University of Southern California Dissertations and Theses

Strategic communication in the fight against HIV/AIDS in the Russian Federation

(USC Thesis Other)

Strategic communication in the fight against HIV/AIDS in the Russian Federation

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content STRATEGIC COMMUNICATION IN THE FIGHT AGAINST HIV/AIDS IN THE
RUSSIAN FEDERATION
by
Biljana Ivatz Markova
A Thesis Presented to the
FACULTY OF THE GRADUTATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF ARTS
(STRATEGIC PUBLIC RELATIONS)
May 2007
Copyright 2007 Biljana Ivatz Markova
ii
DEDICATION
To the millions of men, women and children around the world who are living with
HIV/AIDS everyday and fighting for their right to live their lives just as anyone else.
You are not forgotten.
iii
ACKNOWLEDGMENTS
I want to thank my parents, who have shown me support and unconditional
love of the kind only a mother and a father can have for their children. Your belief in
me keeps me afloat when I’m drowning in self-doubt. Words cannot describe my
gratitude and love for you.
I also want to thank my grandparents, whom I admire for their endless
wisdom, knowledge and strength and whom I love with all my heart—forever.
Thank you to all of my family—I am so grateful to have you because you are my
rock.
To my love, Michael, who has been so endlessly patient with me and has not
left my side, especially when I needed him the most. You are the kindest, wisest,
most beautiful man I know and I am so fortunate to be in your presence.
Thank you to all of my friends—you, who are still there for me after all these
past months of neglect you have endured (you know who you are). Thank you for
always making me laugh and always listening so patiently. Our friendships have
stood the test of time and I am so privileged to have met you.
Thank you to all of my teachers and mentors, who have been an inspiration to
me and through whom I have grown so much. You are so very appreciated for I
cannot think of a purpose more important to the world than yours.
Special thanks to the USC Annenberg School for Communication for giving
me an opportunity to pursue my studies, as well as to my committee members Jerry
iv
Swerling, Tess Cruz and Peter Clarke, as well as Jennifer Floto and Gail Light for all
of their expertise and advise.
v
TABLE OF CONTENTS
DEDICATION II
ACKNOWLEDGMENTS III
LIST OF FIGURES VII
ABSTRACT VIII
INTRODUCTION 1
METHODOLOGY 1
HIV/AIDS AND THE NEXT-WAVE COUNTRIES 3
WHY THE RUSSIAN FEDERATION? 5
PURPOSE OF THIS PAPER 7
THE HISTORY OF AIDS—LESSONS FOR THE RUSSIAN FEDERATION 8
AIDS WORLDWIDE 14
BIOLOGICAL EXPLANATION 16
CHAPTER 1: AIDS IN THE SOCIAL, ECONOMIC, AND POLITICAL
CONTEXT 20
SOCIAL JUSTICE AND AIDS 20
HIV, POVERTY AND AFRICA 21
AIDS—A PREVENTABLE DISEASE? 23
CEE/CIS AND THE RUSSIAN FEDERATION IN TRANSITION: THE HIV EPIDEMIC AS A
RESULT OF HARDSHIPS, DISILLUSIONMENT AND SOCIAL DISLOCATION 27
HIV/AIDS IN THE RUSSIAN FEDERATION - CONSIDERATIONS AND ENABLING
FACTORS 34
CHAPTER 2: ANALYSIS AND EVALUATION OF HIV PREVENTION 52
THE GLOBAL RESPONSE 52
VACCINE 58
STIGMA AND DISCRIMINATION 60
HARM-REDUCTION VS. ABSTENTIONISM—IDEOLOGIES AND REALITIES 64
AIDS IN THE CONTEXT OF HUMAN RIGHTS 69
EVALUATION OF PAST AND PRESENT HIV/AIDS PREVENTION PROGRAMS IN THE
RUSSIAN FEDERATION 74
vi
EVIDENCE-BASED INTERVENTIONS 87
CHAPTER 3: COMMUNICATION AND HIV PREVENTION 98
TARGETING SOCIAL CHANGE 98
CAMPAIGN DEVELOPMENT 100
CULTURAL SENSITIVITY 101
TARGETING SOCIAL CHANGE: THE SOCIOECOLOGICAL MODEL FOR HIV
PREVENTION 102
IMPLICATIONS FOR HIV INTERVENTION IN THE RUSSIAN FEDERATION 104
CHALLENGES AND LIMITATIONS 104
CHAPTER 4: THE STRATEGIC PLANNING MODEL FOR HIV PREVENTION
IN THE RUSSIAN FEDERATION 106
BACKGROUND 108
BUSINESS GOAL 109
STATEMENT OF THE PROBLEM 109
RESEARCH METHODOLOGY 110
SITUATION ANALYSIS 114
COMMUNICATION GOALS 119
OBJECTIVES 121
KEY AUDIENCES & KEY MESSAGES 122
STRATEGIES AND TACTICS 130
TIMELINE 169
BUDGET 172
EVALUATION 172
CHAPTER 5: CONCLUSION 175
BIBLIOGRAPHY 178
vii
LIST OF FIGURES
Figure 1: Adults and children estimated to be living with HIV in 2005 15
Figure 2: Social, cultural and political forces as drivers for the emerging HIV
epidemics 24
Figure 3: Socioecological framework for public health interventions 103
Figure 4: The evaluation pyramid 173
viii
ABSTRACT
The Russian Federation has one of the fastest growing HIV epidemics in the
world today. The Russian government has so far not been able to effectively control
what seems to be an overwhelming problem for a country struggling with many other
issues besides AIDS. In order to prevent an HIV epidemic of catastrophic magnitude,
the Russian Federation must employ immediate and coordinated national action
incorporating all major institutions so as to create a socially, politically and
economically favorable environment for HIV prevention. The problem of HIV/AIDS
in the Russian Federation is critically analyzed, while the results of the analysis and
extensive research are used to provide a strategic plan for health communication
practitioners, organizations and government entities in the region. This strategic plan
is developed with the purpose of offering an extensive overview and broad
guidelines on how to manage the complex fight against HIV/AIDS in the Russian
Federation.
1
INTRODUCTION
Today, Eastern Europe and Central Asia have the fastest spreading HIV epidemic in
the world. With 1.5 million people already carrying the virus, the region has the
highest HIV rates in all of Europe (The Joint United Nations Programme on
HIV/AIDS, 2006). The Russian Federation (RF) alone is home to almost one million
people living with HIV/AIDS (UNAIDS, 2006). The government of the RF has so
far not been able to effectively control the disease, which is rapidly spreading in this
transition economy struggling with many other issues besides AIDS.
In order to avert an HIV epidemic of catastrophic magnitude, the author
proposes a plan that incorporates all major institutions so as to create a socially,
politically and economically favorable environment for HIV prevention in the
Russian Federation. With a tailored and combined HIV/AIDS program for the
prevention, treatment and care of the disease, the epidemic in the Russian Federation
can be slowed, halted and eventually reversed. This paper will critically analyze the
problem of HIV/AIDS in the Russian Federation, while the results of the analysis
and extensive research will be used to provide a strategic plan for health
communication practitioners, organizations and government entities in the region.
Methodology
For the purpose of this work, it was necessary to explore diverse literature on
HIV/AIDS. Most of the general information on global AIDS featured in the
Introduction was extracted from international sources such as the United Nations
2
Joint Programme on HIV/AIDS (UNAIDS) Reports for 2004 and 2006, the World
Health Organization and the Bill and Melinda Gates Foundation. General
information was also reviewed in the introductory chapters of Irwin (2003), as well
as in the comprehensive PBS documentary The Age of AIDS.
The interconnectedness between AIDS and poverty, as well as the issue of
AIDS and the social, political and economic factors in the RF examined in Chapter I
were studied in the works of Stillwaggon (2006), Irwin (2003), and Green (2003).
For the purpose of analysis of the current HIV/AIDS problem in the Russian
Federation, diverse articles by Amirkhanian, Kelly and Rhodes were reviewed.
Alexandrova (2003) offers a comprehensive work on HIV/AIDS and drug use in the
country. Furthermore, articles by Tragakes & Lessof (2003) and Osadcheva (2003)
offer a good overview of the Russian health care system, and the International Labor
Organization offers a history of the spread of HIV/AIDS in the country.
Polubinskaya (2004) presents an analysis of the current law regarding HIV/AIDS in
the Russian Federation.
For Chapter II, literature on specific issues or populations related to the
HIV/AIDS epidemic was reviewed on databases such as Ovid, PsychARTICLES and
PsychINFO using terms such as “HIV,” “AIDS,” “Russia,” “Russian Federation,”
“evaluation,” and/or “prevention” and others. Particular journals such as AIDS,
International Journal of STD & AIDS, AIDS Education and Prevention and others
were reviewed using the same or similar terms. Articles relating to specific topics
such as injecting drug use, antiretroviral therapy, as well as articles used for the
3
evaluation of past HIV prevention efforts in the RF and many others were located in
this manner.
Google was used to find similar articles and Web sites of organizations such
as UNAIDS, the Bill & Melinda Gates Foundation, WHO and others were reviewed.
These search resources provided a great deal of valuable information found in
newspaper and magazine articles (e.g. The Los Angeles Times, The Economist); on
specialty Web sites (e.g. Advocates for Youth at www.advocatesforyouth.org and
Human Rights Watch at www.hrw.org); in numerous other resources (World Health
Statistics); as well as in speeches and conference abstracts.
Strategic communication for HIV prevention as assessed in Chapter III was
studied in the comprehensive work of McKee et al. (2004), while Campbell &
Quintiliani (2006) and Stokols (1996) provide interpretation on socioecological
theory.
The Public Relations Strategic Planning Model in Chapter IV was used as a
template for developing a comprehensive national HIV prevention strategy.
Implications from the extensive research (e.g. Pinkerton et al., 2000; Kelly et al.,
1991; Colebunders et al., 2000; Burrows, 2006; Davis et al., 2000; and many more)
were considered in order to prioritize and define specific strategies and tactics.
HIV/AIDS and the Next-Wave Countries
The recent changes in the market economies of Central and Eastern Europe and the
Commonwealth of Independent States (CEE/CIS) after the Soviet Union’s collapse
4
in 1991 have introduced new challenges into the region. The opening of the borders
in the beginning of the 1990s also opened the region to new health threats such as
HIV/AIDS as well as increased drug and human trafficking (Stillwaggon, 2006). In
general, the CEE/CIS region has experienced many economic, political and social
changes that have led to a period of instability and insecurity (Stillwaggon, 2006).
While the recent spread of HIV/AIDS in the region is contained loosely within the
population of injecting drug users (UNAIDS, 2006b), the epidemiology of HIV
implies that a spread to the general population will follow in the near future unless
drastic measures are not taken immediately (Kalichman, S., Kelly, J., Sikkema, K.,
Koslov, A., Shaboltas, A., & Granskaya, J., 2000).
Even more alarming is the fact that the virus is spreading at a faster rate in
Eastern Europe and Central Asia than anywhere else in the world (UNAIDS, 2006).
Although the epidemic in the region is fairly new compared to other parts of the
world, there are already about 1.5 million people infected (UNAIDS, 2006). This
would have been unthinkable ten years ago in a European country, according to Dr.
Peter Piot, the executive director of the Joint United Nations Programme on
HIV/AIDS (UNAIDS), who refers to Russia and the countries of the former Soviet
Union as the “next-wave countries” of the HIV pandemic. While currently there are
nearly one million infections in Russia, the US National Intelligence Council (2002)
estimates that without a greatly expanded response to the spread of HIV, by 2010
between five and eight million people may be HIV-positive in Russia alone. Clearly
then, such a drastic fall in the population count could pose a serious threat to national
5
security due to increased social instability and a disruptive decrease in national
health.
Experts like Dr. Peter Piot have increasingly expressed deep concern on
AIDS in Eastern Europe:
My biggest worry in terms of countries affected by AIDS is Russia and
the countries of the former Soviet Union, because it’s driven by a heroin
epidemic…although there’s more and more sexual transmission. There
seems to be a real denial about the potential for a huge crisis…How to
get it on the political agenda I don’t know. Knowing also that there is a
demographic crisis in Russia—in other words, the population is
declining for other reasons than AIDS—so a few percentages of the
population infected with HIV is going to have much more serious
consequences. (Simone, 2006)
There has been a general lack of attention from the international community
regarding HIV-related issues in Eastern Europe. Considering the statistics mentioned
above, however, the international community must address the AIDS epidemic in
this region and act immediately in the forms of HIV prevention, treatment, care and
support. The potential human cost of an ongoing epidemic would be unjustifiable
and the harsh consequences for the global community inevitable, considering that, in
the age of globalization, a major health threat in one European country will
eventually affect surrounding nations as well.
Why the Russian Federation?
There are several reasons why the Russian Federation is a good place to start in the
fights against HIV/AIDS in the CEE/CIS region. First, the Russian Federation, in
particular, is one of the most affected countries in the CEE/CIS region with 940,000
6
infections and a prevalence rate of 1.1% of the population (UNAIDS, 2006).
Considering the vastness of its population, without fast and immediate action, the
sheer numbers of new infections could be devastating for the country.
Second, since Russia has a relatively stable government structure, implementing
an integrated HIV prevention program has a high potential for success. In the past
years, we have learned that a broad coalition between science, governments, people
living with HIV, civil society, faiths and business is essential to efficient HIV
prevention (Piot, 2006). In Russia’s political climate, working with the government
and the country’s health system would be not only essential and important, but
inevitable.
Last, given the power and influence Russia still has over its neighboring
countries and the regions of the former Soviet Union, Russia could set an example
and lead the way for effective HIV prevention that others could follow. Each country
in Central and Eastern Europe and the Commonwealth of Independent States would
have to implement more or less different methods depending on the political,
economic and social climates of those countries. However, if Russia were to put
AIDS high on its political agenda, at the same level of importance as nuclear threats
and climate change, smaller countries may recognize both the urgency of the AIDS
pandemic and effective strategies for addressing it.
7
Purpose of this Paper
This work was created with the following objective in mind: To develop a strategic
communication plan that will address all major aspects of tackling the HIV problem
in the Russian Federation. This plan involves the government; the laws and policies
within the state; the health care system; discrimination and stigma within the society
as a whole; people at high risk of HIV infection, such as young people, commercial
sex workers (CSWs), injecting drug users (IDUs), prisoners, and men who have sex
with men (MSM); people living with HIV/AIDS (PLWHA); children orphaned by
AIDS; health care workers; non-governmental organizations (NGOs); international
organizations fighting AIDS; and other important factors and populations critical in
order to create a concerted HIV prevention effort in the RF.
With a tailored and combined HIV/AIDS program for the prevention,
treatment and care of the disease, the epidemic in the Russian Federation can be
slowed, halted and eventually reversed. This paper will critically analyze the
problem of HIV/AIDS in the Russian Federation, while the results of the analysis
and extensive research will be used to provide a strategic plan for health
communication practitioners, organizations and government entities in the region.
The goal of this strategic plan is to improve the social and political climate in the
Russian Federation in order to further short-term as well as long-term solutions for
HIV, such as raising awareness, advocating favorable laws and policies, ensuring
treatment to those infected, educating, changing attitudes and behavior. These efforts
8
can be then extended to other nations with similar challenges in Central and Eastern
Europe and the Commonwealth of Independent States.
The History of AIDS—Lessons for the Russian Federation
The AIDS pandemic probably started with one person being infected by one
chimpanzee in one place at one single point in time. In only 25 years, the virus has
infected 65 million people and taken nearly 25 million lives and, as Dr. Peter Piot put
it, all are “connected with each other by definition because they had sex with each
other, they shared needles, they got a blood transfusion from someone that got it, or
their mother had it… There are no other ways of transmission” (Simone, 2006).
When the first cases of AIDS were discovered in 1981, few understood the
proportions the disease would eventually take on, and fewer still anticipated the
massacre-like effects AIDS would have on some communities around the world
within a few short years. Initially, AIDS was referred to as Kaposi’s sarcoma or “gay
men’s cancer” due to the fact that homosexual men were the first population to be
visibly affected by the disease in New York and California (Brink, 2006). The same
symptoms started to show up all over the country and in Europe, but this time in
women and people from Haitian ancestry as well as in a baby displaying the
symptoms of the mysterious new disease (Simone, 2006). From there on, it
progressed from gay men, IV drug users, hemophiliacs and blood transfusion
recipients, increasingly into heterosexuals in mainly poor and rural communities all
over the world (Brink, 2006).
9
One of the most important years in the history of AIDS is 1996—the year
that the “triple cocktail” of antiretroviral drugs was developed (Machon, 2006). This
treatment, in the coming years, would help millions of people extend their lives by
an average of eight years, dramatically increase the quality of life of people living
with HIV, and probably reduced the numbers of children orphaned by AIDS
considerably. The scientist who developed highly active antiretroviral therapy
(HAART) was Dr. David Ho, scientific director of the Aaron Diamond AIDS
Research Center in New York and probably one of the most important people in the
age of AIDS. HIV was no longer a death sentence for millions on infected people.
Today, HIV/AIDS can be treated as a chronic rather than acute disease when
adequate treatment is available and affordable, thanks to the various drug treatment
combinations. Under international pressure, pharmaceutical companies finally have
dropped the prices of antiretroviral therapy from $10,000 annually ten years ago, to
$140 to $300 currently (Simone, 2006).
On the other hand, due to the stigmatization of the disease, national
governments have been slow to respond to epidemics. The fact that HIV/AIDS has
been traditionally associated with socially stigmatized populations and behaviors has
led to a political policy of denial and ignorance in many countries. A disease that
affects only homosexuals, prisoners, sex workers and drug addicts (so the common
belief) can be easily ignored and kept off the political agenda.
Fortunately, the establishment of the Joint United Nations Programme on
HIV/AIDS (UNAIDS) in 1996, led by Dr. Peter Piot, who soon became the leader in
10
the global battle against AIDS, brought about many positive changes in the way
HIV/AIDS was treated globally (Simone, 2006). Dr. Peter Piot, explained that his
“top priority was exactly to put AIDS on the political agenda. It has to be on the
agenda of presidents, of prime ministers if it’s a national emergency, a matter of
national survival” (Simone, 2006). That, however, was easier said than done.
Unfortunately, many governments have been reluctant to implement an “open” and
explicit approach to HIV prevention. Recently, for instance, the United States denied
Brazil access to funds for HIV prevention because it had not agreed to condemn its
sex workers as immoral (Reel, 2006). But sex workers are Brazil’s partners in HIV
prevention because the government recognizes that in order to stop the spread of
HIV, it must make those who practice high-risk behavior its partners—not its
enemies.
Many grassroots efforts have emerged to substitute for a lack of government
attention to combat the disease and assist people living with HIV/AIDS. The first
successful HIV prevention programs were started locally. Notably, in Uganda, a
woman named Noerine Kalleba, whose husband had died of AIDS, almost single-
handedly created the first successful grassroots support program named TASO—The
AIDS Support Organization. Later, recognizing the importance of HIV prevention,
the country’s President Museweni personally traveled the country in order to spread
the word on AIDS, and so managed to keep the infection rate relatively low with his
ABC program (Abstinence, Faithfulness, Condoms) (Global HIV Prevention
11
Working Group, 2002). Uganda’s effective work was a great success and proved
that, indeed, prevention worked.
In Thailand, HIV spread drastically as a result of an increase of sex tourism,
the availability of cheap heroine, and overcrowded prisons. When the king freed
37,000 prisoners in 1987, HIV prevalence amongst IDUs rose from 2% to 40%
(Simone, 2006). The prime minister in Thailand took action, made HIV/AIDS a
priority and put Mechai Viravaidya (also called the “Condom King”), who had
distributed condoms in local communities for years, in his cabinet (Global HIV
Prevention Working Group, 2002) . AIDS education programming was made
mandatory on public television and the free condom campaign reduced infections
amongst sex workers by 90% over the next years (Simone, 2006). Unfortunately,
Thailand’s government was not so tolerant to its injecting drug user population, and
stigma and fear remained (Simone, 2006).
In the US and in Britain, the first needle exchange programs were established
in the 1980s (Alexandrova, 2004). In the US, however, because President Reagan
pretended the problem of AIDS was non-existent, harm reduction programs
remained local and grassroots-based (Simone, 2006). Meanwhile, in England, the
government was actively participating in HIV prevention. In both countries same
programs were successful on a local level and proved that targeted and explicit HIV
prevention worked.
Despite of the success of grassroots activism, AIDS remains a politically
driven disease and the involvement of politicians is essential to HIV prevention. As
12
Uganda had proven, when politicians talk about the disease, it makes it “politically
correct,” putting it on the national agenda and into the national consciousness. This
political recognition and involvement takes away some of the stigma, the shame, and
the blame while it makes HIV/AIDS relevant to everyone, and not just those deemed
socially unacceptable.
The US President George W. Bush’s PEPFAR fund (The President’s
Emergency Plan for AIDS Relief) with $15 billion donated to the fight on global
HIV/AIDS was a great leap forward regarding the financial commitment countries
were willing to make towards HIV prevention, treatment, care and support. After all,
in 2003, 4.1 million people were infected with HIV in sub-Saharan Africa and only
50,000 were receiving ARVs (The History of AIDS 2003 Onward, 2007). The
United Nations (UN) had created the Global Fund, which was a financial source for
providing universal access to ARVs in more than 115 countries worldwide (The
History of AIDS 2003 Onward, 2007). Bush’s PEPFAR dedicated only $1 billion to
the Global Fund, and allocated the rest of the money towards only 15 countries that
were in immediate need for financial assistance (Simone, 2006). $1 billion of that
money was dedicated to teaching abstinence and using HIV prevention programs as
a chance to do missionary work and distribute the message of Jesus Christ, instead of
free condoms. But abstinence is rarely viable because it does not provide all
vulnerable people with an option that is realistic for their life circumstances.
Unfortunately, none of the money from PEPFAR went to countries such as
Russia, India and China, which have some of the fastest growing epidemics in the
13
world. All three countries had, in fact, denied until recently that they even had an
AIDS problem. The allocation of PEPFAR funds for HIV prevention largely
depended on which countries have the most infections and the smallest budgets. On
the other hand, international organizations, such as UNAIDS, are not just trying to
fix what is already broken, but they are trying to actually prevent potentially severe
future epidemics, in places like the “next-wave” countries. AIDS needs a global
response more than ever, because it has become a global problem. Concentrating
only on the countries that are worst affected and ignoring countries such as Russia
and the Ukraine will only lead to political apathy on the side of those governments
that feel their country’s HIV problem is not as serious as those of other countries.
Especially in Eastern Europe, it has been difficult to pursue governments to
put AIDS on their political agenda (Simone, 2006). The fact that in these regions the
epidemic is mainly driven by drug use frightens politicians away from associating
themselves with a problem that has increased through such illegal and controversial
activities. Governments must begin to distance themselves from the notion that
AIDS is a shameful disease, that high-risks groups or practices somehow must be
ignored, or that condoms are incompatible with religiousness or faith and that they
play no role in HIV prevention.
Commitment and recognition from the government is an important first step
to successful HIV prevention. In addition to that, support is needed from civil
society, people living with HIV, non-governmental organizations, and the private
sector. Private companies have become more likely to provide treatment for
14
employees as the cost of antiretroviral drugs has fallen over the last years, in order to
maintain a stable workforce.
AIDS Worldwide
After 25 years of gathering knowledge about HIV and AIDS, we still have not
managed to eliminate the disease, or come close to reversing the global epidemic.
Today, HIV/AIDS affects 38.6 million people worldwide, 46% of them women and
54% of them men (UNAIDS, 2006). Every day, more than 8,000 people die of AIDS
(that’s one person every ten seconds) and 14,500 are newly infected. Last year, there
were 4.1 million new infections globally and 2.8 million people died of AIDS-related
illnesses (UNAIDS, 2006). HIV/AIDS now kills more people worldwide than any
other infectious disease. It is the leading cause of death in Africa, and the 4
th
leading
cause of death worldwide (UNAIDS, 2006). Because over 95% of new infections
take place in poor countries, the disease is a threat to global development and welfare
(UNAIDS, 2006). Yet, only one in five people at the greatest risk of HIV infection
have access to proven prevention methods such as condoms, clean needles,
education, and testing, while only 7% have access to antiretroviral therapy (ART)
(UNAIDS, 2006).
15
Figure 1:
Source: UNAIDS: 2006 Report on the Global AIDS Epidemic
As can be observed in the above map, the region that is most affected, by far,
remains Southern Africa with 24.5 million infections (64% of the HIV population)
followed by Asia with 8.3 million. The world’s most affected country is Swaziland,
where HIV prevalence in adults aged 15 to 49 is as high as 33.4% (UNAIDS, 2006).
16
Conversely, the affliction is limited to between 0.5% and 1.0% of the population in
technologically advanced regions, such as Western Europe and North America.
Although, compared to Africa and Asia, Eastern Europe and Central Asia
account for a relatively low number of infected people with 1.5 million, this rate is
likely to increase dramatically in the very near future. Considering the low treatment
rate of only about 20% in Eastern Europe and Central Asia (UAIDS, 2006), it is
likely that most of these people will die of AIDS in the next decade. However, this is
not a solution-free predicament and it should be possible to change this trend. Brazil,
for example, once one of the most affected countries, has lowered its prevalence rate
to 0.5% by devoting major resources for the fight against HIV/AIDS, and has been
very successful in providing 83% of its citizens who are HIV-positive with treatment
(Okie, 2006; UNAIDS, 2006).
With major HIV outbreaks still mostly contained within certain high-risk
populations such as injecting drug users and commercial sex workers, the Russian
Federation is still at the early stages of the epidemic. Much can be learned from the
global history of AIDS that can provide valuable information on how to tackle the
epidemic in the future so that a general epidemic—one that spreads among the
general population—can be avoided.
Biological Explanation
What exactly is AIDS and HIV and how does is affect the human body?
17
Acquired Immunodeficiency Syndrome, or AIDS, is the disease observed as a set of
symptoms that point to a person with an impaired immune system and in an
advanced stage of HIV infection. The human immunodeficiency virus (HIV) is
responsible for triggering full-blown clinical AIDS, taking an average of ten years
once the virus is introduced into the bloodstream to do so (Irwin, A., Millen, J., &
Fallows, D., 2003). HIV invades certain cells of the immune system, called “helper
T-cells,” or CD4 cells, reproducing itself within the infected cells and ultimately
bursting into the bloodstream. The immune system, in an attempt to fight the virus,
responds by producing antibodies and more CD4 cells to replenish those killed. This
is ultimately ineffective because HIV destroys ever-increasing numbers of CD4 cells
until the body is unable to fight off all other infections and bacteria, even a simple
cold or the flu, and the immune system stops functioning. At this late stage of the
infection, the person carrying the virus remains defenseless against so-called
opportunistic infections. These vary depending on the specific region of the world
the person is located in, but many people living with AIDS in developing countries,
and especially in Eastern Europe, die of tuberculosis (Irwin et al., 2003). The HIV
serologic test assesses the presence of antibodies against HIV in the blood and a
person who is HIV-positive, or seropositive, has been infected but does not
necessarily have AIDS (Irwin et al., 2003).
HIV is transmitted through unprotected sex with an infected partner, sharing
needles or syringes with infected persons, by receiving a blood transfusion or other
blood products contaminated with HIV, and it can be passed on from a mother to her
18
child before, during or after birth through breastfeeding (Irwin et al., 2003). The risk
of contracting the virus can be considerably reduced by safe sex practices, such as
using female or male condoms, by not sharing needles and syringes amongst
intravenous drug users, proper monitoring of blood supplies and a special short
course of antiretroviral treatment of HIV-positive mothers in order to prevent
mother-to-child transmission.
How is HIV/AIDS currently treated?
Currently, drugs used to treat HIV/AIDS are called antiretrovirals (ARVs). The
complicated combination of these drugs, also called highly active antiretroviral
therapy (HAART), works by stopping the HIV virus from replicating within the CD4
cells (Irwin et al., 2003). Because the AIDS virus in so adaptable, the HAART
therapy, also called “triple cocktail,” consists of different drugs that attack the virus
at once, which reduces the virus’ chance of mutating fast enough and developing
resistance to the drugs. As a result, HAART usually reduces the amount of the virus
in the patient’s bloodstream and therefore allows for the replenishment of CD4 cells
and the restoration of the immune system (Irwin et al., 2003). However, ARVs are
not a cure and patients must remain under a lifelong treatment. Many develop a
resistance to one or more of the drugs and/or suffer, at times, dangerous side effects.
Nevertheless, HAART has managed to dramatically cut AIDS death rates and
enhance the life quality of those infected (Irwin et al., 2003). Those receiving
HAART live on an average about 8 years longer than those without therapy. In sub-
19
Saharan Africa, only about 17% of those who need medications actually get treated
for HIV/AIDS and in the US only 55% receive ARVs (UNAIDS, 2006). In Eastern
Europe and Central Asia, only 20% receive them (UNAIDS, 2006).
20
Chapter 1: AIDS IN THE SOCIAL, ECONOMIC, CULTURAL
AND POLITICAL CONTEXT
Social Justice and AIDS
More than 95% of new infections take place in so-called developing countries, which
makes AIDS a threat to overall global development. The Russian Federation can be
described as being somewhere in between a developed and a developing country.
Economic struggle has defined many developing countries, especially those in sub-
Saharan Africa, for centuries, while Russia’s poverty is newer and not as all-
consuming as that of the Third World.
The RF’s transition to a market economy has been a great burden to its
population. It has produced male mortality rates as high as those in Zimbabwe
(Stillwaggon, 2006), while at the same time it has produced the most expensive city
in the world Moscow—home to many billionaires living in untold luxuries. A look at
the living standard and state of the middle class in the country, on the other hand,
make clear that it will not develop into a new Sweden or Switzerland overnight, if
ever. What is certain is the fact that AIDS and poverty are interconnected, and that
the disease victimizes those who are already in poverty and marginalized. Russia is
no exception.
21
HIV, Poverty and Africa
The stage for the connection between poverty and AIDS was set in Africa more than
500 years ago with the European conquest and later colonization of Africa as,
according to Irwin et al. (2003), “slave-trafficking, military conquest, colonial rule,
and sustained economic exploitation undermined African’s health directly and
indirectly” (p. 2). However, AIDS is not an “African problem” but rather a
“transnational” one, because the “long history of violence and injustice inflicted on
the African continent by colonialism and neoliberal economic and trade policies
shaped the socioeconomic context in which HIV proliferates” (Irwin et al., 2003, p.
2). According to Irwin et al. (2003), we, as citizens of the wealthy parts of the world,
must accept the HIV crisis as our global crisis, because it is our governments,
armies, businesses, and the financial institutions we dominate that “helped create
many of the conditions that have enabled the rapid spread of HIV infection” (p. 2).
It is no secret that the African continent was devastated in the past by the
colonial interests of Western European powers. It continues to get battered by
displacement, hunger, and exploitation of land and people often resulting from
“development” underwritten by the developed world. This invasion of foreign power
destroyed political and social systems, family structures, broke down indigenous
agriculture, and therefore made Africa susceptible to malnutrition and famine,
illnesses and infectious diseases, including AIDS (Irwin et al., 2003). During the
colonial era, entire peoples were wiped out by military conquest, sickness, or
starvation and even after African colonies began to gain their independence in the
22
1960s, the repercussions of the years of political dislocations and social injustices
left Africa dealing with poverty, weak institutions and epidemic disease created
during the colonial period (Irwin et al., 2003). During the past colonial period
sometimes called “neocolonial,” the new African states remained financially
dependent on the former colonial powers and the financial institutions of the West.
Under pretense of aid for “development” and promised economic growth, the West
continues to push Africa into cooperating with their commercial interests. And when
the World Bank and the International Monetary Fund (IMF) created the so-called
Structural Adjustment Programs (SAP’s), the heavily indepted African countries had
to “accept far-reaching economic reform packages in order to qualify for loan
rescheduling and continued international assistance” (Irwin et al., 2003). These
SAP’s included privatizations of many government assets, public sector cuts
(especially in health care and education), minimizing of labor protections,
elimination of price controls and subsidies on food, and the addition of “users fees”
for health services and education (Irwin et al., 2003, p. 4). As a result, the difference
between rich and poor grows wider.
These programs did not stimulate growth and didn’t help reduce the burden of
debt. SAP’s deepened the poverty and raised unemployment in Africa and in the face
of AIDS (which appeared in 1981—the same year the programs were introduced)
undermined the viability of health services through public sector budget cuts and the
introduction of user fees for the remaining health services that people couldn’t afford
(Irwin et al., 2003).
23
Although it is no secret that HIV is an infectious disease, Stillwaggon (2006)
claims that: “the individual transmission and epidemic spread of HIV are not simply
mathematical functions of sexual behavior” (p. 5). Instead, she claims, HIV infection
is influenced by factors no different than those responsible for the spread of other
diseases:
An established literature in public health and a century of clinical
practice demonstrate that persons with nutritional deficiencies, with
parasitic diseases, whose general health is poor, who have little access to
health-care services, or who are otherwise economically disadvantaged
have greater susceptibility to infectious diseases, whether they are
transmitted sexually or by food, water, air, or other means. (Stillwaggon,
2006, p. 5-6)
AIDS—A Preventable Disease?
From the very beginning, guilt and blame have been heavily assigned to the
discussion of HIV and AIDS. Often the disease is seen as preventable, something
that one has brought upon him- or herself by voluntarily engaging in unsafe
behavior. Citizens of wealthy countries often cannot comprehend the poverty in
which the majority of the world’s population is forced to live in, and the hardships
that come with not having the financial freedom to make diverse “lifestyle choices.”
Health experts and others engaged in HIV prevention have often criticized
people’s apparent unwillingness to use condoms, to stop engaging in commercial
sex, to reduce the number of sexual partners, and to give up needle sharing and other
dangerous practices (Irwin et al., 2003). However, the notion of peoples’ ability to
make free choices is often taken for granted and misleading when it comes to
24
discussing the rapid spread of HIV. Understanding the connection between AIDS
and factors such as economic insecurity, gender and racial inequalities, labor
migration, and armed conflict is key to exposing the reality behind the AIDS
epidemic, which has more to do with socioeconomic constraints than individual
proclivities or cultural attitudes (Irwin et al., 2003). According to Irwin et al. (2003),
stopping HIV/AIDS will require exposing the socioeconomic structures that often
curtail people’s options for avoiding exposure to the virus and using education,
empowerment, and social change to loosen these constraints.
Social, cultural and political forces as drivers for the emerging HIV epidemics
can be visualized in the following diagram:
Figure 2:
Source: Gorbach, P. M., Ryan, C., Saphonn, V., & Detels, R. (2002)
25
When Western health officials propose methods for AIDS prevention in the
developing world, such as asking women in poverty-stricken areas to avoid “sugar
daddies” and use condoms, they often fail to recognize that they are often asking
women to give up their only viable option to support themselves and often their
families (Irwin et al., 2003). However, as Stillwaggon (2006) proposes, short-sighted
cookie-cutter policies in the developing world often “attempt to stop HIV
transmission at the last possible moment, instead of grappling with the underlying
causes of the epidemic (p. 3). Similarly, Irwin et al., (2003) denounces this approach:
The language of sexual or lifestyle choice exaggerates the degree of agency
that many people (especially poor people and women) are able to exercise. It
obscures the extend to which people may be constrained by factors they
cannot effectively control. And it brings with it an implicit tendency to see
people living with HIV/AIDS as the authors of their own misery—
individuals who have acted hedonistically or recklessly and are now suffering
the consequences. Often, the most powerful factor restricting people’s
abilities to make sound choices about sexual practices and substance use is
poverty. In combination with other social factors—above all inequality in the
distribution of wealth and social power—poverty limits people’s options for
protecting themselves and forces them into situations of heightened risk (p.
19-20).
In Russia, for example, HIV/AIDS is still mostly seen as a disease that affects those
who “deserve it.” Gender inequalities and the marginalization of certain groups
further heighten the stigma associated with HIV/AIDS. As Heise and Elias (1995)
explain, for many women around the world, practicing sex work sometimes is the
only survival option (as cited in Irwin et al., 2003, p. 21) and many women’s
economic dependence on men, “sugar daddies”, or even their own husbands, leaves
them unable to negotiate condom use.
26
The interconnection of poverty and AIDS is not only preeminent in people in
the developing world. In the US, AIDS is a disease that disproportionately affects
minorities (half of people living with HIV are African-American, while African-
Americans represent only 12% of the population) (Irwin et al., 2003). The effects of
structural racism and other patterns of social exclusion often exacerbate economic
vulnerability that is mirrored in minorities often not having the same access to HIV
prevention methods and education, as well as access to life-saving AIDS treatments.
Different life circumstances, such as unstable families, having no access to quality
education, lack of job opportunities and individual development, often trigger
disillusionment, despair and indifference. Irwin et al. (2003) notes:
In socioeconomically marginalized communities, chronic unemployment
and the limitations of job options to low-skill, low-wage positions
frustrate and humiliate men still taught to see themselves as economic
providers. Combined with the effects of racism, endemic poverty breeds
fatalism and deep-seated anger that may encourage both personal risk-
taking and indifference to other’s welfare (p. 25).
This pattern is seen in low-income countries with generally low living
standards, but also in wealthy countries where undereducated people in poor
neighborhoods often find themselves in the same situation of poverty and
disillusionment. An ethnographic study done by anthropologist Philippe
Bourgois (1997) found that “in the day-to-day experience of the street-bound
inner city resident, unemployment, and personal anxiety over the
impossibility of providing a minimal standard of living for one’s family
translate into intracommunity crime, intracommunity drug abuse,
intracommunity violence” (as cited in Irwin et al., 2003, p. 25-26).
27
All these factors create an enabling environment for the spread of HIV,
while exacerbating the lack of personal agency for people in poverty to make
lifestyle “choices” and limit their risk-taking behavior.
In the Russian Federation, poverty, unemployment and economic
instability often breed the same risk-taking behavior, despair and
indifference. As a result of jolting social change, widening inequalities with a
new market economy and the consolidation of the transnational drug-
trafficking networks in the regions, crime, violence and injecting drug use is
soaring, as are HIV infection rates. Therefore, it is just as important to
address the social drivers of AIDS as it is to important to address all other
contributing factors. The low status of women, poverty and inequality are
reflectors of human rights issues that must be addressed, because, as Dr. Peter
Piot stated at the XVI International AIDS Conference in Toronto (2006):
“[a]n AIDS response that is not as embedded in advancing social justice as in
advancing science is doomed to failure.”
CEE/CIS and the Russian Federation in Transition: The HIV Epidemic as a
Result of Hardships, Disillusionment and Social Dislocation
With the opening of the borders in 1989, massive political, social, cultural and
behavioral changes in the countries of the former Soviet Union, in addition to the
collapse of the public health infrastructure, have created circumstances conducive to
the rapid spread of HIV. The transitions have been accompanied by poverty, mass
28
unemployment, political and social instability, and economic insecurity
(Stillwaggon, 2006). Similarly to Africa, Eastern Europe’s transition to a market
economy was and still is being carried out on the backs of the poorest and weakest:
Russia and the numerous newly independent states formerly part of the Soviet Union
have implemented harsh austerity measures to meet the demands of international
financial institutions and Western governments providing “aid” and loans during this
transition. As a result of these budget cuts, public health services have deteriorated
leaving countries ill-equipped to prepare for or respond to the HIV/AIDS threat
(Irwin et al., 2003).
In Central and Eastern Europe and the Commonwealth of Independent States
(CEE/CIS) the HIV epidemic is new and still concentrated, meaning that most HIV
infections can be still found in defined high-risk groups, such as injecting drug users
and commercial sex workers (Green, 2003). An increase in drug use, especially
amongst young people, is partly fueled by a new situation of instability and
insecurity that is felt by the populations, and partly due to a lack of control and stable
political policies in the countries and at the open borders. Furthermore, UNAIDS and
the WHO suggest that the widespread drug use combined with shortages in job
opportunities and the increasing number of young people failing to complete
secondary school implies that, unfortunately, many of them are yet to join the ranks
of vulnerable groups such as IDUs, commercial sex workers and prisoners (as cited
in Irwin et al., 2003, p. 8).
29
Unstable political, economic and social systems have fostered organized crime,
which now widely controls drug trafficking and prostitution at the borders. For
example, as a result of the transition, the HIV epidemic today is largely driven by
increased import of heroin from Afghanistan, where production increased from about
20 metric tons per year to about 430 metric tons per year, making the country the
global leader in heroin production and export (Green, 2003). In some areas in Russia,
heroine is said to be cheaper than alcohol.
However, the fact that many international AIDS organizations’ and
prevention campaigns’ focus on drug and sex behaviors as the drivers for the
epidemic often masks the broader picture of HIV in Eastern Europe. The epidemic in
these regions must be analyzed in the context of falling living standards and the
collapse of public health services, and thus within the context of economic decline
and disease vulnerability, as Stillwaggon (2006) notes:
The portrayal of the HIV epidemic in the transition economies in
behavioral terms has the effect of emphasizing individual choices,
rather than the causes of those behaviors or the context of poverty that
not only produces the behavior but also makes it more dangerous.
There are two important effects…first, the solutions proposed are, as
in Africa, Latin America, and Asia, exceedingly late; second, it is
politically very easy to write off those affected because they are
members of marginalized, denigrated groups. An epidemic among sex
workers and needle sharers is a problem that many government
officials and citizens think they can ignore (p. 106).
To understand the broader context of HIV in the former socialist economies, several
key factors must be considered. All of the former socialist countries experienced a
sharp decrease in production and GDP during the first five years of transition,
between 1989 and 1994. This, of course, resulted in falling income and a sharp
30
decline in the standard of living. In 1994, all but three of the 25 transition countries
had GDP per capita below that of South Africa, and all but six were below the
average for Latin America and the Caribbean (Stillwaggon, 2006). Most of the
transition countries began to recover after that, however by 2002, only seven
countries had achieved the output of 1989 (Stillwaggon, 2006).
After the transition to capitalism, many of formerly state-run institutions
became privatized. After the privatization, few resources were left to provide for
nutrition, health services, and education for displaced workers and their families
(Stillwaggon, 2006). With the new changes in the economy, unemployment rates
soared and in 2001, 11 countries had official unemployment rates of over 10%
(Stillwaggon, 2006).
1
In 1999, there were 18 million people between the ages of 15 and 24 who
were neither in school nor employed in Central and Eastern Europe (Stillwaggon,
2006). In all but three countries, real wages had fallen considerably since 1989, in
some countries well below 50% of what they were before the transition (Stillwaggon,
2006). These figures are also probably underestimates, for many services that were
previously provided by the state, including free housing at times, were no longer
existent. In addition to that, the transition to a free market economy translated into
lower or nonexistent fringe benefits, reduced vacation time and longer working hours
(Stillwaggon, 2006). Food production fell significantly, which had an impact on
actual availability of food for consumption, as many markets could not sustain

1
It is worth noting that official unemployment rates were generally much lower that
those measured by independent Labor Force Surveys.
31
sufficient import of foreign foods. During the socialist era, the state also provided for
educational, cultural, sports, leisure and transportation facilities and after 1989, the
lack of these services was felt in the functioning in everyday social life (Stillwaggon,
2006).
In the face of these collapsing economies and shrinking opportunities, work
migration became more prevalent. As seen in many African and Latin American
countries, migration generally plays a part in health and social abuse by, according to
Stillwaggon (2006), “undermining long-term unions and increasing the possibility of
exposure to sexually transmitted diseases” (p. 115).
Economic crises and the resulting stress can also be reflected in rising rates of
divorce, suicide, homicide, prostitution, and drug use (Stillwaggon, 2006). For
example, after 1989, there was a sharp increase in births amongst unmarried women
under 20 (Stillwaggon, 2006). In all but three countries in Eastern Europe and the
former Soviet Union, an increase in rates of homicide, suicide, and accidents (mostly
alcohol-related) could be observed. The former socialist countries have populations
that are amongst those with the highest rate of suicide for all ages, including for
females (Stillwaggon, 2006).
In addition, as Stillwaggon (2006) writes, opening the borders has also
implied an increase of tourism, including sex tourism, in Eastern Europe and the
countries of the former Soviet Union:
The poverty at home creates pressure to tolerate the migration of family
members for commercial sex work. Increasing stress, alcoholism, and drug
use in these countries are also producing more dysfunctional families that
32
permit, and even promote, the trafficking of their daughters for commercial
sex work (p. 118).
Prostitution in the former Soviet Union, as everywhere in the world, has always
existed, though far more discreetly, without the blatant advertisements for sex work
now common in the Eastern Europe and the Baltic states (Stillwaggon, 2006).
However, human trafficking is a new phenomenon for the area, due to the lifting of
the previously tight borders of the former Soviet Union. What is also new is the lack
of social stability and security that young people have in the transition economies,
which sucks them into the Western sex market as well as allows for Western clients
to have access to them in Eastern Europe (Stillwaggon, 2006). Today, prostitution is
mostly run by organized crime, with women and girls not only being sold within
Eastern Europe, but also exported to Western Europe and Scandinavia. Moustgaard
(2002) found that the most common destinations for trafficking are Germany and the
United Kingdom, followed by the Nordic countries and the Netherlands (as cited in
Stillwaggon, 2006, p. 119). The new freedom of in- and outflow of people has
fostered the explosive growth of both prostitution and trafficking, forced and
voluntary (Stillwaggon, 2006). It is estimated that as many as half of the women and
girls are trafficked by force or trickery, while some villages in the Nordic countries
have been converted into sex clubs and reports of prostitution concentration camps in
numerous countries where women are kept imprisoned behind barbed wires and in
unimaginable conditions are not uncommon Stillwaggon, 2006). This is a problem
that is likely to persist in the current political and social climate of the transition
countries, since, according to Moustgaard (2002), the “large-scale networks control
33
60 percent of prostitution in Western Europe, as well as drug trafficking” and have
“solid political and financial contacts in the countries of origin, destination and
transit” (as cited in Stillwaggon, 2006, p. 119).
According to Stillwaggon (2006), the increase in drug use should also be seen
as a result of this economic and social distress: “Supply of drugs, part of the legacy
of the Soviet war in Afghanistan, and partly the result of increasingly organized
crime groups, is one aspect of the problem, but a social crisis has produced the
demand” (p. 120). Many young people, especially young males, fail to sufficiently
provide for their families and be productive members of society, and as a result
become a burden to both. Projecting symptoms of a crushing social and economic
system, mentally and/or physically unhealthy men with alcohol and drug addictions
often abuse their wives and children and pass on tuberculosis, STIs, including HIV,
onto them (Stillwaggon, 2006).
Another indicator of the worsening health situation in Eastern Europe and the
Commonwealth of Independent States are the explosive tuberculosis rates. This has
implications for HIV and AIDS, because tuberculosis is one of the opportunistic
diseases people living with HIV most often succumb to, and because in people with
TB, HIV more rapidly progresses to full-blown AIDS (Stillwaggon, 2006). Not
coincidentally, nearly two-thirds of the people living with HIV or AIDS are living in
the countries with the highest tuberculosis burden in the world (Stillwaggon, 2006).
In addition to that, there have been epidemic increases in the rates of non-HIV
sexually transmitted infections (STIs), such as syphilis and gonorrhea, after the
34
collapse of the Soviet Union. For instance, the syphilis rate in Russia in 1988 was 4.2
cases per 100,000 people; by 1997, it had increased to 277 cases per 100,000 (Kelly
& Amirkhanian, 2003). While increases were most sharp amongst young people,
high prevalence of STIs is an indicator of high-risk sexual behavior in the population
(Kelly & Amirkhanian, 2003). Furthermore, STIs biologically facilitate the
transmission of HIV and are likely to increase the speed and efficacy of infection
between infected and uninfected partners (Kelly & Amirkhanian, 2003).
The current statistical data on the transition economies are suspected to
grossly underestimate the actual number of people living with HIV (UNAIDS,
2004). All current data are based on people who have been officially tested for HIV,
thus people who have come into contact with HIV-testing programs (mainly
injecting drug users). Other stigmatized at-risk groups such as men who have sex
with men are more likely to not have been tested for HIV, which implies that hidden
epidemics might be occurring in other segments of the population (UNAIDS, 2004).
HIV/AIDS in the Russian Federation: Considerations and Enabling Factors
As previously mentioned, Russia bears the worst AIDS epidemic in the Eastern
European and Central Asian regions with UNAIDS estimates of nearly one million
infections and prevalence of over 1 percent in the adult population (2006). The
official number of HIV infections was 311,414 in 2005 and most certainly
underestimates by far the reality of HIV/AIDS in the RF (Babakian, 2005). It is
evident that although the epidemic is still in its early stages, it is advancing at a
35
steady rate. Increasingly, HIV/AIDS is starting to break out of high-risk populations,
such as IDUs, and spreading more and more through heterosexual sex. Although in
Moscow in 2000 drug use caused over 80% of the new HIV infections and
heterosexual sex just 10%, by 2004 the proportions were nearly half and half
(UNAIDS, 2004). Currently, HIV has been detected in 88 of the country’s 89
administrative territories, but it is spreading unevenly across the country: 10 of those
territories account for approximately 60% of HIV cases (UNAIDS, 2004).
The difficulty of HIV surveillance and control in the Russian Federation is
partly due to the sheer size of the population and the country itself. The Russian
Federation covers a territory of 17 million sq km and is the largest country in the
world in terms of surface area. The country is divided into 49 oblasts (regions), 21
republics, 10 autonomous okrugs (territories), 6 krais, 2 federal cities (Moscow and
St. Petersburg), and one autonomous oblast—all of these making up a total of 89
equal “federal subjects” (Tragakes & Lessof, 2003). There is a wide range of
different climates, from those of steppes in the South, to sub-arctic in Siberia. Russia
is home to an estimated 143.2 million people, with a decreasing and aging population
since 1992. The capitol is Moscow, with a population of 9 million. The official
language is Russian and the largest religious group is Russian Orthodox, with a large
population of Muslims and a substantial number of atheists (Tragakes & Lessof,
2003). The literacy rate is high at 98.4% (Tragakes & Lessof, 2003).
Clearly, creating HIV prevention programs that serve a country of this size
and diversity can be daunting. Immense economic differences within the population
36
have to be taken into consideration when developing programs. Certain audiences
may have access to sophisticated media outlets and modern health care centers, while
other populations often don’t even have access to running water. The transition to a
market economy has further deepened class distinctions, while the recent changes
have produced a more complex social, political and economic environment.
Cultural, Social, Political and Economic Background in The Russian Federation
Horne (1999) found that the social changes in the CEE/CIS region have affected
“family roles, relationships, and life stability, and have exacerbated such social
health problems as alcoholism, reduced life expectancy amongst men, self-
destructive behaviour, and violence” (as cited in Kelly & Amirkhanian, 2003).
Chervyakov & Kon (1998) and Kon (1995, 1997, 1998) found that:
Traditional Russian cultural factors, such as fatalism caused by the
ideological influence of orthodox traditions, limited knowledge and skills
concerning sexual hygiene, and the low value placed on personal health may
contribute to the rise of STIs and HIV in Russia. A deep change in the sexual
morals and lifestyles in Russia has led to the social acceptance of prostitution
and of temporary sexual relationships among young people” (as cited in
Amirkhanian et al., 2003, p. 205).
As most people in countries in the region of CEE/CIS, Russians were severely
affected by the economic changes that followed after 1989. The growing economic
inequality prevalent since 1990 resulted in the top 10% of the population accounting
for a third of the total income while the bottom 10% accounting only for about 3%
(Tragakes & Lessof, 2003). The rapid deterioration of health with rising mortality
rates and falling life expectancy found in all transition countries has been especially
37
harsh in Russia (Stillwaggon, 2006). According to the World Bank (WDI, 2004),
Russian men have a life expectancy shorter than that of men in Bangladesh and
Bolivia (as cited in Stillwaggon, 2006, p. 126). For instance, Adeyi et al. (1997)
found that a 15-year old male has a 55% chance of dying before the age of 65 (as
cited in Stillwaggon, 2006, p. 127). The factors that cause these high mortality rates
include alcohol, smoking, diet, pollution and occupational hazards. However it must
be noted that unhealthy, self-destructive behaviors such as these are at least partly
symptoms of a collapsing social and economic system (Stillwaggon, 2006).
As in other transition economies, a deteriorating economy started producing
unhealthy, disillusioned men and women who then fell into the circle of abusing
themselves and those around them. Real wages for Russians had fallen to 52.7% in
2001 from what they were in 1989. In 2002, almost 40% of the unemployed were
under the age of 30, while the largest group was confined of people 20 to 24 years of
age (Stillwaggon, 2006). In 2003, Human Rights Watch reported food shortages so
severe in Russia, that there were deaths from starvation and malnutrition-related
infectious diseases among military personnel, while half of pregnant women were
undernourished and only one-third of children could be categorized as healthy (as
cited in Stillwaggon, 2006).
Russia is amongst the countries with the highest incidence of young male
(age 15-19) suicide, with rates more than twice those of other transition countries (in
2001, 39.3 suicides per 100,000; double the rate of 1989) (Stillwaggon, 2006). Child
pornography and trafficking are increasingly serious problems in Russia as well, due
38
to a lack of laws restricting either (Stillwaggon, 2006). The export of Russian women
and girls into Western Europe and beyond is common; for example, there are an
estimated 10,000 women in prostitution in Latvia, 75% of them of Russian ethnicity
(Stillwaggon, 2006). This increase in prostitution in Russia has also been
complimented by an increase of injecting drug use amongst female sex workers. This
is daunting, especially considering the fact that Moscow alone has up to 70,000 sex
workers and the Open Society Institute (2001) estimates that in some cities in Russia,
40 to 80 percent of sex workers are HIV-positive (as cited in Stillwaggon, 2006, p.
121). Many of the injecting drug users are in prison, where a study conducted by
Medicins Sans Frontiers in seven Russian prisons found that 43% of the inmates
were injecting drugs, while 14% of those had started in prison (as cited in
Stillwaggon, 2006, p. 121). Even more troubling, another recent study conducted by
the Central and Eastern European Harm Reduction Network (CEE-HRN) (2002)
study estimated that one-half of Russian college students had injected drugs (as cited
in Stillwaggon, 2006, p. 121). Tuberculosis rates in Russia are also one of the worst
in the world. Since 1992, TB prevalence has increased by 10-15% per year, while it
is 45 times that of the United States (Stillwaggon, 2006).
History of the Spread of HIV/AIDS in Russia
Research on HIV/AIDS began in the former Soviet Union in 1985 as a purely
academic exercise, because there were no cases known yet in the region. The first
case of HIV infection was detected in a South African resident, who had lived in
39
Central Africa and was probably infected through heterosexual contact there
(International Labor Organization, n.d.). In the following two years, more than 100
cases of infection were discovered amongst foreign students in Russia (ILO, n.d.).
Mandatory testing of blood supplies and organ donors was introduced in 1988, while
the government established mandatory reporting of HIV-related data in the Sanitary
and Epidemiological Surveillance Service (SES). The AIDS Centers were created
and HIV databases were developed to be found in the Federal AIDS Control
Research Centre of the Russian Federation’s Ministry of Health (ILO, n.d.).
In the years 1987 and 1988, several dozen cases were diagnosed among
Russians with almost half of the infections found in men who had sex with men and
about 40% stemming from heterosexual contact (ILO, n.d.). Several people were
infected through blood transfusions, although that number remained low. Outbreaks
amongst children at children’s hospitals were detected in 1989, due to medical staffs’
noncompliance with hospital infection control rules (e.g. reuse of syringes) and
excess prescription of injections (ILO, n.d.). From 1990 to 1995, infection rates were
relatively stable, with approximately 100 to 200 infections annually, although
between 20 and 24 million people were tested each year (ILO, n.d.).
In 1995, the first infections amongst injecting drug users were discovered.
That year marks the beginning of the major HIV epidemic in Russia. In 1996, there
were 1,526 new cases, in 1998 there were 8,067, 19,846 in 1999, 59,340 in 2000 and
47,034 for only the first half of 2001 (ILO, n.d.). Injecting drug use accounted for 80
40
to 90 percent of all new transmissions. The majority of HIV cases were found in
large cities—Moscow and St. Petersburg were most affected (ILO, n.d.).
The Federal Law On HIV Control in the Russian Federation was passed in
1995 and is still in effect (Polubinskaya, 2004). It defines certain government
commitments, such as the free provision of health services to people with HIV,
social support, education, retraining and employment of people with HIV (ILO, n.d.).
Testing was made voluntary and anonymous, mandatory only for blood and
transplant donors and certain occupations, enterprises, businesses and institutions
defined by the government (ILO, n.d.). Foreigners coming into the country also have
to present HIV clearance certificates and foreign residents are subject to deportation
if an HIV infection is present (ILO, n.d.). Furthermore, the law protects HIV-infected
Russian persons and their family members from discrimination, grants some special
benefits to them, and guarantees their civil rights with no limitations. Although the
new law also guaranteed funds for HIV/AIDS control through the year 2000, funding
was only provided through 1998, and even then fell short of the actual plan (ILO,
n.d.). The program supplied testing kits, diagnostic equipment and very limited
amounts of medications to all regions of Russia, but only 10 percent of the funds
went towards preventative action (ILO, n.d.).
Most of the HIV/AIDS prevention initiatives are provided by non-
governmental organizations (NGOs) involved in the Russian Federation. There are
probably over 100 different programs claiming affiliation, but few are actually active
(ILO, n.d.). Some Russian public organizations are Infoshare, Moscow; Open
41
Society Institute/Soros Foundation, Moscow; New Age (Novy vek); SPID-
infosvyaz; Humanitarian Project (Gumanitarny Proekt); Return (Vozvrashchenie);
AIDS. Sex. Health Association (Assotsiatsia "SPID. Sex. Zdorovye"); Ogonyok-
VID-Anti-SPID Charity Foundation; We & You Association in Support of National
AIDS Program ("Mi i Vi"); Gera Information and Education Center; Regional
Branch of Future Without AIDS Charitable Organization of Women ("Budushchee
bez SPIDa"); and Accent ("Aktsent") (Osadcheva, 2003). Unfortunately, only 3 to
4% of people know about the public organizations that are actively involved in
solving the problems connected with the fight against drug abuse and AIDS
(Osadcheva, 2003). Many point to their inactivity.
Often, Russian NGOs are funded solely by international organizations, such
as The Global Fund (UNAIDS), and there are many international organizations
active in the Russian Federation. These include Medicines Sans Frontiers
International Humanitarian Organization; UNAIDS – Joint U.N. Program on
HIV/AIDS; UNESCO; UNICEF; The World Health Organization (WHO); and
UNFPA – U.N. Population Fund (Osadcheva, 2003).
Health Care in the Russian Federation
Health Status Beyond HIV/AIDS
The current health status in the Russian Federation is in large part a result of
Russia’s health care system as it existed long before the transitions. The Russian
Federation has had a history of low life expectancy rates throughout the Soviet
42
period as well as after 1990. Improvements had been made continuously until the
1960s, when life expectancy rates stabilized and remained at the same levels during
the following 30-year period (Tragakes & Lessof, 2003). While Western countries’
life expectancy continued to increase over the years, the Russian Federation’s rates
for males remained roughly the same (in 1990, it was 63.8 years compared to 64.3 in
1965) and increased only slightly for females (74.3 years in 1990 compared to 73.4
in 1965) (Tragakes & Lessof, 2003). More troublesome, the gender disparity in life
expectancy in the Russian Federation in the 1980s was the largest in the world with a
12-year difference. According to Tragakes & Lessof (2003), the declining health
status of Russia after the 1960s has been attributed to the following:
Over and above its medical orientation, the health care system suffered
greatly from under-funding as the military demands of the Cold War, and in
particular the race to build missiles, took precedence over all social issues.
The paternalistic Soviet philosophy did not encourage the development of
responsibility of the individual with respect to lifestyle issues that have a
major bearing on health (alcohol use, smoking, diet, etc.), a situation
exacerbated by the heavy dependence on alcohol sales as a means of
circulating currency in a country with little access to consumer goods. And
Soviet medical science was effectively isolated from developments in the
West, not only in terms of knowledge of new treatments but also access to
pharmaceuticals, technology, and the emerging evidence based medicine
movement. The USSR failed to develop a modern pharmaceutical industry
and was dependent on imports from eastern Europe and South Asia. As a
consequence, many ineffective treatments that had either never been adopted
or had long been abandoned in the West remained routine and innovations
developed in the west were not adopted. The consequences can be seen from
the way that rates of avoidable mortality, or deaths that should not occur in
the presence of timely and effective care, remained high in Russia from the
late 1960s onwards at a time when they were falling steadily in the west (p.
9).
By the 1980s, the difference in life expectancy between Russia and the Western
nations were 10 years for men and 6 years for women (Tragakes & Lessof, 2003).
43
Recognizing the fact that many unnecessary deaths in the population were caused by
consequences of heavy alcohol use (e.g. accidental poisoning, sudden cardiac death,
hypertension, suicide, homicide), the government launched an anti-alcohol campaign
in 1985 (Tragakes & Lessof, 2003). The measures were highly effective at first, but
soon after the campaign was abandoned (due to an increase in illicit production and
recovering levels of consumption), death rates resumed. The campaign had failed to
target behavior and attitude change in the population, and was rather prohibitive in
nature (Tragakes & Lessof, 2003).
In 1991, faced with already high mortality and low life expectancy rates
compared to its Western counterparts, the Russian Federation was not prepared to
absorb the unprecedented shock to its health and demographic profiles (Tragakes &
Lessof, 2003). Decrease in birth rates and increasing mortality led to a declining
population that became negative in 1992 (Tragakes & Lessof, 2003). Economic
uncertainty led to a decrease in births and even higher rates of alcohol and,
increasingly, drug abuse. A decrease in fertility can also be observed, partly
attributed to the spread of STIs that had taken on epidemic proportions. For example,
syphilis rates in the RF are the highest in the European region, while incidence has
increased 77 times since 1990, and about 50 times for girls between 10 and 14
(Tragakes & Lessof, 2003).
Today, the life expectancy for males in the Russian Federation is only 59
years, while for women it is 72 years—a difference of 13 years between the genders
(WHO, 2006). For men, it is now actually around five years lower than 40 years
44
ago—a collapse in life expectancy otherwise only found in sub-Saharan Africa. The
leading cause of death is cardiovascular disease, which is mainly attributed to poor
diet, smoking and heavy alcohol use (Tragakes & Lessof, 2003). The rate of heart
disease in Russia is speculated to be the highest anywhere, ever (A Sickness of…,
2006). The second most prominent cause of death are external factors, such as injury
and poisoning, which includes suicide, homicide and alcohol poisonings, with rates
much higher than those in Western nations. The male mortality rate in this category
is over four times higher than that for women, accounting for approximately half of
the deaths of working-age men (Tragakes & Lessof, 2003). Heart disease and
violence, the two prominent mortality causes, are strongly alcohol-related (A
Sickness of…, 2006). The Russian’s propensity to die violently is probably
unprecedented in industrialized industries at peace (A Sickness of…, 2006). The
suicide rate is more than five times that of Britain, and with fewer cars, Russians are
four times more likely to die in traffic accidents. Murder is more than 20 times more
common than in Western Europe (A Sickness of.., 2006). 36,000 Russians died of
alcohol poisoning last year alone. In comparison, in America, it generally kills about
a few hundred (A Sickness of…, 2006). Many consume strong spirits sometimes not
fit for human consumption, as they are produced illegally or by private individuals.
Many children, especially those who are from homes of drinkers, start consuming
alcohol at 13 years of age, or even younger.
Tuberculosis (TB) rates have been continuously high since 1990. For
instance, in 1998, the official TB prevalence was 74 cases per 100 000, which placed
45
the Russian Federation in the top ten countries in the world (Tragakes & Lessof,
2003). These may be underestimates, since the infection rates among homeless
people and refugees are unknown (Tragakes & Lessof, 2003). The infection rates
amongst prisoners in Russia are especially high with one in ten being infected and
with approximately a third of all TB sufferers being in penal institutions (Tragakes &
Lessof, 2003).
Health System and HIV/AIDS Surveillance and Prevention—Theory and Practice
The Russian Federation inherited its current health care system from the former
Soviet Union. It was heavily influenced by a “fear of infectious diseases, by a belief
in the primacy of the industrial worker, and by a commitment to pro-natalist policies
and mother and child health which were to secure the next generation of workers and
citizens” (Tragakes & Lessof, 2003, p. 117). After the dissolution of the Soviet
Union in 1991, the health care system, as well as the administrative system, were
decentralized.
Osadcheva I.I., Khodzhemirova N.D., Kuchma V.R., Alisov D.A., Kulagina
Y.V., & Kuznetsova Y.S. (2003) identified the following entities as being involved
in prevention and treatment of HIV/AIDS in the Russian Federation:
• Health Ministry of the Russian Federation, AIDS Department
• Health Ministry of the Russian Federation, Narcology Scientific
Research Institute
46
• Health Ministry of the Russian Federation, Ivanovsky Virology
Scientific Research Institute
• Russian Academy of Medicine
• Russian Scientific and Methodological Center for AIDS Prevention
and Treatment, plus similar centers in each of the Russian Federation
regions (89 total)
• Russian State Medical University (Virology Laboratory)
• Moscow City Second Clinical Hospital for Infectious Diseases
• Moscow City Center for AIDS Prevention and Treatment, Moscow
Sanitary and Epidemiological Inspection, Anti-HIV (Scientific Center
for AIDS Prevention)
• AIDS (Immunology) Laboratory
The current health care system in the Russian Federation is divided into three levels:
the federal, the regional and the municipal. At the federal level, the Ministry of
Health is the highest administrative body, led by a minister who is appointed by the
prime minister and approved by the parliament (Tragakes & Lessof, 2003). As the
central policy formulating body, it has responsibilities spanning from developing and
implementing federal health programs (including initiatives on TB, AIDS, health
promotion and education, and disease prevention), epidemiological monitoring and
health statistics, control of infectious diseases and control and licensing of drugs
(Tragakes & Lessof, 2003). In addition, the Ministry of Health has federal targeted
programs, which deal specifically with issues such as TB, immunization, diabetes as
47
well as HIV/AIDS (Tragakes & Lessof, 2003). The AIDS Centers are establishments
located in all major cities and regions and are involved in information and analytical,
organizational and methodological, treatment and prevention, and consultation
efforts (Osadcheva et al., 2003). Other institutions are devoted to HIV-related
research, as well as general epidemiology and virology.
The Russian Federation guarantees universal health care for its citizens. A
new compulsory health insurance system was implemented in 1993 in order to
address the severe under-funding of health care (Osadcheva et al., 2003). The
Ministry of Finance plays a large role in health care as it is responsible for
formulating national budgets and determining funding levels, including for issues of
health care financing such as the levels of health insurance contributions (Tragakes
& Lessof, 2003). The federal Mandatory Health Insurance Fund (MHIF) was
established in addition to numerous territorial MHIFs at the regional level so as to
collect and manage insurance revenues from payroll tax on employers on behalf of
the working population as well as regional government contributions on behalf of the
non-working population (Tragakes & Lessof, 2003). These institutions then pass on
the revenues to independent third-party payers, either insurance companies or
branches of territorial MHIFs in the event that no insurance companies have been set
up in a particular area (Tragakes & Lessof, 2003). The insurance companies (or
branches of MHIFs) then engage in selective contracting with providers, as they
monitor utilization, quality and finance and encourage both primary care and
preventative measures (Tragakes & Lessof, 2003). Patients have also the option of
48
voluntary health insurance in order to obtain additional services beyond those
included in the basic package.
In practice, however, the public funds are by far insufficient to meet the
commitments of free health care. For example, even though theoretically
pharmaceuticals are supposed to be dispensed free of charge in hospitals, in reality
patients often have to pay themselves (Tragakes & Lessof, 2003). The conditions of
equipment and facilities have significantly deteriorated as a result of financial
constraints (Tragakes & Lessof, 2003). For example, 45 percent of the hospitals lack
bath and shower facilities and 15 percent of the rural hospitals don’t have running
water (Tragakes & Lessof, 2003). In addition to that, due to the massive
decentralization, the level of control exercised during the Soviet era has clearly
declined, not least due to unclear legislation regarding the respective authorities of
agencies such as the Ministry of Health and the Ministry of Finance and lack of
enforcement.
Under-the-table payments in the health sector are also very common as part
of the larger context of corruption in Russia (Tragakes & Lessof, 2003). A study on
corruption by the Danish government and the World Bank concluded that Russians
pay $36 billion per year in bribes, with health care absorbing the largest share of
these bribes with over $600 million annually (Tragakes & Lessof, 2003). A bulk of
these payments are made in hospitals, most of the time to doctors and nurses. Often,
patients who are able to make large bribes to the medical staff receive preferential
49
and speedier treatment while disadvantaging other patients possibly in more urgent
need for medical attention.
Currently the State Department for Sanitary-Epidemiological Surveillance
(SES) of Russia’s Ministry of Health is responsible for implementing core public
health services, including HIV/AIDS control programs. There are periodic meetings
of various ministries and agencies assuring coherence with other ministries and
government agencies, but inter-agency coordination of HIV/AIDS programs remains
inadequate (ILO, n.d.). The AIDS control centers, 95 in total, with assistance from
the SES centers fulfill the main duty of HIV/AIDS control. Most of the AIDS centers
have diagnostics and medical treatment as their priority, with very little budget
devoted to HIV prevention (ILO, n.d.). The SES stations are prevalent all over the
country reporting upwards from local to federal level and ultimately to the Ministry
of Health (Tragakes & Lessof, 2003). Their functions include, amongst others,
communicable disease prevention and control, immunization, hygiene of children
and teenagers, health and nutrition in kindergarten, epidemiological health, control
and analysis, control of working conditions, health education and promotion of
healthy lifestyles (Tragakes & Lessof, 2003).
The free medical care and pharmaceuticals as stipulated by the Guaranteed
Package Programme of the Russian Federation include coverage of people with
HIV/AIDS. Yet less than 5% of HIV/AIDS patients received life-prolonging
medications in 2005 (Selis, 2005). In addition to that, Russian law protects all HIV-
positive people from discrimination and stigmatization. In reality however, this is not
50
so. People with HIV/AIDS in Russia face severe discrimination in the workplace, at
school, from society as a whole and even in clinics from doctors and nurses
(Klomegah, 2006). For instance, a Human Rights Watch report showed that HIV-
positive women and children are subject to abandonment not only by society, but
also by a government that turns a blind eye to discrimination they face (Klomegah,
2006). Many women reported of having been verbally abused by medical staff and
even having been denied treatment, as well as doctors having breeched their
confidentiality, which can have dire consequences for them such as losing one’s
home, one’s job, and not receiving any medical attention. For this reason, many
infected women hide their status from their families, co-workers, and friends, and do
not seek out counseling and support (Klomegah, 2006). More than 20 percent of the
10,000 children born to HIV-positive mothers in Russia to date have been abandoned
by their parents. Children born to HIV-positive mothers face discrimination and
abuse from day one: They are first put in isolated hospital wards for the first 18
months of their lives until their status is known. Then they may be sent to
orphanages specializing in children with HIV/AIDS. They may not be accepted into
a kindergarten or school because teachers are ignorant to how the disease is spread
and think that it can be transmitted through casual contact.
A Light on the Horizon
AIDS arrived in Russia much later than in many other nations across the world. One
might assume that the country should have been accordingly prepared as a result.
51
“Instead, out of prudishness, intolerance and Soviet-style pig-headedness, the
response was criminally lackadaisical,” an article (A Sickness of.., 2006) in the
Economist claims. Finally this year, Russia’s Vladimir Putin committed to fighting
the epidemic publicly.
Despite all the disillusionment and devastation that stem from AIDS, there is
some hope for Russia. Three months after Bush’s introduction of PEPFAR in 2003,
Russia’s president Vladimir Putin finally recognized the need to put AIDS on his
political agenda. Last year, Putin made it his priority to communicate to the public
about the dangers of AIDS and to increase the federal funds to $124 million on
HIV/AIDS programs from only $5 million the previous year. Recently, the Moscow
City Council asked Putin to ban foreign health charities from AIDS projects in the
capital of the free distribution of condoms and clean needles for injecting drugs,
which they say would undermine Russians' morality. Putin, however, declined,
saying that foreign assistance is crucial to stopping the disease from becoming an
epidemic and further reducing Russia's already declining population numbers.
The first steps have been made for Russia. With President Putin’s
acknowledgement of an AIDS problem and UNAIDS’ recognition of the need to
intervene in the regions of Eastern Europe and Central Asia, the epidemic could be
significantly slowed or even halted.
52
Chapter 2: ANALYSIS AND EVALUATION OF HIV
PREVENTION
The Global Response
Many organizations on the local, national and international level have been
developed over the years. Although the sheer number of different institutions is
enormous, we shall take a look at the bigger international ones that provide the main
funding for many programs over the world. They have many functions, including
gathering information, monitoring developments, organizing meetings and
conferences on HIV/AIDS, and providing resources to smaller local organizations.
The following organizations are fundamental parts of the global fight against
HIV/AIDS, because they are substantive entities with substantial efforts worldwide.
UNAIDS
The Joint United Nations Programme on HIV/AIDS arguably the most important
organization fighting against global AIDS. It unites the efforts and resources of ten
UN system organizations behind the global AIDS response. These include UNHCR,
UNICEF, WFP, UNDP, UNFPA, UNODC, ILO, UNESCO, WHO and the World
Bank. Based in Geneva, UNAIDS works with more than 75 countries worldwide.
The 189 participating nations acknowledged that the AIDS epidemic
constitutes a “global emergency and one of the most formidable challenges to human
life and dignity.” With the Declaration of Commitment on HIV/AIDS (adopted in
2001) and the Millennium Development Goals, the world has agreed on a set of
53
commitments, actions and goals to stop and reverse the spread of HIV. The
Declaration of Commitment covers ten priorities, from prevention to treatment to
funding. It was designed as a blueprint to meet the Millennium Development Goal of
halting and beginning to reverse the spread of HIV/AIDS by 2015.
The Global Fund
The Global Fund to fights AIDS, Tuberculosis, and Malaria (GFATM) was created
by the United Nations to dramatically increase resources to fight three of the world's
most devastating diseases, and to direct those resources to areas of greatest need. It
works with over 115 countries worldwide solely as a financial instrument
distributing funds, not as an implementing entity. Instead it relies on local experts
and research where available. As a partnership between governments, civil society,
the private sector and affected communities, the Global Fund represents an
innovative approach to international health financing. Recently, the Global Fund
allocated $27 million towards several programs in 8 countries in Eastern Europe and
Central Asia for a period of two years.
The Bill & Melinda Gates Foundation
The Bill & Melinda Gates Foundation has done outstanding work, especially
considering that it is based on the generosity of only one man. Preventing the spread
of HIV is the main focus of the organization. It supports efforts to stop HIV
transmission, including funding research for a safe, effective, and affordable HIV
vaccine; microbicides-gels or creams for women; large-scale initiatives to expand
54
access to existing HIV prevention tools; and building commitment for a science-
based approach to stemming the epidemic. In 2006, the Bill & Melinda Gates
Foundation has allocated almost $2 billion towards HIV, TB and reproductive health
alone, and recently donated $500,000 million to the Global Fund.
USAID & PEPFAR
The United States Agency for International Development has provided almost $6
billion to the fights against global HIV/AIDS since its creation in 1986—more than
any other private or public organization. Currently it works with nearly 100 countries
worldwide.
The U.S. government recently created the President’s Emergency Plan for
AIDS Relief (PEPFAR). The $15 billion dedicated to this fund will be used to
support at least two million people living with HIV/AIDS, prevent seven million
infections, and support care for 10 million people infected with and affected by
HIV/AIDS. It works with over 120 countries, but its focus is only on 15 of the most
affected ones, especially in sub-Saharan Africa. While it is important to give these
areas special attention because they are the world’s most affected, it is just as
important to provide funds and leadership to countries where the epidemic is on the
rise, such as the Russian Federation. Russia undoubtedly has more funds than
developing countries in sub-Saharan Africa, but its response nonetheless has been
catastrophically inadequate until now. Therefore, international organizations have a
duty to draw attention to countries such as Russia in order to assure commitment and
cooperation in the fights against HIV/AIDS, as well as human rights issues.
55
International organizations should both pressure the Russian Federation into
dedicating more of the country’s own resources into the fight against HIV/AIDS, and
provide financial and human resources to assure the most adequate response possible
from the RF.
World Health Organization
The World Health Organization (WHO) is the United Nations specialized agency for
health and takes the lead within the UN system in the global health sector response to
HIV/AIDS. Established in 1948 and comprised of 193 member states, the WHO’s
objective is the attainment by all peoples of the highest possible level of health (a
state of complete physical, mental and social well-being). The HIV/AIDS
Department provides evidence-based, technical support to member states to help
them “scale up treatment, care and prevention services as well as drugs and
diagnostics supply to ensure a comprehensive and sustainable response to
HIV/AIDS” (www.who.org).
Overall Outcomes: What Can They Do For the Russian Federation?
In some countries, a decreasing rate of incidence (the annual rate of new infections)
is related to changes in behavior and prevention programs. Changes in incidence,
along with rising AIDS mortality, have caused global HIV prevalence (the
proportion of people living with the virus) to level off. However, the total number of
people living with HIV has continued to rise, due to population growth and more
56
recently, the life-prolonging effects of antiretroviral therapy (UNAIDS, 2006). The
UNAIDS has taken important steps towards improving the global AIDS response,
but most of the goals stated in its Declaration of Commitment (including, the
commitment to provide universal access to HIV/AIDS treatment by 2010) and the “3
by 5” initiative (the goal of providing 3 million people with antiretroviral therapy by
2005) have not been achieved. The initiative has had limited success: in Eastern
Europe and Central Asia only 13% of those infected received treatment. (Russia
provides only 5% with ARVs, even though it is home to the most HIV cases in
region, while Zambia treats 27%, Malawi 20%, and Uganda 51% of those infected
with HIV/AIDS [UNAIDS, 2006].)
Leadership and political action on AIDS have increased significantly since
2001. 90% of the countries reporting to UNAIDS now have a national AIDS
strategy; 85% have a single national body to coordinate AIDS efforts; and 50% have
a national monitoring and evaluation framework and plan (UNAIDS, 2006). Yet,
systems to implement these plans remain inconsistent, as does civil society
involvement and, specifically, involvement of people living with HIV/AIDS.
The PEPFAR program is very significant in that it has shifted funding for
HIV/AIDS from millions to billions, helping the world to see AIDS as much more of
a global priority. This new level of funding will not only drive prevention and
treatment efforts significantly forward, it will also communicate to the world the
significance of the threat.
57
As previously mentioned, international organizations such as UNAIDS, WHO,
UNESCO, UNICEF, and others have been providing assistance for HIV prevention
efforts in the Russian Federation, primarily amongst high-risk groups. For instance,
UNAIDS has been responsible for the financing, development and implementation of
pilot programs aimed at HIV/AIDS prevention amongst IDUs in Moscow, Sankt-
Petersbug and Yaroslavl. Medicines Sans Frontiers and the International Federation
of Red Cross co-sponsor Russian NGOs and help to implement their projects
(Osadcheva et al., 2003).
International and non-governmental organizations are critically important to
the Russian Federation, for the latter has not much experience in HIV prevention.
Such organizations have long-term experience in financing and managing programs
through sponsors’ contributions, including the ability to substantiate financially the
implemented programs, raise funds, and efficiently manage funds (Osadcheva et al.,
2003). They also have extensive experience in what works in HIV prevention and
what does not and can effectively guide Russian programs and NGOs along the right
path. In collaboration with local experts familiar with Russia’s culture, traits and
social norms, international organizations can contribute vital financial resources,
experience and brainpower to help fight the AIDS epidemic in the Russian
Federation.
58
Vaccine
After the virus that caused AIDS was discovered in 1984, Margaret Heckler,
Secretary of Health and Human Services under President Ronald Reagan, announced
that a vaccine should be available in two years. The history of virology had shown
that vaccines could be developed quite easily once the virus for a disease had been
isolated (Simone, 2006). Diseases like smallpox and polio, measles and yellow fever
had been eradicated or efficiently brought under control by vaccines in the past. In
the case of AIDS, however, HIV is one of the most complicated viruses ever found.
It targets and destroys the very immune system that vaccines are intended to trigger.
HIV hides most of its surface behind a layer of sugar, so that our immune systems
cannot recognize that it is an invader. As David Baltimore explains, the immune
system looks for things that are foreign, but the foreign parts of HIV, which are
proteins, are all hidden behind this sugar and our bodies are unable to find any
crevice in that virus that we can attack and kill it with (Simone, 2006). And the
genetic instability of HIV is daunting: millions of viruses are constantly produced
and their mutation rates are spectacular. The immune system is presented with an
endless stream of new forms of the virus that it is unable to recognize and control.
“It’s like it has nine heads; you cut off one and it still has the eight others left” as one
scientist battling with HIV defines it (Simone, 2006). The HIV virus is so
complicated, that finding a vaccine would be like NASA’s moon landing program
(Irwin et al., 2003).
59
Despite of these significant setbacks, there is increasing scientific confidence
that a vaccine can be found. According to the Bill & Melinda Gates Foundation
(2006), currently there are 30 vaccine candidates in clinical trials, including two in
advanced efficacy or proof-of-concept trials. A vaccine might take another 10 years
to develop, and even if a vaccine is found tomorrow, it would take years to produce
and distribute it—and developing countries will probably be the last to receive it. As
Dr. David Ho emphasizes, we cannot wait for a vaccine to save the world from
AIDS:
Even if we come up with a cure or a vaccine tomorrow, just think about
the time that would be needed to implement all these measures widely
throughout the world. So to me, it’s clear that I’m not going to see the
end of this epidemic. And it’s also pretty clear that my children won’t
see the end of this epidemic. I think we’ve won a few battles. I think
most of the time, HIV wins. (Simone, 2006)
When evaluating the future of HIV prevention and treatment, and possibly a vaccine,
we cannot ignore the fact that there are powerful economic interests and related
political forces at work guiding the allocation of billions of dollars for those
purposes. As Green (2003) articulates, “science, reason, and plain common sense can
all become forgotten in the face of such considerations and forces” (p. 5). For private
sector vaccine developers, a major disincentive for investment in HIV/AIDS vaccine
research is the fact that the primary markets for a vaccine would be in the poorest
countries in the world—those least likely to have the resources to ensure reasonable
return on investments. It is a fact that HIV/AIDS affects everybody, but it hits the
poorest and most marginalized populations the hardest. In addition, lifelong ARV
60
treatment, which is primarily available in developed countries, is very profitable for
drug companies.
Regardless of the political and economic factors that play into the global
AIDS epidemic, the fact is that as of right now, there is no vaccine or cure for
AIDS, and in the near future the state of affairs will probably not change
significantly. Currently, we are faced with a global HIV infection rate of
approximately four million per year. Finding scientific solutions such as
microbicides and a vaccine is crucial to the fight on AIDS, however, until the
time comes when a vaccine will be available, and available to all, the lives of
hundreds of millions of people depend on HIV prevention.
Stigma and Discrimination
Due to a lack of education on AIDS, the disease is still little understood in Russia
and is often seen as a foreign import that affects only drug abusers and prostitutes. A
2004 survey in Moscow showed that 70% of the population felt “fear, anger, or
disgust” towards people living with HIV/AIDS (UNAIDS, 2004). Aggression against
HIV-positive people is often caused by unconscious fear based on lack of knowledge
and understanding of the disease. Discrimination against people living with
HIV/AIDS (PLWHA) is partly due to cultural factors reflective of the Soviet era that
expected that “a Soviet person must sacrifice him/herself for other members of the
society…Sacrificing oneself in such a case meant that if you got infected with HIV
61
you must disappear, go away, quit your job, not put shame on your family, become
isolated, and even die” (Osadcheva et al., 2003, p. 10).
Current attitudes in Russia do not only reflect the stigma and discrimination
displayed by the population against people that are HIV-positive, but they also
assume one’s own immunity to the disease. Assuming that HIV affects only those
who are “bad,” who acted in an immoral way and now simply suffer the
consequences as they are “punished” for their actions, a person will automatically
exclude him- or herself from the group perceived as vulnerable to HIV/AIDS. The
Canadian HIV/AIDS Legal Network defines stigma as “a powerful and discrediting
social label that radically changes the way individuals view themselves and are
viewed as persons…people who are stigmatized are usually considered deviant or
shameful, and as a result are shunned, discredited, rejected, or penalized (as cited in
Alexandrova, 2004, p. 293).” Furthermore, the Canadian HIV/AIDS Legal Network
states that people living with HIV/AIDS are stigmatized because:
! HIV/AIDS is a life-threatening disease;
! People are afraid of contracting HIV;
! HIV/ADIS is associated with behaviours that are already stigmatized or
considered deviant, particularly homosexual sex and injection drug use;
! People with HIV/AIDS are often thought to be responsible for having
contracted the disease; and
62
! Religious or moral beliefs lead some people to conclude that having
HIV/AIDS is the result of a moral fault, such as promiscuous or deviant sex,
that deserves punishment (as cited in Alexandrova, 2004, p. 293-294).
There are two kinds of stigma: felt and enacted. Felt stigma is the kind that people
living with HIV (or other diseases for that matter, such as epilepsy) anticipate, the
shame and fear of being discriminated against as a result of their health status. The
anticipation of that stigma often leads to feelings of anxiety and concerns and a
general disruption of their lives preventing them from obtaining employment,
seeking support form friends and relatives, or accessing health services
(Alexandrova, 2004). Enacted stigma refers to actual experiences of discrimination,
such as the ones often faced by people living with HIV in the areas of housing,
employment, prisons, and access to health care and public services (Alexandrova,
2004).
HIV/AIDS-related discrimination, as defined by UNAIDS, is: “Any
measure entailing any arbitrary distinction among persons depending on their
confirmed or suspected HIV serostatus or state of health” (as cited in
Alexandrova, 2004, p. 294). AIDS-related social discrimination also extends
to people whom the disease is associated with in the public mind, namely
already marginalized groups such as IDUs, sex workers, and MSM
(Alexandrova, 2004). In the Russian Federation, AIDS-related stigma and
discrimination run deep. A study conducted by Komsomolskaya Pravda
newspaper published in May of 2004 found that although one in five
63
Russians know someone with HIV/AIDS, 46% of them think that those
infected should be isolated from the rest of society (as cited in Peterson,
2004).
In the RF, even health care workers themselves stigmatize and discriminate
against people with HIV/AIDS. A study conducted among 230 health care workers
(two thirds of whom had professional careers of more than 10 years) to assess their
attitudes towards HIV-positive people found that: over half believed that all patients
should be tested for HIV before being admitted to a hospital, all HIV-positive people
should be treated in special hospitals and that all pregnant women with HIV should
deliver in special hospitals (Stepanova, E.V., Rakhmanova, A.G., & Chaika, N.A.,
2004). A third of all physicians expressed support for a law prohibiting HIV-positive
women from having children; less than 20% of Russian health care workers were
informed about pre- and pot-test counseling; over 40-50% would change their
attitude toward HIV-positive colleagues or patients; 40% would not want to live in a
community with PLWHA and would not allow their children to go to school with or
have contact to children with HIV (Stepanova et al., 2004). Around a quarter of the
surveyed Russian health care workers thought that the HIV epidemic has nothing to
do with their life and 38% of physicians blamed patients for their infections and their
stigmatization (Stepanova et al., 2004).
The stigma and discrimination associated with HIV/AIDS is not just a
problem in Russia or the region of CEE/CIS. It is a global problem and evident in
every country—in some countries it is more overt, in others more covered
64
discrimination, but it exists. However, attitudes in the population can be changed and
impacted by public information and education. People must know that no one is
immune to the disease, that it affects everyone in society, and that people living with
HIV should not be blamed for their status and neither should they be excluded from
society.
Harm-Reduction vs. Abstentionism—Ideologies and Realities
Russia is home to approximately 4-5 million injecting drug users and nearly 82% of
new HIV cases are attributed to injecting drug use. The epidemic is largely driven by
young, sexually active IDUs (Alexandrova, 2004). Needle sharing amongst IDUs is
widespread and the epidemic proportions of STIs in the region are evidence that
condom use is not. Although there has been widespread resistance to harm-reduction
and needle exchange programs, currently there are about 80 different programs
operating in Russia (Alexandrova, 2004). Despite evidence that has proven
methadone to be highly effective as a component of harm-reduction strategies,
methadone maintenance therapy (MMT) remains controversial, not least because it is
listed in the UN Vienna Drug Conventions, which deters nations from allowing its
use (Alexandrova, 2004). In addition to that, since the fall of the Soviet Union, the
illicit drug trade (especially that of heroin) has exploded in the Russian Federation,
as new stricter drug policies have been primarily focused on supply reduction instead
of on the demand side for drug prevention, treatment, and harm reduction (Paoli,
2002).
65
Riley & Hare (2004) define harm-reduction as the following:
Harm reduction can be viewed as both a goal—the reduction of the
number of harms associated with drug use—and a strategy—a
specific approach that focuses on the negative consequences of drug
use rather than on level of use. In both cases…the person’s use of
drugs is accepted as fact. Harm reduction approaches, then, are those
that aim to reduce the negative consequences of drug use for the
individual, the community, and society while allowing that a person
may choose to continue to use drugs…A harm reduction approach to
a person’s drug use in the short term does not rule out abstinence in
the longer term, and vice versa (as cited in Alexandrova, 2004, p. 27).
The roots of harm-reduction are in Europe, where they are recognized for their
efficiency in countries such as the United Kingdom, the Netherlands and Switzerland
(Riley & Hare, 2004; as cited in Alexandrova, 2004, p. 18). The approach of harm-
reduction can be contrasted to the one of abstentionism prevalent mainly in North
America, which emphasizes a decrease in prevalence of drugs, rather than harms
associated with drugs (Riley & Hare, 2004; as cited in Alexandrova, 2004, p. 19).
Abstentionism focuses mainly on punishment of the drug user, ignoring the fact that
there has always been and that there will always be drug use. Furthermore, many
(Erickson, 1992; Nadelmann, 1993; O’Hare, 1992; Riley & Oscapella, 1997) have
argued that “attempts to legislate and enforce abstinence are counterproductive, and
that there are harms due to these measures that are far worse than the effects of the
drugs themselves” (as cited in Alexandrova, 2004, p. 21). In particular, violent
crimes, gang warfare, prison overcrowding, and police corruption associated with
prohibition has led many policymakers to rethink this strategy (Riley & Hare, 2004;
as cited in Alexandrova, p. 21).
66
Harm-reduction is based on a “rational” approach, weighing costs and
benefits. Abstentionism is based on religious ideology, which is fairly typical for the
United States. However, this approach has proven ineffective times and times again,
not just in drug use. For example, politically and religiously driven sexual abstinence
policies in the US rather than research-based approaches of promoting safe sex and
sex education as it is the case in Western European countries, has led to an increase
in teenage pregnancies, HIV prevalence and sexually transmitted infections (STIs)
amongst teenagers. The organization Advocates for Youth (2001) reported that
although sex in the United States is initiated at the same age or earlier than in Europe
and young people in the US have more sexual partners than young people in Europe:
! In the US, the teen pregnancy rate is more than nine times higher than
that in the Netherlands, nearly four times higher than the rate in France,
and nearly five times higher than that in Germany
! In the US, the HIV prevalence rate in young men (15-24) is over five
times higher than the rate in Germany, nearly three times higher than the
rate in the Netherlands, and about 1.5 times higher than that in France
! The estimated HIV prevalence rate in young women (15-24) is six times
higher than that in Germany, nearly three times higher than the rate in the
Netherlands, and is the same as in France
! In the US, the teen gonorrhea rate is over 74 times higher than that in the
Netherlands and France (Feijoo, 2001).
67
Similarly, there is a lot of research supporting the efficiency of harm-reduction
programs as opposed to prohibition policies. For example, witnessing an epidemic
spread of drug use, especially heroin, in the early 1980s, Merseyside in the United
Kingdom developed and implemented the “Mersey Model” of harm-reduction (Riley
& Hare, 2004; as cited in Alexandrova, 2004, p. 22). There, the program included
needle exchange, counseling, prescription of drugs (including heroin), and
employment and housing services (Riley & Hare, 2004; as cited in Alexandrova,
2004, p. 22). As a result, all of the available evidence suggests that the Mersey HIV
prevention strategy is highly effective (see Stimson, 1997, for a review; as cited in
Alexandrova, 2004, p. 23). The number of drug-related health problems has dropped,
self-reported needle and syringe sharing has declined, and official statistics indicate a
decrease in drug-related acquisition crime and HIV infection in many parts of the
region while the national rate is increasing (Riley & Hare, 2004; as cited in
Alexandrova, 2004, p. 22). In Amsterdam, drug use was recognized as a complex
and recurring behavior in the 1980s and it was decided to provide medical and social
care while waiting for natural recovery in order to avoid some of the more harmful
consequences of injection drug use, such as hepatitis B (Riley & Hare, 2004; as cited
in Alexandrova, 2004, p. 23). The pragmatic and nonmoralistic attitude towards
drugs in the Netherlands has also included a focus of attention and resources from
the police on drug traffickers, and not users (Riley & Hare, 2004; as cited in
Alexandrova, 2004, p. 23). This includes not imprisoning drug users, but rather
warning them and sending them to needle-exchange and harm-reduction programs,
68
where they come into contact with counseling and where they can get help and
support.
There is clear evidence that harm-reduction (in particular syringe exchange
programs) are associated with a decrease in risk (decreased sharing) and decrease in
harm (lower levels of HIV infection, increased access to medical care) (Hart,
Carvell, Woodward et al., 1989; Jurgens, 1996; Lurie & Reingold, 1993; Rana, 1996;
Robertson, 1990; Stimson, 1989, 1997; Stimson et al., 1988; van den Hoek, van
Haastrecht, & Coutinho, 1989, Wodak, 1990, 1996; as cited in Alexandrova, 2004, p.
30). Needle exchanges are not associated with an increase in the number of injectors
or a decrease in the average age of injectors. It is also highly cost-effective.
The British Advisory Council on the Misuse of Drugs concluded as early as
1988 that: “We have no hesitation in concluding that the spread of HIV is a greater
danger to individual and public health than drug misuse. Accordingly, services which
aim to minimize HIV risk behavior by all available means should take precedence in
developmental plans” (para. 2.1 as cited in Alexandrova, 2004, p. 24). It is fact that,
in the US and the UK, at least 40% of IDUs are in relationships with non-users
(Drucker, 1986; Rhodes, Myers, Bueno, Millson & Hunter, 1998; as cited in
Alexandrova, 2004, p. 20). In addition to that, about one-third of IDUs are female,
which gives way to virtual spread of HIV to newborns (Riley & Hare, 2004; as cited
in Alexandrova, 2004, p. 20). Not least because of these reasons, and because of a
belief in the right of all people to be treated with dignity and respect, which includes
giving them the power to decide over their own behavior, should harm-reduction be
69
part of any HIV prevention approach. In regards to the global AIDS pandemic, and
the fact that thousands are dying every day, there is no time to wait for a perfect
world.
AIDS in the Context of Human Rights
“Realization of human rights and fundamental freedoms for all is essential to
reduce vulnerability to HIV/AIDS. Respect for the rights of people living
with HIV/AIDS drives an effective response” (Declaration of Commitment
on HIV/AIDS, United Nations General Assembly, Special Session on
HIV/AIDS, 25-27 June, 2001, New York).
As mentioned earlier, without a greatly expanded response to the epidemic,
between five and eight million Russians may be HIV-infected by 2010. Furthermore,
if proper treatment and medications are not ensured for the nearly one million people
that are already infected, it is likely that they all will die within the next decade.
Although not legally binding for Russia, international human rights, as
established by the General Assembly resolution in 1948 (Article 25), dictate that:
1. Everyone has the right to a standard of living adequate for health and well-
being of himself and of his family, including food, clothing, housing and
medical care and necessary social services, and the right to security in the
event of unemployment, sickness, disability, widowhood, old age or other
lack of livelihood in circumstances beyond his control.
2. Motherhood and childhood are entitled to special care and assistance. All
children, whether born in or out of wedlock, shall enjoy the same social
protection (as cited in Alexandrova, 2004).
Furthermore, in 2000 the International Covenant on Economic, Social and Cultural
Rights established in Article 12 the right to the highest attainable standard of health:
70
Health is a fundamental human right indispensable for the exercise of other
human rights. Every human being is entitled to enjoyment of the highest
attainable standard of health conducive to living a life in dignity. The
realization of the right to health may be pursued through numerous,
complementary approaches, such as the formulation of health policies, or the
implementation of health programmes developed by the World Health
Organization (WHO), or the adoption of specific legal instruments which are
legally enforceable.
Article 12.2 (c). The right to prevention, treatment and control of diseases.
The prevention, treatment and control of epidemic, endemic, occupational
and other diseases” (art. 12.2 (c)) requires the establishment of prevention
and education programmes for behaviour-related health concerns such as
sexually transmitted diseases, in particular HIV/AIDS, and those adversely
affecting sexual and reproductive health, and the promotion of social
determinants of good health, such as environmental safety, education,
economic development and gender equity.
The right to treatment includes the creation of a system of urgent medical
care in the cases of accidents, epidemics and similar health hazards, and the
provision of disaster relief and humanitarian assistance in emergency
situations. The control of diseases refers to the States’ individual and joint
efforts to, inter alia, make available relevant technologies, using and
improving epidemiological surveillance and data collection on a disaggregate
basis, the implementation or enhancement of immunization programmes and
other strategies of infectious disease control (as cited in Alexandrova, 2004).
There are international guidelines established, which deal specifically with the states’
obligations towards HIV/AIDS control and people living with HIV/AIDS. Two
important ones are “HIV/AIDS and Human Rights” issued by the UN High
Commissioner for Human Rights and the Joint UN Program on HIV/AIDS
(UNAIDS), as well as the UN Declaration of Commitment on HIV/AIDS, adopted
by the UN General Assembly on 27 June 2001. The fact that these are not legally
enforceable does not imply that the Russian Federation or any other state can ignore
them. They have come into being out of the necessity to establish such guidelines in
71
the face of a global problem, which has implications to the global community. In
addition, they imply that those countries that have signed the declarations are in
agreement about the necessity of these measures. Therefore they can hold
governments, which do not comply, accountable.
Hence, international laws on human rights and welfare declare that it is the
states’ responsibility and duty to provide citizens with health care and services, the
highest attainable standard of health (depending also on the states’ individual
resources), as well as prevention, treatment and control of diseases, particularly
HIV/AIDS. Unfortunately, many states today do not have the financial capabilities to
provide their citizens with free AIDS medication because of the high cost of brand
drugs. Many countries do not have the technological capabilities to produce their
own generic version of HAART. In general, the developing world has few resources
even for HIV prevention efforts, and often it struggles with many issues at once,
such as civil wars, famine, or other major diseases such as Malaria and tuberculosis.
In the case of the Russian Federation, however, resources (even if limited)
can be relocated towards the fight against HIV/AIDS. Because of the potentially
devastating economic, political and social effects that a further spread of the disease
could have on the country, the government has an obligation and a duty to respond to
the HIV epidemic in a major way. The Russian Constitution itself, established in
1993, states the following:
Section One, Chapter Two, Article 41:
Everyone shall have the right to health care and medical assistance. Medical
assistance shall be made available by state and municipal health care
72
institutions to citizens free of charge, with the money from the relevant
budget, insurance payments and other revenues.
The Russian Federation shall finance federal health care and health-building
programs, take measures to develop state, municipal and private health care
systems, encourage activities contributing to the strengthening of the man's
health, to the development of physical culture and sport, and to ecological,
sanitary and epidemiologic welfare. (The Russian Constitution, 1993)
The Russian Federation, therefore, guarantees to provide necessary health care to its
citizens free of charge. Although the constitution does not particularly address
HIV/AIDS, the obligation to strengthen the health service capabilities of the state as
well as work to encourage “epidemiological welfare” are clearly expressed. From
that follows that a lack of commitment by the Russian Federation to the prevention,
treatment, care and support of HIV/AIDS would be unconstitutional. Additionally, if
the state fails to provide those living with HIV with life-prolonging medication, free
of charge if necessary, it can also be considered unconstitutional.
Polubinskaya (2004) found that HIV/AIDS control poses a great challenge to
most democratic states, as they try to achieve the following two equally important
objectives simultaneously:
! To stop (or slow down) the spread of HIV throughout the population; and
! To protect persons living with HIV/AIDS from various forms of direct
and indirect discrimination or abuse (p. 2).
The currently applicable Federal Law, “On Prevention of Spreading in the Russian
Federation of Disease Caused by Human Immunodeficiency Virus (HIV infection),”
came into force on 1 August 1995. According to Article 4 of the Federal Law, the
State vowed to take action to prevent the spread of HIV, including:
73
! Public dissemination of information about the means to prevent HIV
infection, including the use of mass media
! Epidemiological surveillance of the virus’s spread across the country
! Manufacturing and distributing the means for HIV prevention, diagnosis
and treatment
! Accessibility of HIV testing, including anonymous, with pre- and post-
test counseling
! Free access to professional and specialized medical care, and free
medication for in- and out- patient treatment
! Social support for people living with HIV/AIDS including education, re-
training, and employment assistance (Polubinskaya, 2004, p. 2)
The social support provided for people living with HIV/AIDS and their family
members guarantees:
! Prohibition of employment dismissal;
! Prohibition of employment refusal;
! Prohibition of the refusal of entrance to educational and health care
facilities;
! Prohibition of the restriction of other rights and legal interests of persons
associated with HIV (Polubinskaya, 2004, p. 2)
Most democratic governments have the right to health care embedded in their
constitutions and Federal Law often establishes HIV control and protection of people
with HIV/AIDS. The Russian Federation is no exception—if the government does
74
not cooperate in the fight against HIV/AIDS, legal action could be pursued in order
to guarantee the welfare of the individual.
Evaluation of Past and Present HIV/AIDS Prevention Programs in the Russian
Federation
The Current State of Affairs
There are wide gaps in access to HIV prevention in Eastern Europe, the former states
of the Soviet Union and Central Asia. Only 11% of injecting drug users, who are the
primary drivers of the epidemic, have access to HIV prevention services (The Global
HIV Prevention Working Group, 2003). Since IDUs are already stigmatized and
criminalized as a group, it is even harder to effectively reach them. IDUs play such a
vital role in the epidemic that it should be considered a matter of national security
and health to give them access to HIV prevention without fear of being prosecuted or
imprisoned.
Young people are also critically underinformed about HIV/AIDS in the
region. Even though they are usually more informed than older generations such as
their parents, as a population segment that is especially vulnerable they need to be
targeted. Currently, 40% of in-school youth, and only 3% of out-of school youth, are
reached by behavioral change programs (The Global HIV Prevention Working
Group, 2003). The statistics are even lower for sex workers (4%) and MSM (9%)
(The Global HIV Prevention Working Group, 2003).
75
STIs can significantly increase the risk of HIV infection in men as well as
women. The rise of STIs in the Russian Federation is also an indicator of an increase
in risky sexual behavior. Yet, only 16% of people in need of STI services can obtain
them in Eastern Europe and Central Asia. Only 28% of people who want voluntary
counseling and testing (VCT) can obtain them (The Global HIV Prevention Working
Group, 2003).
There are substantial gaps in the knowledge about HIV/AIDS in the general
population as well. For instance, in 2003 in the Ukraine, more than 50% of young
people have neither heard of AIDS or do not accurately understand the disease in
order to be able to protect themselves (The Global HIV Prevention Working Group,
2003). Only 19% of people at risk are reached by mass media campaigns on
HIV/AIDS (The Global HIV Prevention Working Group, 2003).
The emergence of the non-governmental sector has been hampered by the tax
status of non-governmental organizations (NGOs), which restrict the extent to which
charitable organizations have been able to function (Mariner, 2001). However,
NGOs are increasingly focusing on certain cities and regions in the country with, for
example, interventions for IDUs and homosexual males.
Some first steps have been made in terms of mass media approaches as well.
In 2004, Russia’s first coordinated

public education campaign, StopSPID (Stop
AIDS) was launched (James, M., Hoff, T., Davis, J., & Graham, R., 2005).
StopSPID includes public service announcements (PSAs) in TV, radio, print, and
online media; special radio

and television programming and print publications; as
76
well as free

print and Web-based information. StopSPID was created by the Russian
Media Partnership

to Combat HIV/AIDS (RMP)—a group consisting of more than
thirty media

and communications partners, including television networks such

as
NTV, STS, and TNT; print partners such as Izvestia and Komsomolskaya

Pravda;
radio networks such as Ekho Moskvy; wire service RIA

Novosti; and the leading
online company, Russia Online. It is directed by the Moscow-based Transatlantic
Partners

against AIDS (TPAA) with support from Kaiser, Viacom and UNAIDS
Russia and financial support from the Bill and Melinda Gates Foundation. To win
others in the region over for their cause, Kaiser, TPAA,

and UNAIDS co-organized a
Eurasia Media Leaders Summit on HIV/AIDS

in Moscow in 2004, with CEOs from
media companies in

Russia, Ukraine, and other countries of the Commonwealth of
Independent States (CIS) (James et al., 2005).
Nevertheless, the current HIV knowledge levels of the population clearly
show that not nearly enough has been done to stop a major AIDS crisis in a country
of the scope of the Russian Federation. A coordinated and broad approach is needed
in order to significantly affect the current situation. A more in-depth evaluation can
serve to identify which prevention techniques work and which do not and to help
develop a HIV prevention plan that will address all major factors contributing to the
spread of the epidemic.
77
Groups at Risk in the Russian Federation
Because the Russian Federation has a centralized epidemic, we should begin our
discussion of what should be done in regards to HIV prevention by taking a look at
the so-called high-risk groups in the country. The reality is that groups at risk are not
easily divided into neat categories—many groups overlap, and many behaviors
exhibited by one group enforce behaviors assigned to another group: drug users
resort to sex work to fund their habit, while sex workers turn to injecting drugs to
escape the pressures of their work (UNAIDS, 2006). For example, as mentioned
earlier, the number of HIV infections transmitted through sexual contact has risen
dramatically: In 2001, sexual transmission accounted for 4.7% of registered cases
while by 2003 this number had risen to 17.6%. This increase is not lastly attributed
to sex workers, many of whom are also injecting drug users or partners of injecting
drug users. One study concluded that 80% of HIV-infected women in the RF were
involved in both injecting drug use and sex work (Smolskaya et al., 2000; as cited in
Rhodes T., Sarang, A., Bobrik, A., Bobkov, E., & Platt, L., 2004). Studies across the
RF also suggest that 15 to 50% of female IDUs are also involved in commercial sex
work (Rhodes et al., 2004).
The risks of unprotected male-male sex also transfer to women, because men
who have sex with men (MSM) often also have female partners. The primary clients
of commercial sex workers are men who are married or are in serious relationships,
which makes condom use with these partners less probable. Prisoners, who are
78
especially vulnerable, often become IDUs in prison due to the pressures of their
environment and/or engage in unprotected sex with other inmates.
Despite the fact that many of these “high-risk groups” are intrinsically linked
to each other, it is important to identify some groups that are especially vulnerable to
HIV infection in order to create prevention campaigns that are as effective as
possible. In addition to that, many of these groups are highly stigmatized and
marginalized in society, often giving politicians and the public a justification to
discriminate and simply ignore them. Thus, while trying to not openly “point
fingers” at these group identifying them as the sole carriers of the disease in the eyes
of the public and thereby increasing their stigma, it is important to target them with
separate methods such as peer-driven interventions because they are usually hard to
reach by traditional methods such as the mass media or public health counseling.
Acknowledging the special vulnerability of particular populations, while at the same
time not isolating them, will further the cause of placing a high priority on HIV
programming for these populations, and guided by epidemiological surveillance, will
ensure the most effective use of resources.
Injecting Drug Users
There are about 13 million IDUs worldwide of whom 8.8 million are in
Eastern Europe and Central South and South-East Asia (UNAIDS, 2006). By some
estimates, there could be as many as four to five million IDUs in Russia alone
(Alexandrova, 2004), most of them being males. Nearly 82% of new HIV cases are
79
attributed to injecting drug use (Alexandrova, 2004). It is estimated that 1.5 to 8% of
Russian men under 30 have at some time in their lives injected drugs. Of the 36,000
IDUs treated internationally, 80% are in Brazil and the rest (6,000) are spread
amongst 45 other countries (Alexandrova, 2004).
Research conducted in the Russian Federation shows that most of the new
HIV infections are occurring due to sharing contaminated equipment, while 75% of
users reported having shared needles or syringes in the past month (UNAIDS, 2004).
Injecting drug users are one of the groups that are highly marginalized, highly
vulnerable, and highly ignored by politicians and the public at large. Attitudes
towards IDUs are often either assignment of blame, guilt and shame, complete
ignorance, carelessness, fear or other negative feelings.
Sexual partners of IDUs are bridging the HIV epidemic between the high-risk
group and the general population. The Federal Research and Methodological Center
for AIDS Prevention and Control estimates that there are about 9 million sexual
partners of IDUs in Russia (United Nations General Assembly, 2005). A study
carried out in 2003-2004 within the Russian-Canadian project found that 21.9% of
IDUs had engaged in group sex at least once and that 65.3% of men who use
intravenous drugs had sex with women who do not use injection drugs (UNAIDS,
2006b).
80
Sex Workers
Many female sex workers are not in the position to negotiate condom use
because they have been forced into prostitution, or they do not have the
financial freedom to turn down clients that do not want to use condoms. Sex
workers who also inject drugs are at further risk, not least because the
combination of their work and drug taking puts them beyond the protection
of the law and so opens them to exploitation and abuse, including sexual
violence and harm, and incapacity to negotiate condom use (UNAIDS, 2006).
Empowering women by giving them methods to protect themselves,
especially methods that are not immediately obvious to their sexual partners,
is imperative to halting the epidemic. This can be achieved by accelerating
the search for microbicides or oral prevention drugs, which could be decisive
in the fight against AIDS.
The stigma associated with AIDS is a very political one—often politicians
are enthusiastic about AIDS prevention until they have to take a stand on commercial
sex workers, because it is too difficult politically. But it is important to understand
that sex workers are an integral part to HIV prevention: programs must reach out to
them, involve them, empower them to protect themselves and others.
Although prostitution is criminalized in most countries, sex workers have the
same human rights as everyone else, including the rights to education, information,
the highest attainable standard of health and freedom of discrimination and violence,
including sexual violence (UANIDS, 2006). Governments have a responsibility to
81
protect these rights, and, in the context of the HIV epidemic, to reach sex workers
and their clients with the full scope of HIV information, commodities and services.
80% of those who enter sex work in Eastern Europe are 25 years of age and under.
For instance, one study in St. Petersburg, Russian Federation, found that 33% of sex
workers under 19 years of age tested HIV-positive (UNAIDS, 2006).
The Federal Research and Methodological Center for AIDS Prevention and
Control estimated that the number of clients of commercial sex workers ranges
somewhere between 1.3 and 2.6 million in the Russian Federation (UNAIDS,
2006b).
Women
One important aspect to furthering AIDS prevention is empowering women.
Research shows that domestic violence against women and risk of contracting HIV
are interrelated (Kalichman, S. C., Kelly, J. A., Shaboltas, A., & Granskaya, J.,
2000a). Many women today do not have the power to protect themselves from the
disease. This is the case in countries where women’s rights are not as prevalent and
where many are subordinated to their male counterparts. The problem of forced sex
or sexual violence against women is prevalent not only amongst sex workers, but
also in the general population. Violence against women is rarely talked about in the
CEE/CIS region, but is nevertheless very real (Alexandrova, 2004). As long as there
is not some equality offered to women, they will be violated due to fact that they are
not in a position of power. If a woman cannot say “No” or “Yes” and does not have
82
control over her sexuality and body, condom use can be promoted indefinitely, but
the efforts will remain very limited. For example, a study in the Ukraine found that
50 percent of adolescents had experienced unwanted sexual contact and an estimated
36,000 acts of domestic violence against women occur in Russia every day
(Alexandrova, 2004).
The overall gender disparity in the region is personal as well as political.
Forced equality under Soviet rule certainly did not make women equal in every
aspect of life, but at least in the official realms of education and work (Alexandrova,
2004). However, after the changes in the early 1990s, even that little bit of equality
disappeared. The numbers of women in the Romanian Parliament, for instance,
dropped from 34.3% to 3.5% in the 1990 election (Alexandrova, 2004). Women’s
equality was just on paper and far from established in the mindset and mentality of
the region. Nothing has changed in the gender disparity prevalent in the region where
machismo is encouraged in men and passivity in women, leading to a disparity in
power that makes it unacceptable for a woman to refuse unwanted or unprotected sex
(Alexandrova, 2004). Nowadays many Russian women don’t demand that their
partner use a condom because they are afraid of hurting his feelings or not being able
to completely satisfy him sexually (Osadcheva et al., 2003). According to statistics,
about 50% of HIV-positive women in Russia were infected by their permanent
partner or husband (Osadcheva et al., 2003).
In addition to women’s increased social vulnerability to HIV/AIDS, they are
also biologically disadvantaged when it comes to HIV infection. According to the
83
WHO, women are four times more vulnerable to the virus than men, making the
“equal situation” of intercourse, actually unequal (Alexandrova, 2004). This is true
because of several factors: Sperm contains a much higher concentration of HIV than
vaginal secretion and stays inside a woman longer; and the normal barrier to
infection, the vaginal epithelial mucosa is easily disrupted by ordinary trauma such
as childbearing and intercourse as well as STIs (Alexandrova, 2004).
In the Russian Federation, HIV prevalence is relatively high among female
injecting drug users, yet these women are the least likely to access health services
(UNAIDS, 2006), both because of stigma by health care providers and because of the
chaotic lifestyles that made them vulnerable in the first place. Since the number of
infected women is growing, so is the number of children born with HIV. Reluctant to
attend health services when pregnant, these women frequently learn their serostatus
only when they go to the hospitals to give birth and are much more likely to abandon
their newborn children on learning their status—often in the hope that the child will
have a better life without them (UNAIDS, 2006). Not knowing one’s status also
implies an increased risk of mother-to-child transmissions.
80 percent of the new HIV infections around the world stem from
unprotected heterosexual intercourse. Considering the fact that the HIV epidemic in
CEE/CIS is still concentrated amongst IDUs, it is not farfetched to theorize that, if
nothing is done to stop it, the next big HIV wave is going to occur amongst women,
who are the majority of IDUs sexual partners. This will be devastating for society,
84
given that women are often sole providers in households with children, caregivers
and workers in addition to being the suppliers of the majority of unpaid labor.
Young People
It is estimated that up to 25% of IDUs in Eastern Europe and Central Asia are
still in their teens. In the Ukraine, 25% of those diagnosed with HIV are younger
than 20, in Belarus 60% of them are aged 15-24, while in the Russian Federation,
80% of HIV cases are due to injection drug use in young persons under 30
(UNAIDS, 2004). In contrast, in Western Europe, only 30% of the reported cases are
among people under 29 years of age (UNAIDS, 2004).
Because most injecting drug users are young and sexually active, sexual
transmission is on the rise, with increasingly young women being affected. Condom
use is also generally low amongst young people, according to one survey conducted
in the Russian Federation showing that fewer than 50% of teenagers aged 16-20 use
them when having sex with casual partners. The percentage of sex workers reporting
consistent condom use is normally under 50%, while amongst IDUs it is even lower
than 20% (UNAIDS, 2004).
Widespread injecting drug use amongst the young is a sign of their diminishing
social and economic stability. As a result of the economic and political transitions,
there are currently about two million homeless children and teenagers in Russia, who
are exposed to high-risk and dangerous living conditions, such as poverty, dirt, lack
of medical assistance, drug use, prostitution, and risky sexual behavior, everyday
85
(Osadcheva et al., 2003). Social changes within the country have led to many
changes in family values and views on sexuality amongst Russia’s youth, which in
turn led to earlier sexual debut, a generally increased number of sexual partners and
overall risky sexual behavior (Osadcheva et al., 2003). Low levels of information
about AIDS and STIs among young people (in one study, about 2% of the subjects
considered bronchitis to be an STI) causes them to not be afraid of becoming
infected and if they don’t perceive AIDS as a danger they, as a result, don’t feel the
necessity to protect their health and the health of others (Osadcheva et al., 2003).
Prisoners
Prisons are so-called “incubators” of HIV infection because they are sites of illicit
drug use, unsafe injecting practices, tattooing with contaminated equipment,
violence, rape and unprotected sex (UNAIDS, 2006). HIV prevalence in Russian
prisons is estimated to be 4 times as high as that in the general population (UNAIDS,
2006). Often, prisoners already come from chaotic lifestyles and marginalized
populations, such as IDUs and sex workers. There is usually no access to condoms
and sterile injecting equipment. A recent study in the Ukraine found that only 39% of
prisoners had a basic knowledge on how HIV is transmitted. There is often a general
attitude towards prisoners who are IDUs or have male-male sex that they “get what
they deserve.” But it is not only a general human rights issue on part of the
government to protect prisoners as it protects other citizens, but it is also a public
86
health issue because prisoners circulate in and out of prison and, of course, mingle
with the general population.
The Federal Service for the Penitentiary System of the Russian Federation
reports an increase in PLWHA in prisons from 7,500 in 1999 to 32,000 in 2005
(UNAIDS, 2006b). Studies showed that there is extremely poor awareness of HIV
and a variety of risk behaviors and that unprotected sex among men is widespread in
prisons (UNAIDS, 2006b).
Men Who Have Sex With Men
Globally, fewer than five percent of men who have sex with men (MSM) have access
to HIV prevention and care services they need (UNAIDS, 2006). Many factors
contribute to this situation, including denial by societies and communities, stigma
and discrimination, and human rights abuse. Men who have sex with men often get
excluded from HIV services because of homophobia and discrimination, or they
exclude themselves out of fear to get identified as homosexual (UNAIDS, 2006).
The Federal Research and Methodological Center for AIDS Prevention and
Control estimates that there are 2.1 million MSM in Russia (UNAIDS, 2006b). The
Federal AIDS Center estimates that MSM make up for 4 per cent of the adult male
population (UNAIDS, 2006b). Between 1987 and 1995, 34.6% of HIV cases were
identified amongst MSM (UNAIDS, 2006b). Since 2004, the number of homosexual
men tested for HIV decreased continuously, while the number of HIV cases reported
for this group almost doubled (UNAIDS, 2006b). National statistics provided by the
87
Federal Research and Methodological Center for AIDS Control and Prevention
showed 0.5% HIV prevalence amongst MSM in 2004. Risk factors of sexual
behavior of MSM include high number of sexual partners, risky sexual practices
including unprotected anal sex, bisexuality as well as low motivation for safer sex
and accessing STI treatment (UNAIDS, 2006b).
Evidence-Based Interventions
In order to provide some background on the past HIV prevention campaigns
conducted in the Russian Federation, scientific evaluations on programs and
campaigns were researched. To locate such studies, databases such as Ovid,
PsychARTICLES and PsychINFO were searched using terms such as “HIV,”
“AIDS,” “Russia,” “Russian Federation,” “evaluation,” and/or “prevention” and
others. Additionally, particular journals such as AIDS, International Journal of STD
& AIDS, AIDS Education and Prevention and others were searched using the same
or similar terms. The search engine Google was also used to find similar articles and
Web sites of organizations such as UNAIDS, the Bill & Melinda Gates Foundation,
WHO and others were explored for evaluation studies as well.
Although the keywords used produced an abundance of related articles, only
three relevant ones could be found. Many articles reported on research conducted in
the region (e.g. Amirkhanian, Y., Kelly, J., & Issayev, D. (2001). “AIDS knowledge,
attitudes, and behaviour in Russia: results of a population-based, random-digit
telephone survey in St. Petersburg.” International Journal of STD & AIDS. 12:50-
88
57) and could be used in order to study background and the current situation in the
Russian Federation. However, since the purpose of the research was to find scientific
evaluations of such HIV prevention programs, simple reports or descriptions of
programs could not be used. Nevertheless, the three articles that were found to be
useful for this purpose are described below.
Study I: A Video Approach
The study (Torabi, M., Crowe, J., Rhine, S., Daniels, D., and Jeng, I. (2000).
“Evaluation of HIV/AIDS education in Russia using a video approach.” Journal of
School Health. 70(6): 229-233) provided a good example for a quite successful
intervention based on classroom video education on HIV/AIDS. A total of 1,124 7th
to 9
th
graders from a total of 20 public schools in urban and rural areas in St.
Petersburg, Russia were used in this study. Effects on knowledge, attitudes and
practices related to HIV/AIDS were measured. A quasi experimental design with
pre- and post-tests (questionnaires) was conducted on intervention and control
groups. The intervention consisted of a two-hour video focusing on HIV prevention
among middle school students.
A statistically significant improvement from pre-test to post-test for the
intervention group’s scores on knowledge of how to protect themselves from HIV
infection was found. Additionally, statistically significant improvements on attitudes
towards HIV prevention were observed. However, no statistical change was seen on
practices related to HIV prevention. The study confirmed that in general, students
89
did not know where to obtain information on HIV/AIDS and that sex remained a
taboo in the family setting as well as in schools, where providing education on sex
and related issues is often discouraged.
Although HIV prevention through video can be effective, it does not serve as
a substitution for comprehensive school health education. There was also no
evidence for a long-term impact of video education on behavior, attitude or
knowledge.
Given that the study at hand is short-term and included only one two-hour
video on HIV prevention, the results are astonishing. Although the video did not
ultimately impact behavior (or practices related to HIV prevention), it did change
attitudes and increase the knowledge on HIV and how to prevent infection. However,
it often takes repetition and time to achieve behavior change.
Another important aspect of the experiment was the fact that the educational
video was developed with Russia’s unique cultural setting in mind. The tape was
screened for cultural bias by bilingual educators and Russian as well as American
experts familiar with both cultures.
Given the very limited resources of many schools in the Russian Federation,
this can be viewed as one low-cost and effective method to spread information and
education on HIV/AIDS where comprehensive school health education is not
available.
90
Study II: Peer Intervention and Harm Reduction
The study (Sergeyev, B., Oparina, T., Rumyantseva, T., Volkanevskii, V.,
Broadhead, R., Heckathorn, D., & Madray, H. (1999). “HIV prevention in Yaroslavl,
Russia: a peer-driven intervention and needle exchange.” Journal of Drug Issues.
29(4): 777-804) reviewed a peer-driven community outreach program combined with
needle exchange services targeting IDUs. A total of 484 IDUs in Yuroslavl, Russia
were studied for this evaluation.
The study evaluated the development and implementation of the program as
well as in-depth interviews with IDUs considering their drug use, sexual risk
behaviors, knowledge of HIV and other drug-related harms. The success of the
needle exchange program was measured by the number of syringes collected and
given away as related to the number of clients per month.
The program was evaluated after two years of operation. A total of 766 initial
and follow-up interviews were conducted with IDUs who were successfully
persuaded to come to a storefront. The number of syringes exchanged at the
storefront and number of clients per month were recorded during the two-year
period.
The program achieved a reduction in sharing of syringes, cookers/filters, as
well as rinse water. There were no statistically significant changes in unsafe sexual
behaviors (e.g. a refusal to use condoms consistently) while numbers of needle
exchanges fluctuated. However, many of the clients had more than 100 needle
91
exchanges in a given month, which indicates that the program provided for a
secondary syringe distribution system of significant scale.
While these results are encouraging, there are concerns that the reported
decrease in risk-taking behavior such as sharing needles and other injection
equipment might be misleading in some cases. This is due to the fact that the process
of the preparation of home-made drugs itself might involve contaminated blood, as
well as the fact that IDUs often inject several times in one evening, which further
heightens the risk of them not using clean equipment, even though they have been
reported to have exchanged more than a hundred needles within the given month.
This study proves once more that peer-driven programs are absolutely
necessary in reaching IDUs, who are a highly stigmatized and marginalized
population in the Russian Federation. The program reported having major problems
with the local police, authorities and the local media, which portrayed the program as
“an American idea on Russian soil.” The program’s mobile needle exchange van, for
instance, experienced poor visitation rates due to the IDU’s fear of being identified
and persecuted by the police. Their fears proved to be legitimate, since local
authorities were observing the van and policemen actually violently attacked the van
in one instance.
Furthermore, people familiar with the local culture discouraged from offering
sandwiches or even coffee and tea at the mobile needle exchange van out of fear that
it might invite outrage from the local communities, which are highly poor and small
92
incentives such as food and beverages might be seen as “rewarding” IDUs for their
behavior.
Unfortunately, this program did not report increasing safe sex practices
amongst IDUs. Because IDUs reported safer behavior in injection practices, it is
curious why that was not the case when it came to sexual behavior. Possibly, safe sex
was not stressed enough, or maybe it is more difficult to impact sexual behavior than
injecting behavior. Whatever the case, this should be further researched and
experiments should be conducted in order to find a way to more effectively
communicate the benefits of safe sex to IDUs.
What we can take from this study is the imperative need for local, grass-roots
support by the local communities for programs such as these as community outreach
programs cannot sufficiently be implemented within a hostile environment.
Furthermore, it is also absolutely necessary to work out some negotiations with local
police and authorities, as they also pose a major threat to the success of such
interventions.
Again, the need for an orchestrated, strategic communication plan is
prevalent because, clearly, single efforts are not enough to fundamentally change the
viewpoint and hostility of a country towards HIV prevention and human rights
protection of marginalized populations. The message that HIV prevention is in
everyone’s interest must be communicated effectively in order to provide an
environment that is at the least not hostile towards intervention efforts.
93
Study III: Social Networks
The study (Amirkhanian,!Y. A., Kelly, J. A.,!Kabakchieva,!E., McAuliffe, T. L., &!
Vassileva, S. (2003).!“Evaluation of a social network HIV prevention intervention
program for young men who have sex with men in Russia and Bulgaria.”
AIDS Education and Prevention.!New York: Jun 2003.Vol.15,!Iss.!3;!pg.!205)
evaluated a social network-level HIV prevention intervention program. Young men
who have sex with men in St. Petersburg, Russia, and Sofia, Bulgaria were the
subjects of this study. A total of 8 YMSM networks with 48 network members in St.
Petersburg and 6 YMSM networks with 34 network members in Sofia were
recruited.
The study measured whether risky social networks could be recruited,
whether social leadership structure could be measured, whether participants could
be motivated to attend program activities, whether network leaders could be
inspired to carry out their roles as AIDS prevention advisors to their network
members, and whether the program had an impact on HIV-related attitudes or
behaviors within the subjects.
Research was conducted within the timeframe between February and
November 2002 in the form of a pre- and post-program HIV risk assessment
interviews that measured changes in safer sex behavior and risk-related scale
measures.
94
Following the program, subjects reported increased conversations and
comfort talking about AIDS and protection within their social networks. There were
significant increases in participants' accurate knowledge about AIDS and risk-
reduction steps, greater perception that peer group social norms supported safer sex
practices, more positive attitudes toward the use of condoms and safer sex, stronger
intentions to enact risk reduction behavior changes, and greater perceived self-
efficacy or confidence in ability to make these risk reduction behavior changes.
Overall, there was a significant increase in levels of condom use with casual male
partners.
While the study at hand does not report outcomes of a randomized, controlled
clinical trial but rather an evaluation of an applied intervention program, no serious
limitations were reported.
Over a very short period of time (several months), this study reports finding
significant positive HIV-related attitudinal and behavioral changes in the subjects as
well as increased knowledge on HIV/AIDS. The results are very encouraging, for the
study demonstrated that the intervention efforts very successfully managed to
identify and target social networks typically out of reach for other prevention
methods, while doing so through leaders and influencers of those networks.
Interpersonal communication is very effective in impacting behavior, considerable
more so than mass media or other sources.
As cited in the article at hand, Amirkhanian et al. (2001) states: “As a result
of many decades of Soviet and socialist state controls, there is likely to be skepticism
95
and distrust of official government pronouncements as propaganda, especially
among marginalized groups.” This is true for not only the Russian Federation, but for
many, if not all, countries formerly belonging to the Soviet Union. A level of
skepticism towards government is healthy in a democracy. However, in HIV
prevention terms, it means that announcements such as those made by federal health
agencies such as in the CDC in the United States would not be very effective in
countries such as the RF. Especially marginalized populations such as MSM and
IDUs refrain from dealing with government officials, including health officials, out
of fear of disclosure of personal information, such as one’s HIV status (Kon, 1998;
as cited in this article). That is why programs such as these are, as proven, highly
effective in dealing with marginalized populations.
Lessons Learned
The most important implication from the research conducted for this work is
possibly the fact that there is staggeringly little information about scientific
evaluations of HIV prevention work in the Russian Federation. According to
Osadcheva et al. (2003), “[t]he effectiveness of prevention efforts is nearly
impossible to estimate” (p. 42). This surely is due to simply the low number of
prevention campaigns run in the country. However, there are by far many more
campaigns than there are evaluations. It must be noted that the author attempted with
little success to find more studies conducted on programs in order to be able to
analyze strengths and weaknesses of those programs and in order to draw
96
conclusions beneficial for future campaigns. Program evaluation is invaluable; it
offers insight into what works and what doesn’t, it justifies financial and human
means used for prevention efforts, and it prevents practitioners from wasting
resources on approaches that have shown to be ineffective in the past.
The second most important lesson learned from the research on programs is
that many of them are well thought through and applied quite successfully. Those
scientifically evaluated used in this analysis were cost-efficient and effective and can
be said to have achieved considerable results with very limited resources. Thus, HIV
prevention certainly works and, when applied successfully, can save lives.
Third, the programs discussed were indeed able to achieve knowledge
increases and positive attitude changes, but unfortunately not enough behavior
change was observed. This might be due to a) the programs not being run long
enough, and more importantly b) the fact that all of these programs are disconnected
and an overarching national and multi-faceted strategy is missing. Thus, although
these programs were successful in their own means on a very small scale and
amongst very limited target populations, significant behavior change on a national
level is only going to occur as a result of consistent messages delivered through
multiple communication channels and reinforced by multiple sources of information
with significant repetition.
Research conducted on the risk populations in the RF showed that all major
groups are severely underserved. The most vulnerable populations, namely CSW,
MSM, IDUs and prisoners, are barely reached by HIV prevention and/or treatment
97
services (e.g. only 4.9% of IDUs and 16% of CSWs are covered by HIV prevention
services) (UNAIDS, 2006b). Although major global organizations can be a valuable
asset to all countries as they are working hard to provide all people at risk with HIV
prevention, treatment, care and support, individual nations must make HIV/AIDS a
priority in order to make a real difference. Human rights laws for PLWHA that have
been already established in Russia must be strictly enforced, for solely on paper they
are worthless. Severe stigma and discrimination associated with HIV/AIDS in the RF
complicates HIV prevention efforts, further burdens PLWHA, and makes programs
such as needle-exchange services almost impossible to establish in a hostile social
and political environment. Although a vaccine would greatly help the eradication of
the AIDS virus worldwide, science might be years or even decades away from
developing a successful one. Global distribution of a new vaccine alone would take
years to accomplish. Therefore, it is important that, for now, HIV prevention,
treatment, care and support be provided to those who are vulnerable or living with
the virus.
98
Chapter 3: COMMUNICATION AND HIV PREVENTION
Targeting Social Change
In the past, HIV communication approaches attempted to change individual behavior
rather than targeting the broader social environment in which HIV was able to
spread. Often, Western researchers applied approaches that were successful in the
developed world to developing countries, often without success. They failed to
realize that broader cultural factors and social norms were working against the HIV
prevention approach of individual behavior change (McKee, N., Bertrand, J. T., &
Becker-Benton, A., 2004). As a result of research conducted on the individual,
psychological level, failed interventions were blamed on the individual and his/her
personal behavior rather than on fundamentally social issues exacerbating the HIV
problem (Caplan and Nelson, 1973; as cited in McKee et al., 2004).
In recent years, social scientists have become more aware of the socio-
cultural factors that strongly influence complex health behaviors, including sexual
behavior (McKee et al., 2004). As McKee et al. (2004) argues, “Whereas early
theory work tended to focus on behavior change at the individual level, the field has
moved towards theories and models that focus on social groups/communities and on
larger contextual factors” (p. 41). These larger factors include diffusion of
innovations, social influence, social networks and gender inequality (King, 1999; as
cited in McKee et al., 2004, p. 41), as well as the role of structural and environmental
factors (Sweat and Dennison, 1995; as cited in McKee et al., 2004, p. 41) and policy
and economic issues (Carael et al., 1997; as cited in McKee et al., p. 42).
99
Interventions targeting social change usually work on the level of organizations,
2004, p. 41), communities and policy (King, 1999; as cited in McKee, 2004, p. 41).
UNAIDS (1999) developed some guidelines on how to target social change
instead of individual behavior alone (as cited in McKee et al., 2004, p. 43):
! Sustainability of social change is more likely if the individuals and
communities most affected own the process and content of communication
! Communication for social change should empower, be horizontal (versus top-
down), give a voice to the previously unheard members of the community,
and be biased towards local content and ownership
! Communities should be agents of their own change
! Emphasis should shift from persuasion and transmission of information from
outside technical experts to dialogue, debate, and negotiation on issues that
resonate with members of the community
! Emphasis on outcomes should be beyond individual behavior to social norms,
policies, culture, and the supporting environment
The social change model of HIV prevention is not to mean that individual behavior
change is not also targeted; it is just to say that the behaviors and actions of the
individual self cannot be separated from his/her social environment (KcKee et al.,
2004).
100
Campaign Development
McKee et al. (2004) suggest several steps for effective strategic communication for
social change (p. 49-50). This approach can be used as a general guide when
developing campaigns, programs and larger interventions on a national scale:
(1) Analysis: In this step, the current situation is analyzed, including the severity
of the problem and causes for it. The social, cultural and economic factors
that inhibit or facilitate desired social changes are identified, and research is
conducted.
(2) Audience and Communication Analysis: This step includes participation
analysis, which identifies potential partners and allies on the national, district
and community level; social and behavioral analysis on the individual,
community, services, and environmental level; and communication and
training needs assessment, in which media capacity and resources are
identified.
(3) Strategic Design: In this step, communication objectives are established,
communication approaches developed, communication channels determined,
and strategies and budget are developed. A monitoring and evaluation plan is
established.
(4) Development and Testing: Concepts, processes, messages and materials are
tested and revised in this step.
(5) Implementation and Monitoring: In this step, the plan is put into action by
producing and disseminating materials, conducting training for fieldworkers
101
and others, and mobilizing partners and communities accordingly.
Throughout the process, the program is monitored and adjusted.
(6) Evaluation and Replanning: In the next step, outcomes and impact is
assessed, results are disseminated, needs for follow-up or extension are
determined and the program is revised and adjusted once more.
Source: Health Communication Partnership, 2003
Cultural Sensitivity
McKee et al. (2004) argue that traditionally, “’Culture’ has been viewed as a
negative force or a barrier to change instead of an attribute that can work toward
positive ends” (p. 42). UNAIDS (1999) found that “most HIV communication
programs are shaped around theories and models that do not meet regional or local
needs” (as cited in McKee et al. 2004, p. 43). This has been especially true when
these theories have been used to explain HIV/AIDS in the developing world, often
insensitive to major cultural, social and economic differences. For instance, while in
Western countries self-agency and self-efficacy may be assumed (while not in all
sub-groups of the population), in many parts of the world this is not so.
Communication theories that are applicable to the Western world might be
just as applicable in the developing world or specifically in the Russian Federation,
but it is crucial that these approaches be adapted and modified with the local culture
and with the needs of the specific group in mind. Therefore, it is essential to always
incorporate into the design and planning of a campaign the people who are familiar
102
with the local social norms and environment of a particular area as well as people
who are part of the population that is to be targeted.
Targeting Social Change: The Socioecological Model For HIV Prevention
Targeting social change in addition to individual behavior can be accomplished
through a practical framework of conducting public health interventions based on
socioecological theory. In that framework, as interpreted by Campbell & Quintiliani
(2006), it is suggested that “tailored communications may fit in the context of
multilevel interventions where it is hypothesized that an individual-level intervention
is one essential component but will be more effective when it is also supported and
enhanced by activities at more macro levels of change, such as at the social network
or organization level” (p. 9-10).
Thus, in order to develop long-lasting and far-reaching interventions with
maximal potential for impact and sustainability, change has to occur on several
levels: the intrapersonal level, the interpersonal/social network level, the
organizational level, the community level, and the environment/policy level.
Individual programs and steps have to be designed with these goals in mind, so as to
address each level effectively.
103
Figure 3:
Source: Glanz & Rimmer (1995).
Socioecological Framework for Public Health Interventions
Level of Change Theoretical Approach and
Target
Example of Intervention
Strategy
Intrapersonal Individual characteristics that
influence health behavior, such
as knowledge, attitudes, beliefs,
affect, and past experiences
Individual counseling
Tailored communications
Motivational interviewing
Interpersonal/social
network
Interpersonal and group
influences including formal and
informal social network and
social support from family,
coworkers, friends, and so forth
to support healthy behaviors
Peer education
Lay health advisors
Support groups
Organizational Rules, regulations, policies,
incentives, resources, and
facilities that may help promote
and/or maintain recommended
behaviors within institutions
Worksite health promotion
Church-based programs
Community Shared identity, norms, and
values of people in a given
neighborhood or locality;
resources, social capital, and
collective action to improve
health for all members
Community participation
Capacity building
Collective action
Environment/policy Neighborhood, community, or
governmental resources;
institutions, policies, advocacy,
media activities, or other
activities that improve the
supportiveness and availability
of healthy options for residents
of that geographic area
Social marketing
Mass media campaigns
Point of purchase
interventions
Legislation
104
Implications for HIV Intervention in the Russian Federation
The proposed strategic planning model for HIV prevention in the Russian Federation
in the following chapter is loosely based on the theoretical framework of
socioecological theory as well as the idea of targeting social change on a national
scale. It is true that targeting social change is far more labor-intensive, costly and a
lengthy process. Donors and investors in HIV prevention want to see results,
however, and not producing quick results would be counter-productive to HIV
prevention funding. Therefore, a combination of social change in conjunction with
changes in individual behavior are key to HIV prevention success ink the RF,
because it is much more probable that the latter will occur faster within an
environment that supports such positive behavior. The idea of cultural sensitivity
will be translated into using local professionals and individuals from certain target
populations to help develop and implement programs. The campaign development
steps suggested by McKee et al. (2004) will be useful when monitoring and
evaluating interventions and ensuring effective planning of campaigns. Broader
cultural, social, political and economic factors in the RF that influence individual
health behavior will be taken into consideration.
Challenges and Limitations
When advocating social change, there are many challenges that have to be overcome.
The realities of unfavorable social norms, resistant political leadership and economic
obstacles are difficult to conquer, and certainly impossible to change overnight.
105
Some challenges that communication for a national response on HIV prevention
could face are:
! Weak political support
! Sustaining commitment over a long period of time
! Ensuring full participation by all partners
! Ensuring community participation
! Monitoring results on a large scale
! Linking with behavior change communication on smaller scale
! Overcoming deep-seeded cultural biases and beliefs
These are factors that have to be taken into consideration and addressed when
developing a large-scale HIV prevention program. It is clear that grassroots
campaigns cannot function to their full potential if there is no support or even
resistance coming from the top. Similarly, even if the national government is fully
committed, but the social and community support is missing, campaigns will most
probably fail in the long run. Therefore, a concerted campaign must be implemented
that seeks support from all levels, as well as coordinates all aspects of prevention.
106
Chapter 4: THE STRATEGIC PLANNING MODEL FOR HIV
PREVENTION IN THE RUSSIAN FEDERATION
There have been a number of programs conducted in the Russian Federation.
Research showed that some of these efforts have been quite successful and cost-
effective on a very small scale. However, it seems as if there is no coordinated
national plan on how to tackle this overwhelmingly complex problem. Therefore,
many efforts go to waste due to the simple fact that certain laws hinder execution,
the general population is too prejudiced, health care workers not educated on the
issue, and similar obstacles. In order to create effective HIV prevention, there must
exist a national strategy, which ideally combines all efforts and all institutions in the
pursuit of one common goal: To Stop AIDS. This requires coordination and
oversight from the government, favorable national laws, human rights
considerations, a favorable social environment, increased economic stability,
consideration of social and health issues that drive the AIDS virus, and many other
aspects.
Therefore, the following strategic plan is one that takes into consideration all
broad issues and factors relating to the HIV problem in the Russian Federation. After
careful research on the topic, consideration of the specifics of the particular region,
and evaluation of past programs conducted in Russia, this program appears to be the
logical outcome for a national strategy. The government, the health system,
international organizations, the mass media, localized communication efforts such as
peer education groups, the general population as well as at-risk populations must all
107
play a role in HIV prevention. The plan is to provide broad guidelines on how to
manage the complex fight against AIDS, while the specifics of each suggested action
will be left to the experts who will be implementing them in collaboration with
PLWHA and people familiar with the cultural specifics of each region involved. It is
the author’s belief and understanding that AIDS prevention conducted only on a
small scale and in a scattered manner is not effective. In order to really stop the
epidemic and save lives, the political, economic, and social environment must be
favorable (or at least not hostile) to those smaller scale efforts.
The strategic HIV prevention plan is designed for an initial test period of 18
months. However, the campaign will be continued after that trial period and adjusted
accordingly after being evaluated. Because this strategic plan is a very rough draft of
a broad national campaign and does not include specific programs and details, it is
difficult to suggest a concrete timetable for its execution. An HIV/AIDS prevention
campaign is an ongoing process because it is important that changes in behaviors and
attitudes are sustained constantly and that newly acquired behaviors become part of
the individual’s life. The campaign is meant to be long-term in the sense that it is
continuous, self-correcting, and that it is part of something larger that includes
involvement of services and public policy. However, it doesn’t loose sight of
immediate goals such as raising awareness, ensuring treatment to those infected,
educating, changing attitudes and impacting risk-taking behavior within target
populations.
108
Background
The Russian Federation has had a continuously declining population partly due to
high mortality rates and partly due to migration. The country’s struggling transition
economy is further threatened by low adult male life expectancy of only 59 years
and, more recently, one of the fastest spreading AIDS epidemics in the world.
Currently, it is estimated that almost one million people are infected in the Russian
Federation, with an HIV prevalence of about 1.1%. Although the vast majority of
new infections are due to injection drug use, in the recent years increasingly more
heterosexual transmission has been shown. The current infection rate, combined with
Russia’s large population of over 140 million people and the current economic,
political and social burdens that the country is facing, could have disastrous
consequences.
Russia’s current political environment is far from sufficiently supportive of
HIV prevention. President Vladimir Putin only recently started mentioning that there
is an AIDS problem in the RF. The 1995 Federal law On Prevention of Spreading in
the Russian Federation of Disease Caused by Human Immunodeficiency Virus (HIV
infection) is not supported by enforcement or controls in order to ensure its
application. The general health system and HIV treatment efforts are severely under-
funded and there is a general lack of oversight. Deficient access to ARVs further
discourages those at risk to learn about their status and in turn to protect others from
contracting the disease.
109
The social environment in the RF is no more supportive than the political
one— discrimination against people living with HIV/AIDS is prevalent even
amongst health care workers. The stigmatization of HIV infected people only
deepens the silence surrounding the disease and those who are infected and hinders
the spread of education on HIV/AIDS. A lack of education on the disease only
invites more ignorance, misinformation, and the firm conviction that AIDS is a
“shameful” disease that only affects people living immoral lives.
Business Goal
The overall goal of the campaign is to slow, halt and eventually reverse the AIDS
epidemic in the Russian Federation. In order to achieve this, several sub-goals must
be attained:
! Create a political environment that supports HIV prevention.
! Create a social environment that supports HIV prevention.
! Create an economic environment that supports HIV prevention.
! Create a cultural environment that supports HIV prevention.
! Create a health care system that supports HIV prevention.
Statement of the Problem
The US National Intelligence Council estimates that, without a greatly expanded
response to the epidemic, between five and eight million Russians may be HIV-
infected by 2010. Especially in the age of globalization, AIDS poses a considerable
110
threat to global health and global development. Furthermore, in developing countries
as well as in transition economies such as the Russian Federation, AIDS can have
devastating effects on the national GDP, as it affects mostly young people in
working age. Poverty, again, makes people more vulnerable to the disease and
further weakens political and health care systems.
Reducing the spread of HIV via HIV prevention as well as reducing the
human suffering associated with the disease by providing treatment to PLWHA and
creating political, social and economic environments that benefit the cause of
stopping AIDS, is possible and crucial to the survival of the Russian Federation.
Research Methodology
A. Research Goals: In order to develop the most efficient HIV prevention
plan, as much research should be conducted as possible. Given the
complexity of the issue as well as the diversity of the target audiences,
research methods must be designed with each different situation in mind.
Generally, research shall attempt to explore the following issues:
a. Identify key audiences
b. Measure HIV-related risk behavior, including sexual behavior and
drug use behavior amongst appropriate target audiences, including the
general population
c. Measure HIV-related knowledge levels and knowledge patterns
amongst appropriate key audiences, including the general population
111
d. Measure HIV-related prejudices, attitudes and misconceptions as they
relate to stigma and discrimination towards PLWHA amongst key
audiences, including the general population
e. Identify strategies and messages for addressing the problem
A study conducted by Amirkhanian, Y., Kelly, J., & Issayev, D. (2001) based
on a random-digit telephone survey in St. Petersburg, can be used as a guideline to
determining AIDS knowledge, attitudes, and behavior amongst the general
population and could be duplicated in other major cities.
B. Research Methods:
Primary Research:
a. Qualitative research will include in-depth personal interviews and
focus groups. Qualitative methods will be employed within all key
audiences, but especially amongst hard-to-reach audiences such as
injecting drug users, prisoners, commercial sex workers and men who
have sex with men. Due to the vulnerability of these groups, a deeper
understanding of their motivations, attitudes and behaviors is needed
than a survey alone could provide. If time and funds allow it,
ethnographic field observations could be conducted in order to further
gain access to the diverse circumstances of hard-to-reach groups.
Focus groups conducted with all key audiences should consist
of groups made up of 8-10 people and give insight into numerous
topics such as attitudes towards sex, safe sex, HIV, STIs, and drug
112
use. Furthermore, researchers should explore the reasons why these
groups are in their particular life circumstances, if and how much they
are concerned about HIV, what would motivate them to use safe sex
and injecting practices, how they feel about the health care system,
what their experiences are with health care workers and other public
officials, what they would wish for from the health system and
doctors, and similar questions on HIV-related issues. Furthermore,
focus groups can be used to periodically evaluate campaign efforts
such as mass media advertisements or peer-education programs, and
to gather suggestions and ideas for reaching a particular target
audience.
b. Quantitative research should be conducted in order to measure
large-scale trends and in order to gain a sufficient degree of external
validity. Measuring attitudes, knowledge and risk-taking behaviors is
important amongst all key audiences, as questionnaires should be
modified with the specific key audience in mind (e.g. questionnaires
distributed to CSW will naturally differ from those distributed to
health care workers). Large-scale surveys (e.g. for the general
population) can be conducted via telephone or direct mail
questionnaires with a representative sample of a few thousand
subjects.
113
c. Evaluation is critical in measuring outcomes of campaigns and
programs and providing accountability for HIV prevention methods.
Power & Nozhkina (2002), for instance, found that process
evaluations were vital in sustaining the impetus, confidence in
enthusiasm essential to the survival and support of HIV harm
reduction programs in the Russian Federation. As several pilot
programs on harm reduction were tested in Russia, politicians and
health care providers were eager to see some form of results from
these interventions such as decreased risk behavior amongst IDUs in
order to offer the necessary political support and resource allocation
essential to a successful continuing strategy. Interventions can be
measured by conducting research pre- and post campaigns, as well as
periodically evaluating progress made during campaigns.
Evaluation Beyond Individual Behavior: Because this program is
intended to target not simply individual behavior, but mostly the
environment in which HIV spreads, evaluation of success should
include measurement of changes in social norms, policies, culture and
supporting environment. Therefore, factors such as favorable changes
in policies and laws, empowerment of women, and favorable to HIV
prevention changes within the health care system should be also taken
into consideration when evaluating programs and strategies.
114
Secondary Research:
a. Theoretical Approach: Individual programs and interventions should
always be based on theory. Therefore, careful theoretical research
should always be conducted before developing programs.
b. International experience: The AIDS epidemic in the Russian
Federation is fairly new and the country has virtually no experience in
HIV prevention, treatment, care and support. Studying international
interventions and methods can be helpful in developing campaigns in
Russia, because other countries have faced similar problems in the
past. Learning from the international experience is invaluable and can
save the Russian Federation money, time, and many wasted efforts.
c. Local experience: As mentioned earlier, there have not been
numerous local and national HIV prevention efforts in the Russian
Federation up to this point. However, the successes and failures of
those that have been implemented locally should nevertheless be
studied so that the same mistakes are not committed again and so that
successful measures can be duplicated.
Situation Analysis
Strengths Weaknesses
! The Russian Federation is a large,
influential country
! Russia’s vast population
! The vastness of Russia’s land
(difficult to oversee and control)
! The vastness of its population
(difficult to oversee and control)
115
! Russia’s economic potential (e.g.
natural resources, human resources)
! Political leadership has recognized the
HIV problem
! Increased spending on the fight
against HIV this year
! Positive health laws and regulations
(universal health care)
! Relatively strong political leadership
compared to many other countries in
the region (e.g. Ukraine, Bulgaria)
! Positive laws (on paper) regarding
PLWHA and HIV prevention and
treatment
! The Church’s initiatives on HIV
prevention and support for PLWHA
shows Church is a willing contributor
to the fight against AIDS (as opposed
to in many other countries)
! There are Russian NGOs working on
HIV prevention with some experience
already
! Existing HIV prevention mass media
campaigns
! Partially, support from national and
local media (partnership with
UNAIDS, etc)
! First meetings held exclusively for
discussing AIDS in Eastern and
Central Europe
! Government has created several
institutions solely dedicated to
HIV/AIDS and research of the
disease, including AIDS Centers
! High literacy rates, thus education is
on a high level
(difficult to oversee and control)
! Russia’s borders stretch from
Europe to Asia, making it a
pathway for illegal drug trade
! Economic distress,
unemployment and mass poverty
! Social dislocation, disruption in
traditional family values and life
! In reality: A weak and
disorganized health system
! Bribing as a social norm, also
within the health system
! General public uneducated on
HIV/AIDS
! National funds dedicated to HIV
prevention and treatment are far
from sufficient
! Political leadership viewed with
suspicion by the international
community
! Migration of the population
! Organized crime, prostitution
and drug trafficking are out of
control
! Massive economic, political and
social disruptions due to the
market transitions
! Socially, politically,
economically disadvantaged
female population and high
prevalent domestic abuse
! High mortality, especially
amongst working-age men
! High disease rates (e.g. heart
disease, etc)
! High rates of unhealthy
behavior, e.g. smoking, alcohol
! Unusually high number of IDUs,
especially amongst youth
! Young people especially
affected by HIV compared to
other European states
! High STI rates
! No HIV education in schools
116
! Sex, HIV and STIs is taboo in
many households and in schools
! Issues of drug use and
prostitution largely ignored due
to these groups’ legal and social
marginalization
! Condom use and safe sex are
often taboo issues not discussed
amongst partners
! Highly underground MSM scene
with hard-to-reach populations
due to stigmatization
! Official HIV prevalence
understated by government
(officially approximately
300,000 infected vs. unofficially
1 million)
! General population highly
undereducated and ignorant on
HIV-related issues
! Very limited funds for HIV
treatment while government
negotiated prices for medications
are much too high
! AIDS Centers further
marginalize PLWHA when they
really need to be assimilated
! Many orphaned children by HIV
! Increasingly heterosexual
transmission through women,
who have become the “bridging”
population transferring HIV
from high-risk groups into the
general population
! Virtually no psychological
support and counseling for
PLWHA
! For the purpose of HIV
prevention, public distrust of the
government and the media might
be an issue
! Media often disperses negative
and/or false information
regarding HIV/AIDS
117
! Law enforcement interferes with
HIV prevention
! Aging population
! Human rights violations
Opportunities Threats
! International attention on the HIV
problem in the Russian Federation
! International organizations willing to
work with the Russian government
and provide financial resources,
brainpower and experience
! Possibly a better economic future in
the long run due to the market
transitions
! Russia’s positive influence on other
countries in the region if HIV
prevention is carried out correctly and
successfully
! Alongside HIV prevention, Russia has
a possibility to look at other health and
social issues, such as mass alcoholism,
domestic violence, and the epidemic
increase in STIs (especially amongst
the young)—and improve upon them
! Raising the country’s economic
performance if it is able to improve
the level of health (including HIV)
amongst its population
! Falling prices for HIV medications
! The possibility of an HIV vaccine in
the near future
! Winning PEPFAR and Global Fund
financial resources
! Increased global awareness of the
problem of HIV
! Since the population in the RF has not
been exposed to many HIV prevention
efforts, success for
educational/informational campaigns
could be very high (no “message
fatigue” within audience)
! Educating young audiences early can
prevent spread of the disease to next
generations effectively
! Attention from media, politicians
and international organizations
diverted away from the RF due
to much higher HIV prevalence
in other countries
! International distrust of Russian
government (Putin)
! An aging population, high male
mortality, low overall health
levels, in combination with the
explosive growth of HIV will
eventually lower the national
GDP, weakening the country in
the international arena as well
! Heroin market in the Middle
East is exploding, spilling over
to the RF
! Demand for Russian women and
girls as sex workers in Western
Europe and other European
countries
! Pulling of Russian talent out of
the country into countries with
more favorable living conditions
such as the U.S. and Western
Europe (“brain draining” of the
country)
! With increasingly open borders,
foreigners and guest workers
might import HIV, as well as
export the disease to their
countries of origin
! Government and political
leadership might not realize the
urgency of the issue and the
benefit of investing much needed
large resources into HIV
prevention (RF has many other
issues that need attention)
118
generations effectively
! Corporate philanthropy is not common
in the RF; however, companies in the
RF can be introduced to the idea and
persuaded to help fund HIV
prevention efforts
issues that need attention)
! Death toll of the current level of
the disease will be visible as late
as years from now; realization of
the AIDS problem amongst the
government and the population
might come too late
Strategic Implications:
! The HIV-related issues in the RF are very complex and the effects of the disease
multifaceted; HIV prevention must address as many aspects of the AIDS problem as
possible.
! The urgency of the AIDS problem must be communicated especially well to both
political decision makers as well as the public, for the two ultimately influence each
other. Acknowledgement of the urgency must occur now, not ten years from now
when victims start dying in masses.
! Use existing AIDS resources and expand on them. Numerous facilities, NGOs,
laws, partnerships and special institutions are already available; better coordination,
oversight, enforcement and training, as well as better financing will make a
difference.
119
! Continue working with and improving relationships between the government and
international organizations, as well as Russian NGOs and international organizations.
They are crucial to Russia’s HIV prevention success.
! Be prepared to meet a lot of resistance on every level of prevention efforts, from
the general public, to law enforcement, the government, politicians, even health care
workers as well as within affected groups themselves.
! Address short-term as well as long-term factors that drive the HIV epidemic in the
RF. Although changes (especially long-term) cannot occur overnight, steady and
continuous work can make a difference.
Communication Goals
A. Raise awareness about HIV/AIDS amongst target audiences. Raising
awareness is the first step to increased social tolerance towards the issue. This
must be done without spreading panic, but rather by educating and informing
target audiences.
B. Raise personal relevancy of the issue of HIV/AIDS amongst target audiences.
The Russian public feels largely disconnected from the issue of HIV/AIDS
while most think that it affects only other people. In order for change of
behavior to occur, audiences must feel that the issue at hand is relevant to
their lives and their person.
120
C. Communicate the urgency of the issue to target audiences and the fact that
something has to be done immediately. Feeling disassociated from an issue
also makes it easier to ignore it and wait for others to take action. Social
mobilization is of the essence considering the pace of the spread of HIV in
the RF.
D. Communicate to target audiences that stopping HIV/AIDS is in everyone’s
interest. Communicating that HIV/AIDS has implications on the national
economy, on future generations, and that PLWHA are part of society will
help bring the issue closer to home for target audiences.
E. Raise HIV/AIDS knowledge levels, how it is spread and how it can be
prevented amongst target audiences. An increased knowledge about
HIV/AIDS will empower people to take responsibility and action, it will
demystify the issue itself and it will make the pubic more tolerant towards
PLWHA while allowing target audiences to effectively protect themselves.
F. Communicate to target audiences that HIV/AIDS is not a death sentence and
raise awareness about treatment options. This will possibly make people
suspicious of their status more willing to get tested. It will also decrease some
of the negativity and hopelessness associated with the disease and help
PLWHA be more aware of their options.
121
Objectives
A. Within 18 months, increase positive awareness about HIV/AIDS by 30%
amongst target audiences.
B. Within 18 months, increase knowledge about HIV facts and prevention by
25% amongst target audiences.
C. Within 18 months, raise awareness of HIV/AIDS treatment options by 15%
amongst target audiences.
D. Within 18 months, increase self-reported positive sexual behavior by 15%
amongst target audiences.
E. Within 18 months, decrease self-reported needle/syringe sharing by 20%
amongst IDUs.
F. Within 18 months, raise perceived urgency of HIV prevention by 25%
amongst target audiences.
G. Within 18 months, raise personal relevancy of the issue of HIV/AIDS by
20% amongst key audiences.
H. Within 18 months, decrease negative opinions and prejudices regarding
PLWHA by 15% amongst key audiences.
Due to the low number of existing HIV prevention activities in the Russian
Federation and an even lower number of evidence-based interventions, it is difficult
to establish realistic objectives regarding the percentage of expected change within
target audiences. The percentage points mentioned above are rough estimates based
122
on background research and the author’s personal opinion; they are not to be
regarded as precise measurements based on scientific evidence.
It is suggested that the numbers be re-evaluated after the initial trial period
and extensive research conducted in the Russian Federation, so that exact current
measurements and initial baseline data of existing rates can be established.
Key Audiences & Key Messages
A. The general public: Although the general public is never considered a
target audience, in the case of HIV prevention in the Russian Federation it
is crucial to change the mainstream public opinion and attitude towards
HIV/AIDS and PLWHA in order to ensure public acceptance and
tolerance.
B. Young people (divided into target groups of 9-13, 14-17, 18-25 year
olds): This audience includes schoolchildren, college students, university
students, unemployed young people and working young people. It is
important to address schoolchildren as early as possible, because parents
in the RF are not usually open to discussing sex and HIV with their
children. Furthermore, the age of sexual debut amongst young people lies
relatively low in the RF, making it imperative for an educational
campaign to address them before that event. Young age is a time of
experimentation and defined by rebellion and feeling invulnerable. The
fact that STI rates are very high amongst sexually active young people
123
and young adults indicates that risky sexual behavior is not uncommon.
Drug users are also exceptionally young in the RF. Some messages could
include motivating to delay sexual debut, reduce the number of partners,
and to resist peer pressure about having sex early; Raising awareness
about the effectiveness of condoms; encouraging discussion about sex
with sexual partners and using condoms an expected social norm;
communicating that HIV can affect anyone, and that you cannot tell who
is sick by simply looking at them; increasing their perception of personal
risk of HIV/AIDS; and encouraging them to access VCT and counseling
and information regarding reproductive health and STIs.
C. Injecting drug users (IDUs): IDUs are the primary driving force of the
HIV/AIDS epidemic in the RF. While sustaining from putting blame and
isolating this group even further, special communication efforts must be
targeted towards this group in order to stop the spread amongst its
members as well as to women and other “bridge” populations. Some
messages could include communicating the dangers of needle sharing and
educating on how to sterilize equipment or where to obtain clean needles
and syringes; discussing the dangers of sexual risk taking while under the
influence of drugs; discussing the connections between HIV, alcohol and
drug use; promoting condom use and responsibility towards sexual
partners, providing information on where to obtain needle exchange
services, VCT, free condoms, and self-help groups.
124
D. Commercial Sex Workers (CSW): CSW are also highly marginalized and
highly vulnerable to many dangers, such as HIV, violence, drug use and
exploitation. Often, CSW are involuntarily involved in this milieu and
hard to reach. The combination of sex work, possibly drug use and social
disadvantage of women in the RF puts CSW at a very high risk for
infection.
E. Men who have sex with men (MSM): Often hidden and highly
marginalized, this group is hard to reach—not lastly because MSM often
do not identify themselves as such. Often MSM have unprotected sexual
contacts with both men and women, thus putting both sexes at risk in
addition to themselves. Messages could include communicating that HIV
is not visible and that one can’t tell someone else’s status by simply
looking at them; communicating the efficiency of condoms and that the
risks of anal sex are even greater; promoting correct and consistent
condom use with male and female partners and raise awareness about
special issues (e.g. condoms can break when used with oil-based
lubricant); and raising awareness about related issues such as drug and
alcohol use, that can play a role in HIV transmission.
F. Incarcerated persons: Prisons are incubators of HIV infection, due to
activities such as unprotected sex, male-on-male sex, tattooing, drug use,
and rape. Prisoners are captive and cannot escape from dangers while in
125
prison. That is why the government and society have a duty to protect this
group with special care.
G. Street children: Street children are subject to many dangers, such as low
hygiene, sexual and other violence, drug use, and risky sexual practices.
They are highly vulnerable to infection and must be protected by the state
and society.
H. The federal/regional/local government: The government plays a major
role in how HIV/AIDS will be treated as far as priority is concerned and
how it will be viewed by society. Although people in the RF are
distrustful of the government, acknowledgement of and political
involvement in HIV prevention sends a strong message of urgency to the
public. Messages to the government and related institutions include that
the Russian Federation has an obligation not only to its people, but also to
surrounding nations and the world; that the Russian Federation can set an
example for effective HIV prevention in the Eastern and Central
European region; that a further spread of the HIV/AIDS epidemic in the
RF will strongly affect the national GDP, the overall economic health of
the country, as well as social stability; that the international community
will look at the RF with a critical eye, if it ignores the HIV epidemic, that
history will judge us by how we deal with this problem; AIDS is the most
pressing issue of our time; that the population in the RF will soon realize
the scope of the national HIV epidemic. Stopping AIDS has to be the
126
number one priority in the Russian Federation; that this must also
translate into the resources that are devoted to HIV prevention and
treatment; that HIV treatment and protection must be provided to the
citizens of the RF; it is not only their human right, but it is also
guaranteed by the laws in the RF; and that HIV prevention is much
cheaper than treatment. If nothing is done today, by 2020, 85% of the
national health care budget might be necessary to pay for AIDS
treatment.
I. Health regulators on the federal, regional and municipal level: Regulators
responsible for HIV/AIDS issues, the health care system and budget
relocations must be aware of the problem of HIV/AIDS and understand
its urgency.
J. Elected officials: Elected officials must be targeted so that they are not
afraid of political involvement in HIV prevention due to the
consequences it might have on their positions.
K. International organizations (UNAIDS, WHO, etc.): International
organizations have already devoted many resources to HIV prevention in
the RF. However, continuous work with them and building of
relationships is important so as to ensure funding in the future.
L. Russian non-governmental organizations (NGOs): Russian NGOs have
done some work already, but it is far from enough. Raising awareness
127
about their work as well as support and funds is vital to their success in
HIV prevention.
M. Health care workers: Health care workers are often the first contact
people have when they discover they are infected. They are also part of
PLWHA’s health care and treatment. HIV/AIDS education and
knowledge is extremely low amongst health care workers, leading to a lot
of discrimination towards PLWHA from people who are supposed to be
their close allies.
N. Vulnerable Women: Not only are women in a social disadvantage in the
RF, but they are also biologically more vulnerable towards HIV infection.
Women must be empowered to protect themselves and to take control of
their sexuality and their bodies. Young women, women in abusive
relationships and women who are partners of IDUs are especially
vulnerable.
O. Young men and men of working age: Male life expectancy is at a
staggering low in the RF, due to many factors such as alcoholism,
unhealthy living, homicide rates and other social illnesses. This mortality
affects family structures as well as the national economy. Men must be
encouraged to live healthy, abstain from domestic violence and be more
responsible with their sexual behavior.
P. People living with HIV/AIDS (PLWHA): PLWHA must know that HIV
is not a death sentence and they have options for treatment and high life
128
expectancy thanks to medications. They must be supported mentally and
encouraged to be responsible with other people’s health.
Q. Pregnant women with HIV/AIDS: The chances for women with HIV to
bear healthy children are very high with the help of ARVs. Many
pregnant women with HIV/AIDS in the RF are not aware of their status
until birth and many abandon their children afterwards. To prevent this,
these women must be informed early on about their status, their options
and the fact that with medications, they can give birth to healthy children
and live long enough to raise them. Messages include communicating that
they have options and that they need to inform themselves about how to
avoid mother-to-child transmission; that life-prolonging ARVs can
considerably increase their health and the quality of your life and
guarantee the health of the child; and that treatment can decrease mother-
to-child transmission by 50%.
R. Russian large to medium sized businesses: Businesses need a stable
workforce. In many countries today, corporations cover HIV/AIDS
medications for their employees. It is in the interest of businesses to
maintain healthy, satisfied and happy personnel and to ensure that
workers are at their most productive. In addition to that, businesses in the
RF can be made aware of the practice of “corporate philanthropy” and its
benefits to their reputation and bottom line. Businesses can be encouraged
to support HIV prevention. Messages for this target audience could
129
include communicating that corporate social responsibility is one of the
most effective ways to affect a business’ reputation—and the bottom line;
that corporate philanthropy is an investment in business that yields
invaluable returns—those of a good reputation; and that they can help
change history by helping to stop AIDS—the country’s most pressing
issue.
S. Russian celebrities and youth idols: Endorsement by celebrities can help
raise awareness about HIV/AIDS and make it more socially acceptable to
talk about it. Celebrity endorsement could be even more effective
amongst young audiences.
T. Parents: Parents are very important in influencing their children early on.
Talking about sex, STIs, HIV and drugs with children does not only make
them more informed, but also sends the message that the subject is not
taboo.
U. The media (including journalists, editors, other media staff): Since there
is a lot of negative bias in the media regarding the issue of HIV/AIDS,
journalists and other media workers must be sufficiently and objectively
informed about the facts and the social implications so that they can
produce more responsible news and programs. The media industry as a
whole must be persuaded to participate in HIV prevention.
V. The Church, other religious institutions and religious leaders: The Church
can offer mental and spiritual support to PLWHA; set social standards on
130
important issues; and raise awareness, visibility, acceptability and
tolerance towards an issue.
Strategies and Tactics
In order to achieve the goals outlined above, several strategies will be implemented.
Again, since these strategies and tactics serve as a guideline to a broad and
interconnected national strategy, specific programs and details are not included and
will be left to the professionals implementing programs who are familiar with HIV
prevention as well as local culture and laws. A timetable for the execution of these
strategies is not suggested for the same reasons.
Based on the socioecological theoretical framework described in the previous
chapter, the following strategies and tactics can be roughly divided into different
categories of level of change: the intrapersonal level, the interpersonal/social
network level, the organizational level, the community level, and the
environment/policy level. Although many of the proposed strategies overlap into
and/or are part of several different levels of change, they will be considered as part
of the most prevalent category. The strategies are based on the general idea of the
necessity of social change for the purposes of HIV prevention on any level. Cultural
sensitivity and step-by-step campaign development as described in Chapter III are
implied.
131
ENVIRONMENT/POLICY LEVEL OF CHANGE
Coordinated National HIV/AIDS Education and Information Campaign
Objective information on HIV/AIDS, how it is spread, how infection can be
prevented must be easily available to everybody, who wishes to voluntarily inform
him- or herself on the topic. In addition to that, audiences should be exposed to HIV-
related information often and repeatedly, in order to assure message resonance.
Broadly speaking, this can be achieved by the following methods:
1. Using the mass media to spread information on HIV/AIDS to the general
public.
a. Print media publications on HIV/AIDS-related issues including
correct, objective information about the disease, how it is spread as
well as the social aspect of it. Print media has an advantage over
television in that it is able to be more elaborative on issues, offering
background and context to a topic.
b. Public service announcements (PSA), special segments, debates and
documentaries on national and local TV channels, spreading
information on HIV/AIDS and how it affects everyone, while
focusing on HIV prevention. Television media has the advantage
that it is visual and thus possibly more emotionally involving than
other media.
c. Public service announcements and special programs on radio
stations featuring HIV/AIDS information and prevention messages.
132
d. Special websites solely dedicated to the issue of HIV/AIDS in
Russia, as well as HIV/AIDS information on Russian language
websites, such as email sites, government sites, news sites, youth
sites, and social sites. The Internet is interactive and anonymous,
and can be used in many ways to spread information on AIDS (e.g.
links to websites, blogs, forums, etc.)
2. Since there is a lot of bias prevalent in the media as well, media staff must
also be trained and informed. This can be achieved by:
a. Educational and informational seminars for journalists, editors and
other media staff working in television, radio, print and online
media. Seminars will discuss HIV related issues, such as
epidemiology, virology, prevention, treatment, and social aspects of
HIV infection such as stigma and discrimination within society.
3. Targeting special groups and modifying messaging according to their
needs. These groups include:
a. Young people (elementary school, high school, college,
university and those enlisted in the army).
! Lectures and discussions on HIV/AIDS for students in
high schools, college and universities.
! Sex and drug education in elementary schools and high
schools.
! Peer educators to promote HIV prevention amongst youth.
133
! Involve national and local young celebrities in promotion
of HIV prevention.
! Using particular media outlets appropriate for youth (e.g.
youth magazines) and places young people go to spread
the word on HIV/AIDS and prevention.
b. Educators, opinion leaders and people with authority such as
teachers, professors and instructors at colleges and universities;
parents; and health care workers.
c. High-risk groups such as MSM, CSW, IDUs, street children,
and incarcerated people.
4. Individual counseling and interpersonal communication:
a. Patients at test centers and PLWHA.
! Voluntary counseling provided at all hospitals and medical
centers, rehabilitation and treatments centers for IDUs.
! Peer education for hard-to-reach groups such as IDUs, MSM,
CSW and prisoners.
Targeting the” General Population:”
The general population in a campaign is almost never a target audience. However, in
this case, the idea of marketing HIV prevention to the general population is crucial.
Numerous studies show that, in general, knowledge on HIV/AIDS in Russia is low,
and that there are many misconceptions and myths still prevalent amongst Russians
134
(Amirkhanian et al., 2001; Salamov & Pokrovski, 1998; Pinkerton et al., 2003;
Kalichman et al., 2000).
Chatterjee (1999), Fisher & Fisher (1992) & Kelly et al. (2001) argue that in a
country in the early stages of an HIV epidemic, such as the Russian Federation,
educational interventions designed to increase knowledge and promote awareness
may have more substantial effects on behavior change than in wealthier countries
with more advanced informational and educational programs, and would, at a
minimum, provide the necessary background for more advanced interventions (as
cited in Pinkerton, S. D., Dyatlov, R. V., DiFranceisco, W., Benotsch, E. G.,
Smirnova, T. S., Dudko et al., 2003). Studies show that television, radio, and print
media are the most common sources of HIV-related information in this population
(Pinkerton et al., 2003; Vinogradova, 1998). For instance, in a report by UNESCO,
public opinion polls revealed that the general population receives their information
on HIV/AIDS through the following channels (as cited in Osadcheva et al., 2003):
! Radio, television: 67%
! From relatives, friends, acquaintances: 21%
! From government bodies (the Duma, the Cabinet, police, etc.): 9%
! From flyers, leaflets, prevention events organized by health care institutions:
6%
Yet, the majority of the population is dangerously uninformed about HIV/AIDS.
Thus, the level of information about AIDS in 2002 was (Osadcheva et al., 2003, p.
27):
135
! Sufficiently informed: 19%
! Insufficiently informed: 35%
! Relatively badly informed: 44%
According to the same report, opinions on HIV/AIDS and attitudes towards
protecting oneself are driven mainly by fear (Osadcheva et al., 2003).
Misinformation and being not sufficiently informed yet still aware of the threat of
getting infected has led the majority of the population to adapt myths about the
disease and reacting aggressive towards PLWHA. Such myths include beliefs such
as “It is possible to get infected with AIDS just by visiting a dentist or at the
hairdresser’s during shaving or depilation, etc.,” fear of mosquitoes and flies (“They
transmit infected blood”) and refusal to use swimming pools and saunas (“What if
people sick with AIDS go there” (Osadcheva et al., 2003, p. 29). Still, this fear has
not led Russians to adapt protective measures such as using condoms widely, and
instead has caused a general panic within the population. In return, this panic has led
many to simply convince themselves that AIDS is not their problem (that it affects
only drug-addicts, prostitutes and homosexuals) or simply to reject the idea that
condoms are effective in preventing HIV infection because they feel like they could
get infected in so many other ways (swimming pools, mosquitoes, etc.).
Currently, the media are covering the issue of HIV/AIDS in the country either
extensively positive by suggesting that HIV is not really a serious problem, or
extensively negative by reporting that the government is doing nothing in terms of
HIV prevention and treatment and is either incapable or is systematically killing the
136
population in line with some worldwide conspiracy (Osadcheva et al., 2003). A third
type of coverage is also negative with coverage that is generally correct regarding
statistics and so forth, but also highly intimidating to the population, which is left
with the impression that there is no hope for a solution (e.g. "Starting in 2013 the
Russian population will start dying en mass from AIDS-related infections and
tumors") (Osadcheva et al., 2003, p. 29).
Thus, several main considerations are important when developing mass media
campaigns for HIV prevention for the general population. First, since fear has proven
to be ineffective in causing the general population to adapt more positive behaviors
(such as using condoms), it can be concluded that generating fear through a mass
media campaign would only generate more panic amongst the general population
and thus more myths and misinformation. The “fear approach” has also proven
ineffective in other countries’ mass media campaigns (Myhre & Flora, 2000).
Second, the notion that HIV affects only certain groups and not “people that live
normal lives” is even more worrisome because it “leads to a refusal to use
prophylactics and an inclination to risky behavior among people who have been
informed about the danger” (Osadcheva et al., 2003, p. 28). Although it is important
to concentrate certain efforts towards high-risk groups, it is important not to isolate
them form the general population so they don’t become scapegoats for the epidemic.
Third, as previously mentioned, Russians are generally reluctant to trust government
sources. In addition to that, many people also are distrustful of big business or
corporations (for instance, there is a widespread belief that pharmaceutical
137
companies do not release effective AIDS medications or cures because they want to
enrich themselves on the permanent sale of ineffective ones) (Osadcheva et al.,
2003). Regardless of the validity of these arguments, it can be concluded that
prevention programs should not cite government sources or corporate sources as
their sponsors. Furthermore, although the information sources mentioned above
might be the most popular ones in the RF, they might not necessarily be the most
efficient. Judging by the low information levels of the population, it might be
inferred that alternative outlets should be considered. For instance, because
HIV/AIDS information on Russian radio and television is often unreliable, other
sources such as HIV-educated health care professionals or parents might be more
effective. Sex education in schools, magazines specialized in HIV/AIDS topics and
education, and parenthood clinics are other sources that can be explored.
Thus, as a result, the HIV prevention mass media campaign developed for the
Russia Federation targeting the general population should include the following
elements:
! Spread correct information about HIV/AIDS, how it is transmitted and how it
cannot be transmitted. Address widely held myths by identifying them as
such and showing that they are incorrect
! Express that HIV affects everyone, not just certain groups (addressing “high-
risk behavior” rather than “high-risk groups”)
! Although sponsorship can include both businesses and the government, it is
important to not cite them as sponsors directly. Instead, sponsorship by
138
preferably Russian NGOs is possibly the safest route, for they have the best
chances of not being associated with any agenda besides stopping HIV
! Explore alternative outlets and methods of disseminating information on
HIV/AIDS
Furthermore, since many Russian citizens report substantial mistrust of not only
government information sources, but also the media (Pinkerton et al., 2003),
“perhaps combining traditional information sources with communications from
other, more trusted sources would have the greatest impact on increasing knowledge
and promoting safer- sex practices.” Kelly, J. A., St. Lawrence, J. S., Diaz, Y. E.,
Stevenson, L. Y., Hauth, A. C., Brasfield, T. L. et al. (1991) suggest that a
community-level approach involving popular and trusted individuals (opinion
leaders and influencers) might be useful as an alternative information source. Thus,
if awareness in the general population about HIV/AIDS is raised by traditional
methods such as the mass media (TV, radio, newspaper and magazine
advertisements) and simultaneously reinforced by interpersonal contacts and
community-wide HIV prevention efforts, the issue might gain more credibility as
well as possibly make the general population more tolerant towards PLWHA.
Increasing ARV Availability
Although ARVs increase the length and quality of lives for people in
wealthier nations, in countries such as the Russian Federation with weak resources,
high treatment costs, lack of laboratories to monitor the treatment, weak health care
139
systems, and many other competing health care needs are all obstacles to providing
AIDS patients with essential life-saving medications (Colebunders, R., Verdonck,
K., Nachega, J. & Kothari. P., 2000). Because funds for ARV treatment are limited
coming from an already strained health care budget, pressure can be exerted on
politicians and international donor agencies to provide ARVs so that overall health
care budgets can be increased and so that health care services can be improved.
Furthermore, providing ARVs to IDUs as well as other PLWHA has been found to
be highly cost-effective in the long run (Long, E. F., Brandeau, M. L., Galvin, C. M.,
Vinichenko, T., Tole, S. P. Schwartz, et al., 2006).
Several factors should be taken into account considering the distribution of
resources for ARVs:
! Prevention of mother-to-child transmission is highly effective and also highly
cost-effective and should therefore be a priority.
! As mentioned earlier, success of ARVs has sometimes led to an increase in
risky HIV-related behavior amongst people in wealthier countries. Therefore,
prevention efforts need to be strengthened and should not fall short of HIV
treatment concerns.
! When it comes to the distribution of HIV treatment resources, one must keep
in mind that, although it must be considered how to distribute resources most
effectively (such as mother-to-child transmission prevention), we must
refrain from judging the value of one person’s life to another’s.
140
Increasing Governmental Support and Cooperation
According to an epidemiological and economic model of the Russian epidemic
developed by the Moscow office of the World Bank, the Russian Federal AIDS
Centre and the Economics Institute of Charles University in Prague, HIV/AIDS
poses a major threat to the Russian economy and the treatment of AIDS patients
could absorb 82% of the Russian budget by 2020 (as cited in Walgate, 2002). In the
bulletin of the World Health Organization, Vadim Pokrovsky, Chief of the Russian
Federal AIDS Centre and one of the authors of the model, concluded "that the
government must be more active in prevention — not only to fight HIV, but also
because when we fight HIV we are also working for the economy." Therefore,
Pokrovsky continues, since “HIV/AIDS doesn't get enough attention from the
government; we need to show and explain this model to decision-makers... people
from the ministry of the economy, of development — the finance ministries” and
ultimately President Putin himself (as cited in Walgate, 2002).
The cost of inaction, as opposed to that of HIV prevention and treatment, will
be devastating to the Russian Federation. According to the World Bank (2006), a
generalized epidemic among economically active age groups could result in:
! A decline in annual economic growth rates by 0.5–1.0 percentage point
! A 1–3 percent increase in health expenditures
! A rise in the dependency ratio, putting a strain on social protection systems,
especially in countries already experiencing declining total fertility rates,
such as Belarus, Estonia, Moldova, and the Russian Federation!
141
! Increased vulnerability among households as children are forced to drop out
of school to work or take care of siblings, reinforcing the “poverty trap”
For instance, according to the same source, HIV/AIDS in the Ukraine could reduce
the national GDP by up to 6% between 2004-2014, reduce investment by 9% and
leave up to 169,000 children orphaned (World Bank, 2006).
Studies have demonstrated that the "risk environment" in a given country
may influence the efficacy of individual and community-level HIV prevention and
highlights the concomitant urgency for interventions targeting social and
environmental change as a whole (Rhodes, T., Ball, A., Stimson, G., Kobyshcha, Y.,
Fitch, C., Pokrovsky, V. et al., 1999). Strategic communication can serve to increase
governmental cooperation and support for NGOs that practice HIV prevention, to
develop politically protected school-based sex education, to create and improve laws
and regulations on the federal and local level that guarantee and regulate HIV
prevention and treatment, to strengthen the health system, and to gain full and public
commitment from the president and other public officials. This can be achieved by:
! Dialogue and negotiation between organizations and government
! Lobbying governmental entities for the purposes of HIV prevention
! Putting pressure on international organizations to intervene and give attention
to the HIV problem in the Russian Federation
! Raising public awareness about HIV/AIDS and social mobilization will in
turn put pressure on the government to address the issue
142
! Working with the media to expose government inactivity concerning HIV
prevention and set the agenda for HIV/AIDS as a pressing national priority
Pushing for Harm Reduction Programs
Injecting drug users are possibly the most critical target audience in the fight against
HIV/AIDS in the RF. Therefore, IDUs must be addressed in as many ways as
possible and with all methods we have at hand that have proven successful in the
country and elsewhere. There is no time for philosophical and moral questions on
harm reduction, because millions more will be infected if nothing is done while the
HIV epidemic can still be controlled. All that is of essence at this point in time is our
knowledge of the success of harm reduction, and complete dedication by all parties
involved, including the government and society.
Unfortunately, right now in the Russian Federation, harm reduction programs
are largely hindered by laws, economic factors and the law enforcement
(Malinowska-Sempruch, 2002). For instance, although low-cost needles and syringes
are readily available at pharmacies in Russia, IDUs are often reluctant to purchase
them, out of fear of being scrutinized by the police (Irwin, K., Karchevsky, E.,
Heimer, R., & Badrieva, L., 2006). According to Irwin et al. (2006):
All the economic, legal, and drug interdiction conditions that
commonly impede HIV prevention among IDUs flourish in the
Russian Federation. In January 1998, the Federal Law on Narcotic
Drugs further expanded one of the worlds most restrictive and
repressive drug policies with no accompanying strategy for
prevention or treatment. In Russia’s difficult transition to a market
economy, widespread crises of poverty and unemployment have made
corruption the standard practice of state institutions and
143
establishments in Russia (Gilinskiy, 2001). Hence, the routine
extortion of drug users serves as a regular source of economic
opportunity for many police officers (Paoli, 2002). Because drug laws
are somewhat open to interpretation and enforcement, drug users must
frequently pay fines to police on the spot. Studies showed that police
practices in five cities in Russia presented a serious impediment to
needle exchange efforts (Des Jarlais et al., 2002), whereas 16 cities
showed high rates of overdose episodes and reluctance to seek
emergency treatment services due to fear of prosecution (Tikhonov et
al., 2003).
Thus, government support and cooperation from the law enforcement must be sought
in order to create effective harm reduction programs that include needle exchange,
counseling and testing services. Although this will not happen overnight, it is
important to continuously lobby and negotiate for softer persecution of drug users,
while the efforts should be concentrated on drug traffickers instead. Even if the
general laws will be difficult to change, practitioners can work towards encouraging
law enforcement to “ignore” drug users as much as possible or, ideally, to refer them
to harm reduction programs instead.
Furthermore, studies suggest main barriers to treatment access for IDUs were
financial constraints, fear of registration as a drug user, and perceived low efficacy of
available treatment services (Bobrova, N., Rhodes, T., Power, R., Alcorn, R.,
Neifeld, E., Krasiukov, N. et al., 2006). Harm reduction programs and registration of
drug users was associated with loss of employment, breaches in confidentiality, and
stigma (Bobrova et al., 2006).
In a study reviewing successful international harm reduction programs found
that “high coverage” programs had the following features in common: (1) harm
reduction principles used to develop programs suited to the context; (2) prioritized,
144
staffed, and funded advocacy; (3) support from the general community and its
government representatives, religious leaders, and other opinion leaders; (4) a crucial
role for law enforcement; (5) funding that facilitated expansion to achieve high
coverage; (6) sustained funding; (7) context-appropriate differences in ways of
approaching injecting drug users and the services most likely to attract them to a
program; (8) replication of a single program to address IDUs in other districts, cities,
provinces; (9) convenience of access; (10) involvement of IDUs; (11) management
issues; and (12) learning from experience (Burrows, 2006). Therefore, covering as
many of the above “requirements” for successful harm reduction programs will
ensure the most efficient application of resources.
Improving Living Conditions for PLWHA
Improving the quality of life of people living with HIV/AIDS is crucial in the fight
against the AIDS epidemic. Ensuring better treatment of PLWHA is necessary not
only for basic human rights reasons—it is inevitable if we want to encourage people
at risk to come forward and get tested and seek out medical assistance and
counseling. Stigma and discrimination can cause PLWHA to hide their positive
serostatus and not seek out treatment and support, and those who think they might be
infected to prefer to not be informed about their status and thus put themselves and
others at risk.
A study conducted in St. Petersburg, Russia, concluded that HIV infected
people in Russia experience a wide range of social, psychological, and care access
145
problems (as cited in Amirkhanian, Y. A., Kelly, J. A
.
, & McAuliffe, T. L., 2003a).
A large portion of the HIV-positive participants reported having experienced
discrimination including being forced to sign documents acknowledging their HIV
status (47.9%), refusal of general health care (29.6%), being fired from their jobs
(9.9%), and being forced out of their family homes (9.0%) (Amirkhanian et al.,
2003a). Over 30% of the subjects had probable clinical depression, about half still
engaged in unprotected sex with HIV negative partners, while condoms were only
used one-third of the time with casual partners and the majority of IDUs reported
still sharing needles (Amirkhanian et al., 2003a). Pregnant women who are HIV-
positive face severe discrimination and social hostility in the forms of public
pressure and a clear message that “sexual life and reproductive choice — to have or
not to have a child — are not issues for them any more” (Osadcheva et al., 2003, p.
37). Having no accurate information on the issue, these women are often faced with
life-altering decisions they have to make on their own in a hostile environment.
Providing counseling and psychological support to HIV-positive people is
very important. Infection has very serious emotional and social consequences while
the realization of having to cope with a deadly disease is a traumatic experience
(Amirkhanian et al., 2003a). A person must learn to adapt to the new situation in an
environment that is highly prejudiced about AIDS. Unfortunately, infection for many
also means that family and friends will distance themselves from the infected during
a time of extreme psychological stress. Therapy and counseling can alleviate the
psychological stress of an HIV patient as well as help his/her family cope with a sick
146
member. HIV-positive persons should also be educated as much as possible on their
condition, how to protect themselves from secondary diseases and how to protect
others. Counseling for pregnant women with HIV is especially important, given their
special condition and given that they are making choices for themselves and for their
child. Counseling should always be available, voluntary and provided by specialized
staff while HIV-status of a patient should be kept highly confidential.
The creation of AIDS Centers around the country has generally been a step
backward in the fight against HIV. Generally, there is a widespread opinion in
Russia that PLWHA should be isolated from the larger society since they pose a
threat to others (Osadcheva et al., 2003). These special AIDS Centers further deepen
the perception in the general public that AIDS patients should be isolated and treated
in special institutions. Patients visiting the centers are automatically displayed and
identified as HIV-positive for everyone to see and those trying to maintain
anonymity and secrecy about their serostatus might be discouraged from going there
out of fear to be recognized. Ordinary medical workers at regular hospitals might
also be led to think that they will not have to treat HIV-positive people (Osadcheva
et al., 2003).
Yet under Russian law, HIV-positive people have the right to be treated at any
medical institution of their choice. Furthermore, PLWHA are equal members of
society and in order to assure them the same benefits as other citizens as well as
quality of life, the “principle of social integration and mutual help” must be prevalent
in the treatment of PLWHA (Osadcheva et al., 2003, p. 37). In practical terms that
147
principle means that PLWHA must be treated at regular hospitals. Hospitals must
therefore ensure that all of their staff is trained in HIV-related issues so that they
understand how the disease is transmitted and so that they do not openly or indirectly
discriminate HIV patients. Experienced special staff should be available that
provides counseling for HIV patients and their family members.
In addition to that, generally:
! PLWHA should not be made up to be the “victim.” Although society should
be encouraged to show compassion and tolerance towards PLWHA in order
to defy stigma and discrimination and to foster understanding, PLWHA must
be also encouraged to take charge of their lives instead of feeling helpless and
hopeless.
! PLWHA are an irreplaceable resource in HIV prevention. Their experience
and familiarity with the issue should be used to create effective prevention
programs and they should always be involved in the development and
execution of interventions.
Improving Epidemiological Control
Better HIV/AIDS surveillance is absolutely necessary in the RF. This will not only
help paint an accurate picture of the situation in the country, but it will also help
evaluate and monitor programs. This in turn, will make it easier to show results and
return-on-investment for donors and organizations providing funds. Since the official
number of current HIV infections in the RF (about 300,000) differs considerably
148
from estimates by international organizations (about one million infected), it can be
implied that the current HIV surveillance system needs improvement.
Better coordination and oversight is needed within the heath care system in
the RF. International Organizations can assist the RF in building a dependable
surveillance system so as to build dependable HIV prevention.
Creating a Favorable Health Care System
The fact that HIV and AIDS patients are currently being treated separately from
other patients is a contradiction in itself to Russian law as well as to successful HIV
prevention. If we want to defy stigma and discrimination towards PLWHA, which
will also translate into more efficient HIV prevention, then we must fully integrate
PLWHA into society, including schools, the workplace, families, and very
importantly—health care. For this purpose, the RF must:
! Eliminate AIDS Centers, which only exacerbate the hate and fear felt by the
general public towards PLWHA
! Threat HIV/AIDS patients in all regular hospitals and in a manner that is
humane and sensitive towards their needs. Those infected have, by law, the
full right to be treated in regular hospitals just like anyone else
! Educate and inform all health care workers, including nurses, counselors,
psychologists, and doctors. Health care workers must be well-informed on
objective facts about HIV/AIDS, how it is spread and prevented, HIV
treatment, and social implications of the disease
149
! Always have staff available that specializes in HIV/AIDS and has experience
in counseling for PLWHA, as well as deeper knowledge of treatment options
and such specifics as mother-to-child transmission
! Monitor health care staff for discrimination of PLWHA and give patients an
opportunity to voice their concerns and complaints about their treatment at
health care facilities. Violation of anti-discrimination laws and policies
should be appropriately penalized
! Voluntary counseling and testing (VCT) should be more readily available in
all health facilities and visitation should be encouraged through
communication campaigns
In the Long Run: Structural Changes in the Russian Federation
The World Bank (2006) recommends that, in order to deal with deep-seated and
complex factors fostering the spread of HIV in the region, political leadership must
address the following:
! Fostering economic growth through poverty-reduction policies and programs
! Controlling drug trafficking and the borders
! Reducing overcrowding in prisons through effective judicial reforms
! Decreasing unemployment and improving employment opportunities for
young adults
! Curtailing human trafficking
150
! Improving testing, counseling, and TB control through better public health
infrastructure
These goals cannot be achieved overnight. One must keep in mind that the Russian
Federation until less than two decades ago was subject to a completely different
political system. The time that the country has had to deal with such tremendous
transitions is very limited and a population’s mentality that has been built in half a
decade cannot be turned around in 18 months. However, it is important to be aware
of these factors as they have serious implications on the HIV epidemic and to work
towards impacting them with every single program and campaign that is being
implemented.
Involvement of International Organizations
International organizations that have been involved with HIV prevention for years
can be an irreplaceable asset to smaller organizations developing programs. In
addition to that, international organizations can provide assistance on a larger scale,
such as to government, local specialists, health workers and others involved in HIV
prevention. Especially the Russian Federation can benefit from such involvement,
considering the young stages of its epidemic and intervention efforts. In
collaboration with locals familiar with the specifics of the culture, international
organizations can serve to train, support, and provide intellectual and practical
guidance.
151
Furthermore, international organizations such as UNAIDS, the Bill and
Melinda Gates Foundation, and the CDC (the U.S. Centers of Disease Control) with
an abundance of financial and human resources are able to put pressure on the
Russian government on issues such as human rights and the country’s global
responsibility to put a halt to the HIV epidemic, for it affects us all. Through
diplomacy, negotiations, and lobbying, much can be achieved in finding solutions
that will be beneficial for all parties involved and most importantly—that will save
lives.
INTERPERSONAL/SOCIAL NETWORKS
Reaching Special Groups
Targeting Young People
One study conducted found that high risk-taking sexual behavior and low knowledge
of HIV-related issues were prevalent among students in St. Petersburg, Russia
(Amirkhanian, Y. A.,!Tiunov D.V.,!Kelly J.A., 2001a). Another study found that,
amongst Russian STI clinic patients, greater HIV/AIDS knowledge was associated
with younger age, higher educational attainment, positive attitudes toward condoms,
having more sources of information about HIV/AIDS, and believing that the
government is telling the truth about AIDS (Pinkerton et al., 2003). Thus, while
young people might know more about HIV/AIDS than their older counterparts, they
are still dangerously underinformed.
152
In the RF, young people account for a majority of IDUs. In combination with
the epidemic rise in STIs amongst youth, which points to an apparent sexual risk-
taking behavior, this can be disastrous. Some ways on how to practice HIV
prevention for young people are:
! Entertainment-Education: Young people are the biggest consumers of
entertainment media (McKee et al., 2004). Therefore using such
vehicles as music videos, educational videos, game shows and sports
can be very effective in reaching young audiences
! Sex and health education in schools has been proven to promote
responsibility, and not early sexual debut (as many regulators and
parents fear) (UNAIDS Inter Agency Task Team on Education,
2004). Education should be curriculum-based, start as early as
possible and be continued throughout high school while adapting
accordingly to the age group targeted
! Out-of-school groups such as street children and young people who
dropped out of school, college or university need to be targeted by
peer-interventions, which have been shown to be highly effective
amongst such groups (UNAIDS Inter Agency Task Team on
Education, 2004)
! Youth media such as special shows and programs on TV and radio, as
well as youth magazines can be used to reach young people
153
! Hotlines and Computer Counseling are a great way to offer this
audience an anonymous way to ask questions and learn about HIV
prevention (McKee et al., 2004).
! Placing HIV prevention messages where young people are. Mass
media messages should be tailored specifically to young people’s
needs, such as MTV’s “Staying Alive” program.
! Health services should be made more readily available for young
people. This is where trained health care personnel can provide
counseling and testing specialized to young people
! Having open discussions about sex and health issues with parents has
been shown to lead to less risk behaviors such as drug use and early
sex in children and young people. Since sex is somewhat of a taboo
topic in Russia, parents should be encouraged to inform themselves
and talk to their children about HIV prevention
A Word on “High-Risk Groups”
CSWs, MSM and IDUs are the populations most affected by HIV/AIDS in the
Russian Federation. At the same time, these groups are often hidden and
marginalized and not affected by traditional prevention efforts (Amirkhanian, Y. A.,
Kelly, J. A., Kabakchieva, E., McAuliffe, T. L. & Vassileva, S., 2003). As a result,
they must be reached by alternative methods. While these groups need special
attention and increased prevention services, they should never be singled-out,
154
isolated and further marginalized by HIV prevention efforts. Therefore, within the
general public, high-risk groups should never be referred to as such, since it only
leads to further discrimination and disassociation form the issue of HIV/AIDS by
those who do not perceive themselves as members of these “groups.” Instead, they
should be rather referred to ask groups practicing “high-risk behavior.” In addition,
members of these groups are a valuable resource and our most important allies in
HIV prevention. In order to walk the fine line between “paying special attention to”
and “finger-pointing,” several methods can be employed.
Targeting social networks and peer-driven interventions can be a very effective
strategy in reaching risk groups. Past research suggests evidence showing that
recruiting public opinion leaders influence risk behavior change (Kelly, 1991).
Amirkhanian et al. (2003) found that targeting naturally existing intact social
networks in an environment in which population members do not perceive
themselves as belonging to a community and where there is little precedence of
strong community-based organizations and NGOs such as in the RF, can establish
new group norms, reduce risk behavior of network members and reach members of
social networks only known to leaders of those networks. For this purpose, social
networks in a community have to be identified, members of those networks have to
be identified and enumerated, leadership has to be identified and HIV risk behavior
has to be established so that effective measures can be taken and outcomes of the
intervention can be measured. Not only is this model applicable to IDUs, MSM and
CSWs, but it also allows for high-risk groups to be reached efficiently by people they
155
trust, while at the same time they are targeted without blameful exposure to the
public.
Peer-driven interventions have been found to be highly effective in promoting
HIV prevention. Programs can be developed on a large scale that recruit members of
local IDU, CSW or MSM populations, train them to be educators within their
communities, and encourage others in those populations to do the same—all for a
small compensation and the larger moral incentive of being part of HIV prevention
efforts in one’s community. In this way, this PDI design contains all six factors
demonstrated to, in combination, promote behavioral change in individuals: (1)
increases in knowledge, (2) skills building, (3) motivation and incentives, (4) peer
pressure, (5) social norms, and (6) repetition (Fisher & Fisher , 1992; Kelly et al.,
1989; Kelly et al., 1990; as cited in Sergeyev, B., Oparina, T., Rumyantseva, T.,
Volkanevskii, V., Broadhead, R., Heckathorn, D. et al., 1999).
IDUs
IDUs are the primary driver of the HIV epidemic in the RF and the CEE/CIS region
as a whole. A considerable portion of resources should be devoted to this group in
particular, since they represent about 85% of new infections.
! Advocacy for less disciplinary and penalizing strategies for IDUs is crucial
on the government level, amongst law- and policy makers. This can be
achieved by lobbying, negotiations, working with law enforcement directly
and social mobilization of IDUs themselves
156
! Peer-driven interventions are very effective amongst IDUs because they are
hard to reach and often fear being prosecuted or jailed. Leaders and respected
individuals amongst IDUs can be trained to educate others on sterile injection
equipment, safe sex practices, distribute clean needles and condoms, and
refer others to harm reduction programs and VCT
! Harm reduction programs can serve to promote HIV prevention in a non-
judgmental environment. They can include needle-exchange services,
substitution programs, VCT, self-help groups and many other services
! Reaching sexual partners of IDUs and making them part of the IDU HIV
prevention efforts is crucial, because they are often at great risk of infection
! Because of the high number of IDUs amongst young people in the RF, it is
important to educate youth on how to avoid drug use altogether. McKee et al.
(2004) suggests the use of “life skills training,” which teach young people
interpersonal skills and thinking skills where young people are at risk due to
boredom, unemployment, poverty, and presence of drugs in their
communities (p. 160)
MSM:
Often hidden, MSM do not self-identify as homosexual and thus are difficult to
identify and target as such. In a society, where acceptance for MSM is very low,
using the mass media to address them directly should be avoided. The mass media
157
can, however, serve to raise awareness within the general public about the issues
MSM face.
Peer education and interventions can be effective in reaching members through
individuals they trust and respect and whom they will not associate with
stigmatization. Trained educators can successfully facilitate correct condom use,
distribute condoms and lubricants and refer clients to other services. In general,
Fisher et al. (1992) argues, HIV prevention for this group should:
! Address their sexual practices with both male and female partners.
! Correct misconceptions about risk.
! Address behavior practices rather than homosexual identity.
! Recognize risk issues faced by the female partners of MSM (as cited in Kelly, J
A., Amirkhanian, Y A., McAuliffe, T L., Granskaya, J V., Borodkina, O I.,
Dyatlov, R. V. et al., 2002).
Especially in a society where homosexual behavior is not accepted, MSM often
prefer to stay anonymous. Therefore, services such as hotlines with counselors
trained to discuss issues of sexuality and sexual identity for men, and Internet sites
that MSM use to socialize and meet can be efficient vehicles to reach them.
CSW:
HIV prevention for commercial sex workers can take on a very similar approach to
that of injecting drug users, not at last because those groups are often interconnected.
However, due to the complex nature of this group, which is a) mostly defined by
158
women (who are already especially vulnerable to HIV infection), b) often threatened
by the dangers of sex work, as well as increasingly by those of c) injecting drug use,
the approaches to HIV prevention in CSW can include education, empowerment,
prevention, care, occupational health and safety, decriminalisation of sex workers,
and human-rights-based approaches. Some approaches to HIV prevention amongst
CSWs are:
! Peer education can serve to educate CSW on issues directly related to their
work by others who have practiced sex work in the past or even currently do
so. Peer educators will be less judgmental and will possibly be able to offer
CSWs information that is more suitable to their special life circumstances,
since a regular health care worker might not be familiar with all issues this
group faces on a day-to-day basis. Peer educators can provide training in
correct condom use, condom-negotiating skills, safety tips for street-based
sex workers, and even distribution of male and female condoms.
! Occupational health and safety guidelines for brothels could be distributed by
directly communicating to those in charge. A similar approach in Thailand
had great success when brothels and other related institutions agreed to
participate in the 100% condom campaign.
! Self-help organizations and workshops for CSWs can help not only educate
them on how to protect themselves, but can also serve to teach them job skills
that could help them remove themselves from commercial sex work.
159
! Health services and drop-in centers for CSW can help provide them with
access to VCT, testing for STIs, obtaining condoms and birth control and
maternal health services—all in a safe space that will not be stigmatizing
such as regular hospitals and clinics.
! Lastly, advocating for changes in laws and policies that discriminate against
CSWs, drive them underground and increase their own as well as their
client’s risk, is possibly the most important long-term strategy in decreasing
the risk for CSW (McKee et al., 2004, p. 141).
Addressing HIV in Conjunction With Other Health and Social Issues
As mentioned above, there are many social and health issues that significantly drive
the spread of HIV. In order to achieve effective HIV prevention on the national level,
these factors must be addressed as well and national consciousness on the
connectedness between these issues must be raised.
STIs: The epidemic increase of sexually transmitted infections amongst the general
population and especially young people along with the HIV epidemic implies that
sexual risk behavior is the norm rather than the exception in the RF. In addition to
that, some STIs such as herpes can lead the carrier to have a greater vulnerability to
HIV infection than healthy individuals. For these reasons and because HIV, after all,
counts as a sexually transmitted infection, it is important to address STIs in
conjunction with HIV prevention. This can be achieved by:
! Training staff specialized in HIV testing and counseling to also counsel
patients on STIs
160
! Include discussion about STIs in sex education at schools
! Offer STI testing everywhere where there is HIV testing, such as at harm
reduction program sites
! Address STIs in all HIV prevention communications targeted at high-risk
groups, such as CSWs and MSM
Tuberculosis: As mentioned earlier, TB and HIV are interlinked. Therefore, they
must be addressed in conjunction (Drobniewski, F. A., Atun, R., Fedorin, I., Bikov,
A. & Coker, R., 2004). This can be achieved by:
! Working with existing programs that fight TB in the RF to expand on TB
prevention and to raise awareness about the connection between TB and HIV
! Counseling PLWHA on how to protect themselves from TB infection
! Offering TB testing in conjunction with HIV testing
! Treating TB in conjunction with HIV
Alcohol Abuse: As Russia's alcohol consumption per capita is among the highest in
the world, alcohol-associated behaviors are an important contributor to the HIV
epidemic (Krupitsky, E., Zvartau, E., Karandashova, G., Horton, N J., Schoolwerth,
K R., Bryant, K. et al., 2004). National campaigns raising awareness about alcohol
abuse in conjunction with HIV prevention could be effective in curbing both social
ills at the same time. This could be accomplished by:
! Working with existing programs that address alcoholism in the RF
! Creating separate messages and awareness campaigns that show the
connection between alcoholism and HIV
161
Domestic violence/women’s position in society: Women in Russia are especially
vulnerable to HIV infection due to their unequal position in society as a whole:
“Strict gender-role socialization, double standards for sexual behavior, and
relationship power imbalances against women foster an environment that accepts
sexual coercion against women, and these same conditions are directly related to
women's vulnerability to HIV/AIDS” (Kalichman et al., 2000a, p. 279). The
correlation between women’s diminished power in society and HIV infections
implies that the two issues could and should be addressed together. Furthermore, the
country’s scarce HIV prevention resources demand efforts to consolidate
interventions for multiple social problems (Kalichman et al., 2000a).

However, it
should be taken into consideration that empowering women on these issues does not
exclude men from them; on the contrary, prevention initiatives for both domestic
violence and HIV-AIDS in Russia should include men as the target of intervention
(Kalichman et al., 2000a). Some suggestions on how to approach this problem:
! Giving women access and informing them about HIV and how to prevent
infection (a report by UNAIDS, UNFPA and UNIFEM in found that 43% of
women in the CEE/CIS region did not know that a healthy-looking person
can have HIV and that condoms protect against the disease)
(UNAIDS/UNFPA/UNIFEM, 2004)
! Empowering women by communicating that domestic violence, sexual
violence, coercion, and rape are not acceptable, that they have the right to
protect themselves and their health, that HIV prevention is their responsibility
162
as well, that they need to talk to their partners about safe sex, and that they
have control over their sexuality and their bodies
! At hospitals and after gynecological exams, distributing female condoms and,
when available, microbicides, which give women power to have control over
HIV prevention
! Communicate to women that if their partner uses injecting drugs, they are at
higher risk of HIV infection
! Teach them how to negotiate condom use with their partners or husbands,
when they are aware that their partners use drugs or have multiple partners
! Men and boys should be made part of decreasing mental and physical
violence against women and be addressed in all communications
ORGANIZATIONAL
Involvement of the Church and other Religious Groups
Although the Russian Orthodox Church has not been actively involved in HIV
prevention until now, individual priests and their parishes have taken the initiative to
work to support HIV-positive people (Osadcheva et al., 2003). The church can
provide moral and spiritual support to those infected with HIV, their relatives and
friends, as well as help spread the message of tolerance and compassion towards
PLWHA. For instance, the church has organized regular prayer for the health of
HIV-positive people in a number of cities, including Moscow, St. Petersburg,
Podolsk, Kaliningrad, Minsk, and Tver (Osadcheva et al., 2003).
163
Although people in high-risk groups might not be easily reached by religious
institutions, the Church can certainly serve to influence the general population in
their attitudes towards the disease and HIV-positive people as a whole. HIV
prevention programs should seek to involve the Church and actively educate priests
and clergymen on the disease and related issues so that they can in turn provide
correct information to their communities. Active support from the Church can help
make the issue of AIDS more relevant and acceptable, less “shameful,” and to a
large extend more perceivable as a problem that affects everyone in the eyes of the
general population.
! The Church should publicly address the issue of HIV/AIDS and ask the
public to provide help and support to PLWHA and be compassionate and
tolerant towards those infected
! Priests should be encouraged and trained to provide moral support to
PLWHA
Prisons
The population of Russian prisons is one of the largest in the world. As of 1 April
2002, there were 1,220,368 people living in prisons in the country (Alexandrova,
2003) (or a total of approximately 0.85% of the total population). Some data suggest
that 15 to 20 percent of all people living with HIV/AIDS in Russia are in prisons and
detention facilities (Alexandrova, 2003). Considering the fact that many people in
prison already stem form marginalized groups such as CSWs and IDUs and taking
164
into account the special nature of their environment, prisoners are considered a high-
risk group and require diverse HIV prevention methods.
Prisons are HIV-facilitators. Many risk behaviors occur in prison, including
tattooing, unsafe sex, male-on-male sex, and injecting drug use. Given the special
living conditions of this population and their vulnerability to HIV/AIDS in prison,
interventions amongst incarcerated populations are crucial.
Following a careful examination of HIV risk-taking behaviors amongst
prisoners in the Russian Federation, Frost & Tchertkov (2002) conclude with several
implications for HIV/AIDS prevention in prisons:
1. Since sex in prison is a highly sensitive topic to most prisoners, it should be
addressed in a way that is sensitive to different circumstances it occurs in,
from conjugal visits to relationships formed in prison with opposite sex or
same sex partners to coercive and violent sex occurring in prisons. In addition
to that, interventions should address broader topics of sexuality and sexual
health, along with all other sexually transmitted infections and their
prevention as well
2. Considering how widespread tattooing is in prison amongst both sexes, the
authors recommend using “tattoo masters” as peer educators and health
facilitators during tattooing sessions
3. Given the complexities of risk taking behavior and the relationships
amongst these risks, the intervention designs should address the general
prison population instead of targeting particular groups, such as IDUs
165
4. Since the data showed that Russian prisoners are partially aware of HIV risks
and are already taking some steps to reduce infections, the authors suggest
that interventions should build upon prisoners’ existing body of knowledge
and foster their demonstrated efforts for health:
! Condoms should be made available for those who want to use
them
! Disinfectants for tattooing and injecting equipment should be
provided
! Information about boiling and other sterilization techniques
should take into account the cooking facilities available
! Syringe-exchange programs should be established to further
reduce the frequency of giving or taking used injecting
equipment among the prisoners who inject drugs (Frost &
Tchertkov, 2002)
In addition to that, the following should be offered in combination with the above
measures:
! Voluntary and anonymous HIV and STI testing and counseling
! Some form of HIV information visible to prisoners at all times, such as
informational posters and brochures
! Treatment options. Since HIV treatment is guaranteed to all Russians by law,
it is also guaranteed to prisoners. However, the reality is that financial
resources in the Russian Federation for HIV treatment are very limited.
166
Therefore, the available resources should be equally divided by population
percentage.
2
A famous quotation by the Russian author Feodor Mikhailovich Dostoyevsky
(1821–81) once noted: “The degree of civilization in a society can be judged by
entering its prisons.” Thus, a society can be judged on how it treats its weakest
populations, its incarcerated populations. We shall not forget that a life is as valuable
as any other.
COMMUNITY
Raising Awareness About Organizations Fighting HIV/AIDS
There are many organizations in the Russian Federation that are devoted to fighting
the AIDS epidemic. Unfortunately, only 3 to 4% of people know about the public
organizations that are actively involved in the fight against drug abuse and AIDS
(Osadcheva et al., 2003). Many perceive the organizations as being inactive, and
many of them in fact are (Osadcheva et al., 2003). However, in order to attract
people to these organizations and programs, they must be visible and considered
legitimate and trustworthy.

2
For instance, if the Russian prison population is 2% out of the whole population, then 2%
of resources devoted to HIV treatment should be devoted to prisoners. Although this might
cause some dissatisfaction amongst the general population or authorities (“Children are
dying of HIV and we are relocating resources to prisoners?”), one cannot forget that
prisoners are entitled to the same human rights as all other citizens and may not be
disregarded when it comes to their health. Choosing the relocation of resources according to
one’s perception of another person’s worth and right to live is immoral and unethical, not to
speak of impractical due to the highly subjective nature of this question.
167
NGOs have the most experience in “field” HIV prevention such as community
outreach and peer interventions. Therefore they can be resources for guidance on
developing and executing interventions. In order to improve NGOs and their
visibility, the following steps should be implemented:
! Invest more funds into linking media PSAs with local NGOs providing
HIV prevention services, creating websites for NGOs and advertising in
local communities
! Connecting Russian NGOs with international organizations fighting
HIV/AIDS and other networks made up of international alliances and
NGOs (e.g. GYCA—the Global Youth Coalition on HIV/AIDS)
! Working to increase funds for NGOs and their programs from local,
national and international donors
! Promoting more interaction with and involvement from the local
communities
! Bring community-based programs to scale through the mass media by
involving them in the national strategy as a partner
Involvement of Communities and Social Mobilization
Communities should be involved in social mobilization by serving as partners, not
simply “targets” of campaigns. Thus, they must be actively involved in changing
their social environment. Communities in this sense, as suggested by McKee et al.
(2004), are defined by (i) communities defined by residential proximity, (ii) groups
168
brought together by common interests or beliefs, such as religious communities, and
(iii) communities of vulnerable groups, such as CSWs, MSM, and IDUs (p. 52).
Only by making communities an ally contributing to a broader national strategy, is it
possible to connect all links necessary in order to achieve real social, political, and
economic changes beneficial for HIV prevention.
Involving communities means involving them into the design and planning of
programs and campaigns and empowering them to take charge of or “own” their HIV
prevention efforts. By feeling as part of the effort, commitment and responsibility
will grow and the “bottom-up” support for HIV prevention on a large scale can
sufficiently influence government, policy- and lawmakers to take action. Some ways
to involve communities are:
! Seminar and workshops conducted within communities to spread the word
and educate people on HIV prevention and related issues
! Using local media outlets such as local TV and radio stations and
publications
INTRAPERSONAL
Intrapersonal change is promoted directly or indirectly in most of the above
strategies and tactics. Counseling, for instance, is recommended in conjunction with
campaigns targeting youth and other groups practicing risk behaviors. In addition, it
is the author’s belief that change on the broader social, political, economic and
cultural level of a country will most likely lead to intrapersonal change in most
169
individuals. HIV prevention targeting social change on the level of organizations,
communities and policy can be effective in changing individual’s perceptions,
attitudes, beliefs and knowledge levels (McKee et al., 2004). As mentioned earlier,
the social change model of HIV prevention is not to mean that individual behavior
change is not also targeted; it is just to say that the behaviors and actions of the
individual self cannot be separated from his/her social environment (KcKee et al.,
2004).
Timeline
The campaign will initially run for 18 months. After that period, careful evaluation
of the efforts will reveal which strategies and programs have been successful and
need to be extended/funded and which ones have not been successful and need to be
adjusted, changed or eliminated. However, HIV prevention is not temporary—it is a
permanent process. Even in Western countries, where HIV is largely under control,
relapses occur—especially when people become aware of available treatments.
Change in behavior and firmly rooted attitudes require time and dedication, and
won’t happen overnight. Therefore, this program will run indefinitely and adapt and
change according to the nuances of the problem as well as to the environment.
It is the author’s suggestion that enough time be devoted to research and
careful preparation of programs and strategies, so as to make the most efficient use
of scarce resources. However, one must not forget that every day that passes with
inaction, more and more people become infected. Since 2004, HIV infections have
170
increased by 60% in the Russian Federation. That means that every day is valuable
and must be used in order to deliver prevention faster. The author cannot stress
enough how important it is to evaluate and monitor programs for all the reasons
mentioned earlier. Due to the scarcity of resources that can be devoted to HIV
prevention, many program developers/executioners choose to safe means by
skipping research and evaluation. This must not be so, because research and
evaluation are two of the most important steps in HIV prevention.
Because this strategic plan is a very rough draft of a broad national campaign
and does not include specific programs and details, it is difficult to suggest a
concrete timetable for its execution. In general, it is the author’s suggestion to devote
about 20% of the time and resources to research, monitoring and evaluation of the
programs. Another 15 to 20% can be devoted to careful program planning and
preparation, organization of resources and finding sponsors, for instance. Thus, we
are left with 60% of time and resources devoted solely to the execution of the
programs. With time, programs that enjoy greater experience and success can
possibly devote somewhat more time and resources to execution, while pilot
programs will require more theoretical and research work.
Taking into account the research conducted for this work, the author also
suggests that as many strategies and tactics as possible be applied immediately and in
concert. Inactivity cannot be justified and it is the author’s belief that tackling the
problem from as many sides as possible will be more effective than attacking it little
by little. For instance, although harm reduction programs will be more successful
171
once attitudes in the general population have been changed and law enforcement has
been successfully persuaded to be more tolerant towards IDUs, we simply cannot
wait for the prior two conditions to be in place before we implement harm reduction.
However, if society, regulators and the law enforcement are addressed and harm
reduction program sites are opened all at the same time, positive change might even
be observed quicker than if we were to tackle one problem at a time.
Some communication efforts, such as HIV prevention mass media
campaigns, can follow a logical progression of the information offered to audiences.
For instance, considering that the Russian audiences are largely uninformed about
HIV/AIDS, that myths about the disease are widespread and that the general
population is highly prejudiced against PLWHA, it is important to start by giving the
general population the basics first before following through with more complex
information. A mass media campaign could start by defying myths and offering basic
facts on HIV/AIDS and the basic ways on how to protect oneself from infection.
After that, it could focus on instilling a sense of personal responsibility for one’s
health and addressing the issues of social implications of HIV/AIDS, stigma and
discrimination and tolerance towards PLWHA. Later on, the campaign could tackle
the issues of the connection between other social ills and HIV/AIDS as a whole and
how all of us are immensely affected by HIV not only in the RF, but in the world.
172
Budget
It is very difficult to estimate the total costs of a national HIV prevention strategy.
The expenses greatly depend on the exact steps that will be initiated and the diverse
programs that will be implemented. International funding devoted to the RF has
increased twelve-fold within the past several years to $600 million at the end of 2005
(World Bank, 2006). Russia’s president Putin has significantly increased national
spending on HIV prevention and treatment from $5 million in the previous year to
over $100 million in 2005 (World Bank, 2006).
Compared to financial resources available in the past devoted to the fight
against AIDS, the financial sustainability of HIV prevention and treatment seems
much more feasible in the RF. The funds available today are enough to be able to
start a decent amount of well-designed and researched activities, which, by showing
accountability and success, could lead to an expansion of the national AIDS budget
as well as to increased international assistance.
Evaluation
According to Gilliam et al. (2003), evaluation of programs is imperative in order to
support the implementation and transfer of effective interventions, account for
services, demonstrate effectiveness, and improve programs. Davis et al. (2000)
suggest the following model for intervention design/evaluation:
173
Figure 4:
Source: Davis et al. (2000).
Community Planning is an evaluation of the community where the prevention efforts
are to be implemented so that planning can be specifically tailored to the
population’s needs. This includes studying things such as the particular culture,
political climate, target audiences, social status of the population, current HIV
prevention methods (if any at all), medical facility capabilities, etc. Intervention
planning specifies the program that is to be implemented and specific goals and
procedures. Process monitoring is keeping record of the what, who, when, how, and
where of the program by monitoring the activities. Process evaluation on the other
hand looks at how efficiently the program was implemented, thus, how close the plan
agrees with the reality. Outcome monitoring assesses if measurable goals, such as the
number of IDUs the program attempted to reach, were accomplished. Outcome
evaluation then reviews the overall effectiveness of the program, representing a more
174
in-depth evaluation of all factors taken together (e.g. cost effectiveness, degree of
behavioral change, etc). Finally, impact evaluation, looks at the impact of HIV
prevention as a whole, or as a combination of several efforts, on the larger scale,
such as on social norms, laws, political climate, etc. This is particularly important
since it looks at HIV prevention in a broader sense, as made up of many different
particles, instead of singling out separate efforts and viewing them disconnectedly.
The above model can be used for nearly all prevention programs and
campaign. It can’t be stressed enough how imperative it is to invest time and
resources into evaluation in order to provide accountability and proof of success for
programs, in order to be able to coordinate efforts on a national scale, and in order to
gain valuable experience throughout the process. At least 20% of time and
human/financial resources should be invested into evaluation while the research can
be outsourced to an independent organization in order to ensure unbiased evaluation.
175
Chapter 5: CONCLUSION
HIV/AIDS is the most urgent global problem today. The stigma associated with the
disease as well as the fact that the majority of new infections occur in economically
disadvantaged countries has considerably slowed the global response to this problem
in the past. Only in recent years has AIDS received the international attention it
deserves and the necessary financial and human resources devoted to fighting it.
However, this is only the beginning: We must ensure that AIDS awareness and the
means provided for HIV prevention, support and care are not diminished until the
epidemic is halted, reversed and eradicated globally. We must also ensure that the
response to the epidemic is as complex as the disease itself, for the ways of
transmission are few, but the social, political and economic drivers are many. The
AIDS problem must be tackled on a larger scale, with the broad picture in mind and
strategically.
The strategic plan proposed in Chapter IV directly addresses the overall
business goal stated above in that it offers strategies to achieve structural change on a
larger national scale. Implemented in concert these strategies and tactics can affect
the political, economic, social and cultural environment in the country, as well as
create a health system more adequate for HIV/AIDS prevention, treatment, care and
support. With time and consistency, therefore, these propositions can work to slow,
halt and reverse the AIDS epidemic in the Russian Federation. The objectives and
communication goals outlined above are rough estimates and suggestions of
intermediate steps that need to be reached in order for the overall goal to be met.
176
After careful evaluation and extensive research within the country, more concrete
numbers and goals can be determined, and a detailed outline for individual projects
established.
One of the strengths of this strategic plan is that it is based on the Public
Relations Strategic Planning Model, which is traditionally used for public relations
campaigns. A public relations perspective can be a great asset since it offers an
outside viewpoint into a field usually reserved for students and practitioners from
other social and scientific disciplines. More importantly, knowledge of public
relations practices can be helpful when advancing the cause of HIV/AIDS prevention
amongst government agencies, businesses, the media and international organizations.
On the other hand, it is crucial that the public relations standpoint be complemented
by, amongst others, health communication specialists, scientists, sociologists and
practitioners in the medical field in order to create a well-rounded approach to a very
complex problem.
Limitations of this plan include the existence of a large number of
information on the topic that is either non-relevant to the purpose of this paper or
even contradictory in some cases. Detailed research on many of the topics treated in
this work is very limited and evidence-based intervention information regarding HIV
prevention programs in the Russian Federation close to non-existent. Due to the
author’s limited experience with Russian culture and traditions, there might be many
overlooked cultural factors that could potentially counteract HIV prevention as
proposed. Other challenges might be institutions and populations that are very
177
resistant to change because of inherent biases and prejudices underestimated in this
paper. Another factor are the uncertain future consequences of the disease. In years
from now when the real repercussions of HIV become more visible in the RF, will
the general population become more fearful, prejudiced and hateful towards PLWHA
as a result? Predictions made for the Russian Federation based on knowledge from
other parts of the world and different time periods can be helpful, but nonetheless it
is not fully reliable for no two nations are the same. Ultimately, the Russian
Federation has many other issues to work on besides AIDS that are of major
importance, such as human trafficking, organized crime and alcoholism amongst
many others. Although the government might officially state its commitment for the
battle with HIV/AIDS, this particular problem might remain low on the “to-do” list.
The Russian Federation cannot afford to commit the same mistakes as
countries with older epidemics have committed in the past. The full extend of even
the current state of the AIDS epidemic in Russia will only become clear in years
from now, when thousands will have succumbed to the disease and when possibly
millions more are infected. The Russian Federation cannot afford the loss of human
life on such a scale and ignorance cannot be an excuse for inaction. Resource-poor
countries such as Uganda have proven in the past that it is only a matter of political
will and national dedication to turn around the epidemic. Russia has the financial
resources and international support to slow and halt the spread of HIV within the
country and to save millions of lives. There is no time left to wait.
178
BIBLIOGRAPHY
A Sickness of the Soul. (2006). The Economist. September 7. Retrieved 20
September, 2006 from
http://www.economist.com/world/europe/displaystory.cfm?story_id=E1_SRJTNVJ
Alexandrova, A. (2003). Russia: New Criminal Process Code Promises a More
Tolerant Incarceration Policy. Canadian HIV/AIDS Policy & Law Review, 8(1): 54.
Alexandrova, A. (2004). AIDS, drugs and society. New York, NY: The International
Debate Education Association.
Amirkhanian, Y., Kelly, J., & Issayev, D. (2001). AIDS Knowledge, Attitudes, and
Behaviour in Russia: Results of a Population-Based, Random-Digit Telephone
Survey in St. Petersburg. International Journal of STD & AIDS,12, 50-57.
Amirkhanian, Y. A., Kelly, J. A., Kabakchieva, E., McAuliffe, T. L. & Vassileva, S.
(2003). Evaluation of a Social Network HIV prevention Intervention Program for
Young Men Who Have Sex With Men in Russia and Bulgaria. AIDS Education and
Prevention, Vol. 15, Iss. 3.
Amirkhanian, Y. A., Kelly, J. A
.
, & McAuliffe, T. L. (2003a). Psychosocial Needs,
Mental Health, and HIV Transmission Risk Behavior Among People Living with
HIV/AIDS in St Petersburg, Russia. AIDS, Volume 17(16), 2367-2374.
Amirkhanian, Y. A.,!Tiunov D.V.,!Kelly J.A. (2001a).!Risk Factors for HIV and
Other Sexually Transmitted Diseases Among Adolescents in St. Petersburg, Russia.
(Statistical Data Included).!Family Planning Perspectives,!33.3:!106.!
Babakian, G. (2005). Positively Abandoned: Stigma and Discrimination Against
HIV-Positive Mothers and Their Children in Russia. Human Rights Watch, Vol. 17
No. 4(D).
Bill & Melinda Gates Foundation, The (2006). New Approaches to HIV prevention.
(August, 2006). Seattle, Washington. Retrieved August 21, 2006 from
http://www.gatesfoundation.org/nr/downloads/globalhealth/aids/pwg_2006_report.p
df
Bobrova, N., Rhodes, T., Power, R., Alcorn, R., Neifeld, E., Krasiukov, N. et al.
(2006). Barriers to Accessing Drug Treatment in Russia: A Qualitative Study Among
Injecting Drug Users in Two Cities. Drug and Alcohol Dependence, Vol 82(Suppl 1),
S57-S63.
179
Borisenko, K., Tichonova, L., and Renton, A. (1999). Syphilis and Other Sexually
Transmitted Infections in the Russian Federation. International Journal of STD &
AIDS, 10, 665-668.
Brink, S. (2006). AIDS at 25: From Free Love to Safe Sex. Los Angeles Times. 5
June 2006.
Burrows, D. (2006). Advocacy and Coverage of Needle Exchange Programs: Results
of a Comparative Study of Harm Reduction Programs in Brazil, Bangladesh,
Belarus, Ukraine, Russian Federation, and China. Cad. Saúde Pública, vol.22, no.4,
871-879.
Campbell, M. K., Quintiliani, L. M. (2006). Tailored Interventions in Public Health.
Where Does Tailoring Fit in Interventions to Reduce Health Disparities? American
Behavioral Scientist, Vol 49, no. 6, 775-793.
Chervyakov , V., & Kon, I. (1998). Sex Education and HIV Prevention in the
Context of Russian Politics. In Rosenbrock, R., ed., Politics behind AIDS politics:
case studies from India, Russia, and South Africa. Berlin: Public Health Policy.
Colebunders, R., Verdonck, K., Nachega, J. & Kothari. P. (2000). Impact of New
Developments in Antiretroviral Treatment on AIDS Prevention and Care in
Resource-Poor Countries. AIDS Patient Care and STIs, Vol. 14, No. 5, 251 –257
Davis, D., Barrington, T., Phoenix, U., Gilliam, H., Collins, C., Cotton, D., & Chen,
H. (2000). Sustainability of Technology Transfer. AIDS Education and Prevention
12 Supplement A, 115-125.
Dehne, K., Grund, J., Khodakevich, L., & Kobyshcha, Y. (1999). The HIV/AIDS
Epidemic Among Drug Injectors in Eastern Europe: Patterns, Trends, and
Determinants.” Journal of Drug Issues, 29(4), 729-776.
Drobniewski, F. A., Atun, R., Fedorin, I., Bikov, A. & Coker, R. (2004). The ‘Bear
Trap’: The Colliding Epidemics of Tuberculosis and HIV in Russia. International
Journal of STI & AIDS, 20 04; 15: 641-646.
Feijoo, A. (2001). Adolescent Sexual Health in Europe and the U.S.—Why the
Difference? Retrieved 19 August 2006 from
http://www.advocatesforyouth.org/PUBLICATIONS/factsheet/fsest.htm
Fisher, J.D. & Fisher, W.A. (1992). Changing AIDS-Risk Behavior. Psychological
Bulletin, 111, 455-71.
180
Frost, L., & Tchertkov, V. (2002). Prisoner Risk Taking in the Russian Federation.
AIDS Education and Prevention, 14 (Supplement B), 7-23.
Gilliam, A., Barrington, T., Davis, D., Lacson, R., Uhl, R. & Phoenix, U. (2003).
Building Evaluation Capacity for HIV Prevention Programs. Evaluation and
Program Planning, vol. 26, Iss. 2, 133-142.
Global HIV Prevention Working Group, The (2002). Global Mobilization For HIV
Prevention. A Blueprint For Action. Retrieved 26 September, 2006 from
http://www.kff.org/hivaids/200207-index.cfm
Global HIV Prevention Working Group, The (2003). Access to HIV Prevention.
Retrieved 26 September 2006 from
http://www.gatesfoundation.org/nr/downloads/globalhealth/aids/PWGFundingReport
.pdf
Gorbach, P. M., Ryan, C., Saphonn, V., & Detels, R. (2002) The Impact of Social,
Economic and Political Forces on Emerging HIV Epidemic [Epidemiology, Social,
Cultural and Political]”. AIDS, vol. 16 Supplement. 4, S35-S43.
Green, E. C. (2003). Rethinking AIDS prevention. Westport, CT: Praeger Publishers.
HIV/AIDS and Human Rights (2002). Human Rights Watch. Retrieved 26 January,
2007 from http://hrw.org/wr2k2/hivaids.html
International Labor Organization. (n.d.) The HIV/AIDS Epidemic in the Russian
Federation. Retrieved 8 September 2006 from
http://www.ilo.ru/aids/docs/dec02/cis/Russia-eng.pdf
Irwin, K., Karchevsky, E., Heimer, R., & Badrieva, L. (2006). Secondary Syringe
Exchange as a Model for HIV Prevention Programs in the Russian Federation.
Substance Use & Misuse, 41, 979–999.
Irwin, A., Millen, J., & Fallows, D. (2003). Global AIDS: Myths and facts.
Cambridge, MA: South End Press.
James, M., Hoff, T., Davis, J., & Graham, R. (2005). Leveraging The Power Of The
Media To Combat HIV/AIDS. Health Affairs, 24, no. 3, 854-857.
Kalichman, S., Kelly, J., Sikkema, K., Koslov, A., Shaboltas, A., & Granskaya, J.
(2000). The emerging AIDS crisis in Russia: review of enabling factors and
prevention needs.” International Journal of STD & AIDS, 11, 71-75.
181
Kalichman, S. C., Kelly, J. A., Shaboltas, A., & Granskaya, J. (2000a).

Violence
Against Women and the Impending AIDS Crisis in Russia. American Psychologist,
Vol. 55, No. 2, 279-280.
Kelly, J. A. & Amirkhanian, Y. A. (2003). The Newest Epidemic: A Review of
HIV/AIDS in Central and Eastern Europe. International Journal of STD & AIDS,
vol. 14, 361-371.
Kelly, J., Amirkhanian, Y., McAuliffe, T., Dyatlov, R., Granskaya, J., Borodkina, O.
et al. (2001). HIV Risk Behavior and Risk-Related Characteristics of Young Russian
Men Who Exchange Sex for Money or Valuables From Other Men. AIDS Education
and Prevention. 13(2), 175-188.
Kelly, J A., Amirkhanian, Y A., McAuliffe, T L., Granskaya, J V., Borodkina, O I.,
Dyatlov, R V. et al. (2002). HIV Risk Characteristics and Prevention Needs in a
Community Sample of Bisexual Men in St. Petersburg, Russia. AIDS Care, 14(1),
63-76.
Kelly, J. A., St. Lawrence, J. S., Diaz, Y. E., Stevenson, L. Y., Hauth, A. C.,
Brasfield, T. L. et al. (1991). HIV Risk Behavior Reaction Following Intervention
With Key Opinion Leaders of a Population: An Experimental Analysis. American
Journal of Public Health, 81, 168–171.
Klomegah, K. K. (2006). Russians Abandon HIV-Positive Patients. Inter Press
Service News Agency, (2006, August 23). Retrieved 9 September 2006 from
http://www.ipsnews.net/print.asp?idnews=29997
Krupitsky, E., Zvartau, E., Karandashova, G., Horton, N J., Schoolwerth, K R.,
Bryant, K. et al. (2004). The Onset of HIV Infection in the Leningrad Region of
Russia: A Focus on Drug and Alcohol Dependence. HIV Medicine, 5(1), 30-3.
Long, E. F., Brandeau, M. L., Galvin, C. M., Vinichenko, T., Tole, S. P. Schwartz, et
al. (2006). Effectiveness and Cost-Effectiveness of Strategies to Expand
Antiretroviral Therapy in St. Petersburg, Russia. AIDS, 20(17), 2207-2215.
Lowndes, C., Renton, A., Alary, M., Rhodes, T., Garnett, G., & Stimson, G. (2003).
Conditions for Widespread Heterosexual Spread of HIV in the Russian Federation:
Implications for Research, Monitoring and Prevention. International Journal of Drug
Policy. 14, 45-62.
Machon, K. (2006). Looking Forward, Looking Back. Positive Living 13 July, 2006.
Retrieved 20 January, 2007 from http://www.napwa.org.au/index.php?q=node/572
182
Malinowska-Sempruch, K. (2002). Law, Ethics, and Human Rights. The Need for
Harm-Reduction Approaches in Eastern Europe and the Former Soviet Union.
Canadian HIV/AIDS Policy & Law Review, 7(2-3), 84-8.
Mariner, W. (2001). Legal Issues in HIV/AIDS Prevention and Treatment in the
Russian Federation. Boston: Boston University HIV/AIDS Project. USAID-Boston
University Cooperative Agreement for Technical Assistance in Russian Health
Legislation and Regulation.
McKee, N., Bertrand, J. T., & Becker-Benton, A. (2004). Strategic communication in
the HIV/AIDS epidemic. New Delhi, India: Sage Publications.
Myhre, S. L. & Flora, J. A. (2000). HIV/AIDS Communication Campaigns: Progress
and Prospects. Journal of Health Communication, Vol. 5 (Supplement), 29-45.
National Intelligence Council. (2002). The Next Wave of HIV/AIDS: Nigeria,
Ethiopia, Russia, India, and China. Report ICA 2002-04 D. Washington, D.C.:
National Intelligence Council. September.
Okie, S. Fighting HIV — Lessons from Brazil. New England Journal of Medicine,
354.19, 1977–1981. Retrieved 6 June, 2006 from
http://content.nejm.org/cgi/content/full/354/19/1977
Osadcheva I.I., Khodzhemirova N.D., Kuchma V.R., Alisov D.A., Kulagina Y.V., &
Kuznetsova Y.S. (2003). Cultural Approach to HIV/AIDS Prevention and Care in
Russia. Research Institute of Hygiene and Protection of Health of Children and
Teenagers of Russian Academy of Science. The report was created with the
assistance of the UNESCO office in Moscow.
Paoli, L. (2002). The Price of Freedom: Illegal Drug Markets and Policies in Post-
Soviet Russia; Annals of the American Academy of Political and Social Science.
Cross-National Drug Policy, vol. 582, 167-180.
Peterson, S. (2004). Reluctantly, Russia Confronts AIDS. The Christian Science
Monitor. 16 August. Retrieved 26 September 2006 from
http://www.csmonitor.com/2004/0816/p06s01-woeu.html
Pinkerton, S. D., Dyatlov, R. V., DiFranceisco, W., Benotsch, E. G., Smirnova, T. S.,
Dudko et al. (2003). HIV/AIDS Knowledge and Attitudes of STI Clinic Attendees in
St. Petersburg, Russia. AIDS and Behavior, Vol. 7, No. 3.
Piot, P. AIDS: The next 25 years. Speech at the XVI International AIDS Conference,
Toronto, August 13, 2006. Retrieved August 25, 2006 from
http://data.unaids.org/pub/Speech/2006/20060813_SP_Piot_en.pdf
183
Polubinskaya, S. (2004). Federal Law ‘On Prevention of Spreading in the Russian
Federation of Disease Caused by Human Immunodeficiency Virus (HIV Infection)’:
Background, Content, and Perspectives. Retrieved 9 September 2006 from
http://www.tpaa.net/files/upload/publications/839.pdf#search=%221996%20Federal
%20Law%20On%20HIV%20Control%20in%20the%20Russian%20Federation%22)
Power, R. & Nozhkina, N. (2002). The Value of Process Evaluation in Sustaining
HIV Harm Reduction in the Russian Federation. AIDS,16, 303--4.
Reel, M. (2006). Where Prostitutes Also Fight AIDS. Washington Post, 2 March,
2006. Retrieved 12 October, 2006 from http://www.washingtonpost.com/wp-
dyn/content/article/2006/03/01/AR2006030102316.html
Rhodes, T., Ball, A., Stimson, G., Kobyshcha, Y., Fitch, C., Pokrovsky, V. et al.
(1999). HIV Infection Associated With Drug Injecting in the Newly Independent
States, Eastern Europe: The Social and Economic Context of Epidemics.” Addiction,
94(9), 1323-1336.
Rhodes, T., Lowndes, C., Judd, A., Mikhailova, L., Sarang, A., Rylkov, A. et al.
(2002). Explosive Spread and High Prevalence of HIV Infection Among Injecting
Drug Users in Togliatti City, Russia. AIDS. 16, F25-F31.
Rhodes, T., Mikhailova, L., Sarang, A., Lowndes, C., Rylkov, A., Khutorskoy, M. et
al. (2003). Situational Factors Influencing Drug Injecting, Risk Reduction and
Syringe Exchange in Togliatti City, Russian Federation: A Qualitative Study of
Micro Risk Environment. Social Science & Medicine. 57, 39-54.
Rhodes T., Sarang, A., Bobrik, A., Bobkov, E., & Platt, L. (2004). HIV Transmission
and HIV Prevention Associated with Injecting Drug Use in the Russian Federation.
International of Drug Policy, 15.
Russian Constitution, The (1993). Retrieved 23 July, 2006 from
http://www.constitution.ru/en/10003000-01.htm
Salamov, G. G. & Pokrovski, V. V. (1998). Moscow Sexual Workers: AIDS
Knowledge and Sexual Practices. International Conference on AIDS, 12, 60224.
Retrieved 5 November 2006 from
http://gateway.nlm.nih.gov/MeetingAbstracts/102232175.html
184
Selis, S. L. (2005). Russia Must Treat Drug Users to Contain HIV/AIDS Epidemic,
Research Shows. Center for Health Policy/Center for Primary Care and Outcomes
Research, Stanford University. Retrieved 8 September 2006 from
http://chppcor.stanford.edu/news/russia_must_treat_drug_users_to_contain_hivaids_
epidemic_research_shows_20050718/
Sergeyev, B., Oparina, T., Rumyantseva, T., Volkanevskii, V., Broadhead, R.,
Heckathorn, D. et al. (1999). HIV Prevention in Yaroslavl, Russia: A Peer-Driven
Intervention and Needle Exchange. Journal of Drug Issues. 29(4), 777-804.
Simone, R. (Producer). (2006). Frontline: The Age of AIDS (Television
Documentary). A co-production of WGBH/FRONTLINE and Paladin InVision Ltd.
With Silverbridge Productions Ltd. and Granada International Media Limited in
association with Channel Four (UK).
Somlai, A., Kelly, J., Benotsch, E., Gore-Felton, C. Ostrovski, D., McAuliffe, T. et
al. (2002). Characteristics and Predictors of HIV Risk Behaviors Among Injection-
Drug-Using Men and Women in St. Petersburg, Russia. AIDS Education and
Prevention. 14(4), 295- 305.
Stepanova, E.V., Rakhmanova, A.G., & Chaika, N.A. (2004). Stigmatization of HIV
Positive Persons by Russian Health Care Workers. Int Conf AIDS. 1-16; 15: abstract
no. TuPeD4983. Medical Academy for Postgraduate Studies, Saint-Petersburg,
Russian Federation.
Stillwaggon, E. (2006). AIDS and the ecology of poverty. Oxford University Press,
Inc.
Stokols, D. (1996). Translating Social Ecological Theory Into Guidelines for
Community Health Promotion. American Journal of Health Promotion, vol. 10, no.
4.
Torabi, M., Crowe, J., Rhine, S., Daniels, D., and Jeng, I. (2000). Evaluation of
HIV/AIDS Education in Russia Using a Video Approach. Journal of School Health,
70(6), 229-233.
Tragakes, E. and Lessof, S. (2003). Health Care Systems in Transition:
Russian Federation. Copenhagen: European Observatory on Health Systems and
Policies, 5(3).
UNAIDS (2004). The Changing HIV/AIDS Epidemic in Europe and Central Asia.
Geneva: UNAIDS, 2004. Retrieved 25 September, 2006 from
http://data.unaids.org/Publications/IRC-pub06/JC1038-ChangingEpidemic_en.pdf
185
UNAIDS (2006). 2006 Report on the Global AIDS Epidemic. Geneva: UNAIDS,
2006. Retrieved June 27, 2006 from
http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp
UNAIDS (2006a). High Level Meeting on AIDS, 2006. (May 31 – June 2, 2006).
Retrieved August 15, 2006 at
http://www.unaids.org/en/Conferences/2006HLM/default.asp
UNAIDS (2006b). Country Report of the Russian Federation On the Implementation
of the Declaration of Commitment on HIV/AIDS, adopted at the 26
th
Special Session
of the United Nations General Assembly, June 2001. Geneva: UNAIDS, 2006.
UNAIDS Inter Agency Task Team on Education (2004). Education Sector Global
HIV & AIDS Readiness Survey 2004. Paris: UNESCO, 2006. Retrieved 5 November
2006 from http://unesdoc.unesco.org/images/0014/001446/144625e.pdf
UNAIDS/UNFPA/UNIFEM (2004). Women and HIV/AIDS: Confronting the Crisis.
Geneva: UNAIDS/UNFPA/UNIFEM, 2004. Retrieved 30 September 2006 from
http://www.unfpa.org/upload/lib_pub_file/308_filename_women_aids1.pdf
UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance (2002).
Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections:
Russian Federation, 2002. Geneva: UNAIDS/WHO, 2002.
Vinogradova, T. (1998). Survey of Information Sources on AIDS/STI in St.
Petersburg Students of High Schools and Colleges. International Conference on
AIDS, 12, 189.
Walgate, R. (2002). AIDS Could Dominate Russian Budget by 2020. Bull World
Health Organ, vol.80, no.8, 686-687.
World Bank (2006). HIV/AIDS in ECA, Overview. Retrieved 19 November 2006
from
http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/ECAEXT/EXTECA
REGTOPHEANUT/EXTECAREGTOPHIVAIDS/0,,menuPK:571181~pagePK:510
65911~piPK:64171006~theSitePK:571172,00.html
World Health Organization (2006). World Health Statistics 2006. Geneva: WHO
Press. Retrieved 25 October 2006 from http://www.who.int/whosis/whostat2006.pdf

Abstract (if available)

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

Communications and messaging strategies to encourage African-American women to practice safer sex/HIV prevention measures

PDF

Through targeted public relations awareness campaigns, community based organizations can raise the level of HIV/AIDS awareness among black women, thereby reducing the rate of HIV/AIDS infections ...

PDF

Stage of readiness and learning styles -- a tailored HIV/AIDS prevention intervention for youth detained in the Los Angeles County Juvenile Justice system

PDF

Strategic communications in dietary supplement marketing — a case study of the marketing of Coenzyme Q10 supplements

PDF

They wanted their stories told: digging through artist Donell Hill’s attic to unearth the forgotten history of 11 Texans living with HIV/AIDS in 1994

Asset Metadata

Creator Markova, Biljana Ivatz (author)

Core Title Strategic communication in the fight against HIV/AIDS in the Russian Federation

School Annenberg School for Communication

Degree Master of Arts

Degree Program Strategic Public Relations

Publication Date 02/15/2007

Defense Date 02/14/2007

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag evidence-based intervention,HIV prevention,HIV/AIDS in economic, social, political context,national response to HIV/AIDS,OAI-PMH Harvest,public health intervention,public relations strategic planning model,socioecological model for HIV prevention

Language English

Advisor Swerling, Gerald (committee chair), Clarke, Peter (committee member), Cruz, Tess B. (committee member)

Creator Email markova@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-m258

Unique identifier UC1192105

Identifier etd-Markova-20070215 (filename),usctheses-m40 (legacy collection record id),usctheses-c127-168263 (legacy record id),usctheses-m258 (legacy record id)

Legacy Identifier etd-Markova-20070215.pdf

Dmrecord 168263

Document Type Thesis

Rights Markova, Biljana Ivatz

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Repository Name Libraries, University of Southern California

Repository Location Los Angeles, California

Repository Email cisadmin@lib.usc.edu