TVER, Russia -- He's thin and smiles easily and, at 20, does not look
like someone who has already spent three years in prison for robbery. But
Sasha Volgin is determined to be a tough guy even though the AIDS virus
now runs through his veins -- and those of his 16-year-old pregnant girlfriend.
"HIV is like a cough," he says dismissively. He sees no need to take
medicine. He does not need friends. He does not fear death. He did not
react when he learned of his condition. Or so he says. "I'm not expecting
any help. We will die here, and our kids will die here."
This brand of Russian fatalism terrifies Alexander Kolesnik, head of
the AIDS clinic in Tver, a mid-size industrial city 120 miles north of
Moscow, and it terrifies the international health care community as well.
The AIDS epidemic that once bypassed the East has now begun to ravage Russia
and some of its neighbors, and only slowly is the world's largest country
awakening to the potential threat.
While the numbers remain small compared to those in Africa, the Caribbean
and the United States, HIV infection is growing at a faster rate in Russia
and the rest of Eastern Europe than anywhere else in the world, according
to UNAIDS, the consortium of international agencies fighting the disease.
Nearly 50,000 people in Russia tested positive for the virus since January,
a 60 percent jump in just six months. Because official statistics generally
reflect only the tip of the story, specialists estimate that the 129,261
cases registered by the Russian Health Ministry probably translate to as
many as 750,000 in reality.
The escalation might only grow worse. Until now, the infection has been
largely confined to intravenous drug users in Russia, but doctors believe
it is about to break out into the general population through sexual transmission,
meaning that Russia is heading down the same road already traveled by the
countries with the world's worst AIDS problems.
"If you just extrapolate from what we have seen in the last decade,
it's going to be a disaster," said Armin Fidler, the European health care
sector manager for the World Bank. "It has the potential to become a huge
tragedy."
"This is of great concern. This requires immediate action," said Stefano
Lazzari, an epidemiologist at the World Health Organization in Geneva.
"When the numbers increase so dramatically, you know an epidemic is going
on."
At the moment, the total infected population in Russia remains a fraction
of HIV/AIDS cases in countries that have suffered from the disease for
many years. As a proportion of the population, the number of infected Russians
was just one-third that of the United States, according to 1999 data from
UNAIDS.
But for Russia, the arrival of AIDS amounts to another blow at a time
when the country's collective health is already under devastating assault
by epidemics of tuberculosis, syphilis and hepatitis. The health crisis
has pushed life expectancy for Russian men below 60 years and contributed
to a falling population, even as other major industrialized countries continue
to grow.
The spread of disease is tied in part to the burgeoning drug problem
that has developed since the fall of the Soviet Union. The government reports
that drug addiction has multiplied 12 times over the past decade and attributes
80 percent to 90 percent of the HIV infections to dirty needles. Hepatitis
B and C, which are transmitted through blood and sexual activity, have
risen rapidly as well. "Basically these epidemics are feeding each other,"
Fidler said.
The international community has responded with alarm. Nonprofit groups
such as Doctors Without Borders and George Soros's Open Society Institute
have initiated projects intended to increase prevention and education,
while the U.S. National Institutes of Health and the World Bank have stepped
in with their own programs. Russia's AIDS crisis also was on the agenda
of the Group of Eight summit earlier this month in Genoa, Italy.
But Russia historically has been suspicious of outside help and its
reluctance has frustrated some in the West. The World Bank's proposal to
help with prevention and with treatment of HIV-infected children has been
tied up because Russia has balked at accepting a $150 million grant that
also targets tuberculosis.
"The authorities and the population at large are not at all alarmed
at the present time because it's early in the epidemic," Fidler said. "That
dynamic is what really worries us because if the epidemic remains unchecked
-- and at the present time we have every indication that it is unchecked
because not much is being done -- then we will have an explosion in the
years to come."
Russian authorities deny that they have ignored the potential peril.
"For some time, this was a hidden problem, but it has become obvious and
open," said Irina Kashkarova, the leading AIDS expert at the Health Ministry.
The country's leaders "do understand the seriousness." The government this
year has begun providing HIV-infected babies with medication, she said.
Like others here, Kashkarova attributed the emergence of the AIDS virus
to the opening of the country to the outside world and the resulting economic
and social turmoil that has left many young people disconnected. "Any country
during a time of crisis and a transformation period suffers certain difficulties.
The young generation reacts to all these difficulties and troubles. So
I think as Russia is moving toward capitalism, unfortunately, it repeats
all the mistakes made by other countries when they were walking down the
same route."
Similar outbreaks of HIV infection have been detected in other former
Soviet republics, including Ukraine, Belarus and Moldova, more so than
in Central European countries such as Poland, Hungary and the Czech Republic,
according to the World Health Organization. Ukraine in particular has the
worst numbers in the region and a higher proportionate rate of infection
than the United States.
In Tver, a provincial city on the scenic Volga River between the giant
metropolitan centers of Moscow and St. Petersburg, the growth of HIV infections
has baffled local officials struggling to get a handle on the epidemic
before it gets out of control.
Until 1997, there were just eight known cases of HIV infection in Tver,
six attributed to heterosexual contact and two to homosexual activity.
But economic problems in this struggling factory town led to the influx
of drugs in the mid-1990s, with opium and later heroin readily available
for roughly the cost of cigarettes.
As of July 1, Tver had registered 2,342 people with the infection, with
many more thought to be carrying the virus without knowing or notifying
authorities.
The enemy is not only the disease but Russian culture and prejudices.
"Our population has certain stereotypes and that is that you will get the
infection only if you are a drug user," said Kolesnik, the head doctor
at the local AIDS clinic. "On the contrary, we keep saying the infection
is spreading and it's not just about drug use."
Kolesnik cited studies showing that 60 percent of drug users here say
they have sexual relations with non-drug users. "Maybe when people start
to die, then it'll have an impact on them," he said. "We are losing time
now."
At Kolesnik's clinic, however, even the patients seem almost blithe
about the situation. Natasha Ivanova was 15 when she started using heroin.
A friend offered it to her and she decided to try it. She came from an
economically stable home with a father who worked as a logger and a mother
who worked as a teacher.
"I didn't have a clue," she said, sitting in Kolesnik's office the other
day, wearing a blue turtleneck sweater and bobby pins in her hair. "I didn't
have any idea what the consequences would be. I was so small at the time."
Then she got pregnant by her boyfriend, who was also a drug user, and
in March when she went for a blood test discovered that she had HIV. Her
baby was born on May 24, but it is too early to know whether little Katya
is infected as well. Natasha now is just 17 and living with the boyfriend.
"I'm not scared," she said. "Now it's more or less normal because my
friend also has HIV, so people know about it. We all know that we can use
drugs and get AIDS."
Sasha Volgin said he did not know much about AIDS either before learning
last winter that he had the virus. He said he got it from a one-night stand
with a young woman shortly after getting out of prison last fall and learned
about it when another woman he impregnated got a blood test. But he acknowledged
that it could have been from the needles he shared while using heroin.
The disease has spread, he said, because of the lack of order in Russia.
"People do not have any way out. . . . People just don't know what they're
doing. They start to steal, they use drugs, they drink. They don't know
what
to do."
As for him, "I'm not afraid. I'm alive. If I die, then I die."
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