In his 20 years on this earth, Dima has seen a lifetime of abuse. At 16 he shot his first heroin, and in the years since he has lived on and off the streets of St. Petersburg. What life is left for him is likely to be brutal and short. "I can't say this is how I hoped to die," he says. "But at least I'll have plenty of company where I'm going."
Dima's humor may be black, but sadly, his prediction may be right. Something terrible is happening in Dostoyevsky's old city. Doctors believe that as many as 40,000 young people in St. Petersburg, mostly addicts, were infected with HIV last year. Five time zones to the east, in the Siberian outpost of Irkutsk, the toll is rising with equal ferocity. The same in Tolyatti, a grim city of automobile workers on the Volga in Russia's heartland. Moscow leads the nation with as many as 100 new HIV cases registered each day. In fact, virtually no place in Russia has been spared. Says Irina Savchenko, the head HIV specialist at the Ministry of Health: "By now wherever you look, from Kaliningrad to Kamchatka, from Grozny to Murmansk, HIV is not only there, it is moving faster and faster."
After a false lull for most of the first post-Soviet decade, HIV is now sweeping across Russia faster than almost anywhere else in the world. In the last year alone, the number of registered cases of HIV has more than quadrupled, from 15,652 to 80,300. Experts believe the actual number is 10 times higher. "It will not be long before we have 1 million Russians infected with HIV," says Dr. Vadim Pokrovsky, who has directed the country's federal center for the fight against AIDS since 1985.
Vladimir Putin describes Russia as "a great power with unlimited potential." But given the rise of HIV, tuberculosis and other diseases, Putin's Russia is in danger of becoming known as a land of unending affliction. Even the most ardent patriots concede that their country is dying. Fewer and fewer Russians are able to escape the clutches of the old scourge of alcoholism, and the new one, drug abuse. In the past decade, the death rate has risen by a third, while the birthrate has fallen precipitously. Last year alone, the population dropped by about 750,000. Hepatitis B and C rage, while old world diseases largely extinct in the West - measles, typhoid and diphtheria, to name a few - are staging a comeback. But HIV poses the greatest danger. "The HIV epidemic is a tragedy in itself," says Pokrovsky. "Far worse will be the eventual depopulation of the country. Not only will those with AIDS die, but they will not have children."
On one recent frigid night in St. Petersburg, near a metro stop on the city's desolate southern edge, two dozen teenagers gather outside a retrofitted bus. They are there to get clean needles, free condoms and, for many, their first HIV test. In the first 10 months of last year, St. Petersburg registered 3,652 new cases of HIV, compared with 400 in 1999. "From 13-year-olds to over-30-year-olds, they come to us," says Sergei, a former addict on the Mdecins du Monde team that has been providing anonymous HIV tests and psychological counseling - something the state does not offer - since 1998. In recent months, the crew has seen the HIV rate skyrocket. "Nearly one out of four kids we test is positive," says Dr. Vladimir Musatov, the team's medical coordinator and deputy head of St. Petersburg's AIDS clinic. "The epidemic is growing faster than anyone dared imagine."
Tolyatti, home to the giant AvtoVAZ car plant, offers a terrifying example of the epidemic's speed. The city has 3,250 registered cases of HIV. A year ago, it had 11. "We are waking up late," admits Dr. Larisa Mikhailova, head of the city's drug treatment clinic. "We should have started working with the addicts years ago. Now for thousands it's too late."
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Tolyatti also reveals the economic and social forces behind the rise of HIV in Russia. The trouble is drugs - to be precise, heroin. Nearly every registered case of HIV in the city stems from a shared needle, primed with $2 worth of smack. "If we didn't have heroin," proclaims Mikhailova, "we would not have HIV."
The tragedy is born of prosperity. "We're a young city, and we're a well-off city," says Mikhail Khoutorskoy, head of the local health department. Once a boon, that combination is now lethal. Jobs at the car plant pay well by Russian standards. And nearly one out of five residents is under 16 years old. "These are the kids who wanted to live free," says Alexander Ablamonov, a weary doctor who nightly crisscrosses Tolyatti's most populous region - "Car Factory District" - answering SOS calls in one of the city's 44 ambulances. "They've got freedom now, and this is what they do with it." One recent night, Ablamonov and his crew responded to seven calls. Four were drug overdoses.
The Ministry of Health - whose AIDS department comprises a staff of three - cannot cope. It cannot even keep an accurate tally of the HIV cases registered. The federal statistics lag far behind the numbers reported in the provinces. In Irkutsk, the Siberian city that thanks to a sudden flood of Central Asian heroin witnessed an HIV explosion in 1999, seven out of 10 addicts tested are infected with HIV. "The numbers grow by thousands each week," Savchenko concedes , while the federal funds budgeted for all AIDS programs in 2000 was a scant $1.75 million. "We need more than an education campaign," says Pokrovsky, the federal AIDS center director. "Putin must see this as a national security threat. He must declare war on HIV."
As grim as the epidemic is now, the prognosis is worse. Unlike the early stages of the AIDS crisis in the West, HIV in Russia is spread among the country's burgeoning population of intravenous drug users - an estimated 2 to 3 million nationally. "Today the infected are mostly addicts, but addicts are sexually active and addicts also become prostitutes," says Dr. Yevgeny Voronin, who heads a clinic in St. Petersburg that is Russia's largest facility for mothers and children with HIV. As the virus spreads through sexual contact, experts foresee a heterosexual HIV boom in three to five years. Condoms, once scarce in the U.S.S.R, are now in every pharmacy. But they are rarely used.
The virus moves swiftly but invisibly. Only 741 Russians are known to have died of AIDS to date. "It's hidden because we haven't yet had one known case of AIDS in our city," says Mikhailova in Tolyatti. "But in a few years, the plague will appear before our eyes." Pokrovsky explains: "Treatment today costs $10,000 a year, and in eight years we are likely to have a million people with AIDS. And so the state would have to spend at least $10 billion on treatment. The question 'To treat or not to treat' will arise, and given our federal budget, I think I know the answer we'll hear."
Still, those on the front lines have hope. More and more Russian cities are launching prevention programs, like those in St. Petersburg, Irkutsk and Tolyatti, where former addicts have teamed up with doctors to stem the HIV tide. Not all understand the urgency of the cause. In Irkutsk, local officials have thwarted attempts to distribute clean needles, but in Tolyatti two needle exchange points opened last fall. "It may be a small step," says Mikhailova, "but it's a big one psychologically." She notes that the city even funded the program, giving a grand total of $28,571.
"No one can save us except ourselves," says Aleksei Surikov, a 25-year-old former addict who works in a fledgling Irkutsk detox center that has helped more than 50 young addicts go clean. "If we do nothing, we'll lose every addict here. They believe in nothing. Not the state, not the church, not school, not their parents. But if we can reach them, something changes. We can help them change their lives."
These street warriors know well they face a Sisyphean struggle. Russia's health care system is antiquated, worn-out and desperately underfunded. The World Bank is expected to lend Russia $50 million for HIV and AIDS prevention and $100 million for TB treatment. "Russia still has a window," says Jean-Jacques de Saint Antoine, head of the World Bank's Russian health program. "The virus has barely entered the mainstream population." But from the country's head AIDS doctor to the prevention activists on the St. Petersburg bus, people involved in the HIV fight know that the funds, spread out over five years, will not suffice. They complain above all of the silence in the Kremlin. "It comes down to economics and a political will," says Voronin, the young doctor in St. Petersburg. "Putin must make HIV his top priority. Never mind Chechnya. This is our future and we are losing it."
Late last year the author and Nobel laureate Aleksander Solzhenitsyn described the crisis bluntly, questioning the urgency of Putin's campaign for a new state hymn and flag. "You cannot save a dying country with symbols," the writer chided. "When men are dying without any hope in the prime of their lives, it makes no difference what hymn is sung over their heads." Adds Mikhailova in Tolyatti: "Attention must be paid, and something must be done." The politicians may not like it, but as more and more young Russians succumb to HIV, it will become harder to hide the obvious: Russia stands to lose a generation.
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