It is common knowledge that illicit drug use in the Russian Federation has reached critical proportions. It is also common knowledge that people who use drugs are among those most at-risk of infection with H.I.V. And it is common knowledge that since the beginning of the H.I.V./AIDS epidemic three decades ago simple tools such as Medication Assisted Therapy (methadone, buprenorphine) and clean needle-exchange services have proven very effective in decreasing drug abuse and reducing risk of infection with H.I.V., Hepatitis C and other diseases.
So why has this evidence had so little impact on the policies and programs of the Russian Federation?
Russia has one of the world’s highest levels of injecting drug use. The estimated number of injecting drug users is 1.8 million, and the estimated number of opiate users exceeds 1.6 million. A decade ago 100,000 people were H.I.V. positive in Russia. Today there are over 1 million, and injecting drug users represent some 78 percent of all H.I.V. cases in the country. This means that more than one third of all injecting drugs users are H.I.V.-positive — with peaks at three-quarters in some cities — and three-quarters of them are also living with the Hepatitis C virus. The human cost is devastating, and the social fallout is appalling: Russia now accounts for two thirds of the Eastern Europe and Central Asian H.I.V. epidemic, the fastest growing in the world.
Confronted with such a huge political and social issue, the Russian authorities have come up with answers of their own. For example, the recently adopted “State Anti-Drug Policy Strategy of the Russian Federation” reinforces the government’s opposition to the use of Medication Assisted Therapy, or MAT, for opioid dependence with essential drugs such as methadone and buprenorphine. Both of these agents are on the World Health Organization’s essential drug list but remain banned in Russia in a holdover from Soviet times.
Russia also restricts such measures as needle and syringe exchange programs. The new National Drug Strategy proclaims a “zero-tolerance” approach to drug use in a country that already incarcerates enormous numbers of young people for substance use — and does so without drug treatment for those who need it.
These policies fuel poor treatment, discrimination and vulnerability to disease among drug users. They are contrary to WHO and U.N. recommendations, and go against the “E.U.-Russia Roadmap on the Common Space of Freedom, Security and Justice,” which emphasizes the principles of nondiscrimination and respect for human rights. They also contradict the 2001 Declaration of Commitment on H.I.V./AIDS and the 2006 Political Declaration on H.I.V./AIDS, both of which have been signed by the Russian Federation.
Yet the policies implemented by the Russian authorities have resulted in desperate situations for most of the people who use drugs in the country. Examples of intimidation include the muzzling of an outspoken advocate for methadone, Dr. Vladimir Mendelevich, who has been prohibited from practicing narcology since 2006. The recent shutdown of the Andrey Rylkov Foundation Web site over allegations of supporting drug use (that is, talking about the use of methadone) is another.
Russia’s national policies have driven drug use underground, and only made people who inject drugs harder to reach — with only 25 percent of them having access to anti-retroviral treatment. Drug offenses now account for 20 percent of the prison population. True, the government has promised to increase funding for prevention and treatment of H.I.V./AIDS. But advocates doubt that organizations will receive the promised money, given that less than $5 million of 2011’s $17 million prevention budget was spent. Russian health policies raise additional worries, as officials refuse to focus on high-risk groups such as sex workers, gay men and drug users — those most in need.
There is strong scientific evidence for supporting medication-assisted therapies and needle exchange programs. Mathematical models show that needle exchange programs prevent H.I.V. infections among drug users, their partners and family members at a cost of approximately $9,400 per avoided H.I.V. infection — compared with the lifetime cost of treating a person living with H.I.V./AIDS, approximately $200,000.
MAT is recommended by the United Nations General Assembly and the Commission on Narcotic Drugs, the United Nations Economic and Social Council, the International Narcotics Control Board and the European Council. The World Health Organization recognizes MAT as the most effective treatment for people with drug dependency, lists methadone and buprenorphine as essential medicines, and promotes MAT as core to a comprehensive package for the prevention, treatment and care of H.I.V. among drug users as well as the reduction in crime. Methadone is used successfully in more than 60 countries, including throughout the European Union. Russia stands virtually alone in its rigidity on this issue.
Turning the tide on the H.I.V. epidemic in Russia, as in so many other countries, is first and foremost a matter of politics — of political will, of evidence-based decisions, of a wise middle — and long-term allocation of funds, of a recognition of human rights for all, of making the end of stigma a political vision.
Russia has the means to enshrine health as a human right. Combination prevention is the future. For injecting drugs users, this means clean needles and syringes, Medication Assisted Therapy for those who want drug treatment, and access to anti-retroviral therapies for all H.I.V.-positive drug users. That combination works.
As the Russian Federation joins member states from around the globe at the annual Commission on Narcotic Drugs meeting taking place in Vienna this month, its authorities might well take heed to urgently endorse these proven harm-reduction strategies, and to show their citizens and the world that they are embarking on safe, wise and sound public health policies.
By Bertrand Audoin, the executive director of the International AIDS Society and Chris Beyrer, a professor of epidemiology, International Health and Health, Behavior and Society at the Johns Hopkins Bloomberg School of Public Health.