Pubdate: Sun, 09 Jul 2006
Source: Baltimore Sun (MD)
Copyright: 2006 The Baltimore Sun, a Times Mirror Newspaper.
Contact:  http://www.baltimoresun.com/
Details: http://www.mapinc.org/media/37
Author: Erika Niedowski, Sun Foreign Reporter
Bookmark: http://www.mapinc.org/hr.htm (Harm Reduction)
Bookmark: http://www.mapinc.org/find?137 (Needle Exchange)

RUSSIA RESISTS NEEDLE SWAP

Officially, Exchanges 'Taboo' In Nation With High HIV Rate

MOSCOW -- Every Wednesday afternoon, Petya Nikitenko invites into his 
office some of the men and women Russia usually tries to ignore. Some 
have spent time in jail or have sold sex. All have abused drugs. Now 
that they have come for help, Nikitenko counsels them on the dangers 
of using intravenous drugs. One of the risks is that, by sharing 
needles, they will become infected with HIV.

What he does not do - and what HIV-prevention programs in Russia 
often cannot do without bringing unwelcome attention from the 
government - is distribute clean needles that could help prevent the 
spread of the virus.

No one disputes that getting addicts into treatment - and permanently 
off drugs - is the best response to addiction. But that conflicts 
with the realities of the disease. Many intravenous drug users aren't 
ready to quit, and many are unable.

Needle exchange as a "harm reduction" strategy, as the name suggests, 
tries to reduce the damage from drug use. After 20 years of 
experience with this approach, the majority of public health experts 
agree that giving sterile needles to addicts can prevent HIV 
infections and save lives.

More than 40 countries, from the United States to Kyrgyzstan, allow 
needle exchanges. The Joint United Nations Programme on HIV/AIDS 
(UNAIDS), which is coordinating the global fight against AIDS, calls 
the practice an "essential component" of HIV-prevention efforts. The 
World Health Organization says there is "no convincing evidence" that 
needle exchange programs cause unintentional harm; landmark research 
that followed drug users in Baltimore, where needle exchange was 
introduced in 1994, found that distributing needles did not encourage 
drug use. Also, the National Research Council and the Institute of 
Medicine declared in 1995, based in part on studies in Baltimore, 
that exchange programs reduced the number of HIV infections without 
increasing drug use.

But here the thinking is different.

"We tried, but it was a taboo in Moscow," said Nikitenko, whose 
organization in 1999 launched the only type of needle exchange the 
city has tolerated - one that authorities didn't know about.

He started small, distributing needles to addicts he knew and 
trusted, and who trusted him. As word of the exchange spread, a line 
formed outside his center's front door in a bleak residential 
neighborhood. After less than two years, he ran out of money and 
needles. His would-be backers wanted him to get approval from city 
authorities, but every attempt was rebuffed.

"Knowing the situation," Nikitenko said, "it's better to keep silent now."

Officially, about 342,000 Russians are infected with HIV. Public 
health experts in Russia and the West estimate that the real number 
exceeds 1 million, by far the highest figure in Europe. Russia's 
Federal AIDS Center, meanwhile, projects that the number of HIV 
infections by 2020 could rise to at least 5 million, and perhaps as 
many as 15 million - more than 10 percent of Russia's population.

The sharing of dirty needles accounts for at least 70 percent of the 
officially registered cases. But even as the government prepares to 
highlight AIDS and other infectious diseases at the Group of Eight 
summit that opens Saturday in St. Petersburg, the government 
continues to treat needle exchanges as a problem rather than a solution.

Authorities have refused to promote them, a stand that reflects a 
deeply rooted stigma surrounding drug use as well as a mistaken 
belief that needle exchanges encourage it. Officials' lack of support 
for the programs might also reflect a potentially serious 
miscalculation about the potential social and economic costs of an 
AIDS epidemic.

Russia hardly needed an ally for its resistance to needle exchanges. 
But it found one in the United States.

Convincing findings American public health policy can affect medical 
policies worldwide, creating a momentum hard to reverse.

In 1988, when needle exchange programs were relatively new, Congress 
passed legislation banning the use of federal funds for such 
programs. Its action reflected Congress' uncertainty over two issues: 
whether exchanges reduced HIV transmission, and whether they might 
encourage drug use.

By the late 1990s, a wide body of research backed the programs' effectiveness.

A 1997 study published in the British medical journal The Lancet 
found annual decreases in HIV infection rates among drug users in 
cities with needle exchange programs. In cities without such 
programs, infection rates increased by about 6 percent, the 
researchers at Australia's University of Melbourne reported.

A later survey comparing infection rates in 100 cities in two dozen 
countries had even more convincing findings: The infection rate 
declined 19 percent a year in communities with needle exchange 
programs, while in communities without such programs, infections 
increased 8 percent.

But Congress, during the Clinton administration, left the ban on 
federal funds in place, in the belief that providing needles to 
addicts at taxpayer expense sent the wrong message about drugs.

The Bush administration has taken things further by lobbying to limit 
access to needle exchanges globally.

In late 2004, for example, the State Department asked the U.N.'s 
Office on Drugs and Crime not to promote needle exchange programs in 
any of its work. Antonio Maria Costa, as head of that U.N. office, 
pledged to review his agency's publications. Its Web site 
subsequently dropped references to needle exchanges.

The U.S. Agency for International Development, the government's lead 
agency for foreign aid, has spent nearly $6 billion on HIV/AIDS 
programs. In February 2005, it asked its offices worldwide to verify 
that they were complying with the regulation barring grants to 
programs that include needle exchanges.

A few months later, a U.S. representative at a meeting of the U.N. 
Commission on Narcotic Drugs lobbied successfully against any mention 
in the commission's final report of needle exchange or any other 
"harm reduction" techniques, such as needle sterilization kits.

Russia's official resistance to needle exchange has left many harm 
reduction programs struggling for money and for support from local 
officials. About 60 such programs remain open, fewer than in 2002.

"Harm reduction in Russia was difficult to roll out, but it's even 
more difficult now," said Anna Moshkova, former program officer for 
the Open Society Institute's International Harm Reduction Development 
program. Government officials, she said, "are creating lots of obstacles."

Dr. Aleksei Mazus, head of the Moscow AIDS Center, need look no 
farther than his own hospital to see the link between drugs and AIDS. 
By his count, three-quarters of his patients are intravenous drug 
users. The hospital has 150 inpatient beds and an outpatient center 
that treats 300 clients a day.

Yet Mazus remains deeply skeptical, even scornful, of needle exchange programs.

"Giving out a syringe is just a first step," he said, suggesting that 
proponents of harm reduction seek to make drugs acceptable. "How far 
will this lead you?"

'Crisis among crises' Since 2001, according to government statistics, 
the number of new HIV infections among drug users has declined, a 
drop that officials say could be owed in part to addicts' refusing to 
be tested for fear of arrest on drug charges.

But transmission has moved beyond groups at highest risk. Larger 
numbers of people are becoming infected through heterosexual sex, and 
more HIV-positive women are passing the virus on to their infants.

Other health issues, however, generate greater concern.

Russia has one of the world's highest rates of cardiovascular 
disease, more than triple the rate in the United States and 
accounting for more than half of all deaths here. Forty thousand 
people each year die of alcohol poisoning. More than 30,000 each year 
die of tuberculosis. Russia is also the only industrialized country 
where life expectancy is falling: A male born today has a life 
expectancy of 58 years - 12 years less than in the United States and 
six less than 40 years ago.

So, for Russia, HIV is merely "a crisis among crises among crises," 
as described by researchers at the University of Wisconsin, Madison 
and the Center for Strategic and International Studies in Washington. 
Even among health professionals working with AIDS patients, the 
researchers found, AIDS is viewed not as the most pressing priority 
but as one of an overwhelming multitude.

And for a decade, needle exchanges have operated in a legal limbo.

Law enforcement agencies first assumed that the programs were 
illegal, on the grounds that any action that "inclines" someone to 
consume illicit drugs was a crime. Changes in the law allowed 
exchanges if the needles were distributed to prevent infectious 
disease. But in the past two years, activists have been waiting for 
new guidelines from the Health Ministry and the Russian Federal Drug 
Control Service.

"In principle, the Federal Drug Control Service is not against needle 
exchange programs," Aleksandr Mikhailov, the agency's deputy 
director, said in an interview. "But these programs must be regulated."

He outlined the agency's requirements: Needle exchanges must operate 
out of government facilities such as hospitals or drug clinics. 
Addicts who use the services must register. Only licensed health 
professionals can distribute the clean needles.

Mobile needle exchange units, which reach addicts on their own turf, 
would apparently have to shut down. Recovering drug addicts, a 
critical part of HIV prevention efforts, would be barred from 
distributing needles. So-called "secondary exchange," in which 
outreach workers rely on addicts to distribute needles among their 
networks, would also be banned.

Perhaps most important, activists say, addicts who want to use clean 
needles might be deterred from seeking them if they can't do so anonymously.

A Matter Of Morality

In St. Petersburg, Russia's second-largest city, municipal health 
officials openly support harm reduction programs, such as the needle 
exchanges that a group called Humanitarian Action runs in a hospital 
and from a bus.

Some days, as many as 60 addicts push open the back door of the bus 
and climb aboard; other days, as few as a half-dozen. Patience is one 
of the most important attributes for the health workers inside.

They collect dirty needles, usually dozens at a time, from the 
addicts. Clean needles are handed out in unmarked plastic bags. Drug 
users can undergo anonymous blood tests, get information about 
infectious disease and receive counseling.

Aleksandr Tsekanovich, executive director of Humanitarian Action, has 
reached out to local police. Some officers said that they understood 
and appreciated his work, but that he had to understand theirs: The 
number of drug arrests by a department is a measure of its success.

U.N. experts say needle exchange programs must reach 60 percent of 
the drug addicts in a given community to have an impact on the spread 
of the AIDS epidemic. Aleksandr Komarovsky, a young psychiatrist who 
works on the bus about 30 hours a week, says that as many as 150,000 
drug addicts might live in St. Petersburg. Needle exchanges, he says, 
reach no more than 10 percent.

Moscow, by contrast, does not even allow the exchanges, despite a 
large network of organizations willing to run them and an 
indisputable need. The number of drug addicts in 2004 was officially 
nearly 23,000, but, according to drug specialists, in reality perhaps 
10 times that.

The city's campaign against HIV and AIDS focuses on fidelity. It 
ignores all other behaviors. And this spring, the Moscow City Council 
proposed banning non-governmental groups that receive money from 
abroad for HIV prevention work. The tasks that the groups do, the 
council said, including handing out condoms and clean needles, are "immoral."

Even among doctors, addiction is often viewed less as a medical 
condition than as a moral flaw best addressed by jail.

In December, on World AIDS Day, Gennady Onishchenko, the nation's 
chief epidemiologist, estimated that 100 Russians a day become 
infected with HIV. Asked what role needle exchanges and other harm 
reduction work could play in slowing the virus' spread, he said, "If 
you ask me what is the most effective method, I would say, 'Hang 
pimps on aspen trees.'"

Sun reporters Douglas Birch and Alec MacGillis contributed to this 
article from Baltimore.
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MAP posted-by: Beth Wehrman