Drugs And HIV infection In The Russian Federation

 

Alexander Smirnov (an independent journalist)

 

Materials prepared  for “Harm Reduction Initiative – RF”, MSF-H

Moscow, March-April, 2001.

 

The first case of HIV-infection in the USSR was registered in 1987. At that time mass media started a discussion on the usage of disposable syringes in hospitals and other medical institutions (back then, non-disposable syringes were mostly used in medical establishments). In the year of 1995, not more than 1000 of HIV-infection cases a year were being registered in the country, people would mainly get infected via sexual intercourse or in medical establishments (for example, by blood transfusion). By the end of 1994, only 2 authentic cases of infection via intravenous injection of drugs had been registered, but in 1996, the epidemic among injecting drug users (IDUs) began. In 1999, 14,980 HIV-positive people were registered (which was 3,5 times as many as in the previous year), and the total amounted to 25,842 people, some 15,000 of them were infected IDUs. By the end of 2000, it had grown up to 80,000 people, and more than a half of them were infected IDUs. April, 2001: The State Sanitary Epidemic Service reports that the latest approximate number of HIV-infected people is 102,000, 10% of whom are children, and 578 were born from HIV positive mothers.

 

Years ago, HIV began spreading in so-called “risk groups”. Nowadays, the main problem is the wide spread of the epidemic among the general population, and the beginning of the next stage (sexual route predominates) of the epidemic, as it happened, for example, in the Kaliningrad region. According to the academician Vadim Pokrovskiy, Head of the Center of Scientific Methods of HIV Control and Prevention, there is the first case when there has started an epidemic of HIV among IDUs, and today, “everybody in this group who could get infected, is infected; and now the level of contracting via sexual intercourse is increasing as well” (from his speech at the Round Table on “AIDS in Russia: what is to be done?”, November 29, 2000).

 

Drug use in Russia

 

The phenomenon of drug use, including injecting, has been known in Russia for quite a long time. In 1835, Nikolay Gogol described opium use in his novel “Nevskiy Prospect”, but it was only due to the writer’s erudition ¾ a year before, the book of Thomas De Quincy “Confessions of an English Opium-Eater” had been translated into Russian and attentively studied by Gogol. De Quincy was also mentioned by Dostoevskiy, Turgenev, Hertzen, and other Russian writers. In the middle of the XIX century, many members of the higher society used to take opium. Morphine and cocaine addiction became famous at the turn of the centuries. In 1927, Mikhail Bulgakov wrote a story “Morphine” ¾ a story of a young doctor who became an opium addict and was trying to “get cured” with the help of substitution of morphine by cocaine. In 1934, a Paris emigrants’ magazine “Illustrated Russia” published “confessions of a Russian opium-eater” ¾ “A Novel With Cocaine” by M. Ageev (Marc Levi, 1898-1973). Today, the Russian “drug library” includes a great number of names, among which there are Egor Radov, Pavel Pepperstein, Victor Pelevin, and Bayan Shiryanov (Kirill Vorobyov), whose shockingly sincere story “The Lowest Pilotage” on the life of “vint” addicts was first published in the world wide web, and in March, 2001, it was published as a separate book by the publishing house “Ad Marginem” (Moscow).

 

In the beginning of the 70-s, the problem of drug addiction was officially considered insignificant in the USSR, except for alcohol addiction. In a manual on psychiatrics, published in 1971, besides this disease, morphine, hash, and cocaine addictions are also named (the latter is characterized as “not existing in practice”). Actually, the desired was posed as the real, though the use of drugs at those times was really the lot of the marginal: criminals, bohemia, few hippies, etc., besides, it occurred among doctors and medical workers. Drug use was most widely spread in port towns and South regions, along the so-called “drug belt”. Since the beginning of the 50-s, the inner opium market appeared in the USSR, there were production plantations in the Kuibyshev (Samara), Gorkiy (Nizhniy Novgorod) regions, in Tatarstan, not mentioning the republics of Middle Asia, where opium poppy was a traditionally cultivated plant, as in the adjoining Afghanistan. In the 60-s, great cannabis plantations of many hectares appeared in the Krasnodar and Stavropol regions, and the Ukraine is still exporting several tons of cannabis a year. So, by the mid 70-s, drug use had become rather habitual, though socially not understood phenomenon in several regions of the country. And since the moment, when our army entered Afghanistan, there had begun forming the currently existing drug traffic.

 

The main drugs in the USSR were: 1) cannabis products; 2) morphine and its home-made analogue - “cherniy”, “chernaya”, or “chernyashka” - a dark colored solution made of fresh poppy bulbs or poppy straw; 3) different stimulators like pervitine (not produced since 1972) or ephedrine (distribution was limited in 1985), as well as various psychotropic substances: cyclodole, prokapan, relanium, etc. At the turn of the 80-s and the 90-s, the so-called “drug revolution” took place, which coincided with the times of “Perestroyka” and “Glasnost” introduced by Gorbachev. The disintegration of the USSR and a social turn-over which shocked the society changed not only the political system. The information on the life in the West, which had been previously concealed, became available, including the information on drug practices there. First of all, such information found response with young people and contra-cultural spheres. Today, many people refer to this period, approximately since 1987 to 1994,  as to “our remake of the 60-s”. The additional factor which influenced the wide spread of drug use was that of the anti-alcohol campaign initiated by Gorbatchev and carried out in rather a radical way. It was legal to buy a bottle of vodka only having a special coupon, once a month. The age qualification was also introduced. The limitations imposed on alcohol provoked, so to say, “maintenance therapy”: young people began active experiments with substances which change consciousness. Besides, open borders contributed not only to the development of an open society, but that of drug business as well.

 

The first popular injecting drug in Russia was “vint”, or a home-made analogue of pervitine (metamphetamine). It was synthesized by underground chemists of Leningrad somewhat between 1985 and 1986. The entire scientific literature on “vint” consists of only half a dozen texts, written by drug treating doctors mainly in the beginning of the 90-s, when there was a splash of pervitine use. The preparation of “vint” is a rather difficult procedure which needs a precise knowledge of the recipe, since the smallest mistake can make the substance become toxic (for example, red phosphorus and iodine are some of its components). Those who mastered its preparation were of much respect, and often became dealers. The effect of “vint” and the withdrawal syndrome it causes are the same as those of the real pervitine. “Vint” users had their own mythology. In particular, they believed that the substance had medical, antiseptic effect and aroused supernatural capabilities of brain (telepathy, etc.). The use of “vint” turned into a special ceremonial: first, the necessary components were to be obtained, then a “boiler” was searched for, finally people would sit down and make injections. Up to the mid 90-s, “vint” was likely to be the most popular injecting drug.

 

A less popular drug was that of ketamine (calipsole), injected intramuscularly, more rarely - intravenously, widely used in anesthesia, and with a very pronounced hallucinogenic effect when used in small doses. In Russia, the most well-known is ketamine produced by the “Fereine” company and calipsole produced by “Gedeon Richter”. In the second half of the 80-s, drug treating doctors in St. Petersburg conducted some experiments with ketamine as a psychedelic substance able to treat alcohol addiction. Since the beginning of the 90-s, a special subculture of ketamine users has formed in Russia, the Ukraine, Belorussia, Moldova. It was often used in groups with one syringe. Though the substance is included into “The List of Drug Substances, Psychotropic Substances and Their Precursors, Subject to Control in the Russian Federation”, it was easily available even in the middle of the 90-s, and militia officers didn’t identify vials with ketamine as a drug.

 

The turning point occurred approximately in 1994 - instead of “vint”, prepared in home laboratories, heroin took the first place, and Russia turned form a territory of drug transit into a drug consumer. And, partially, into a drug producer: not only “vint” was produced at homes, but also various psychedelic substances, for example, the famous “Piter acid”. Local mushrooms containing psylocibine become popular, cocaine, which disappeared in the 20-s, appears on the market again, at a rather high price - up to $150 for a gram; ecstasy becomes very popular, as well as LSD, various amphetamines, whose effect is similar to that of the previously produced “vint”. In large cities, one can find even meskaline and DMT. Today, one unit of heroin (up to 0,5 grams of a dissolved drug) varies in price from 50 to 150 roubles in different regions. The main supplies of heroin to Russia, according to the official point of view, come from Afghanistan and “The Golden Triangle” (Birma, Laos, Thailand). There are several grades available on the black market. The wide spread of HIV-infection is closely connected to the expansion of heroin (which is the most popular injecting drug in the Commonwealth of Independent States today).

 

HIV and Harm Reduction Measures

 

Russia, the Ukraine, Belorus, Moldova - these are the most affected countries of the Commonwealth of Independent States (CIS), with a rather high percentage of HIV-positive people in relation to the total number of population. The most rapid spread of infection is reported in Russia, and besides, infection cases connected to the injection of drugs are reported in 86 out of 89 administrative units of the Russian Federation. In 1996, the virus penetrated from the Ukraine into the groups of IDUs of the Krasnodar and Stavropol regions. However, the first outburst of the epidemic among IDUs, as it was mentioned above, occurred the same year in the Kaliningrad region. Today, this region is the second one after Irkutsk regarding the infection rates, the third position occupied by Moscow and the Moscow region. Everywhere, the explosive spread of HIV-infection is connected to a big number of IDUs, their prevention ignorance, tough policies of low enforcement and relatively low prices on heroin (for example, a pack of “Marlboro” costs 20 roubles in Kaliningrad and Moscow, a rather good dinner - 130 roubles, and a unit of heroin - 100 roubles). Since 1997, in Moscow, and then in other regions, there gradually begins the joint work of governmental and non-governmental organizations on HIV prevention among drug users. First of all, it is “Harm Reduction - the Russian Initiative”, a program implemented by the Dutch section of “Medecins sans Frontieres”. From 1998 to 2000, the Ministry of Health and “Medecins sans Frontieres” were holding trainings on specific prevention among IDUs for medical specialists and AIDS-service NGOs: as a result, harm reduction projects were started in more than 40 cities, most of them supported by OSI (Soros Foundation). For nearly three years, such programs were carried out in a difficult situation, under a gradually reducing pressure of law enforcement agencies. On December 12, 1999, the Chief Sanitary Doctor of the Russian Federation Gennadiy Onischenko issued a “Decree On Urgent Measures Of Preventing The Spread Of HIV-infection”, where he stressed the effectiveness of Harm Reduction programs in Kaliningrad and St. Petersburg. This decree has excited certain optimism.

 

Drug Law

 

It’s important to say a few words about the overall attitude of the Russian authorities to the problem of drug use and the HIV epidemic among IDUs. Up to 1998, there had been a rather liberal “Federal Law on Drugs and Psychotropic Substances” which clearly divided the consumer and the dealer, and the consumer was not liable to criminal responsibility. This division was fixed in a special “Summary Table of Resolutions of the Regular Committee on the Drug Control {CCCD} on defying small, big and especially big amounts of drug substances..., found in illicit possession or circulation”. The title of this table reveals its real value: after checking with it, the sentence was defined. Since 1998, there is a new, much more stringent “Federal Law”. Though it seems that the use of drugs is still not a penal action, but the Table was changed so much that the amount exceeding 0,005 grams of heroin became considered as an “especially large” one, and it is less than an average market unit (some 0,5 g). From the point of view of the law, it doesn’t matter whether you have 0,1 gram of heroin on you or 1 kilo - both are “especially large” amounts which imply a prison punishment from 7 to 15 years (Part 4 of Article 228 of the Criminal Code). Almost every user automatically finds him(her)self liable to the Criminal Code. In fact, the CCCD is a public organization which functions as an expert but de jure its resolutions have no law-defying force. But de facto they do. The Head of the CCCD is the academician Eduard Babayan, a staunch supporter of repressive measures towards drug users, and a radical opponent of any decriminalization, supporting penitentiary institutions in all matters. The logic of Mr. Babayan is very simple: if drugs are not officially produced, imported and sold in our country, then any action related to them automatically becomes a crime, and thus, any amount of drugs is criminal.

 

The main enforcement agency is the Directorate on Combating the Illicit Drug Trade (UBNON), headed by Lieutenant-General Alexander Sergeev. The UBNON consequently supports the war on drugs. In 1998, after establishment of first syringes exchange programs in Russia, A. Sergeev sent a letter to the Ministry of Health, where he claimed that such programs “will bring more harm to Russia than benefit”, and “by the healthy part of the society they are considered as a moral and ecological intervention which threatens the national security.” The TV programs “Petrovka, 38”, “Dezhurnaya chast” and others, produced under control of the Ministry of Internal Affairs, regularly show Russian frontier-guards shooting at “that side”, and bags of seized and burning drugs. At the same time, the official statistics both of the UBNON and of other agencies of the Ministry of Internal Affairs indicate the opposite: the amount of crimes connected with illicit circulation of drugs is constantly growing. Many politicians and deputies of the State Duma also come out in favor of a more stringent legislation. Here it is necessary to mention that many countries have rather stringent laws, but the specific character of the Russian law enforcement agencies is a common use of illegal methods. Cases of bribing, tortures, drug-planting, provocation etc. are heard about all the time. Regional UBNON are often engaged in drug trade themselves, and the level of corruption is high.

 

Lev Levinson, a lawyer and an assistant of a famous deputy of the State Duma of the RF Sergey Kovalev (SPS fraction), stands up for the revision of the law on drugs. In his opinion, “the hardening of the law on drugs is forced by the Ministry of Interior”, and there is “a preliminary consent of those who it depends upon at the Duma, to begin “softening” of the article 228” (from an interview to the magazine “Mozg”). The amendment to the Administrative Code initiated by Levinson and his colleagues wasn’t passed, but it got 200 votes (225 were necessary). Levinson believes that an addition to the Law on Mass Media is also a very important issue. It prohibits “drug propaganda” and contradicts to the clause on the freedom of speech. As “propaganda” doesn’t have a clear legal definition yet, and the law is not supported by the Criminal Code so there are no sanctions that would make it work, it is now only a potential threat, but theoretically, any mentioning of drugs, differences between them can be seen as an offence and is not “welcomed” at all.

 

Another staunch supporter of the liberalization of drug laws is Lev Timofeev, a former dissident who once was imprisoned in a Soviet jail and now is the head of the Research Center on Illicit Economics at the Russian State University of Humanities (RSUH). He believes that “there is only one way to cope with drug Mafia: to legalize drugs - all and completely”, but it’s impossible to do so in Russia, since “there is no money neither for gaining a victory with the help of legalization, nor for a total ban” (“Moscow News”, #27, July 20-26, 1999). Timofeev is the author of books “Drug Business. The Primary Theory of the Sphere of Economics. Moscow: the RSUH, 1998”, “The Institutional Corruption. Studies in Theory. Moscow: the RSUH, 2000”, and numerous articles.

 

Health Policy

 

Two opposed and uttermost approaches to the problem of drug use - war and legalization - are represented above. For the last two years the situation has been slowly improving. The approach of the Ministry of Health has been significantly changed: from emotions to pragmatism. The former head of the Department on HIV/AIDS Prevention of the Department of the State Sanitary and Epidemic Surveillance of the Ministry of Health Mikhail Narkevich, who began this work at the times of the former USSR, told me a year ago about the policy of the Ministry of Health: “Bans won’t be able to stop the epidemic. General Sergeev is a good, normal person, but he should deal with those who violate public order”. Narkevich and his department has done a lot to help international and Russian non-governmental organizations aimed at harm reduction and work with HIV+ IDUs in Russia. In the April of 2000, he was replaced by Alexander Goliusov who takes active part in working out a new National Program on HIV/AIDS Prevention, where non-governmental organizations play a very important role. He believes creation and funding of harm reduction programs is necessary, and he suggests that a drug user should not be treated as a criminal, but as a person who needs help. The Chief Narcologist of Russia Vladimir Egorov has undergone a long progress from sharp rejection to cooperation with harm reduction projects on the basis of “complete mutual understanding”. The Chief Sanitary Officer G. Onischenko, we’ve already mentioned, who is famous for being “incorruptible” supports the liberalization of attitude towards drug users and drug addicts, too. The academician V. Pokrovskiy, Chief of the Russian Federal AIDS Center, carries out an active PR-campaign aimed at HIV prevention. He believes that the actual number of HIV-infected people in Russia is around half a million cases, and pretty soon it will grow up to a million. But there is problem of “double statistics”, - official (“registration”) and unofficial (“research”) data. The same goes for the number of drug users, who somehow don’t hurry to become officially registered. That’s why they speak about 1.5-2 million of users, but only 209,000 are officially registered.

 

Mass Media and Publications

 

The work of mass media in covering the problem is extremely insufficient. Up to the last two years TV and press used to demonstrate poor preparation and tendentious approach. As a result, there was formed the image of a terrible drug addict ¾ an enemy of the nation, a carrier of diseases, deserving to be eliminated physically. An aggressive approach was demonstrated by many politicians and narcologists. Until recent times, they absolutely agreed with militia in treating drug users as criminals. If still there is a suspicious and sympathetic attitude to an HIV-infected person, then to a “bad drug addict” it is exceptionally negative. Drug users themselves also come under the charm of their own devilish image, feeling themselves desocialized, good for nothing, outcast and hopeless. There were some attempts to move this from the dead point. Since 1999, a magazine for drug users “Mozg” was published by the Harm Reduction Program of Medecins Sans Frontieres. The magazine is designed for drug users, and is a possibility for them to express themselves on its pages. There have been 7 issues published and distributed all over Russia, as well as in the Ukraine and Belorussia. They have had much response.

 

In 2000, some official mass media have also started to express their support for harm reduction measures: a weekly socio-political magazine “Kommersant-Vlast” have dedicated a whole issue to this topic (#16, April 25, 2000); such newspapers as “Novye Isvestiya”, “Kommersant-Daily”, “Isvestiya”, “Moscow News”, and some others have also regularly published ponderable and competent materials in this regard. Regional press regularly covers the issues related to HIV epidemic and writes about work of almost 50 Needle Exchange Programs in different Russian cities. But still, the effort by mass media in this field needs to be greatly enhanced.

 

Public Health and Organizations Involved

 

Since the end of the 90-s, in Russia, several International non-governmental organizations have taken an active part in the work connected with drug users and the prevention of HIV infection. Medecins sans Frontieres – Holland provided a training for medical specialists from different regions and as a result of this training currently there are about 50 programs on HIV prevention among IDUs (in Omsk, Ekaterinburg, Krasnoyarsk, Kaliningrad, Volgograd, Tver, Nizhniy Novgorod, etc.). These projects were most often implemented on the basis of local AIDS-Centers, drug treatment and infectious hospitals or NGOs. The components of such programs include needle exchange and condom distribution; outreach; medical and psychological counseling of IDUs, referral to other medical and social services.

Most of these HR projects are financed by the Open Society Institute - Russia (the Soros Foundation), which, in cooperation with MSF also provides technical support for the programs (trainings, counseling, fundraising etc). All in all, there are 36 projects financed by OSI all over Russia. As a matter of fact, it is an important aspect of the situation in Russia: the funding of such activities comes mainly from abroad, and almost all organizations are connected with each other in this or that way. For example, the International Program of The UN Program on AIDS - UNAIDS which cooperates with the Ministry of Health, and supports projects in 17 regions of Russia, or the Russian regional non-commercial organization “AIDS-Infoshare” which conducts a broad informational work, on the one hand, it publishes brochures for sex-workers, and, on the other - a specialized magazine “for organizations working in the sphere of HIV-infection prevention”. The DFID (the UK Department for International Development) also conducts a large-scale activity. It started its office in Sverdlovsk region (Ekaterinburg), and together with the Soros Foundation, supports 3 projects there at the same time developing an informational and educational campaign in Sverdlovsk and Samara regions.

An important indicator of the local support to the programs is the fact that some of the regional projects received financing from the local budgets.  For example, there is a republican program in Republican Tatarstan, city program in Republic Saha-Yakutia (the city of Mirniy).

 

At the present moment, there are three harm reduction projects in St. Petersburg, implemented by the “Vozvraschenie” Fund, the international medical organization “Medecins du Monde”, and the municipal infectious hospital. There are three mobile syringe exchanges (especially equipped buses) circulating in the city. The gravity of the situation is proved by the fact that two years ago one of such buses was burnt down by unknown persons. In Moscow, there were several attempts to start a NEP, (one by MSF-Holland and another by the Charity Foundation “No to Alcohol and Drug Addiction” (NAN)), but the municipal authorities haven’t allowed NEPs in the city, and so far the outreach workers are engaged only in informational work and counseling. For the time being, the Ministry of Health of Moscow Oblast, as a self-administered agent of the Russian Federation, not dependant from Moscow authorities is looking at opportunity to develop harm reduction activities.

 

Self-help groups

 

In March, 2000, a self-help organization of drug users “Kolodetz” was started in Moscow. The organization made itself sound by an action in a suburban region of Moscow called Perlovka, where some 50 people took part in the act of collecting and public burning of used syringes. In their interview to a TV channel, officers of the local militia department expressed positive attitude towards such an action. The group receives methodological support from the Dutch self-help organization LSD. Besides, there are other self-help groups in some Russian  cities (eg, Volgograd, Omsk), which are not yet officially registered, but are developing their own activities.

 

 

To sum up, we can say that for the last two years, both official and social vision of the problem of drug use and the spread of HIV-infection has undergone a significant progress. An overall very hostile attitude of law enforcement agencies is still in place, but a tendency for a sort of smoothing and humanization in medical spheres has been outlined. An example may be the governor of Sverdlovsk Oblast Eduard Rossel: two years  ago he stood up for application of capital punishment to drug dealers, and at the same time, he didn’t distinguish them from common users. And quite recently, he has positively appreciated the achievements in the sphere of methadone programs (though he didn’t express a definite support). Now, there are acute debates held on the expediency of Russian experiments with substitution therapy (methadone or buprenorphine programs). Also, the assignment of a loan of the World Bank is being awaited now, and its great part will be used for HIV-infection prevention among drug users.