Russia faces formidable challenges in the second decade of its major human immunodeficiency virus (HIV) epidemic. Although Russian public health and medical responses are growing, they remain inadequate for the current crisis. HIV prevention lessons can be learnt by Russia from mistakes and innovations of the early epidemic in the United States, western Europe and Australia.
The human immunodeficiency virus (HIV) epidemic in Russia has been driven by injection drug use. The dire consequences of this epidemic in Russia reflect their public health and medical care approach to both HIV infection and drug users. Many of the mistakes that were made in the United States in the first two decades of the acquired immune deficiency syndrome (AIDS) epidemic with regard to HIV infection and drug users are being repeated in Russia at a comparable time-period in the disease's evolution in that country. Criticism has been leveled at Russia for its lack of adherence to the World Health Organization's recommendations for preventing HIV in drug users [1–3]. Two decades of additional experience with HIV among drug users in other countries may provide insight to advance successes and mitigate failures in Russia's second decade of the HIV epidemic.
Russia has approximately 1 million HIV-infected people among its 140 million population . Eighty-three per cent have a history of injection drug use and most of the remainder are sexual partners of injection drug users (IDUs) . The estimated HIV incidence rate among IDUs in St Petersburg is 14.1 per 100 person-years . Simply stated, the HIV epidemic is not under control. Given that 1.8 million IDUs currently live in Russia , and that condom use by Russian drug users is not the norm , there is great risk for further expansion of the epidemic.
In the United States and Europe, the clinical syndrome that became known as AIDS resulting from HIV infection was spreading actively among IDUs during the late 1970s and early 1980s. It was not a problem in Russia at that time. HIV only began to spread among IDUs analogously in Russia in epidemic proportions two decades later, in the late 1990s and at beginning of the new millennium .
During the first two decades of the AIDS epidemic, mistakes were made in the United States and some other countries with regard to the public health and medical response; hence, HIV seroprevalence in IDUs was high, ranging from 22% to more than 50% . Exceptions to this trend exist, most notably in Australia with an HIV seroprevalence rate among IDUs of 1% . This is due largely to that country's aggressive adoption of harm reduction measures, such as syringe exchange and opioid agonist therapy (OAT) programs, as early as the mid-1980s. In the United States, distribution of clean needles and syringes to IDUs was shunned by government officials with disastrous consequences. Addiction treatment and OAT, essentially methadone, existed but were not actively expanded and improved in order to confront the epidemic directly (e.g. routine implementation of HIV testing within methadone programs was not instituted initially). More than a decade after the onset of the US/western European AIDS epidemic, while advancements were being achieved in elucidating viral etiology and developing effective antiretroviral medications, researchers reported that an infected person's entry into HIV care was commonly not occurring until the disease had become advanced [10,11]. Active efforts to engage HIV-infected people and, in particular, HIV-infected drug and alcohol users, were inadequate and not a high priority on the HIV activists or researchers' agenda.
Today in Russia, two of the most glaring policy mistakes from a public health perspective are the absence of OAT and the suboptimal distribution of clean needles and syringes . Without a doubt, these measures have proved themselves immensely valuable in limiting the spread of infection even in the face of ongoing drug use. Needle availability from pharmacies in much of Russia is a step in the right direction, but insufficient to meet the needs of HIV prevention efforts.
One very positive dimension of HIV prevention among drug users in Russia is the comprehensive ‘opt-out’ strategy for HIV testing that has long existed in many spheres, particularly within the narcology treatment system . Such a phenomenon differs sharply with the approach that existed in a comparable period in the United States, during which unawareness of HIV status was the major factor underlying the years of delay between HIV infection and entry into medical care .
Despite these testing policies, HIV-infected IDUs in Russia are not receiving care at acceptable rates. Although drug use accounts for more than 80% of Russian HIV infections, IDUs comprise fewer than half of those receiving HIV care . In fact, Russia is among the countries with the lowest antiretroviral therapy (ART) coverage for those with advanced HIV .
One source of delay into medical care for those with HIV infection is the time between awareness of HIV infection and engaging with HIV medical care . This is a poorly documented but suspected problem faced by many HIV-infected drug users in Russia in 2011. While IDUs face barriers to HIV care such as stigma, discrimination, addiction-related priorities, providers' pessimistic perceptions regarding adherence and unstable living situations [16,17], the problem is also structural. Although the HIV care system is evolving with introduction of narcologists into some AIDS treatment centers, coordination of narcology and HIV care remains unaddressed. Medical care in Russia is provided within silos of excellence with specific expertise. In a narcology hospital, addiction is addressed. In an infectious disease hospital, infections such as HIV and hepatitis B and C are treated. However, coordination of care between different physical sites of care is exceedingly limited, and yet patients who suffer from both maladies, addiction and HIV, are common in Russia. Those affected do not benefit from the expertise of providers of both disciplines giving coordinated medical care. Such fragmented systems of care have been shown to worsen access to HIV treatment . It is time to actively facilitate thousands of infected Russian substance users into HIV care; with appropriate systems established, many could transition directly from narcology treatment.
Russia's long-standing excellent record of HIV testing is a bright light within the country's strategic plan to address HIV infection, but it is not sufficient. Innovative strategies need to be employed to engage individuals into the HIV care system. What will it take to engage HIV-infected drug users into care? Here, lessons from those countries with the unfortunate additional two decades of history addressing HIV among drug users could be informative.
Enhanced engagement of drug users into HIV care will be advanced by addressing five major challenges: reducing stigma towards drug users and the HIV-infected; developing protocols to facilitate transitions and coordination between HIV and narcology treatment systems; developing multiple points of entry for individuals into HIV and addiction care; expanding needle and syringe exchanges; and adopting OAT to treat opioid dependence with pharmacological agents. Engagement will enable efforts to achieve effective delivery of antiretroviral treatment to drug users. Engagement will also provide opportunities to mitigate sexual risk behaviors and its consequences among drug users, a high priority as the epidemic spreads from IDUs to the general Russian population . Such efforts could focus on unsafe sex behaviors  and treatment of sexually transmitted diseases.
In the first two decades of the HIV epidemic in the United States, many missed opportunities to confront this disease effectively among drug users occurred. Bringing that experience to bear in a very different and yet not so different context holds opportunity to help transform the raging Russian HIV epidemic into one that employs the best strategies to engage reluctant patients in medical care and reduce the spread and consequences of this 21st-century Russian scourge.