed facility supported by Humanitarian Action and linked to the Botkin Infectious Disease Hospital, the service run out of the government AIDS Center, and a fourth facility at the government center for drug addiction or “narcology” center.¹²⁰ Several people told Human Rights Watch that this last center was not very active. Based on the experience of both drug users and service providers who spoke to Human Rights Watch, however, the most important source of sterile syringes for injection drug users is drug stores, which are permitted to sell syringes to adults in unrestricted numbers. The cost of a syringe at an all-night drug store in February 2004 was 3 rubles (U.S. $0.10). State-supported impediments to access to both needle exchange points and drug stores represent important barriers to HIV prevention.

Drug users repeatedly told Human Rights Watch that police patrols of drug stores, especially all-night drug stores, deterred them from purchasing syringes. Boris K., age twenty-five, who spoke to Human Rights Watch shortly after exchanging several hundred syringes at the mobile syringe exchange of Humanitarian Action, said, “There are problems [for drug users] in the drug stores….Sometimes the staff of the store signal the police, or there are police hanging around, inside and outside.” Natalya R., twenty-six, a former drug user, noted: “They were trying to do something good by keeping some drug stores open twenty-four hours. Night time is the most dangerous time for drug users; it’s the time they shoot. But only a few of the stores are open, and they are all controlled by the police—sometimes police in uniform, sometimes plain clothes.”¹²¹ “No one will buy syringes at night from a drug store – it’s too dangerous. Sometimes there are even police officers in the drug stores,” said Maria K., twenty-eight.

Vladimir A., thirty-six, who characterized himself as an experienced drug user, noted: “A lot of users will just think that it’s better to use old needles than to have contact with the police. Police can hang out where the [needle exchange] bus stops or near the drug stores where you can buy syringes. If they catch you with syringes, even if you have no heroin, you can be arrested or have to pay $500. Some drug stores even signal the police [when someone buys needles].” Viktor B., twenty-two, a former drug user said: “I myself lived in a neighborhood [where the police patrolled the drug store]. They just stand there the whole night and wait for the young ones,” he said. Noting that there were times when drug users judged it unwise to approach drug stores, he explained other means of needle access: “We didn’t throw out our old ones. We tried to take them and wash them, and we would put them in a safe place where we could find them again.” Human Rights Watch researchers twice visited all-night pharmacies at midnight in Saint Petersburg and encountered a police patrol on one of these occasions, but we were not impeded or questioned when we purchased syringes.

Programs that exchange sterile syringes for new ones provide an alternative source of syringes to drug stores and also provide counseling and referral to health care and other services for drug users. In Saint Petersburg, the NGO Humanitarian Action has been operating a mobile syringe exchange service in a large bus since 1997. In early 2004, the bus served as many as seventy clients per day.¹²² According to the staff of Humanitarian Action, police interference with the syringe exchange bus was a problem in the early years but had lessened in recent years. Human Rights Watch spoke with one drug user who said he was harassed by the police near the needle exchange bus in 1999 and another who said a friend of his was accosted by the police after having visited the bus in 2001.¹²³

Even if these incidents are in the past, the fear of apprehension by the police kept some drug users from using the bus-based exchange. “The bus is out in the open. Everyone can see it; there’s nowhere to hide,” said Ilya S. “If I had to come all the way across town, I wouldn’t do it,” said Pavel O., who lived near one of the regular stops of the bus. Dimitry L., twenty-six, noted: “Some don’t go to the bus even if they are close by because they’re afraid of the police. One time [in May 2003] I came to the bus with my car, not to exchange needles but just to help out on the bus. I parked by the bus. I had the sticker in my windshield [showing his affiliation with the NGO that ran the bus], but the police came to my car three times to ask me what I was doing there. These are isolated incidents but they happen.”

Dr. Igor Piskarev, project coordinator at the Botkin syringe exchange, said that fear of encountering the police was for some drug users a barrier to using fixed as well as mobile syringe exchange facilities. He noted: “Of course not all drug users come to a place like this….Saint Petersburg is a big city. For many of them it’s a long trip. On the way back they would have syringes, and the police might bother them.” He added: “The central authorities of the police understand the services and they normally support the idea, but sometimes they need to fill their detention quotas.”¹²⁴ Anna Chikhacheva, a social worker at the exchange, noted: “Carrying the used syringes to the center could also be a problem….The police just want money. Sometimes they don’t even take the needles.”¹²⁵ Piskarov suggested that having needle exchange sites in more neighborhoods would help resolve these problems.

Several drug users told Human Rights Watch that they were detained simply for carrying syringes, which is not against the law in the Russian Federation, or for having needle marks on their arms. “I was found with syringes,” explained Fyodor N., age twenty-three:

For syringes, they would take us away and keep us in jail. The main reason why they arrest you is to find out the places where the dealers are. But if you tell [on the dealers], your circle will find out, and then you’re in trouble. But the police ask a straightforward question: “where do you buy?”. If you have a syringe and you’re a drug user and say you don’t know, you’re lying....They make you choose right away—put you in an isolation cell right off, or they take you to meet up with your drug seller.¹²⁶

He noted, as did several other interviewees, that paying off the police could end either the detention or the forced identification of dealers if the sum paid were sufficient.

In the last few years, Humanitarian Action, the NGO with the longest experience of syringe exchange services in Saint Petersburg, took the innovative step of making overtures to the city police department to talk about the importance of syringe exchange for HIV prevention. Alexander Tsekhanovitch, president of Humanitarian Action, said: “I visited with all the police chiefs in the district. They’re very smart and well educated, and they absolutely understand what we’re doing. But, they say, remember we get medals for arresting drug users. We can’t say to our people ‘stop arresting drug users’; this is how their performance is evaluated.” In spite of this constraint, Humanitarian Action was able to organize a training session in late 2003 for a number of police officers that included the participation of former drug users and people living with HIV/AIDS.

As noted by Dr. Igor Piskarev above, for drug users who cannot or choose not to purchase syringes at drug stores, harassment by police on the street is a concern because there are so few syringe exchange points. The health professionals interviewed by Human Rights Watch were not in complete agreement on the need for more syringe exchange services. Dr. Musatov of Botkin Hospital, for example, characterized three fixed needle exchanges and a mobile service for a city like Saint Petersburg as a “low level of access,” but Dr. Vinogradova, the chief physician of the City Health Committee, judged that the existing services were sufficient to meet the demand.¹²⁷

National and international law and HIV prevention among drug users

Article 41 of the Constitution of the Russian Federation guarantees the right of all citizens to “the right to health care and medical assistance” and further stipulates that medical assistance “shall be made available by state and municipal health care institutions to citizens free of charge with the money from the relevant budget, insurance payments and other revenues.”¹²⁸ Article 19 of the Constitution provides broad protection from discrimination in the realization of the rights accorded to citizens by the Constitution.

Under international law, individuals have a human right to obtain life-saving health services without fear of punishment or discrimination. This report describes actions of the state that directly obstruct injection drug users’ ability to protect themselves from infectious disease and other health complications associated with drug use. The International Covenant on Economic, Social and Cultural Rights (ICESCR), which has been ratified by the Russian Federation, recognizes in article 12 “the right of everyone to the enjoyment of the highest attainable standard of health.”¹²⁹ The ICESCR requires all the steps necessary for “the prevention, treatment and control of epidemic

State action to impede people from attempting to protect themselves from a deadly epidemic is blatant interference with the right to the highest attainable standard of health. There is no dispute as to the effectiveness of sterile syringes in preventing HIV, hepatitis C and other blood-borne infections. Public health experts are unanimous in the view that providing access to sterile syringes neither encourages drug use nor dissuades current users from entering drug treatment programs.¹³³ The reality is that the near absence of humane drug treatment programs 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.

Multilateral organizations such as the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have issued numerous nonbinding guidelines and declarations on combating the spread of HIV through public health approaches to drug use. A WHO Fact Sheet on HIV prevention lists syringe exchange and pharmacy sale of syringes as “the two strategies that have proven effective” at reducing HIV transmission among injection drug users.¹³⁴ At the June 2001 United Nations General Assembly Special Session (UNGASS) on HIV/AIDS, member states included in their final declaration of commitment a pledge to make available by 2005 “a wide range of prevention programs” including “sterile injecting equipment” and “harm-reduction efforts related to drug use.”¹³⁵ The U.N. Commission on Narcotic Drugs (CND) has failed to support such efforts, but in March 2002 it adopted a resolution on HIV and drug use that “encourages Member States to implement and strengthen efforts to raise awareness about the links between drug use and the spread of HIV, hepatitis C and other blood borne viruses” and “further encourages [them] to consider the potential impact on the spread [of these diseases] when developing, implementing and evaluating policies and programs for the reduction of illicit drug demand and supply.”¹³⁶

The 1998 UNAIDS/Office of the High Commissioner for Human Rights (OHCHR) International Guidelines on HIV/AIDS and Human Rights, which represent the consensus of governmental and nongovernmental experts as well as networks of people living with HIV/AIDS, recommend that national public health laws “fund and empower public health authorities to provide a comprehensive range of services for the prevention and treatment of HIV/AIDS, including

Other harassment and abuse of drug users and sex workers in the law enforcement system

Numerous drug users and service providers in Saint Petersburg told Human Rights Watch that police target drug users for certain kinds of abuse in addition to those noted above, including a wide range of abuses of due process in the arrest and detention of drug users. To the extent that this is the case, these abuses may contribute to drug users’ fear of seeking out services for prevention of HIV and other diseases, particularly where such services involve walking long distances in places where police may be active. Pavel O., thirty-eight years old, recounted the events of his detention by police in March 2003. He said he had never before had problems with the police.

It was probably a set-up. I was trying to sell my apartment and many people knew that. The police knew that I might have a lot of money. That night I had ephedrine on me, but the police said it was heroin. I was walking close to the police station; it would be stupid to carry heroin around there—everyone knows that. The police were trying to get big money from me. They asked for 500 dollars; they wouldn’t ask straight off for so much without knowing that they could get it. [During my two-day detention] there was no talk of food. They even took my aspirin away from me—I had the flu. The reason they let me go was that I was so sick that I couldn’t understand what they were asking me. But I had to sign a city arrest warrant. They detain a person and wait until he desperately wants drugs, and then they ask him for his contacts. The first question is always “Do you have any money?” If not, “Is there anyone who can help you [to get money]?” They’re not even interested in where you got your drugs, just how much money you can pay now and how much later.¹³⁹

Like a number of drug users interviewed by Human Rights Watch, Pavel O. was unable to afford legal counsel and was provided a lawyer by the city. “You don’t pay for one of those, and that’s why the service is like it is. He barely uttered a word. When the judge asked if the prosecution’s argument was right, he just nodded. I tried to speak myself, but the judge was irritated,” he said.

Several drug users described being forced by police to incriminate others as a condition of avoiding arrest or long detention. Dimitry L., twenty-four, described an incident from 2003:

I was detained at the entrance to the building where drugs were being sold. They asked me to buy drugs in front of them [so they could see the dealer]. When I refused, they started beating me on the arms and legs and hit me with a gun. They took me to the station, but I was released the next morning. They threatened to plant drugs on me, but for some reason I was lucky, and they finally lost interest.¹⁴⁰

In addition to the fear of being caught with syringes by the police, numerous drug users told Human Rights Watch that police check the arms of people they suspect of being drug users, and if they find marks that indicate injection drug use, the user or former user is vulnerable to wide range of abuses. Boris K., twenty-five, an injection drug user, told Human Rights Watch:

I’ve been stopped by the police. They ask me where I’m headed. Drug users are not considered people; they can do anything to you. They just classify people in their minds—drug users at the bottom, then alcoholics and gypsies. They believe drug users are always at fault. They judge you by your appearance. They make you show them your arms, and if they see needle marks, they demand money—you pay or you can be detained. I did get detained, but another time I just put 100 rubles [U.S. $3.45] in my passport and I got off; it just happens that way.¹⁴¹

Alexander Rumantsyev, director of the NGO Delo, which provides support to people with HIV/AIDS and drug users, said “planting drugs is common. If the police stop a drug user and see needle marks on his arm, they plant drugs and then beat him or do what they want.”¹⁴² Viktor B., who eventually served two short prison sentences for drug use and drug dealing, recounted his experience: “I knew where to get heroin, and others didn’t know, so they gave me money and I went and bought it. There wasn’t a lot; the police planted more.”¹⁴³ Josef R., twenty-three, a former drug user, said that users, once in detention, have to be aware that they are vulnerable to extra charges being pinned on them. “If you’re weak, they will charge you—you can’t be weak,” he said.¹⁴⁴ These and other persons interviewed by Human Rights emphasized that, in their experience, paying off the police would result in release.

Rumantsyev, who has followed the legal disposition of the cases of a number of drug users, noted that the acquittal rates against drug users in the Saint Petersburg area are near zero.¹⁴⁵ This rate would mirror very low acquittal rates previously reported in Russia by Human Rights Watch and others.¹⁴⁶

The Saint Petersburg-based NGO Humanitarian Action provides services to sex workers and estimates that the great majority of them, perhaps as many as 90 percent, are also drug users and that many of them turned to sex work because of the financial demands of finding narcotics.¹⁴⁷ Like drug users not involved in the sex trade, women sex workers interviewed by Human Rights Watch faced regular harassment by police, who apparently regarded them as a source of both money and sex. Ludmila F., twenty-nine, described her experience:

If they [police] come and we don’t have money, they take us to the police [station]—100 rubles [U.S. $3.45] [as a fine] each time. The amount of money also depends on how many police cars come. Sometimes they come several times a day. So they take us to the police station sometimes for the whole day—twenty-four hours—depending on the mood of the officer on duty and whether he is drunk or not, then let us go. Sometimes they beat us, make us wash floors in the police station. They may make us have oral sex with them for free.¹⁴⁸

Sex workers said both the charges brought against them and the fines levied are arbitrary and seem to depend on the whim of the particular police officer. “They fined me 1500 rubles [U.S. $51.72] for prostitution. It used to be 64 rubles [U.S. $2.21]; now it’s 1500….They just said I should pay and go….The hearing was like that—they came in the court room and then just went out,” said Elena A.¹⁴⁹ Yulia L., thirty-six, said the police detained her once or twice a month in the last year, sometimes for hooliganism and sometimes for drugs, and that the penalties varied and sometimes included free sex.¹⁵⁰ “Sex workers and drug users are a big source of income for the police,” said Anna Chikhacheva, a social worker who coordinates Humanitarian Action’s activities with sex workers.

In their harassment especially of drug users and sex workers, the police find themselves the beneficiaries of a “win-win” proposition. They can be rewarded officially for filling their detention quotas, and they can be rewarded informally in whatever payments they can extort from drug users or sex workers detained or threatened with detention. Since drug users and sex workers are widely regarded in society as undesirable elements, the police face little risk of social censure in these actions.

Another drug control activity of the police that has been cited by activists in Saint Petersburg and Moscow as a threat to human rights is the practice of nightclub raids by narcotics police. Most of the drug users interviewed by Human Rights Watch said they did not frequent nightclubs, but several expressed concern about this practice as one more restriction on their right to be free from arbitrary arrest and detention. Press reports of high-profile raids in Saint Petersburg and Moscow in late 2003 noted that nightclub patrons in these raids have been forced to show their arms, been forcibly searched, been made to wait for hours standing pressed up against a wall or face down on the floor, and in some cases been required to give a urine sample.¹⁵¹ Commenting to the press after one such raid in Moscow, SDCC deputy chief Alexander Mikhailov noted that the law permits these raids and said: “If necessary, we will raid the Moscow Conservatory.”¹⁵²

National and international law related to these abuses

Article 3 of the Law on the Police of the Russian Federation provides that “the activities of the police [be] conducted in accordance with principles of respect for human rights and freedoms, lawfulness, humanism and transparency/openness.¹⁵³ A similar article in the criminal procedure code (article 9) prohibits torture and cruel and degrading treatment. Violations of these principles, including coercion of detainees described to Human Rights Watch by numerous current and former drug users, are punishable according to the terms of article 302 of the Criminal Code of Russia, which states:

Coercion of a suspect, defendant, victim [of crime] or witness into giving testimony or coercion of an expert into giving a conclusion by means of threats, blackmail or other unlawful means by an investigator or person carrying out the inquiry is punishable by deprivation of freedom for a period of up to three years.¹⁵⁴

In addition, article 21(2) of the Criminal Procedure Code prohibits torture, cruel and degrading treatment. The criminal code makes torture and cruel and degrading treatment a criminal offense in articles 117 and 302.

Several Russian statutes stipulate the conditions under which persons can be detained by the police. According to the Law on the Police, police officers may only request a person’s identification documents if “sufficient ground” exists that that person committed a criminal offense or misdemeanor.¹⁵⁵ Should the person be unable to identify him or herself, the police may detain him for up to three hours for identification purposes. There are a number of other well defined circumstances in which police may detain an individual.¹⁵⁶ The practice of frequent detention of suspects rather than the use of other measures of restraint, even for nonviolent first-time offenders, has been criticized internationally, including by the U.N. special rapporteur on torture.¹⁵⁷

In international law, article 9 of the International Covenant on Civil and Political Rights (ICCPR) stipulates that “no one shall be subjected to arbitrary arrest or detention. No one shall be deprived of his liberty except on such grounds and in accordance with such procedures as are established by law.”¹⁵⁸ This principle is echoed in section 1.5(5.15) of the Organization for Security and Cooperation in Europe (OSCE) Copenhagen Document, which also guarantees habeas corpus: “[A]ny person arrested or detained on a criminal charge will have the right, so that the lawfulness of his arrest or detention can be decided, to be brought promptly before a judge or other officer authorized by law to exercise this function.”¹⁵⁹

HIV prevention in prison

In Saint Petersburg, as elsewhere Russia, drug users have a high likelihood of spending time in police detention or in prison at some time in their lives. The Ministry of Justice, which oversees medical services in the prison system, has taken some steps to acknowledge and address HIV risk in prison. The Ministry has allowed some NGOs to enter the prisons to provide information on HIV prevention and even gave an award to the AIDS Foundation East-West, a Moscow-based NGO, for its work in prisons.¹⁶⁰ The ministry has facilitated the implementation of externally funded programs to address the severe problem of tuberculosis in Russian prisons;¹⁶¹ tuberculosis is an important opportunistic infection associated with HIV/AIDS as well as a public health concern in its own right. Notwithstanding these measures, HIV prevention and AIDS care in prisons remains fraught with difficulties, and the case of Saint Petersburg illustrates many of these.

According to Dr. Dimitry Ruksin, chief of the State Sanitary and Epidemiologic Supervision Center of the Saint Petersburg and Regional Correction Department, over 50 percent of the inmates in the prison system of Saint Petersburg and the surrounding region were incarcerated because of drug-related crimes.¹⁶² He said, however, that this percentage in his view is declining with the lower popularity of heroin compared to noninjected synthetic drugs, which are less associated with offenses that entail prison sentences. In addition, Ruksin noted that since early 2002, procedural changes to cut down on arbitrary imprisonment have resulted in a significant overall reduction in the prison and pre-trial detention populations. From 32,000 in the mid-1990s and 28,000 at the end of the 1990s, he said, the Saint Petersburg region now has about 18,000 inmates in its fourteen facilities. These include the Kresty pre-trial detention center, the biggest correctional facility in Europe.

Ruksin noted that in 1998 the prison authorities began seeing a significant increase in HIV infection among inmates, particularly injection drug users. All inmates are tested for HIV upon entry to the correctional system in Saint Petersburg even though, as noted above, the law was changed in 2001 to eliminate obligatory testing of detainees. A 2000 survey of 9727 inmates in Saint Petersburg found that 46 percent were HIV-positive and 58 percent had injected drugs in the previous year.¹⁶³ The NGO Delo estimated in early 2004 that there were about 3000 persons with AIDS incarcerated in Saint Petersburg and the Leningrad Region.¹⁶⁴ “Of course it is recognized that there is drug use in prison, but the prison regulations don’t allow drugs,” Ruksin noted, and there is no syringe exchange or other official provision of sterile syringes in the prison system. “We are trying to plant in their minds some ideas about clean needles, but our regulations don’t allow syringes in prison. The city has syringe exchange points on the outside.”

Former inmates interviewed by Human Rights Watch in Saint Petersburg confirmed the presence of all kinds of narcotics in prisons, obtained mostly from the guards, who they said also supplied inmates with needles for a fee. Fyodor N., twenty-four, a veteran of the armed conflict in Chechnya, said: “There was a lot of drug use in prison [in 2002 and 2003]—all kinds of drugs. The guards who had been paid off supplied the prisoners with drugs and needles. People could get anything through from the outside; the guards would turn a blind eye for money.” Ekaterina S., a person living with HIV/AIDS whose boyfriend was incarcerated in 2002, said he was able to get a greater variety of drugs in prison than when he was out of jail, but all of them were much more expensive in prison than outside.¹⁶⁵

Former inmates reported that in addition to a lack of harm reduction services, the absence of basic education on HIV transmission and the lack of access to condoms in the prison system were of concern. As Viktor B. noted: “Someone came to the cell to tell me [I was HIV-positive], and I had to sign a statement that said I was aware of the law, that I would get three to eight years in prison if I infected someone. But I was told nothing about the disease.”¹⁶⁶ Fyodor N. suggested: “They need to explain to people what AIDS is, even for the HIV-positive people to learn about what it is to be HIV-positive.”¹⁶⁷ Asked about providing basic information on HIV transmission, including sexual transmission, to inmates, Ruksin of the correctional service said: “We try to do that, but we have regulations that forbid sex among inmates, so it’s difficult to handle,” but he noted that condoms are provided in the rooms that are used for conjugal visits to prisoners.¹⁶⁸

Ruksin suggested that the 2001 order eliminating mandatory segregation of HIV-positive inmates has been interpreted in Saint Petersburg to allow individual correctional facilities to decide how to house HIV-positive prisoners. He said that in all but one of the prison colonies today and in Kresty pre-trial detention center, there are separate wards for HIV-positive inmates but HIV-positive people go there voluntarily. “We are trying to implement non-isolation of HIV-positive and HIV-negative people,” he said. Ekaterina S. told Human Rights Watch that her boyfriend, who was released from Kresty pretrial detention center in October 2003, was told he had no choice but to stay in the HIV-positive section of the facility.¹⁶⁹

Human Rights Watch spoke with a number HIV-positive persons who had been incarcerated in Saint Petersburg and spoke of both difficult living conditions and the larger problem of the lack of HIV prevention services in prison for drug users and inmates more generally. Viktor B., twenty-two, noted: “When I was in pre-trial detention, there were three cells with HIV-positive people, but they were all full. Where I was, there were ten beds and thirty-five of us—we have to sleep in shifts. So they sent me in with the others.”¹⁷⁰ Fyodor N. described his attempt to seek better living conditions for people with HIV in 2002 and 2003 when he was in pre-trial detention:

I was kept in the HIV-positive ward [after I got my test result]. The people who were kept there went crazy. Many were serving long sentences, and they thought they would die there, so some of them did everything possible to die even sooner. There wasn’t much difference in the treatment of HIV-positive prisoners compared to the rest. We didn’t get better health care—we got some vitamins now and then, but they were past their expiration date. I wrote about this to the prison authorities because I knew that they had money that was supposed to be spent on AIDS in prisons. I complained over and over again about the food. Finally I was summoned to the prison authorities and they said if I want to have a normal life in prison, I should stop my complaints….But I succeeded somewhat with my complaint. Before, we had fifty-four people in cells with a capacity of thirty-three. After my complaints, the number of inmates in the cell never exceeded the cell capacity.¹⁷¹

When Fyodor N. and his fellow inmates finally were told that they did not need to be isolated any longer, a number of them resisted this change. He said this was at least partly because the HIV-negative people understood HIV/AIDS very poorly and might be inclined to blame the HIV-positive people if someone was infected and partly to avoid accidental transmission. “If you’re in with the rest, someone could use your razor…you never know what could happen,” he said.

HIV/AIDS and public health experts have long criticized the practice of segregation of HIV-positive prisoners because, in addition to adding to the stigma of HIV, this isolation can result in a false sense of security from the idea that HIV will not be transmitted in the HIV-negative part of the prison. According to the Canadian HIV/AIDS Legal Network, HIV-based segregation in prisons “would create the unrealistic and dangerous assumption among prisoners and staff…that all prisoners with HIV or AIDS are held in those special [isolation wards]. This could easily lead to the further assumption that prisoners held in other prisons need not practice safer sex or safer needle use.”¹⁷² The lack of HIV prevention services for prisoners is of concern to the general population as well as to inmates because the great majority of prisoners are in prison for relatively short periods. Ruksin estimated the average prison stay in the Saint Petersburg region to be approximately six months.

Prisons are also lacking in services for detoxification or rehabilitation of drug users other than simple withdrawal¹⁷³. Ruksin attributed this to a lack of resources for this purpose. Viktor B. said that he underwent detoxification in prison in Saint Petersburg. “Drug rehabilitation was being put on a dry regime. They close the door and that’s it. You beg or you don’t beg [for help]—there’s no point. They don’t call the doctor, nothing. If you start to get convulsions, they call the doctor and give you a tablet of analgesic, but that’s it.”¹⁷⁴ Ruksin said that in general it was not possible to transport prisoners for care such as drug rehabilitation to specialized facilities outside the prison system but that care outside prison was arranged for specialized surgery.

Human rights and international standards on HIV/AIDS and drug use in prison

Article 22(1) of the U.N. Standard Minimum Rules for the Treatment of Prisoners recommends that medical services in prisons be “organized in close relationship to the general health administration of the community or nation.”¹⁷⁵ In this spirit, the World Health Organization (WHO) Guidelines on HIV Infection and AIDS in Prisons¹⁷⁶ makes several suggestions that are pertinent to HIV prevention and AIDS care in Russian prisons. The guidelines note that HIV prevention measures in prison should be comparable to those in the surrounding community and should be based on “risk behaviours actually occurring in prisons, notably needle-sharing among injecting drug users and unprotected sexual intercourse” (article A.4). Regarding injection drug users in particular: Article C. 24:

In countries where bleach is available to injecting drug users in the community, diluted bleach or another effective viricidal agent, together with specific detailed instructions on cleaning injecting equipment, should be made available in prisons housing injecting drug users or where tattooing or skin piercing occurs. In countries where clean syringes and needles are made available to injecting drug users in the community, consideration should be given to providing clean injecting equipment during detention and on release to prisoners who request this.

The guidelines go on to say that since “penetrative sexual intercourse occurs in prison, even when prohibited, and condoms should be made available to prisoners throughout their period of detention” (article C.20).

The WHO guidelines recommend the prohibition of compulsory HIV testing of prisoners and detainees as “unethical and ineffective” (article B.10). They further note that isolation or segregation of HIV-positive prisoners is not “useful or relevant” (article D.27) and should only be considered as a temporary measure in cases where HIV-positive inmates also suffer from infectious tuberculosis or for some other justifiable clinical reason (article D.28). Article L.51 of the guidelines recommends compassionate early release of inmates with advanced AIDS, to the degree that judicial standards will allow. The guidelines also emphasize the importance of peer education in HIV prevention and education activities among prisoners and drug users.

The United Nations Guidelines on HIV/AIDS and Human Rights spell out some measures to be taken in prisons (in paragraph 29):

Prison authorities should take all necessary measures, including adequate staffing, effective surveillance and appropriate disciplinary measures, to protect prisoners from rape, sexual violence and coercion. Prison authorities should also provide prisoners (and prison staff, as appropriate), with access to HIV-related prevention information, education, voluntary testing and counseling, means of prevention (condoms, bleach and clean injection equipment), treatment and care and voluntary participation in HIV-related clinical trials, as well as ensure confidentiality, and should prohibit mandatory testing, segregation and denial of access to prison facilities, privileges and release programmes for HIV-positive prisoners. Compassionate early release of prisoners living with AIDS should be considered.¹⁷⁷

Russian national law, including article 29 of the health law of 1992 and article 12 of the Criminal Implementation Code, guarantees adequate health care for prisoners and persons in detention. Prisoners needing specialized care are entitled by law to received care by specialists outside the correctional institution, both as outpatients and through hospitalization when needed.¹⁷⁸

Discrimination against drug users in health services

Since drug users were the population most heavily affected by HIV in the early years of the AIDS epidemic in Russia, they also dominate the population now beginning to need and seek treatment for AIDS. In Saint Petersburg, they are systematically excluded from the limited antiretroviral (ARV) treatment program of the city. Dr. Elena Vinogradova, the chief physician of the City Health Committee, said that among the approximately 150 persons being provided with free ARV treatment by the city in February 2004 were a number of former drug users, but that active drug users were not seen to be a good risk for the treatment. “Treatment is expensive, and it’s not provided to active drug users. People have to sign a contract that they will continue to come every month; if they don’t they know they can be taken out of the program. We know all of the people on treatment. We know who can be trusted and who not,” she said. She said the city’s position is to give priority to children who are infected from being born of HIV-positive women and to mothers. “Children need their mothers,” she noted. “If the mothers die, it’s an extra burden for the state to pay for the care of the children.” She said that she was in the middle of an intensive effort to secure more funding from the city to expand the treatment program significantly.

The head of the Federal AIDS Center, Dr. Vadim Pokrovsky, told Human Rights Watch, however, that research conducted by his institution demonstrated that active drug users can comply well with ARV treatment regimens. He said that federal policy, therefore, is not to exclude active drug users from treatment but recognized that the city and regional AIDS centers with resource-strapped treatment programs may have nonclinical reasons to make this exclusion. The findings Pokrovsky reports from his research echo a large and growing body of clinical studies that indicate that active drug users are able to comply with ARV treatment at rates similar to those of the general population.¹⁷⁹

Ekaterina S., age thirty-two, an HIV-positive woman who was not a drug user, told Human Rights Watch that she had a sister who was infected through injection drug use.

The doctor told me that they would rather give treatment to me than to my sister who still uses drugs. They told my sister “you’re not worth it—sooner or later you’ll just wind up in prison.” I don’t understand this. All people are equal. If I had to choose between getting treatment myself and giving it to my sister, I would choose her. She’s only twenty-five; she has plans for the future.¹⁸⁰

Human Rights Watch spoke with a number of HIV-positive persons, including drug users and former drug users, who said the city used social criteria other than just active drug use to exclude people from the treatment program. “They tell people that if they don’t live with their parents or someone ‘stable’ they can’t get the treatment,” said Fyodor N.¹⁸¹

For persons not benefiting from free ARV treatment from the city, it was possible in February 2004 to obtain antiretroviral drugs in Saint Petersburg, as in Moscow and other large Russian cities, but at a cost of about U.S. $1000 per month for triple therapy.¹⁸² The average wage in Saint Petersburg was estimated in February 2004 to be about U.S. $250.¹⁸³ Active drug users are probably less likely than the average wage earner to be able to afford this sum. In addition, several former drug users and persons with HIV/AIDS told Human Rights Watch that while the ARV treatment is free to those admitted to the program, being in the program requires having a viral load test,¹⁸⁴ which costs 6000-7000 rubles (U.S. $207-241).¹⁸⁵ Dr. Vadim Pokrovsky of the Federal AIDS Center recognized this to be a constraint and said that the federal government would in 2004 supply the regional and municipal AIDS centers with lower-cost kits for viral load testing.¹⁸⁶

The scarcity of ARV treatment, especially for drug users, is particularly important in light of the apparent scarcity of humane services to treat the addiction of drug users. As noted above for prisons, health practitioners in the regular city health system are limited in the options they can offer to treat drug addiction. This is partly because opiate substitution drugs such as methadone, which are central to detoxification programs for heroin users in most countries, remain illegal in Russia. Vladimir A. said there were many twelve-step programs and very expensive privately offered programs. “The state narcology centers are inhumane—no medicines, no care, the places are dirty and cold, they just keep you there. The private providers often are not competent, but they say ‘give us thousands and we will cure you.’ Some parents will pay anything to see their child off drugs.”¹⁸⁷

Some drug users said they faced discrimination and abuse in access to health services more generally. “I had a clot in my vein from a bad shooting. I had fever and headaches and needed a doctor. I called an ambulance [public ambulance service]. Two guys came and asked me what the problem was. They suggested some medicine that wasn’t free. But then they said it was my time to die, it was high time that I died,” said Pavel O. Dr. Musatov of the Botkin Hospital said health service access for drug users is complicated by several factors:

There is a real problem of access. First, injection drug users often are not registered in Saint Petersburg, they have no passport, no insurance; these are now obligatory documents. Secondly, some health professionals don’t understand the principle of supporting drug users. Third, the absence of substitution therapy is a problem. With heroin, people have these ups and downs and may be driven to criminal acts and a blow-up of emotions. With substitution therapy, we could treat this.¹⁸⁸

Asked whether drug users are also hesitant to seek services for fear of being registered by the government as addicts, Musatov said that at Botkin Hospital, it is the practice to register only the main infectious disease diagnosis with which a drug user presents and not to register the addiction as would be done at a city narcology center.¹⁸⁹ A 2001 study of drug users by the Pasteur Institute of Saint Petersburg found that 70 percent of those surveyed had never sought medical care of any kind at least partly due to fear of stigma.¹⁹⁰

Article 2 of the ICESCR prohibits discrimination in the realization of all the rights covered in the covenant, including the right to health. In General Comment No. 14on the right to the highest attainable standard of health, the Committee on Economic, Social and Cultural Rights repeatedly stresses the importance of equality of access to health care without discrimination.¹⁹¹ According to the committee, “health facilities, goods and services must be accessible to all, especially the most vulnerable or marginalized sections of the population, in law and in fact, without discrimination on any of the prohibited grounds.” The prohibited grounds include both “physical or mental disability,” “health status,” and any “other status” that has “the intention or effect of nullifying or impairing the equal enjoyment or exercise of the enjoyment or exercise of the right to health.”¹⁹²

The same U.N. drug control conventions that the Russian Federation cites in banning methadone oblige it to provide humane addiction treatment services for drug users. The Single Convention on Narcotics Drugs of 1961 and its additional protocol of 1972 and the Convention on Psychotropic Substances of 1971, to which the Russian Federation is a party, oblige states to establish rehabilitation and social reintegration services for drug users according to international standards.¹⁹³ A 2004 position paper of the World Health Organization, UNAIDS and the U.N. Office on Drugs and Crime states that substitution maintenance therapy with methadone or another opiate substitute “is a critical component of community-based approaches in the management of opioid dependence and in the prevention of HIV infection…,” emphasizing also the effective track record of this therapy.¹⁹⁴

Discrimination against people with AIDS and public knowledge and attitudes about AIDS

The stigma and abuse faced by drug users because of their addiction is compounded when they are HIV-positive or assumed to be HIV-positive. Discrimination based on HIV status is rampant in Saint Petersburg, which as a major city with a government concerned about HIV/AIDS probably has one of the better informed populations in Russia with respect to the epidemic. People living with HIV/AIDS who spoke with Human Rights Watch recounted consistent and numerous stories of discrimination and abuse related to their HIV status. These include many stories of discrimination by health professionals and other persons who apparently did not understand the basic facts of HIV transmission.

As in other jurisdictions in Russia, the city health system of Saint Petersburg includes specialized facilities such as the AIDS Center and the “narcology” center, as well as local health clinics that are meant to offer a variety of standard services to people in the surrounding neighborhood. According to a decision of the city’s legislative body in 2002, people with HIV/AIDS should be able to obtain routine non-invasive health care and check-ups at their neighborhood clinics.¹⁹⁵ Natalya R., twenty-six, a person living with HIV/AIDS, described an experience at the city clinic in her neighborhood:

Six months ago, I went to a city clinic in my neighborhood for a consultation (with the gynecologist). They did the standard tests, including blood tests. I went the second time three or four days later. It was a big scandal. They said I should have warned them that I was HIV-positive. They were shouting, and they pushed me out of there—they said, “You people know the place where you’re supposed to go.” So I went to the AIDS Center, and the gynecologist there saw me and we talked. The gynecologist there called back to the city clinic, and they had a heated discussion. That clinic is close to my house and convenient, but I would never go there again. If you go for testing in the AIDS Center, they give you proper counseling; this is not true in the other place. It’s absolutely different when you get a test result in the city clinic—they threaten and intimidate you and don’t give you any useful information.¹⁹⁶

Andrei Panov, a person living with HIV/AIDS and the director of Peter Positive, a support group for HIV-positive people in Saint Petersburg, explained that he and his wife had recently had a baby. “The pediatric health worker came to us and told us not to kiss the baby or to touch the pacifier….When things like that happen, you wonder how we’re going to solve the problem [of discrimination] more globally,” he said.¹⁹⁷

Oksana B., twenty-five, who had been living with HIV for almost four years when Human Rights Watch met her, was working with other HIV-positive people in the support group Svecha (“Candle”) especially to provide assistance for HIV-positive persons rejected by their families or facing discrimination in other spheres. “The most difficult thing is when your loved ones push you away,” she said. Svecha has seen many such incidents, she continued:

There are many where their parents don’t want them to live with them anymore. Many people just don’t tell anyone about [their HIV status] because they’ve seen what happens to others, and they’re scared. Many people have had the experience of being fired from work….We have many plans, many people [with HIV/AIDS] who want to help each other….Everyone understands that if we don’t help ourselves, no one will help us.¹⁹⁸

Mariana Liptuga, HIV/AIDS program coordinator for the Christian Interchurch Diaconal Council in Saint Petersburg, ran up against health professionals who were underinformed about HIV/AIDS when in 2002 she began exploring the question of whether people with AIDS might be treated in the palliative care centers of the city health system. The city has ten hospices that have a mandate to provide in-patient and home-based palliative care to cancer patients. Recognizing that the city cared for AIDS patients only in the AIDS Center and in Botkin Infectious Disease Hospital and that the number of AIDS patients was growing, Liptuga raised the idea that AIDS patients should be able to enter the city’s palliative care facilities and was quickly met with resistance. She surveyed forty doctors and nurses in the palliative care system and found that almost 70 percent of the nurses said that they would refuse to care for people with AIDS, and 50 percent of the doctors said that the AIDS patients would pose a serious danger to themselves (the doctors).¹⁹⁹ Twenty percent of the nurses believed that the AIDS patients would pose a serious danger to other patients. In the end, according to Liptuga, two of the palliative care centers said they would admit people with AIDS, and the rest said they would support some level of home-based care for people with AIDS.

Numerous people living with HIV/AIDS who spoke to Human Rights Watch expressed concern over the way in which they found out from health professionals that they were HIV-positive. “The doctor summoned me and put a piece of paper in front of me and said ‘read this’. I still have it—it said I was ‘AIDS-positive,’” said Dimitry L., who said he felt as though he would probably die soon after. Several members of the HIV-positive persons group Svecha in Saint Petersburg told Human Rights Watch about an eighteen-year-old young man of their acquaintance who, when he got his results, was told by the doctor “you will die in a year.” This young man sold all of his possessions and was soon after in a fatal car crash, which some of his friends believed was a suicide.²⁰⁰ Oksana B. said she had a similar experience when she became pregnant, having already been diagnosed as HIV-positive. “Some doctors said I should give birth, some said ‘think about what you’re doing to yourself and the child.’ When I went to the consultation, the first question was ‘do you have someone to leave the child with?’ as if I were going to die tomorrow,” she said.²⁰¹

Dr. Vinogradova of the City Health Committee said that the AIDS Center provided continuous training for doctors and that incidents of discriminatory behavior in nonspecialized city health facilities had become less frequent since the city issued its regulations on HIV-related discrimination in health services.²⁰² She explained that she herself has intervened in cases such as this. She also said that she knew that the counseling associated with HIV testing and explanation of test results left much to be desired in some cases and that the AIDS Center was continuing to address this problem in the training of doctors and nurses.

A lack of understanding of HIV/AIDS is not limited to health professionals. Mariana Liptuga of the Interchurch Diaconal Council described to Human Rights Watch her effort to approach one of the Council’s partner organizations to arrange a meeting place for Svecha. In 2003, she approached an organization that had space in a building where a children’s shelter also was operated. She said that the reaction was at first very negative—“People said ‘it’s impossible that we should use the same toilet as those people”—but after the Council did a seminar on HIV/AIDS, the group agreed to allocate the space to Svecha. One day, however, a spot of blood was found near the entrance to the building, and one of the workers in the building said that it must be from HIV-positive people and it would endanger everyone in the building. It turned out that the blood was that of a cat injured near the building.²⁰³ “These are people who should know better,” she said. “There are still some people who, when I tell them that I work on HIV/AIDS, tell me I should be very careful [not to catch HIV].” Andrei Panov of Peter Positive said that when he led a group of HIV-positive people to talk to church members about World AIDS Day, people asked whether they were communists but were more accepting after they heard about World AIDS Day.

Many of the stories of discrimination recounted to Human Rights Watch appear to have their roots in public ignorance about the basic facts of HIV transmission, especially the apparently widely held idea that HIV is highly contagious on casual contact.

Nongovernmental organizations working on HIV/AIDS in Saint Petersburg organized a public rally for World AIDS Day (December 1) 2003 attended by an unprecedented 800 to 1000 people. To increase attention to HIV/AIDS around the time of this event, the NGO Delo in Saint Petersburg enlisted the cooperation of a local journalist, Leonid Balyabin, to produce a number of informational television spots on HIV/AIDS. Balyabin also conducted a “man on the street” poll in the center of Saint Petersburg to ask people what they knew about HIV/AIDS. He told Human Rights Watch:

We asked people about a number of things—for example, if there was an HIV-positive child in your child’s school, what would you do? They said they wouldn’t want their child in that school. Some people, asked about AIDS, said “you should just keep as far away as possible from it.” Some said they wouldn’t even talk to someone with AIDS.²⁰⁴

Three segments produced by Balyabin were shown on principal news channels of the city. He was in the process of producing a fourth segment that would focus on the lack of access to generic drugs in Russia when he was called into the office of his editor. Balyabin said his editor told him, “we don’t need any more of these shows in AIDS. This is negative information that will just frighten people.”

Experiences such as this are apparently not new in the history of Saint Petersburg. Dr. Valina Volkova, then head of infectious diseases in Saint Petersburg, said in 2001 that she contacted all the local broadcast media in an effort to get them to help inform the public about HIV/AIDS but could not get any to respond.²⁰⁵ In a 2000 editorial entitled “Law enforces ignorance of AIDS risks,” the editors of the Saint Petersburg Times, an English-language newspaper in the city, complained in that they had been criticized by government officials for featuring an article about the growing problem of drug use and its link to HIV/AIDS in their newspaper. The newspaper was warned that writing about drug use could be a violation of article 1 of the Press Law, which forbids mass media publication of “information about the means, methods of production, preparation and use of narcotic substances.” The editors criticized the law: “It is a shame that sufficient education programs about the dangers of drug use are not widely available, but it is a greater shame that [the] media, which have the power to provide that education, are forbidden from doing so by lawmakers embarrassed about the problems their laws are written to cover up.”²⁰⁶

It is not only news media outlets that have been constrained in providing information to the public on HIV/AIDS. A web site called “drugusers.ru,” run by and for drug users to provide them with information about harm reduction, among other topics, was shut down briefly by SDCC officials in early 2004, and the administrators of it were sought for questioning.²⁰⁷

A story recounted to Human Rights Watch by Irina P., twenty, illustrated both the depth of discrimination faced by people with HIV in Saint Petersburg and the progress that is possible when people are able to assert their rights. At age sixteen when she was in secondary school, Irina P. tested positive for HIV, and her HIV status became known to other students in the school. Parents called the school, demanding that she be expelled. Irina P.’s family supported her, engaged legal counsel, and eventually persuaded the director of the school to allow her to finish her course of study. She continued to face stigma from some classmates, but she finished school and went on to be certified to teach physics. Soon before Human Rights Watch met Irina P. in early 2004, she was asked by the same school director to return to the school as a teacher. This happy ending is a bit dulled by the fact that as a teacher, she was not allowed to speak to students about HIV/AIDS and even the biology teacher, according to her, was very constrained in what she could say about HIV/AIDS in class.

Dr. Vinogradova of the City Health Committee recognized that there remains a long way to go to educate the public about HIV/AIDS. “In the declaration from the 2001 AIDS summit of the U.N., countries agreed that 95 percent of their people have to know about AIDS. We are now in 2004, and certainly 95 percent of the people here are not aware of the basic facts,” she said.²⁰⁸ Dr. Vadim Pokrovsky of the Federal AIDS Center in Moscow said he believes Moscow and Saint Petersburg particularly have spent too little of their AIDS resources on public education. He said he was optimistic that the upcoming NGO-led effort supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria would fill this gap to some degree.²⁰⁹

Human rights and international and national standards

The Russian national law on HIV/AIDS (Federal Law on Prevention of the Dissemination in the Russian Federation of the Disease Caused by the Human Immunodeficiency Virus of 1995) contains prohibitions against “limitations of the rights of HIV-infected persons,” including dismissal from work, refusal to hire, refusal to provide medical assistance, limitation of housing rights and “limitation of other rights and legal interests” based on HIV status (article 17), though the word “discrimination” is not used.²¹⁰ Article 4 of the law provides that the state will guarantee “regular information of the population, including through the mass media, about accessible measures for the prevention of HIV infection.”

Under international law, all persons have the right to equality before the law and equal protection of the laws. The guarantees of equality before the law and equal protection of the laws prevent a government from arbitrarily making distinctions among classes of persons in promulgating and enforcing its laws. Under article 26 of the ICCPR, “the law shall prohibit any discrimination and guarantee to all persons equal and effective protection against discrimination on anyground such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status.”²¹¹ At its fifty-third meeting in 1995, the U.N. Commission on Human Rights concluded that “discrimination on the basis of AIDS or HIV status, actual or presumed, is prohibited by existing international human rights standards” in that the term “or other status” in international human rights instruments (including the ICCPR) “can be interpreted to cover health status, including HIV/AIDS.”²¹²

The U.N. International Guidelines on HIV/AIDS and Human Rights enjoin states to “enact of strengthen antidiscrimination and other protective laws that protect vulnerable groups, people living with HIV/AIDS and people with disabilities from discrimination in both the public and private sectors” (guideline 5).²¹³ The guidelines note particular areas in which discrimination is likely and which merit legal protection, including (1) the right of people to freedom from HIV screening for employment, promotion, training or benefits, (2) protection from discriminatory acts such as “HIV/AIDS vilification,” (3) the urgent need for privacy laws to protect the confidentiality of all medical information, including HIV status, and the need for disciplinary and enforcement mechanisms in the case of breaches of confidentiality.²¹⁴

The experience of those affected by HIV/AIDS documented in this report illustrates the importance of the link between discrimination based on HIV status and the right of all people to accessible and scientifically sound information on HIV/AIDS. The right to information on HIV/AIDS is also essential to the ability of all persons to realize the right to life. The right to life is “the supreme right from which no derogation is permitted even in time of public emergency which threatens the life of the nation,” as guaranteed in article 6 of the ICCPR.²¹⁵ Noting that the right to life “is a right which should not be interpreted narrowly,”²¹⁶ the Human Rights Committee has observed:

The expression “inherent right to life” cannot properly be understood in a restrictive manner and the protection of this right requires that States adopt positive measures. In this connection, the Committee considers that it would be desirable for States parties to take all possible measures to reduce infant mortality and to increase life expectancy, especially in adopting measures to eliminate malnutrition and epidemics.²¹⁷

Because of the uniquely devastating nature of HIV/AIDS, the failure to provide complete and accurate information about HIV/AIDS prevention may result in an arbitrary deprivation of the right to life.

The U.N. Guidelines on HIV/AIDS and Human Rights emphasize the need for states to take affirmative action to provide adequate, accessible and effective HIV-related prevention and care education, information and services.²¹⁸ The guidelines specifically call on states to “ensure the access of children and adolescents to adequate health information and education, including information related to HIV/AIDS prevention and care, inside and outside school,” tailored appropriately to age level and capacity and enables them to deal positively and responsibly with their sexuality.²¹⁹

High-level political commitment to fighting HIV/AIDS and related human rights abuses

The government of the Russian Federation has two structures within the Ministry of Health that are concerned with HIV/AIDS—a three-person office that is a sub-department of the department of epidemiological surveillance, headed by Dr. Alexander Golyusov, and the Federal AIDS Center, which directs research and provides some guidance to the regional and city AIDS centers, headed by Dr. Vadim Pokrovsky.

Given the size and potential destructive power of the AIDS epidemic in its territory, however, the Russian government has devoted comparatively little money and personnel to fighting HIV/AIDS. The annual federal budget for HIV/AIDS for the last several fiscal years has been about U.S. $4-5 million for an epidemic that is estimated to have infected over 1 million people and to be growing rapidly in the population of approximately 145 million. When the resources of the regional and municipal AIDS centers are included, governmental allocations at all levels to HIV/AIDS in the current year may be as high as U.S. $22 million.²²⁰ In comparison, for example, the government of Poland, with a population of 39 million people and an estimated 13,000 persons living with HIV/AIDS with a much lower estimated per capita income than that of Russia, allocated U.S. $11.7 million in the last fiscal year.²²¹ Romania with its population of 22 million and a very small number of people with AIDS, allocated $48 million over the last three years, including over $25 million for antiretroviral treatment.²²² In 2002, Pokrovsky said Russia needed $65 million urgently for prevention and treatment programs.²²³ In April 2003, the World Bank announced a $150 million five-year loan to Russia to combat HIV/AIDS and tuberculosis, which should support improved public awareness as well as laboratory and epidemiological testing and surveillance capacity.²²⁴ The Economist reported that the loan was settled “after four years of squabbling about how to spend it.”²²⁵

Dr. Golyusov of the Ministry of Health told Human Rights Watch that the fact that there is a special program in the ministry for HIV/AIDS and not for any other particular disease indicates that the government has a special commitment to fight HIV/AIDS. He noted, in addition, that there are five positions allocated to the HIV/AIDS unit in the ministry, but it has not been possible to fill the two vacant slots because the salary that the government can offer is low relative to the qualifications that are sought.²²⁶ The Russian Federation is one of the few countries in the world that does not have an interministerial program to combat HIV/AIDS, one of the main recommendations of the United Nations from the early years of the epidemic.²²⁷ There is an interministerial body for health policy, Golyusov noted, and he said he favored establishing one for HIV/AIDS.

The disparity between the government’s estimates of the impact of the epidemic and those of other bodies, including international organizations, may be related to the relatively low resource allocation to AIDS programs by the government. In February 2004, for example, federal authorities estimated that between 4000 and 5000 Russians living with HIV/AIDS were in need of antiretroviral treatment; the government estimated that nationwide it was providing treatment for about 1500 of those.²²⁸ At a February 2004 meeting organized in Moscow by the World Bank on access to antiretroviral treatment in Russia, however, the World Health Organization (WHO) representative in Russia, Dr. Mikko Vienonen, noted that WHO’s goal for Russia was to ensure ARV treatment for 50,000 persons by December 2005,²²⁹ indicating that the U.N. agencies have a rather different estimate of the scale of treatment need from that of the government. Dr. Pokrovsky said that he would not expect to see 50,000 persons in need of ARV treatment until about 2008.²³⁰ Dr. Vienonen said WHO was hoping to bring to Russia in the first half of 2004 a team of experts that would look into the impediments to registration of generic ARV drugs in the country.

Attending the World Bank meeting were representatives of the major bilateral donors to health programs in Russia, the U.N. agencies and NGOs working on HIV/AIDS in Russia, and a representative of the Ministry of Trade and Economic Development. The absence of a representative of the Ministry of Health was noted by numerous participants. Konstantin Lezhentsev, policy director of the International Harm Reduction Development Program of the Open Society Institute, noted at the meeting that while pursuing registration of generic drugs, the Russian government had not taken advantage of some price discounts offered by brand-name drug manufacturers, as had been done in Ukraine and other countries in eastern Europe.²³¹ The representative in Moscow of Merck & Co., Inc. told Human Rights Watch that this was the case with respect to the ARVs offered at a discount by Merck since 2001.²³²

In late 2003, the Global Fund to Fight AIDS, Tuberculosis and Malaria announced a U.S. $88.7 million grant for five Russian NGOs working in ten of Russia’s eighty-nine regions.²³³ Global Fund grants are normally awarded to a “country coordinating mechanism (CCM)” or government-NGO-private sector entity the formation of which is usually a requirement for consideration of a grant proposal. The Russian NGOs were able to present a proposal because the government had not formed a CCM to which the NGOs could bring their ideas for a proposal.²³⁴ The government later formed a CCM and submitted a proposal to the Global Fund that was rejected in 2003. Dr. Pokrovsky of the Federal AIDS Center said the government would submit another proposal to the Global Fund to seek support for expanded ARV treatment.²³⁵