Russia's HIV Epidemic Starts in Its Prisons

Russia is home to the world's most explosive HIV epidemic, with an estimated 1.2 million infections accounting for 55 percent of the total number in Europe.

While the epidemic is concentrated among people who inject drugs — primarily opioids — there is growing evidence that it is spreading to the general population. Despite this, the government exacerbates the problem by creating a climate of fear, repression and stigmatization for drug users while simultaneously denying them access to effective treatment programs.

Since 1997, a federal law has banned the single most effective treatment for opioid dependence:?  opioid substitution therapy (OST) with methadone or buprenorphine, approved by the World Health Organization.

Patients on OST experience a reduction in opioid use, HIV transmission and criminal behavior. Drug treatment in Russia, however, is not based on evidence: Viktor Ivanov, chief of the Federal Drug Control Service, continues to claim that the efficacy of OST is not proven.

As a result, the most vulnerable populations are further marginalized and subjugated to abuse masquerading as treatment. The Russian Orthodox Church operates rehabilitation centers based on faith alone, while other centers brutally handcuff patients to beds.

Perhaps worse, government policy actually boosts the spread of HIV. Research shows that extrajudicial policing and police harassment in Russia creates an environment of fear, contributing to syringe sharing.

Police and courts typically treat opioid dependence as a crime rather than a chronic relapsing condition. It is no surprise, then, that many substance users pass through the prison system at some point in their lives. But with basic preventative measures lacking both inside and outside the criminal justice system, a high-risk injection environment is created, further propagating disease. Nor is it a problem isolated to prisons. With one of the highest incarceration rates in the world (470 per 100,000 population), Russia's estimated 300,000 former prisoners released into the community each year pose a serious risk to public health.

While alternatives to incarceration should be sought whenever possible, prison is an optimal environment for the implementation of prevention, detection and control measures, especially given that HIV prevalence is generally several times higher than in the community. To determine the most appropriate interventions, our team at the Yale School of Medicine, together with local prison departments, is carrying out the first rigorous and representative health assessments of prison populations in the post-Soviet space.

While countries of the former Soviet Union are characterized by epidemiologically similar HIV epidemics, there are marked differences in individual country's HIV responses, and their treatment outcomes reflect these differences.

Our data from Ukrainian prisons show a prevalence of infectious diseases higher than elsewhere in the world, attesting to the urgency of the situation.

While Russia and Ukraine together account for 90 percent of the region's infections, the number of registered people living with HIV/AIDS continues to rise in Russia, while the overall number of newly registered cases in Ukraine has decreased — a change largely attributed to a reduction in transmission among injection drug users.

Ukraine has been a leader in the region for implementing evidence-based policy. OST programs have been running for 10 years with an enrollment of more than 8,000 patients in June. This is far below the recommended 40 percent coverage for people who inject drugs, but is a significant example for other post-Soviet health systems.

But Russia's recent involvement in Ukraine is putting these fragile public health structures in danger, with disastrous consequences. The transfer of Crimea to Russia's jurisdiction this spring stopped provision of methadone, leaving more than 800 people without the most effective treatment for opioid addiction. More than 40 percent of these patients were diagnosed with HIV and hepatitis C, a quarter were co-infected with tuberculosis. Forty-three have since left the peninsula in search of treatment in mainland Ukraine and dozens are reported dead.

In the east, meanwhile, the Kremlin-backed insurgency is causing disruptions in opioid-substitution delivery to the region, leaving patients facing imminent withdrawal. Beyond refugees running from the line of fire is a hidden humanitarian catastrophe with lasting effects on health care and quality of life. The tide of the HIV epidemic in the region can be turned back, but only through transnational cooperation and rigorous research, rather than intuition and moralistic principles.