AIDS in Russia. In sickness and in chaos

Russia wins some serious money to fight AIDS. But it could go to waste

WITH perhaps a million Russians carrying HIV, but just $4.2m in the government's annual AIDS budget, it should be good news that the Global Fund has granted Russia some $120m over five years to fight the disease. Two-thirds is for buying drugs, which should allow up to 50,000 people to be treated by 2009. A mere 1,500 are in treatment now, though the World Health Organisation (WHO) reckons nearly 60,000 need it. Yet the biggest problem is not shortage of money. Russia has conflicts between departments and clinics, no agreed policies for testing and treatment, and no clear picture of how AIDS is evolving. It also seems not to care about cutting the cost of treatment. Unless these things are sorted out, the Global Fund's money could go down a black hole.

The grant assumes that a standard “first-line” cocktail of three drugs will cost $2,000 a year, and a more sophisticated “second-line” package $3,000. By 2008 it should be just $500-800. The government's budget should rise to $20m by 2006 and $54m by 2009. Yet last year the Russian health ministry was paying nearly $8,000 for a typical first-line package. That is not only more than the same drugs cost in America but, more strangely, about one-quarter more than typical retail prices at Moscow pharmacies or over the internet. And the federal budget is not set to change until 2006 at the earliest.

Drug firms are said to have promised to cut prices if patient numbers grow. But the only thing that can force them down is competition from cheaper generics. These are used in many poorer countries, and most are on the WHO's “prequalified” list, so that countries can approve them faster. But Russia has registered only one locally made generic so far. CIPLA, an Indian generic maker, says that approval in other countries takes 12-18 months. In Russia it has been trying to register one drug for nearly three years and several others for two years. That, says CIPLA, is because the health ministry insists on a declaration that the drugs do not infringe the original patents. Yet other countries dealing with AIDS have waived patent protection, a practice allowed by the WTO, which Russia hopes to join next year.

One problem with generics may be resistance from Russian doctors. “I don't know how well generics work,” says Yevgenia Sinchik, at the St Petersburg AIDS clinic. “We're not a third-world country, so we should try to meet world standards.” Aleksei Mazus, director of the Moscow AIDS centre, is more categorical: “Do these people understand the difference between normal medicines and fakes?”

Another dispute is over whom to treat. The Global Fund grant is aimed at “vulnerable” groups, among them drug addicts and sex workers. In the West HIV has spread mostly through sex; in Russia over 80% of people have caught it from dirty needles. But addicts often fail to stick to the strict drug regime, which can lead to drug-resistant strains. Dr Mazus argues that the grant is misdirected, and that only ex-users who can show they have kicked the habit should be treated. Yet he also claims that, in Moscow, everyone who needs treatment, including addicts, gets it. But that is still only 1,000 people. At least five times that number should be getting treatment if the WHO's nationwide estimate of 60,000 infected people is right. Are the others being ignored? Or avoiding doctors and tests, because they know they will be?

The statistics are clouded by bureaucratic rivalries. Officially 283,000 are registered with HIV, but that does not include new cases from Moscow for the past year thanks to a dispute over data. A decision to move the cost of HIV testing from federal to regional budgets has, says Vinay Saldanha of the Canada AIDS Russia Project, led to “a very splotchy epidemiological portrait”. Poorer regions do fewer tests and neglect hard-to-reach groups like drug users. That produces wild variations: in some places the infection rate seems to be falling, in some HIV seems to spread mainly through heterosexual sex, and nobody can say how far AIDS has spread into the population as a whole.

Another controversy concerns “harm reduction”, notably the policy of giving addicts free clean needles to slow the spread of HIV. Dr Mazus says this can encourage non-drug-users to try drugs. He has similar doubts about “safer-sex” education: “What kind of approach is that to something that is such a serious relationship between people?” Again, he is not alone. A big AIDS conference in St Petersburg in May, took a stand against harm reduction, in a city that has one of Russia's biggest needle-exchange programmes.

With its population already declining fast, Russia cannot ignore AIDS. A World Bank study two years ago predicted that, by 2020, the effect of AIDS on the budget and the workforce could lop a full percentage point off annual GDP growth. Yet President Vladimir Putin has given AIDS only the briefest mention in public. An outgoing deputy health minister, Gennady Anishchenko, is taking the AIDS brief to his new job as head of the consumer-protection agency. That hardly makes this lethal epidemic seem a top priority.

• Primary Source

http://www.theglobalfund.org/search/portfolio.aspx?lang=en&countryID=RUS http://www.theglobalfund.org/search/portfolio.aspx?lang=en&countryID=RUS

http://www.theglobalfund.org/en/ http://www.theglobalfund.org/en/

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