With the Sochi Winter Olympics now on, the eyes of the world’s media are on Russia. In the run-up to the games, much of the press focused on the country’s legislation banning the ‘promotion’ of homosexuality and the rising levels of homophobic rhetoric and violence that followed, leading some people to call for a boycott of the games. Less has been written about the plight of another of the country’s marginalised groups, however.
According to Harm Reduction International’s most recent Global state of harm reduction report, there are an estimated at 1.8m injecting drug users in Russia, more than 37 per cent of whom are infected with HIV, while opioid substitution therapy remains steadfastly unavailable.
‘The government thinks that the main threats to the country are gay propaganda and opioid substitution treatment (OST), things like that – that they contradict our traditional
values and we should oppose them,’ Anya Sarang of the Moscow-based Andrey Rylkov Foundation for Health and Social Justice tells DDN. ‘OST is still unavailable and government opposition to it remains very vocal and strong.’
Given the weight of international evidence, how does the Russian government justify its position on OST? ‘Basically they say that it’s a bad idea to replace one drug with another, and that substitution therapy is not effective,’ she says. ‘The chief narcologist of Russia says we don’t need this therapy and instead they put a lot of effort into naltrexone programmes and all kinds of antagonist treatment. Naltrexone is much more expensive, but they say it’s the Russian way to treat addicts. But even these programmes are very few, and go in the face of clinical trials – if they are available they’re very expensive and so not many people can afford them.’
Although there are some harm reduction services operating in the country, they remain ‘politically marginalised’, says HRI, with national drug policy depicting needle and syringe exchange programmes as ‘a threat to effective drug control’.
‘There are a few needle exchange programmes,’ says Sarang. ‘We managed to keep funding from the Global Fund [to fight AIDS, Tuberculosis and Malaria] for this, but I don’t even know how many of them are still working. Our organisation runs its own needle exchange, needle distribution programme and street outreach work in Moscow, but we get nothing from the Russian government – the funding comes from the Open Society Foundations, the Levi Strauss Foundation, people like that. It’s all private foundations, as well as some remaining money from the Global Fund project, but now Russia isn’t even taking the money from the Global Fund, so I don’t know how long that will keep running.’
In fact, the government’s antipathy towards harm reduction even extends to attempting to ban the Andrey Rylkov Foundation from publishing information about methadone on its website and passing an order to close down the site a couple of years ago, a move described as ‘totally unacceptable’ by Human Rights Watch (DDN, June 2012, page 5). ‘They still don’t like it,’ says Sarang. ‘We went to the national courts but they ruled in support of the Federal Drug Control Service that we cannot place any information on methadone on our website – even information from UN agencies like WHO or UNAIDS. It’s very oppositional to the international position on substitution treatment.’
Despite the harassment, however, the foundation manages to keep the site going, alongside its outreach and other work. ‘We just had to move the website hosting from a Russian provider to an American provider so we still keep all this information, but now they have a new internet law which basically allows Russian officials to block access to any site they don’t like. They haven’t done it to ours yet but it’s possible, and without any legal procedure. So I’m not sure how long we’ll be able to provide this.’
The consequences of the government’s policies are becoming increasingly stark, however. According to UNOWED, the Russian Federation, US and China account for almost half of the people in the world who inject drugs and are living with HIV (21 per cent, 15 per cent and 10 per cent, respectively), while Russian health watchdog the Federal Surveillance Service for Consumer Rights and Human Welfare says that more than 54,000 new HIV cases were registered between January and September last year alone, up more than 7 per cent on the corresponding period in 2012.
Unsurprisingly, nearly 60 per cent of the new cases were the result of injecting drug use, and the Russian Federal AIDS Center states that the country now has the fastest-rising infection rates in the world.
The numbers are especially troubling given that HIV infection rates are falling in much of the rest of the world, with a 33 per cent drop overall since 2001 (DDN, October 2013, page 5). ‘They’re managing to control the numbers due to scaled up prevention efforts and access to treatment, but in Russia the numbers are still rising,’ she says. ‘The majority of people who are getting HIV are drug users and if you don’t have harm reduction programmes and needle exchange programmes then there’s no prevention.’
And as there are increasingly few prevalence studies being carried out among drug users it can be hard to even establish the real extent of the problem, she says. ‘Russia is so huge and it depends on the region. In Moscow the last estimates, around four years ago, were that HIV prevalence was below about 14 per cent, but the prevalence studies documented up to 75 per cent in the city of Biysk, in Altai Krai, and in Samara Oblast it was above 60 per cent. But I think the average number is still just under 40 per cent.’
Even the government’s claims that it is addressing HIV by providing medication such as antiretrovirals to anyone who needs them should not be taken at face value, she says. ‘A couple of years ago I was interviewing a large number of drug users for a WHO project and we found that, to have adequate access to medication, the doctors were saying, “you should treat your HIV but before you start your medication you should do something about your drug use.” But because there is no access to substitution treatment, no rehabilitation centres, no help, people go away and they get lost and they come back only when they’re dying.
‘If you don’t provide adequate drug treatment then it’s impossible to treat people with HIV, so when the government says, “everybody who wants medication can get it”, it’s hypocrisy,’ she continues. ‘Theoretically it’s true but they’re not able to get through this labyrinth of bureaucratic procedures to start treatment, and they’re not able to even maintain their HIV treatment because they go into drug relapses.’
The figures for hepatitis C infection among people who inject drugs also make grim reading, standing at more than 70 per cent according to recent estimates. ‘In some places it’s even above that – approaching 90 per cent – and hep C treatment is not available in Russia at all,’ she says. ‘Or it’s available, but only to the few people who can buy it – it’s very expensive – and even then not to drug users. With HIV at least some people have treatment, but with hep C it’s a really bad situation.
One fundamental root of the problem is that, in Russia, people who use drugs have no human rights, she states. ‘If you take the national drug strategy there’s no mention of human rights, and even if we talk to human rights organisations in Russia they’re not really interested in drug users.’ And there’s no mention of harm reduction in the strategy either, presumably? ‘Harm reduction is mentioned, yes, but it’s mentioned as a threat. The strategy is based on the principle that there should be a zero tolerance approach.’
Given how isolated the Russian government’s position has become, is there anything that the international community could realistically be doing to put pressure on them? ‘I don’t know if it’s even possible to influence them,’ she says. ‘They have a strong standpoint in the international arena, they are very powerful and basically they can do whatever they want. Even at the high-level UN meetings on human rights they present substitution treatment as a threat. The government’s position is basically that everyone in the world is wrong, and they are right and that they should use this strong repression and base policy on zero tolerance with no regards to human rights or the health of people. This position is not changing, and there’s no flexibility.’
One thing she would like to see that could potentially make a difference, however, is for western clinicians to stop engaging with medical and clinical trials in the country, she states. ‘If would be good if they didn’t give health officials and drug treatment officials the money for these trials for antagonist treatments, for example.
‘American researchers come to Russia with their clinical trials because no one’s really interested in naltrexone in the US. They pilot their studies, the Russians receive huge funding and then the Russian officials present it as the Russian way of treating drug addiction, as some kind of miracle treatment. Of course everybody understands that it’s nonsense. OK, it’s one medication option, but it’s never been the most effective, and even if they do the clinical trials of new preparations they should compare them to the gold standard addiction treatment, which is substitution. So it’s not very ethical to do this in Russia.’
As well as providing more grounds for the Russian government to oppose substitution treatment, the main motivation is ‘basically economic’, she stresses. ‘It’s a very corrupt public health policy. If they’re being fed by their colleagues from the US and wherever with this clinical trials money, and they’re selling this expensive, not very effective medication, then of course they’ll keep doing it. So it would be good if at least on a professional level there was a change of position from the western researchers using Russia for this purpose.’