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.

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