HIV/AIDS in and Eurasia Volume 1 This page intentionally left blank HIV/AIDS in Russia and Eurasia Volume 1

Edited by Judyth L.Twigg

Foreword by Strobe Talbott HIV/AIDS IN RUSSIA AND EURASIA, VOLUME I © Judyth L. Twigg, 2006. Softcover reprint of the hardcover 1st edition 2006 978-1-4039-7057-2 All rights reserved. No part of this book may be used or reproduced in any manner whatsoever without written permission except in the case of brief quotations embodied in critical articles or reviews. First published in 2006 by PALGRAVE MACMILLAN™ 175 Fifth Avenue, New York, N.Y. 10010 and Houndmills, Basingstoke, Hampshire, England RG21 6XS Companies and representatives throughout the world. PALGRAVE MACMILLAN is the global academic imprint of the Palgrave Macmillan division of St. Martin’s Press, LLC and of Palgrave Macmillan Ltd. Macmillan® is a registered trademark in the , United Kingdom and other countries. Palgrave is a registered trademark in the European Union and other countries. ISBN 978-1-349-53219-3 ISBN 978-0-230-60339-4 (eBook) DOI 10.1057/9780230603394 Library of Congress Cataloging-in-Publication Data is available from the Library of Congress. A catalogue record for this book is available from the British Library. Design by Newgen Imaging Systems (P) Ltd., Chennai, India. First edition: December 2006 10987654321 Contents

List of Tables vii List of Figures ix Foreword xi Strobe Talbott

Introduction 1 Judyth L. Twigg 1. The Early Days of the HIV/AIDS Epidemic in the Former Soviet Union 7 Murray Feshbach 2. Russian Politics and HIV/AIDS: The Institutional and Leadership Sources of an Inadequate Policy 33 Celeste A. Wallander 3. NGOs and HIV in Russia: Lessons from a Unique Case Study 57 Julie Stachowiak and Alena Peryshkina 4. The Economic Impact of HIV/AIDS in Russia: Current Trends and Perspectives 77 Shombi Sharp 5. Has the Window of Opportunity Closed? The Contributions of Bilateral Donors Supporting HIV/AIDS Activities in Russia and Eurasia 103 Vinay P. Saldanha 6. International Donor Support to the and Region: Opportunities and Challenges 133 Bertil Lindblad vi Contents

7. HIV and Drug Use in Eurasia 141 Robert Heimer, Robert E. Booth, Kevin Irwin, and Michael Merson 8. Rights and Lessons Scorned: Human Rights and HIV/AIDS in Russia and Eurasia 165 Joanne Csete 9. AIDS and Security in Russia 181 Harley Balzer

Notes on Contributors 207 Index 215 List of Tables

1.1 HIV Cases by Main Risk Factor, Annual Incidence, USSR, 1987–1990 29 4.1 Understanding Economic and Social Impact Level, Time, and Degree 82 4.2 Existing Models of the Economic Impact of HIV/AIDS in Russia 85 4.3 External Sources’ Prognoses of HIV Prevalence in Russia, 2005–2050 85 4.4 Optimistic and Mid-Range Projections of Three Models 86 4.5 Resulting Demographic Profiles from Three Optimistic and Mid-Range Scenarios 87 9.1 Estimate of Share of 18-Year-Olds Entering Higher Education 183 This page intentionally left blank List of Figures

1.1 Contact Tracing Chart, First Known Case of HIV in the Soviet Union 10 1.2 HIV Incidence and Prevalence, USSR, 1987–1990 27 1.3 HIV Cases by Main Risk Factor, USSR, 1987–1990 28 4.1 Russian Population Projections in the Absence of HIV/AIDS 79 4.2 Age Density of HIV Infection in Russia at the End of 2002 83 4.3 World Bank “Optimistic” Scenario, Cumulative HIV Cases 88 4.4 ILO All Scenarios, Cumulative HIV Cases 88 4.5 Impact of AIDS on GDP Levels—Three Models 90 4.6 ILO Estimates of Medical Expenditures, All Scenarios 92 4.7 Social Policy Implications: ILO “Risk Group Saturation” Scenario 93 4.8 Russia Dependency Ratios by Age Structure 94 4.9 Impact on Life Expectancy, Medium Scenario 97 4.10 Effect of Declining Life Expectancy on HDI in Russia 97 4.11 Cost-Benefit Analysis of HIV/AIDS Prevention Programs in the Russian Federation 99 5.1 Amount of USAID Funding for HIV/AIDS for Countries in Former Soviet Union, 2000–2003 109 This page intentionally left blank Foreword

Strobe Talbott

In nearly 40 years of travels in Russia, one encounter has made more of an impression on me than any other. It was a visit, on an unseason- ably warm winter afternoon in early 2005, to the Outreach Center of the Botkin Infectious Diseases Hospital at 4 Kremenchugskaya Street in St. Petersburg.1 My fellow visitors from Washington and I later found out that the facility shares the building with the hospital’s morgue. We were there to meet with about 30 members of a support group for People Living With HIV/AIDS. The fact that those words are now capitalized says a lot about how awareness of the disease has spread through the global culture. The inclusion, in that phrase, of the word “living” carries a message of hope that those now infected will, thanks to currently available treatment, survive to see the disease defeated. But in St. Petersburg—one of the most severely afflicted cities in the country—that hope is dim. The number of those who stand a chance of treatment is a tiny fraction of those who are HIV positive. Therefore the overwhelming majority of our hosts in St. Petersburg— all of them young, most still in their twenties—will die within five to ten years. Knowing that, my fellow visitors and I were all the more struck by how healthy many of them looked. When they spoke, there was little self-pity, bitterness, resignation, or despair. Instead, they infused their end of the conversation with a spirit of solidarity, courage, and practi- cality, sometimes laced with wry humor. While they had different observations and questions, they offered variations on a single theme: their determination, truly, to live with the disease as long and as nor- mally as possible, and to be active in their own treatment and care. They were therefore eager to learn about the price and distribution of xii Foreword antiretrovirals in the United States. They also wanted to ensure the health of uninfected spouses and partners, hence their curiosity about new methods of prevention under study in other countries—ones that were largely unknown in Russia, such as microbicides in the form of a vaginal gel or foam that could protect uninfected women and, unlike condoms, permit them still to have children. On the walls of the common room where we met were whiteboards and broadsides conveying basic facts and debunking widespread myths about transmission. The discussion left us in no doubt that these vic- tims of HIV/AIDS were more knowledgeable about their disease than a number of the academic specialists, including doctors, with whom we had met in St. Petersburg and Moscow (some of whom believed that HIV could be contracted through sweat, tears, and saliva). Not surprisingly, these young Russians were critical of their gov- ernment, the medical establishment, and prevailing attitudes among their fellow citizens: as one of them put it, “We are marginalized, stig- matized, and isolated.” In drawing them out on the shortcomings of Russian policy, we acknowledged that as Americans, we were mindful of our own recent history. It took the United States a number of years to overcome its own prejudices about the disease and its victims—and we still have a way to go. We expressed the hope that Russia would not repeat the mistakes of countries that were hit earlier by this plague. “Well,” said an artist and filmmaker at the AIDS Center, “our coun- try has spent a lot of its history trying to catch up with yours. We’ve done it in bad ways. Let’s hope we can do it in some good ways.” Judy Twigg, the editor of this volume, was in St. Petersburg as part of our delegation. She has been a teacher for me and others in our crash course on HIV/AIDS in Russia, and she has assembled just the right group of authors here. In her introduction and their chapters, they lay out the problem with rigor, clarity, objectivity, and knowledge. Like medicine at its best, this book combines expert diagnosis with prescription of realistic and aggressive treatment—and, crucially, prevention. A recurring and overarching message is that the Russian government must open its eyes on the subject of HIV/AIDS. A country in denial is a country in danger. An effective campaign to combat HIV/AIDS also means that other countries, especially the United States, along with international organizations, must do more to help. But Russia has to be receptive to that help. As Joanne Csete and Robert Heimer and his colleagues Foreword xiii stress, there is almost no testing for HIV/AIDS among the most high- risk and peripatetic parts of the population, such as soldiers, sailors, sex workers, truck drivers, and the police. As a result, the disease is all the more likely to spread. Reading the manuscript of this book, I found myself recalling Illness as Metaphor, the famous book-length essay that the late Susan Sontag published in 1978. Her principal point was that we should not regard disease—she had in mind particularly the one that would ulti- mately kill her, cancer—“as an evil, invincible predator.” Many Russians, including ones in high places, fall into that trap, only they see those stricken as an alien presence in their midst. Just as the American outbreak was, for years, regarded by religious and polit- ical conservatives as God’s punishment of gays, Russian authorities and much of public opinion regard HIV/AIDS—unlike, say, cardiovascular illnesses, hepatitis, and tuberculosis—as a “social disease,” to which undisciplined or unworthy members of society are susceptible. Many have kidded themselves into thinking that it is confined to “narcoma- niacs.” They are in denial not only about the disease itself but about the extent to which one of the principal causes of its spread, drug use, is a mainstream phenomenon in Russia. Several chapters address the criti- cal importance of needle exchange and other harm reduction measures. In 1988, Sontag updated her thinking in AIDS and Its Metaphors. She warned against describing the disease in “the language of political paranoia, with its characteristic distrust of a pluralistic world.” Once again, Russia is a case in point. There is an undertone of xenophobia in how the disease has, along with its sufferers, been politicized. Over the past few years I’ve heard talk in Moscow and elsewhere about HIV/AIDS either as “an African disease” (a deeply pejorative depiction in the Russian context) or as a “Western disease”—a curse that has been visited on Mother Russia because of her relatively recent openness to an outside world rife with heroin and homosexuality. Never mind, as the chapter by Bobrik and Twigg points out, that an unknown but probably growing number of Russians are being infected through heterosexual contact. In another sense, the Russian official response to HIV/AIDS is itself a metaphor: just as the state is leaving those people we met in St. Petersburg to their fate, it is jeopardizing its own survival. As several contributors to this volume stress, Russia is uniquely vul- nerable to the epidemic. Unlike other countries at or beyond a tipping point—India, China, and —Russia faces a decline in its xiv Foreword population. HIV/AIDS adds to the creeping demographic catastrophe that has been underway since Soviet times. Indeed, one reason that the USSR ended up on the ash heap of history is that its regime failed abysmally to fulfill the most basic requirement for the survival of any state: a demonstrated ability to take care of its citizenry. The Soviet system was dedicated to strength, but it was the wrong kind of strength—the kind that comes out of the barrel of a gun. One manifestation of the fallacy of Soviet power was a chronic health crisis and a steady decline in life expectancy. It is, to use a common Russian expression, “no accident” that the three countries with the world’s fastest rate of increase in HIV/AIDS infection during the late 1990s—Russia, Ukraine, and Estonia—are former Soviet republics. Russia’s post-Soviet leaders have so far failed to face up to, much less deal with, the looming calamity. Boris Yeltsin, in his understand- able impatience to dismantle the Communist monolith, erred on the side of reliance on privatization, with all that entailed in corruption and inequity. Vladimir Putin has made the opposite mistake. In order, as he sees it, to salvage the integrity and primacy of the state, he has tried to res- urrect the old top-down, center-outward paradigm of how Russia should be ruled, which the Soviet experience should have discredited; and he embodies the old mindset that equates strength with discipline, subjugation, and, inevitably, intimidation rather than the full partici- pation of the citizenry in their own governance. In short, he’s offering an authoritarian version of the social contract, but he’s not delivering on his end of the supposed bargain. As this book, particularly the chapters by Murray Feshbach and Celeste Wallander, makes clear, state authority in Russia today is, by and large, subjecting HIV/AIDS to malignant neglect. In addition to the tragic human consequences within Russia of this obscurantist and self-deceptive policy, there are major international consequences as well. A sick, weak, dying Russia is a tragedy in its own right and a danger to the world, starting with its immediate neighbors. The St. Petersburg (or, as it is still officially known, the Leningrad) region is not just a disaster area in the making for Russia— it is, as a busy port city, an international hot spot, since carriers of the virus move across borders into the Baltic and Nordic states. If Russians look eastward, the geopolitical dimension of their health crisis is even more ominous. Their country is, territorially, the largest on earth. Its natural-resource-rich but underpopulated lands beyond the Urals share a nearly 3,000-mile border with China, which Foreword xv is resource-poor but the most populous country on earth. Even though China too has a serious HIV/AIDS problem, the percentage of its giant population that is infected is miniscule compared to Russia’s or Ukraine’s. It doesn’t take a crystal ball in the Kremlin or anywhere else to imagine how that match-up could turn out to be the one of the most destabilizing facts of the twenty-first century—and HIV/AIDS is an exacerbating factor. For that reason, along with basic humanitarian ones, it is vital that the U.S. government do more to put HIV/AIDS on the agenda of U.S.- Russian relations. Judy’s introduction and Vinay Saldanha’s chapter on bilateral assistance make this point with the most force and specificity. In Russia as elsewhere, there is only so much that governments can do by themselves. That means partnering with civil society. The Russian government has cracked down on independent, grassroots, socially (not to mention politically) active organizations. It needs to do just the opposite—in general, for the health of Russian democracy, but also with regard to the physical health of the Russian people. To stand some chance of success, both Russian policy and Western collaboration with Russia on the issue of HIV/AIDS should give prior- ity to rebuilding the health care system, including support for NGOs as caretakers, educators, and advocates. The communiqué issued by the Group of Eight (G8) leaders at the end of their summit in Gleneagles, Scotland in 2005 endorsed the goal of universal access to AIDS treatment by 2010 for anyone who needs it. Admirable and ambitious as that timetable is, its target date will be too late for many of the brave young men and women we met in St. Petersburg. As it happens, that city is where the G8 met in the summer of 2006. Given the magnitude of the threat his country faces, President Putin might have done worse than to take his seven guests to the Botkin Outreach Center. And since he didn’t make the offer, they should have gone on their own—and then told him what they saw, heard, and felt.

Note

1. I was part of a delegation jointly organized by the Center for International and Strategic Studies and the Brookings Institution to investigate HIV/AIDS in Russia in February 2005. Our task force issued a report in May 2005 that is available online at http://www.brookings.edu/fp/200505russia_taskforce.htm.