Almost as soon as two HIV-prevention activists set up outside the pharmacy in the outskirts of Moscow with two huge backpacks of supplies, a skinny young man with mussed hair and an impish grin quickly walked up to them.
“Do you have any ointment?” he asked, lifting up the leg of his tracksuit trousers to show a mass of red sores.
Asking what else he might need, the activists put bandages and clean needles in a plastic bag.
“I don’t have any immunity, and this stuff is expensive in the pharmacy,” the young man said, giving his name only as Pavel, 28. His health problems arose from drinking and injecting heroin.
Asked if he takes steps to protect himself from contracting the Aids-related virus, he said he got clean needles, condoms and advice from the activists from the Andrey Rylkov Foundation.
This was Maryino, a far-flung district in south-east Moscow Drug addicts tend to gather near the nondescript pharmacy here because it sells tropicamide eye drops, which are typically used to dilate the pupil, without a prescription. Users add tropicamide to intravenous drugs to amplify the effect of the low-grade heroin they’re using.
More than a dozen used needles were scattered in the parking lot and park outside the pharmacy, where a few middle-aged women were walking their dogs.
“We call them snowdrops,” said activist Lena Remnyova, who was giving out flyers inviting people to a drive to clean up the used needles. “Some people find flowers when the snow melts; we find needles,” said colleague Asya Sosnina.
Moscow is at the epicentre of a rising HIV epidemic: while the number of those infected in Russia pales in comparison with the numbers in sub-Saharan Africa, it is one of the few countries where rates are growing rather than declining.
The government does not offer substitution therapy or harm reduction outreach, and the impact of grassroots groups such as Rylkov, which has only 15 staffers, is limited.
The official count of Russians living with HIV has risen to 930,000 from 500,000 in 2010, and the actual number is probably much higher. (Of those registered, some 192,000 have already died.)
Vadim Pokrovsky, head of the federal Aids centre in Moscow, predicted this month that at least two million Russians are likely to be officially registered as HIV-positive within five years, and a total of three million will have the virus.
According to Pokrovsky, the failure stems from a lack of funding and the Kremlin’s family-values-based approach to HIV prevention. Funding for fighting the disease has increased to 21bn roubles (£270m) this year, but most will go to antiretroviral therapy rather than preventative measures, he said.
“We need to spend 10 times more on prevention,” Pokrovsky was quoted as saying earlier this month. “We need many more resources and we need some political decisions – and changes in the law in connection with methadone and the private lives of individuals.”
The reasons behind the HIV epidemic are twofold: intravenous drug use and unsafe sex. More than 60% of HIV-positive Russians are thought to have used drugs, but the most common method of spreading the disease is heterosexual intercourse. Yet what groups like the World Health Organisation see as the most effective treatment of intravenous drug addiction is illegal in Russia. Opioid substitution therapy programmes to wean addicts off drugs are banned, and the use or distribution of methadone is punishable by up to 20 years in prison.
Crimea, annexed from Ukraine in March 2014, served as a case study in the effects of such an approach. For many of the 800-plus patients who had been undergoing substitution treatment there, being cut off from these programmes was a death sentence.
Michel Kazatchkine, the UN special envoy for HIV/Aids in eastern Europe and central Asia, said in January that 80 to 100 of these patients had died.
Pokrovsky has proposed introducing sex education to Russian schools, but in December children’s rights ombudsman Pavel Astakhov, who once argued that the “best sex education there is, in fact, is Russian literature and literature in general”, pledged it would “never” be taught in Russia.
“Most Russians are not in an official marriage, and a change in partners can lead to infection,” said Ilya Lapin, an HIV prevention advocate. “A man infects himself and then he infects his partner. The problem is the lack of knowledge and education, even though it’s easier to teach prophylactics than treat the disease.”
Instead of harm reduction programmes to improve the safety of drug addicts as a first step toward curing addiction, the official policy is one of rehabilitation in state-run institutions. But the paperwork required and strict schedule inhibits many drug users, and only 10-15% of patients at the city’s substance abuse centre make it through the month of detox and on to the free rehabilitation programme.
The lack of outreach has driven organisations such as the Rylkov Foundation to hit the streets for guerrilla harm-reduction work.
Five evenings a week, part-time employees like Remnyova and Sosnina stand near pharmacies selling tropicamide over the counter, mostly in the outlying districts of the city, where the drug problem is most acute.
Besides clean needles and bandages, they hand out HIV and hepatitis tests, the organisation’s newspaper and other HIV prevention literature, and naloxone, a drug that can be injected to help reverse an overdose.
“Our government thinks you need to just get rid of your drug addiction and your life will all work out,” said Maksim Malyshev, a former heroin user who kicked his addiction with the help of harm reduction activists and became outreach coordinator at the Rylkov foundation.
“But we’re realists because many people in our team are from the subculture, people who used drugs, people who still use drugs. To just quit completely doesn’t work, so we try to do things a different way.”
In the two hours before the pharmacy closes, 14 men and seven women accept bags of medical supplies and quickly whispered advice from the two activists. As they stand near the pharmacy, its security guard comes out to berate them for helping drug users. He leaves them alone after they point out that it’s his pharmacy that is selling drugs without a prescription.
Many addicts – knowing there is widespread stigma against them among both medical personnel and the population at large – are deterred from seeking help or getting treatment for infections. “When people see my hand and how varicose it is, they say get out of here,” said Sveta Yevseyeva – an occasional heroin user for the past 10 years – of the discrimination she faces every day. She can’t get a job because she’s on a register of known drug users, to which people are added if picked up by the police while high or if they leave detox early.
Many of those who stopped said they were aware of HIV prevention methods but that clean needles and medical products were hard to afford.
“We try to use clean needles and not share with unknown people, only with ones we know aren’t sick,” said one man who would give his name only as Sergei. But he admitted that a friend of his had been admitted to emergency care two months ago with Aids.
Activists hope President Vladimir Putin will adopt a more progressive approach to HIV prevention before it’s too late. “Organisations like ours inform him, we send him reports, we do independent reports, we study international recommendations,” Lapin said. “We talk about this, but he doesn’t hear us.”
This article was amended on Sunday 24 May 2015 because it incorrectly stated that the HIV-prevention activists gave out antibiotic ointment.
Alec Luhn | The Observer
Photo | Robin Hammond | Panos