HIV/AIDS in Russia 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 States, 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 Eastern Europe and Central Asia 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.