The relatively delayed arrival of HIV/AIDS in Russia in 1987, combined with the country's isolated (political) position, led to a lack of knowledge on HIV prevention among medical professionals, political decision makers and the general public. The socio-economic upheaval in Russia and the other Newly Independent States (NIS) of the former Soviet Union has seriously hampered the health system's ability to respond to new problems such as the HIV epidemic. The health system is over-expanded and under-funded, leading to material shortages and non-payment of salaries, both of which have hurt the capacity and morale of health care workers.

By 2000, the world's steepest HIV curve was recorded in the NIS, where the number of people living with HIV/AIDS (PLWHAs) more than doubled each year. So far, Russia, Ukraine, Belarus and Kazakhstan are the hardest hit by the HIV/AIDS epidemic in the region. According to WHO and UNAIDS, the number of PLWHAs in Russia is between 0.5 million and 1.1 million – five to ten times the registered number. The Russian Federal AIDS Centre predicts five million Russians will be living with HIV/AIDS by the end of 2005.

Injecting drug use (IDU) is widespread among young people and HIV is spreading especially fast among this group, from where it threatens to spread to the general population by sexual transmission. Repressive anti-drug laws are causing the imprisonment of many PLWHAs, mainly injecting drug users (IDUs). The Russian parliament estimated in 1997 that there were more than 2.5 million drug users in the total population of about 142 million. Currently, over 90% of new HIV infections in Russia are among IDUs.

As increasing numbers of people with HIV develop medical problems associated with AIDS, they will soon start to overwhelm the health structures of these countries. To prevent further worsening of the epidemic and to assist Russia and other NIS republics to deal with the massive HIV/AIDS epidemic, a consortium of international organisations introduced a new approach addressing drug issues, called harm reduction. The Russian Ministry of Health adopted the approach as official policy.

Harm reduction: a key strategy

Harm reduction, supply reduction and demand reduction are three complementary approaches to address drug use and its harmful consequences. Supply reduction includes seizing drugs through customs operations and assisting drug producers to substitute opium poppies for legal crops, for example. It also includes arresting drug traffickers and breaking up supply routes for illicit drugs. Demand reduction is a complex of measures, provided by social, education and medical services, to promote a healthy, drug-free lifestyle.
Harm reduction policies, strategies and activities aim to limit or reduce the nature and extent of adverse consequences of drug use, related to health, social, economic and legal issues. The harm reduction approach acknowledges that there are no known interventions for completely eliminating drug use or drug-related problems in any city, community or country. The principles of harm reduction include:

• Avoidance of increasing harm: a law-enforcement-only approach may slightly decrease illicit drug use, but increases the likelihood of HIV infection among IDUs by driving them ‘underground', out of reach of HIV prevention services;
• Emphasis on short-term pragmatic goals over long-term idealistic goals;
• Emphasis on the dignity and human rights;
• Establishment of a scale of means to achieving specific goals: this hierarchy is used to provide small, achievable steps which can be encouraged by harm reduction programmes;
• Use of multiple strategies;
• Involvement of drug users in the planning and implementation of programmes.

The main type of harm reduction programme used in the Russian Federation is needle and syringe exchange, together with counselling, outreach, peer education and support, and other activities connected with needle exchange. By early 2001, the Russian Federation had at least 48 needle and syringe exchange programmes (NSEPs) established – from Kaliningrad in the west to Khabarovsk in the east, and from Archangelsk in the north to Astrakhan in the south.

Needle exchange and other preventive health activities

The riskiest activity for HIV infection during injection is frequent sharing of injecting equipment with unknown others. Clean needle exchange or distribution prevents or reduces this practice. Worldwide, 134 countries report the practice of injecting drugs for recreational or non-medical purposes. Of these countries, 114 have reported HIV infection among IDUs, with 46 countries implementing at least one needle and syringe provision, or needle and syringe exchange programme. A worldwide survey found that in cities with needle exchange, HIV seroprevalence among IDUs decreased by 5.8% per year, while it did not increase drug use or the number of IDUs. In cities without needle exchange, however, HIV seroprevalence among IDUs increased by 5.9% per year.

In addition to risks from sharing needles and syringes, drug users risk contracting HIV in drug preparation, manufacture and purchase (such as liquid drugs in syringes that may not be sterile). NSEPs and educational programmes also need to address drug users' sexual behaviour through prevention education (use of condoms, negotiation of safe sex) and condom distribution.

Focus groups, in-depth interviewing and the use of ethnographic methods such as observation, can identify HIV transmission points and assist in understanding the social nature of drug users' lives. Based on this information, education programmes can develop appropriate HIV prevention strategies. The goal of such strategies must be to change the social norms surrounding drug injecting and sexual behaviour. By encouraging a large percentage of injectors to switch to safer behaviours, HIV prevention becomes the norm. Accompanying a change in social norms, each individual drug user must decide to protect his/her health. Many IDUs, however, do not worry about HIV infection, despite the realisation that HIV infection will cause serious physical problems and will likely lead to death (especially in transitional and developing countries). This appears to be the result of internalisation of negative attitudes towards drug users expressed by parents, media, health care workers, militia and the general community.

Harm reduction training

Most of the 48 NSEPs in Russia resulted from a training programme conducted by international NGOs in 1997. In September 1997, one of these, MSF-Holland, started a training programme to ensure that HIV prevention workers among Russian IDUs had the necessary skills to:

• conduct outreach and communicate with drug users and ex-users;
• conduct  rapid situation assessments to determine the extent of drug use and related HIV risk and infection;
• plan interventions that reach IDUs and encourage them to maintain or adopt behaviours to protect themselves against HIV infection;
• write funding proposals to acquire funds to develop these plans;
• train their colleagues and others in their city or region in the above skills.

The course was based on an action-research approach developed by WHO in collaboration with UNAIDS and NGOs, called "Rapid Assessment and Response" (RAR).  It consists of three main components: assessment methods and sources of data; key areas of assessment; and the development of action plans for intervention implementation.
Almost 200 participants from 61 cities attended the training course. The largest participant groups were from government AIDS centres (68) and narcological (drug treatment) hospitals and dispensaries (60). About 25% of participants were from NGOs and the others were from government infectious disease hospitals and research institutions.

At the beginning of the training programme, there were only four HIV prevention interventions among IDUs in Russia. By June 2000, 35 programme proposals from these training participants had received funding, representing an almost nine-fold increase in HIV prevention programmes among IDUs in 30 months.

Effectiveness of Russian NSEPs

In April 2001, initial data from two projects evaluating the introduction of needle and syringe exchange programmes (NSEPs) in the Russian Federation, and preliminary data from a large evaluation undertaken in 1999/2000 of NSEP clients in five Russian cities, showed substantial reductions in previously identified injection risk behaviours such as needle sharing.

Specifically, the study found significant reductions in receptive syringe sharing (sharing by receiving, rather than giving a syringe), injecting at an anonymous injecting venue (or "shooting gallery"), and buying drugs already loaded in a syringe. However, injecting in a group, sharing utensils such as the vial in which drugs are produced, and using syringes to share drugs in group injecting did not change significantly. These three risk behaviours are tied closely to the group preparation of liquid drugs. It is not yet determined how the widespread introduction of heroin, as exists today, would affect these behaviours.

Preliminary data from another study in Sverdlovsk showed similar results: those IDUs who had been attending a NSEP for at least three months were more likely to use only their own needle, syringe, filter and drug solution and were less likely to use syringes to share drugs between several syringes in group injecting, compared to IDUs who had never attended a NSEP. However, purchasing ready-made drugs was virtually unchanged by NSEP attendance, and the effects of the NSEP on numbers of IDUs adding blood to drug solutions was the opposite of the intended effect. Again, this is likely to change due to changes in drug use patterns, but this finding emphasises the need for NSEPs to concentrate on the social nature of drug preparation and use.

Conclusion

An evaluation of prevention work among injecting drug users in early 2001 discovered several positive findings. When harm reduction work began in the Russian Federation in 1996, few people working on the issue believed that 48 functioning NSEPs would be operating nation-wide less than five years later. The evaluation found that the level and breadth of services was good, but that the quality and reach of the services needed to be improved.

A comprehensive multi-disciplinary approach – with active involvement of all key players, especially PLWHAs, in decision-making, design and implementation of programmes – is needed to address the epidemic effectively. Russia and the other states of the former Soviet Union can still benefit from the global experiences with HIV prevention and avert the disastrous impact the epidemic has had on many other countries. Vision, commitment and leadership at the highest political level are needed to support and encourage these developments.