Killer virus set to plague Ukraine and Russia as political warfare rages and currencies fall. Surrounding countries also witness HIV scourge advance
Text by Michael Bird. Graphics by Alex Morega
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“There are reasons to believe the economic crisis might make things worse by contributing to transgressions and reducing the capacity to respond,” David Wilson, World Bank
HIV is spreading at a dangerous rate in nations in the greater Black Sea area, passing a record 100,000 new cases.
Data above shows the rise in 2013, but preliminary numbers for 2014 show an epidemic in escalation.
Hotspots for the HIV rise are Ukraine and Russia - two countries facing economic crisis and armed conflict, factors which could provoke a further surge in the virus.
Smaller countries in the region are also recording rises, with decade-highs registered in Bulgaria, Armenia, Belarus and Turkey.
Meanwhile Georgia, Azerbaijan, Moldova, Romania and Ukraine have maintained a record post-Soviet rate for the past four years.
None of these nations is experiencing a decreasing trend in new cases.
“We are all concerned about the rise of HIV/AIDS in the region, perhaps the region where HIV is growing fastest,” says the World Bank's Global AIDS Program Director David Wilson. “Russia faces a large and potentially growing epidemic.”
Due to the low uptake of HIV testing in the region, up to 60 per cent of viral carriers could be unaware of their infection, according to the World Health Organization (WHO).
The true figure of new cases per year could be 300,000 per year with over three million people now living with HIV.
Yet HIV is in decline in nearly every region across the rest of the world, due to a toolbox of social and medical methods to contain the virus.
“We have clear well-proven interventions and if we target them well, we could check HIV,” adds Wilson.
Rates can be diminished by giving drug users access to sterile syringes, to stop them sharing needles containing blood infected with the virus.
Allowing heroin users to switch to taking a substitution drug, methadone, also slows the viral spread.
Medicine available to treat carriers of HIV on a regular basis also reduces the chances of further contagion.
"Unfortunately, political opposition and laws in Russia doom all of these approaches," says Robert Heimer, professor of epidemiology and pharmacology, Yale School of Medicine.
Here we detail the reasons for this epic rise.
Drugs: Russia seeing upsurge
Injecting drug use is the key reason for the rise of HIV in Russia. The virus spreads among those injecting drugs, due to their practice of sharing dirty needles.
However the Russian state will not finance health workers to exchange dirty for clean needles, arguing that this practice encourages drug use.
Last year, 58 per cent of new HIV cases were due to infected syringes to inject heroin and its codeine-based home-made alternative Krokodil. This figure on the rise.
Russia is the crucible of HIV in the region. Its new HIV numbers boomed from 58,000 new cases in 2010 to 78,000 in 2013 - accounting for three quarters of cases of the nations under our analysis.
The total number of people living with HIV in November 2014 in Russia was 864,394, although under the WHO’s “iceberg principle” that reported cases are a fraction of reality, this figure could be 2.4 million.
Russia’s method of dealing with the spread of HIV is based on an ultimatum ideology to drug users: give up first, then receive care.
The country bans the medical prescription of methadone, which allows users to extract themselves from drug communities, re-enter civil society and regulate their lives. The state argues that taking methadone is an addiction.
In neighboring Ukraine, the situation is different. NGOs are financed in the tens of millions by foreign donors. There are 8,000 patients on substitution treatment, such as methadone, the largest number in Eurasia.
Half of these patients are HIV positive and Ukrainian experts argue this has been crucial to curbing the viral spread [read Anton's story here].
But Russia prefers to combat HIV by encouraging abstinence and healthy living, through promoting sport and exercise.
“Based on international practice and guidance, the three interventions - needle exchange, substitution therapy and treatment for people with HIV - would help to check Russia’s epidemic,” says Wilson.
Romania also witnessed a deluge in new cases of HIV among drug users from 2010 to 2011 - when its 20,000-strong injecting drug community was almost free of new cases of the virus.
In 2010, the capital of Bucharest was hit by the spread of legal highs - stimulants which could be bought over the counter as ‘bath salts’ or ‘doll-cleaning powders’, but which contained a spin on the chemical formula for amphetamine.
Users switched from heroin to injecting these cheaper substances, but experienced paranoia, schizophrenia and paralysis.
To get a quicker high, they also increased the regularity of injections, from three or four to up to 15 times per day [read Ciobi’s story].
At the same time, the Global Fund closed its programs in Romania for combating HIV, such as vans which travel to drug hotspots to provide users with clean needles.
This double-blow allowed the number of cases of HIV among drug users to rise by 200 per cent year-on-year in 2011.
“Users come to these place to shoot up in groups,” says Alina Dumitriu, executive director of Bucharest HIV NGO Sens Positiv.
This makes needle exchange a key factor in limiting the viral spread.
Since then Romania’s Government criminalized the sale of “legal highs”, but powders are still available on the street.
Now heroin is returning with a vengeance to Bucharest.
Economic collapse: virus spread in the balance
Russia’s currency has been in freefall with the deputy Governor of the central bank Sergey Shvetsov last year calling the situation more serious than his “worst nightmares”.
Meanwhile Ukraine suffers from inflation of 25 per cent and an economy propped up by the International Monetary Fund and cash from the west hoping to consolidate Kiev’s western-facing ambitions.
There is strong debate over whether money woes could lead to a rise in HIV cases, particularly among drug users.
“Much of the drug use that contributes to HIV has its origins in the earlier economic crisis [in the region] following the end of communism and recent data from Greece and Romania shows a sharp spike in HIV infections after the economic crisis in Europe [in 2008],” says the World Bank's David Wilson.
“There are reasons to believe the economic crisis might make things worse by contributing to transgressions and reducing the [state's] capacity to respond.”
However the picture may be more chequered.
"The timing of the 1998 financial crisis in Russia and the beginning of the first wave of HIV among drug injectors is hard to explain as anything more than a coincidence," argues Robert Heimer. "The expansion of drug markets and the replacement of marijuana by heroin in many major Russian cities seems to be at the heart of that HIV epidemic."
Vadim Pokrovskiy, director of Russia's Federal AIDS Center, also says that so far he has "no evidence" of economic hardship causing a rise in HIV among drug users.
"We have found more HIV cases in regions with better economic situation," he says. "Such regions have been more attractive for drug dealers."
Sex: Taking over as HIV cause in Ukraine and Moldova
A rise in HIV numbers through sex has eclipsed drugs as the main route for new cases in Moldova and Ukraine.
By January 2014 there were 139,573 Ukrainians living with HIV - and estimates assess that AIDS-related complications claim 17,000 lives each year in a country of 45 million people.
An integrated network of associations, funded by money from abroad, has helped stabilize the numbers of new infections to around 21,000 each year.
In 2001, around two-thirds were infected with the virus through sharing dirty syringes and almost one-third through sex.
However by 2013 these figures were reversed.
“Since 2008, the HIV epidemic changed from the route of injecting drug users to sex,” says Pavel Skala, associate director: policy & partnership at NGO Alliance Ukraine. “But injecting drug users are still the major source, through sex, including sex workers.”
Now half of Ukraine’s 310,000 injecting users have access to services, such as clean needles. Around one fifth of them have HIV. This has brought down risky behavior in the last five years.
“The more clients to whom we provide service, the less HIV transmission - in Russia this is another story,” says Skala.
A similar pattern has occurred in Moldova [Read our Report here]. The ex-Soviet nation saw an HIV boom in the late 1990s due to a surge in the injection of heroin and home-grown poppy concoction shirka. Needles were scarce and sharing was commonplace [Read Gary’s story].
Since then, international funds have pumped millions into promoting harm reduction services - and the number of new cases is stabilizing at around 700 per year, of which 92 per cent come from sex.
“People believed HIV was due to drugs,” says Roma, a consultant at Chisinau’s Regional Social Centre providing services for people living with HIV. “Now we are more democratic and more libertine. Through the Internet, we can find a partner much faster for sex for two or three days. Sex plays a very large role.”
Although the public is aware of the importance of condom use, they do not strap on a prophylactic in a sufficient number of instances to curb the spread of the virus in these ex-USSR states.
Both Ukraine and Moldova also see growing numbers of men having sex with men as a cause of HIV.
At present the viral number is around 5.9 per cent of the estimated 176,000 male-on-male sexual partners in Ukraine.
“They are not so accessible for prevention services,” says Pavel Skala, “and this is a huge group.”
War: Ukraine conflict sees risky behavior up
Conflict in Ukraine’s east and the annexation by Russia of Crimea is causing unemployment, displacement and economic hardship across the country - factors likely to spur the rise of HIV.
NGO Alliance Ukraine has been operating on a national scale for over 14 years, but its services are now under threat in Donetsk and Luhansk, while its operations in Crimea have ended.
The Alliance still has harm reduction projects in Luhansk and Donetsk, a hotbed of HIV in the region and home to one in five new cases of the virus.
Here users have increased their number of visits to get clean needles and support.
“There is definitely an increase in risky behavior,” says Pavel Skala. “It’s sometimes dangerous for drug users to walk on the street and go to exchange needles - so some users are really stigmatized.”
Users themselves are marginalized by the rebel authorities in the occupied regions, who reportedly enlist drug users as “slaves” to dig trenches for their soldiers.
According to official estimates, the level of HIV has started to rise because of dangerous practices in these areas, home to almost a quarter of Ukrainians living with HIV.
“Infections with syphilis, TB and HIV will increase,” says Skala.
A growing number of ‘drug refugees’ from Crimea, Donetsk and Luhansk, who no longer have access to substitution drugs such as methadone, are moving to cities such as Kharkov and Kyiv [read Maxim's story].
These supplies are due to run out in east Ukraine by February 2015.
Skala believes once the patients run out of methadone, they will be forced to migrate or could regress to taking illegal drugs.
Following the Russian annexation of Crimea, users were left without their regular fix of methadone or buprenorphine.
Many fled to mainland Ukraine for treatment, some detoxed and others returned to injecting illegal drugs.
Traumatized by the sudden change in their body, those working with the cases estimate around 30 died from problems such as heart failure and overdosing.
"The denial of methadone for treating people with opioid abuse disorder that occurred in the Crimea and separatist parts of Ukraine will put many people at risk for transmitting or acquiring HIV," says Robert Heimer, Yale School of Public Health.
Money: Fall in funding risks viral spike
Prevention, treatment and care of HIV in the region depends on western financing, mostly from the Washington-based Global Fund to Fight AIDS, Malaria and TB.
"The Global Fund programs in east Europe were more effective in the region than other [programs]," argues Russian Federal AIDS Center's Vadim Pokrovskiy.
But the World Health Organization says this funding route is “unsustainable” in the long-term.
The Global Fund - which has 14.82 billion USD at its disposal for three years - changed its funding model in 2014 to focus on countries more affected by the diseases, mainly in the southern hemisphere.
It also introduced a new mechanism in which Ukraine was called, confusingly, an “Upper Lower-Middle Income country”.
“The fund considers us a middle income country and we are on the same list as some countries from Latin America and Asia - but this does not take into account the recent crisis in Crimea or the conflict in eastern Ukraine,” says Pavel Skala.
While funding remains constant at 51 million USD per year for Ukraine between 2014 and 2015, NGOs argue that a greater proportion is now going to combating TB, while around 39 per cent less is earmarked for HIV elimination.
The Global Fund says there is no breakdown for how this money is differentiated between the diseases.
“No one can say exactly what funding will be in 2015 until grants are prepared, signed and implemented,” argues Seth Faison, head of communications at The Global Fund.
As countries reach a higher income status, the Global Fund expects to exit their financing to allow local health authorities to take over.
“I am not expecting any increase in funding from the Ukrainian Government - this is because of a crisis, the economic situation and the war,” says Skala.
When I went to visit the Alliance Ukraine offices in Kyiv in November, the network was in the process of cutting staff.
“It is coming at the worst time, as we have never had such huge decrease in budget with such a huge crisis in Government financing, it might be really disastrous,” says Skala.
In 2017, Ukraine is likely to see a halving of its annual financing from the Global Fund from 57 million USD to 27 million USD.
“It would be wise to increase funding everywhere people are affected by HIV,” says the Global Fund’s Seth Faison. “We are increasing funding in every region, yet we understand that people affected by HIV and TB and malaria in many countries are arguing that they need more. They are right.”
In Romania, when the Global Fund stopped financing HIV/AIDS prevention programs in 2010, the local Government did not support the continuity of services such as paying staff to facilitate needle exchange to drug users.
The number of injecting drug users with HIV boomed.
This was in the hundreds in Romania, but in Ukraine a similar pattern could be in the thousands.
Skala says the Romanian lesson taught him “we don’t want same picture in Ukraine.”
The state should step in to finance, and is usually willing to fund treatment for HIV/AIDS carriers.
But countries are less open to financing prevention, which is a cheaper and more effective method of curbing HIV.
However this can mean the Government giving money to NGOs on the ground - a structure alien to many post-Communist states.
“In many cases, when [external financiers] fund NGOs directly, when donors leave, the Governments don’t have the tradition, the experience, the confidence or competence to start financing civil society directly,” says the World Bank's David Wilson.
In India, the Bank encouraged a Government partnership structure with NGOs to combat HIV.
“When we operate to help governments, we work with civil society,” says Wilson. “In India, we were the first and final external financier of India’s HIV program, which subcontracted thousands of NGOs to help with key members of the population.
“This addresses what has been a real failure in the global HIV response in the last three decades - we have done really well at financing and supporting NGOs. We haven’t done as well in increasing Government capacity to trust civil society and contract them and manage them and see them as vital delivery partners.”
Unknowns: No certainties on Turkey's recent HIV peak
While countries in the Caucuses and Bulgaria have been witnessing a moderate rise in the numbers of HIV, Turkey, which has never suffered from an HIV epidemic, experiences alarming figures.
Turkey has seen a sharp increase in HIV numbers to over 1,000 for the first time in 2012 and with 1,313 cases in 2013, according to the Turkish Ministry of Health.
The official body claims that the source of 52 per cent of cases are “unknown” and that 33 per cent come from heterosexual sex and 14 per cent from homosexual sex, and near-zero from injecting drug users.
Experts believe a higher number may be coming from men having sex with men, which is a difficult issue to confront in a country of mostly conservative family values.
While this is still a low prevalence for a major country, Turkey has no harm reduction services for drug users or widespread awareness campaigns, nor are international groups such as UNAIDS present in the country, which is sure to face further scrutiny.
Although some opioid substitution therapy exists, the country also does not have any needle exchange programs in place, lacking the armory to combat a full-scale viral attack.
“Turkey is not facing a large injecting drug use epidemic like other countries in the region,” says David Wilson, who has worked in the nation. “My sense is with a bit of international collaboration Turkey has the resources to manage what is likely to be a relatively small epidemic."
Caveat: Work in progress
The statistics for the maps on this page come from a variety of official sources.
The data is as consolidated as possible, but not perfect, and we are looking for the best way possible to map this information.
So we welcome feedback or criticism, please direct them to the writer at [email protected]
Sources: CNLAS (Ro), The Federal Service for Supervision of Protection Consumer Rights and Human Welfare (Ru), National AIDS Center (Ar), National Report (Az), Republican Centre of Hygiene and Public Health (Bl), Min of Health/UNAIDS (Bu), Hospital for Dermatology and Infectious Diseases (Mo), Min of Health (Tu), NCDC (Ge), Alliance (Ukr), ECDC/WHO, GARPR.
We are aware that the Russian data is for the entire country, not just those oblasts close to the Black Sea region and, with this in mind, it would also be better to include Central Asian countries as well, where there is also a problem with HIV.
Yes, we want to do this is the future.
This article is also published in EU Observer
This article was financed by the Award for Best Initiatives of European Online Investigative Journalism, Robert Schuman Centre for Advanced Studies (European University Institute, Florence, Italy).
Thanks to Anna Lyubenova and Valentin Simionov and Stelian Dobrescu and Ana Maria Grigoriu for design advice
Some information on Turkey was corrected in this article