HIV/AIDS came to Russia and Eastern Europe after it already hit epidemic levels in other high risk areas. But was Russia ready for it? The evidence indicates that the country was unprepared. Throughout the 1990's, those infected with HIV were virtually all from traditionally high risk areas of the population. Recently, however, fears that the virus would move into the general population have been realized since the infection rate has hit the critical 1% prevalence threshold of an epidemic. (8) Several aspects of both Russia's culture and political economy make HIV a disease which is very hard to detect and to treat. This paper explores the dynamics of the changing demographics of those infected with HIV as well as Russia's peculiarities in addressing this change on both a micro and macro level. International support for HIV/AIDS treatment in Russia will also be explored.
The first AIDS case in Russia was registered in 1987. By the end of the twentieth century there were only about 20,000 cases out of a population of 145 million people. (3) A superpower and member of the esteemed G8, one might have thought Russia would have been prepared for HIV/AIDS as the world watched HIV/AIDS spiral out of control in Africa and the Far East. However, "out of prudishness, intolerance, and soviet-style pigheadedness, [Russia's] response was criminally lackadaisical." (8) Rates have nearly doubled every year since 1998 (3) and almost overnight, a disease which was formerly confined to IV drug users and sometimes commercial sex workers had generalized into Russia's population as a whole. Moreover, the infection rate could be up to four times that of reported figures due to various factors explained presently.
Four factors are most adverse in putting Russians in touch with prevention, healthcare, support, and treatment.(3) First, Russia lacks an adequate administrative infrastructure to facilitate such programs. Poor understanding of HIV/AIDS is not just confined to the populace as a whole but is common also among health professionals. Further, economic and social gender differentiation increases women's vulnerability to infection. Finally, stigma and discrimination against people with AIDS, especially against women, leaves HIV+ persons fearful of more than just the physical aspects of the disease. What has resulted is an increase by a factor of over a hundred the number of teens infected with HIV with the fastest growing HIV prevalence rate among pregnant women. (3)
With regard to Russia's homegrown fight against AIDS, "political will and resources, both human and financial, are lacking." (7) One need only take a cursory view of HIV/AIDS spending in Russia to see the large contrast between the large amount of money coming from abroad to that allocated by Russian legislators and tax payers. In 2006, funding from the Global Fund and the World Bank increased spending in Russia on AIDS programs by a factor of ten. (3) Dismal domestically generated funds result from an already overstrained Russian healthcare system that faces perhaps the worst figures of heart disease of all time, anywhere. Smoking tobacco, drinking alcohol, violence, and a harsh climate are just a few factors that contribute to an average life expectancy for men of 59 and around 70 for women. Such figures resemble sub-Saharan African nations more than they do a European nation. Also, past legislatures have been reluctant to further burden the healthcare system by spending money on a disease that mostly affected drug users and prostitutes.
One important thing to keep in mind when examining foreign aid for AIDS programs in Russia is that often social conservatives from the west find eager Russian converts when the fall of communism left a moral/religious vacuum in the region. Worker solidarity and the cry of the proletariat went silent when the cold war ended. Many Russians resented the Orthodox church for collaborating with the communists but retain its socially conservative roots. The result is that foreign donors meet little resistance when they insist upon abstinence programs instead of teaching safe sex or handing out clean needles. Also, many Russians see the United States as the leader in AIDS treatment and figure that if America' official stance on prevention is abstinence, then it must be the preferred method.
Non-Governmental Organizations (NGO's) historically have had a hard time working with the xenophobic Russian people and government. Most real work dealing with HIV/AIDS occurs at regional AIDS centers across the country. Local activists say that these regional centers avoided working with NGO's until 2006 when they were pressured to do so by the Global Fund to Fight AIDS. One of the first things President Vladimir Putin did after being elected in 2000 was to stop the Peace Corps from working within the country. The World Bank has offered Russia a $145 million loan for Tuberculosis and AIDS treatment but the loan is pending Russian approval. (7) It seems as though Russian officials are more interested in preserving the image of a powerful Russia than they are in accepting help from abroad to build one.
The fall of the USSR prompted a major economic transition from communism. The result was a major decline in health expenditures and life expectancy. What follows is a rapid decrease in the quality of health professionals who are knowledgeable about HIV/AIDS. During a study of two regions, Nizhny Novgorod and Sverdlovsk, patients were asked to evaluate the doctors who treated them for HIV/AIDS. "Across both Nizhny Novgorod and Sverdlovsk, people living with HIV/AIDS- men and women, intravenous drug users, and [those recently infected]- universally expressed dismay at their treatment by medical practitioners in the course of the diagnosis, care and support, and treatment." (3) Neither region seemed to provide better care than the other.
Although mistreatment of those infected with HIV/AIDS was fairly uniform, in some specific cases pregnant women faced additional discomfort and discrimination. Personal stories of two women illustrate such scenarios. Both HIV+ women were pressured to abort their pregnancies because they were told it would be impossible to deliver healthy babies. The first woman was told her baby would be born dead. When she went to another doctor, she was told the fetus was already dead. Finally, she borrowed money from her parents to see a private doctor, who helped her deliver a healthy child. Another woman did abort her pregnancy after she was pressured. After learning of other women who had delivered healthy babies, the next time she became pregnant she waited until the fetus was eight months old before she consulted a doctor. (3)
Poor standards for healthcare started during testing, for which regional centers claim they provide pre- and post-test counseling. In neither region did anyone report receiving pre-test counseling. As one young woman in Nizhny Novgord reported, many who tested positive went into a state of shock,
"When I tested positive, I was completely shocked. I was told to go see a counselor. When I met the counselor, she said: 'You are infected HIV. Please be advised that knowingly spreading HIV is a criminal offense under Russian law. If you have unprotected sex and spread the virus, you will be incarcerated. Sign this document to show that you have understood.' That was all the counseling I got. When I got in the hallway, I thought I would faint. I didn't know anything about ARV's [anti-retrovirals]. I found out about them only last year when I was in Moscow." (3)
Unfortunately the particular hardship women face in confronting the disease is not confined to their medical treatment.
Until recently, the AIDS virus was largely transmitted through intravenous drug use. Throughout the 1990's, 80-90% of people who injected heroin were HIV+ and a study taken in St. Petersburg showed that 70% of intravenous drug users were men. (1) In 1992, gay bars became legal in Russia. Women who became commercial sex workers in order to buy heroin and homosexual men acted as bridge groups into the general population. In the Siberian city of Irkutsk, a study showed that 70% of new HIV cases in women were transmitted through sexual intercourse. (1) In 2005, 43% of new cases throughout Russia were found in women and over two-thirds of those were through sex. (1)
Commercial sex workers who service men on their commutes to and from work served as an important bridge population into the general population. Many of these men would return home to their wives after having unprotected sex with intravenous drug-using prostitutes. Condom use in Russia is very unpopular and often people don't even have access to condoms that function properly. Among married couples, condom use is even more rare. So married women are extremely vulnerable to contracting HIV from their husbands. As has already been stated, HIV/AIDS rates are growing fastest among pregnant women. In this section, the vulnerability of women to economic and social pressures to remain in such relationships will be examined.
There are two man ways unequal social and economic status affects women's access to HIV services. First, their unequal earning power in the workplace makes them more susceptible to poverty. Over fifty thousand adults in St. Petersburg alone are homeless. (1) Paul Klebnikov wrote in his book, Godfather of the Kremlin, that throughout the 1990's around three million people died premature deaths from malnourishment and poor health conditions. Poverty was a reality in Russia even before the ruble crash of 1998, when inflation invalidated the bank accounts of Russians across the board and wealth was confined to only those who possessed capital in some form besides Russian currency. Women stay with their husbands, often in the face of physical and psychological abuse, because they fear they cannot support themselves on their own. This is especially true for women with children. "In this way, economic dependence and fear of poverty drive women to remain in situations that endanger their health and restrict their access to HIV services." (5)
Further, women across Russia who became HIV+ reported rejection and, in some cases, violence from their husbands once the illness became known. One woman in Nizhny Novgorod was beaten severely by her husband, who soon abandoned her to raise their small child alone. Another woman, this time in Sverdlosk, said that her husband became violent and depressed upon learning of her HIV+ status until she was forced to leave. "Domestic violence and the fear of domestic violence restrict women's options when they seek care and treatment for HIV and AIDS." (3)
Social stigma and discrimination affects most HIV+ people but two factors leave women particularly vulnerable, especially those who contracted the disease through sexual contact. First, many Russians associate HIV/AIDS with intravenous drug use. "The high prevalence rate among injecting drug users, the emphasis on them in 'targeted' HIV interventions, and the virtual absence of public awareness campaigns all contribute to the perception in Russia/AIDS that HIV is an ailment that afflicts drug users but not the general populace." (4) Many young women who acquired HIV through sex feel uncomfortable at support groups which are frequented largely by drug users, especially when they are held in regional 'narcological institutes'. (4) Such women also are subject to demands from their doctors for a list of all those with whom they shared needles. If doctors make such a conclusion, members of the general public can hardly be expected to act with more knowledge. Finally, the emphasis on abstinence programs instead of teaching safe sex leaves women more vulnerable to contracting a disease which is biologically four times more likely to infect women during sex than men. (6)
So what should be done to help curb the outbreak of HIV/AIDS in Russia and to give those already infected the care they so desperately need? One idea is to make AIDS a women's issue. There is already an effective infrastructure in place to deal with other women's issues such as domestic violence, trafficking, female poverty, gender discrimination, etc. Such organizations may be invaluable to touching women who would otherwise be out of reach of HIV/AIDS programs. Another idea is to broaden the target of interventions to more than just drug users in an effort to ease the public perception that HIV/AIDS is a drug users' disease. (2) Third, a national, umbrella organization should be put into place to coordinate HIV/AIDS programs which would effectively build HIV/AIDS infrastructure nationwide. Finally, doctors need to be educated immediately so the rest of the public can follow.
BIBLIOGRAPHY
Aral, Sevgi, Janet St. Lawrence, et. al. "Commercial Sex Work, Drug Use and Sexually Transmitted Infections in St. Petersburg, Russia." Division of STD Prevention, Centers for Disease Control and Prevention. Dec. 15, 2004, pp. 1-16.
Amirkhanian, Yuri A., Jeffrey A. Kelly, et. al. "Evaluation of a Social Network HIV Prevention Intervention Program For Young Men Who Have Sex With Men in Russia and Bulgaria." Center for AIDS Intervention Research, 15, (3), 2003, pp. 205-220.
Burns, Katya. "Russia's HIV/AIDS Among Women and Problems of Access to Services." Problems of Post-Communism. 54.1 (Jan./Feb. 2007), pp.28-36.
Frost, Lizz and Vladimir Tchertkov. "Prisoner Risk Taking in the Russian Federation." AIDS Education and Prevention. 14.B (2002), pp. 7-23.
Klebnikov, Paul. Godfather of the Kremlin. New York: Harcourt, 2000.
McCrae, Robert R., Paul T. Costa, Jr. et. al. "Personality Correlates of HIV Stigmatization in Russia and the United States." Gerontology Research Center, National Institute on Aging , NIH, DHHS, December, 2005.
Morrison, Stephen J and Jennifer G. Cooke. "The Second Wave of the HIV/AIDS Pandemic." A Conference Report of the CSIS Task Force on HIV/AIDS. Dec. 2002, pp. 39-45.
"Sick to the Soul." The Economist. Sept. 9, 2006, pp. 51-52.
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