INADEQUATE FIGHT AGAINST DRUGS HAMPERS RUSSIA'S ABILITY TO CURB H.I.V.

MOSCOW - They look like addicts anywhere in the world: tattered and
vacant-eyed, they circle Moscow pharmacies known to sell prescription
drugs illicitly, looking for something to inject for a quick high.

Though public examples of Russia's problem with heroin are not new
and seldom bring even raised eyebrows among locals, the issue has
recently come to symbolize a broader failure. The country has become
one of the world's low points in the effort to fight the spread of
H.I.V., and unchecked intravenous drug use is the biggest cause,
international health officials say.

The epidemic here has defied worldwide trends, expanding more rapidly
year by year than almost anywhere else. Nearly 60,000 new cases of
H.I.V., the virus that causes AIDS, were documented in Russia in
2009, an 8 percent increase from 2008, according to Unaids, the
United Nations H.I.V./AIDS program. Of those new cases, more than 60
percent were believed to have been caused by intravenous drug use,
and many of the others were believed to have been infected through
sex with addicts.

Though South Africa, with more infections than any other country, far
outstripped that total number, with an estimated 390,000 new
infections in 2009, the rate of new infections annually has decreased
there by nearly half since its peak in the late 1990s.

"I've been researching the problem of H.I.V. infection for 25 years,
and I must say that the situation has become significantly worse" in
Russia, said Dr. Vadim V. Pokrovsky, the head of the country's
Federal AIDS Center.

While in recent years the government has increased its efforts to
fight the disease, Dr. Pokrovsky said, current programs almost
completely neglect those groups at the heart of it.

Officials estimate that well over a million people abuse drugs
intravenously in Russia, often sharing and infecting one another with
tainted needles. They are among Russian society's most marginalized
people, more likely to face a few weeks handcuffed to a clinic bed
than to receive basic treatment to break their addictions. Meanwhile,
officials have treated sex education and other preventative programs
with open hostility.

"Which are the main infected groups? Injecting-drug users and sex
workers," said Lev Zohrabyan, the Europe and Central Asia adviser for
Unaids. "It turns out that these are the groups where the money must
be directed to change the picture. But if you open the budget, you
will see that for prevention work among these groups for the next two
years there is nothing."

Top officials have consistently blamed the United States' failure to
eradicate heroin production in Afghanistan for Russia's intravenous
drug problem. About 90 percent of Russian addicts use Afghan heroin,
according to the Federal Drug Control Service.

Yet once the drugs pass through Russia's porous borders with former
Soviet republics in Central Asia, dealers find a ready market of
addicts with few tools to help them quit. While some regions have
experimented with needle-exchange programs, the practice, which has
proven effective at reducing the spread of H.I.V. in other countries,
has not been adopted on a national level.

The country's top medical and political officials have roundly
condemned drug substitution therapy for heroin addicts - the use of
methadone or other narcotics, widely considered an effective way to
wean people off the drug - on the basis that it substitutes one form
of addiction for another. Doctors who have flouted the official ban
on the treatment have faced prosecution and even harassment by
Kremlin-backed youth groups.

The Russian Orthodox Church, which has become a significant voice in
the country's political affairs in the past decade, has also
expressed strong opposition to such preventative measures.

Even a new antinarcotics strategy ordered by President Dmitri A.
Medvedev last summer acknowledges Russia's failure to adequately
confront the problem. "Prophylactic activities, medical aid and
rehabilitation of patients with drug addiction are not sufficiently
effective," said the document, posted on Mr. Medvedev's Web site.

Many of the addicts gathered outside one pharmacy in southern Moscow
said they had often tried to stop. "You want to quit, and you don't,"
said a graying 33-year-old named Maxim who had the scarred arms of a
dedicated user. Another man, who had quarter-size holes gouged into
his body from injection-related infections and would not give his
name, said he feared that he would be arrested if he sought treatment
- - a worry that is not completely unfounded here.

The police often arrest drug users, sending them to special
detoxification centers where doctors encourage, and sometimes force,
immediate abstinence, which can in some rare cases be fatal. Last
summer, organizers of the 18th annual International AIDS Conference
held in Vienna issued a declaration - aimed at Russia and the
countries of the former Soviet Union, in particular - arguing that
such practices drove addicts underground, complicating
H.I.V.-prevention efforts.

It is not that the government has failed completely to recognize the
gravity of the epidemic. Russia's national security strategy,
approved by Mr. Medvedev, identifies the spread of H.I.V. and AIDS as
"one of the main threats to national security in the sphere of
medicine and health."

Russia now has more than 500,000 officially registered cases of
H.I.V., though Unaids and other experts have estimated the actual
number to be closer to one million, as many as in the United States,
which has more than twice the population.

Part of the problem is that the government came late to the fight.
The epidemic has been raging since the Soviet collapse two decades
ago, but a major government response came only in 2006 when Russia's
obligations as host of the Group of 8 summit meeting pushed officials
to take a more active role in fighting the disease. Vladimir V.
Putin, who was president at the time and is now prime minister,
ordered the largest increase in financing in any area in Russia's
history, and spending has grown annually ever since.

This year, the government plans to nearly double spending on H.I.V.
drugs to about $600 million and expand prevention programs focusing
on youth, said Galina G. Chistyakova, a Health Ministry official who
helps oversee Russia's H.I.V. and AIDS policies. She denied that
Russia was having trouble curbing the epidemic, noting that the
ministry had documented a slight dip in the number of new infections
in 2010 compared with a year earlier.

Dr. Pokrovsky and others said that government programs often became
ensnared in Russia's large and inefficient bureaucracies. Even
efforts to provide AIDS patients with treatment, which constitute the
bulk of government financing, have fallen short.

Patients and doctors have complained of frequent shortages of
antiretroviral drugs to the point where patients have created online
communities, like pereboi.ru, that monitor drug deficits and help
those in need of medicines connect with people who have extra
supplies. Patients have also held street protests, and others have sued.

Many addicts who become infected do not even know that medicines are
available, said Pyotr Nikitenko, 28, a former heroin user who now
works for a Moscow-based outreach group called Yasen. He said he was
able to wean himself off heroin with the help of his family, escaping
the fate of most of his friends, who he said now were H.I.V. positive.

"I continue to bury them," Mr. Nikitenko said. "They continue to die
from AIDS, or rather they are dying more and more frequently."