Perspective: To Prevent AIDS in Russia, Drug Addicts Need Care

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Russia has one of the fastest spreading HIV epidemics in the world, driven largely by the government’s refusal to institute measures to treat the country’s drug addicts — measures that have dramatically reduced HIV infections in drug addicts in other countries, including the U.S.

The New York Times reported yesterday that 60,000 new cases of HIV were seen in Russia in 2009, up 8% from the prior year. At least 60% of those new cases were spread by intravenous drug use, according to the Times, and a good portion of the rest of the new cases were likely the result of sex with drug addicts. (More on Drug Policy Backfires: Controlling Meth Ingredients Fails to Cut Drug Supply)

Writes the Times’ Michael Schwirtz:

Officials estimate that well over a million people abuse drugs intravenously in Russia, often sharing and infecting one another with tainted needles. They are among Russian society’s most marginalized people, more likely to face a few weeks handcuffed to a clinic bed than to receive basic treatment to break their addictions. Meanwhile, officials have treated sex education and other preventative programs with open hostility.

Which are the main infected groups? Injecting-drug users and sex workers,” said Lev Zohrabyan, the Europe and Central Asia adviser for Unaids. “It turns out that these are the groups where the money must be directed to change the picture. But if you open the budget, you will see that for prevention work among these groups for the next two years there is nothing.”

According to Schwirtz, Russia blames America’s failure to eradicate Afghanistan’s opium crops for the IV drug problem in Russia. But if the U.K.’s current shortage of heroin, due to Afghan crop failures this year, are any indication, the international heroin supply has actually been significantly reduced. Regardless, changes in the supply side have never had any impact on the HIV epidemic.

So, what’s really driving Russia’s problem? Politics. The country has a long-standing ideological opposition to the use of “substitute” maintenance drugs like methadone and buprenorphine to treat IV drug addicts. Yet methadone is the best known treatment for heroin addiction: according to numerous reviews of the voluminous international data, it reduces relapse and death rates better than any other treatment, including all therapies based on abstinence. The effectiveness of buprenorphine treatment for heroin addiction is also well-supported by research. (More on Salvia, a Mexican Hallucinogen Piques Scientists’ and Regulators’ Interest)

In all countries that have successfully reduced HIV infection rates among intravenous drug users, health officials have instituted maintenance treatment programs. But they have all also simultaneously increased clean-needle availability — the other public-health measure that undergirds many effective AIDS-prevention programs. In that respect, Russia has not been entirely remiss: it does offer some needle-exchange programs that provide addicts with clean syringes and educate them not to share.

Alone, methadone maintenance programs and legal needle-and-syringe exchanges cannot stop an epidemic. But the evidence is pretty clear that together, they can. Case in point: New York City.

In the not too distant past, New York was the epicenter of the AIDS epidemic among America’s drug addicts. In the early 1990s, at least half of all intravenous drug users in the city were HIV-positive. But a recent study of HIV infection rates among injected-drug users in New York found that while 21% of addicts tested positive for HIV between 1984 and 1994, that figure dropped to just 6% in people who used IV drugs between 1995 and 2008.

What changed? The two groups are distinguished by the prevention measures most available to them. In the 1980s and early ’90s, New York City had a large methadone treatment system, but awareness of the spread of HIV among drug addicts was initially low; at the time, syringe exchange programs were also either illegal or just getting started, and needle possession was illegal. (More on The Most Dangerous Drugs? Alcohol, Heroin and Crack — in That Order)

In 1992, needle exchanges were legalized in New York City, and massively expanded by 1995. Over-the-counter sales of syringes in New York became legal in 2001.

Nationally, the AIDS epidemic in addicts has subsided too, with only 12% of new cases linked to IV drug use, down from more than 1 in 3.

Given that the data overwhelmingly show that maintenance programs and needle exchanges, together, can significantly reduce the spread of HIV, Russia’s refusal to treat the country’s million-plus drug users is putting millions more of its citizens — including nonusers who may be partners of drug users or of infected former partners — at deadly risk.

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