A Turning Point for Russia and HIV?

Something noteworthy happened a couple of weeks ago on Russian social media. The country’s best-known vlogger, Yuri Dud (pronounced “dude”), released a two-hour documentary spotlighting Russia’s HIV/AIDS crisis. To say it went viral is an understatement: at over 16 million hits, and counting, it’s one of the most instantly popular YouTube videos in Russian history.

The two-hour film covers a range of topics long absent from Russian public discourse. Through a series of highly personal interviews of people living with HIV, Dud walks viewers across the most basic elements of the epidemic. His conversations with young Russians reveal a shocking ignorance of even the most basic facts about HIV transmission and prevention. Underlying everything is Dud’s central message that, when virally suppressed through medication, people living with HIV can lead healthy lives and are not at risk of transmitting the virus to others. The upbeat, casual footage of subjects laughing, playing with their children, and speaking openly about their status is groundbreaking in a country where many still see a positive HIV diagnosis as a death sentence.

The impact was immediate. Within a week, the number of Russian-language Google searches on “HIV” and “AIDS” had increased fourteen-fold. Major cities have seen a surge in HIV testing, with many people copying Dud’s on-air rapid oral swab test. A handful of physicians’ groups and popular television shows have aired well-received follow-up programming.

Dud’s video has created a singular, long overdue moment. He’s touched on long-taboo subjects at the heart of Russia’s HIV epidemic: drug addiction and the lack of humane services available for drug users, condom use, and the wholly ineffective reproductive health education in the country’s school system.

Raising general awareness about HIV/AIDS in any society is a positive step. Getting the Russian government’s attention is even better. A deputy health minister has already sung the video’s praises on social media, and the deputy head of the parliament’s health committee has scheduled a public viewing and roundtable discussion to explore ways of improving access to HIV prevention and treatment services. The health minister in the Rostov region has released a job ad for someone to produce TikTok videos depicting the lives of people with HIV. Perhaps most importantly, Alexei Kudrin—the powerful and respected former minister of finance who’s currently head of the Accounts Chamber—has announced that his agency will implement a study later this year on the effectiveness of government HIV/AIDS services.

But this enthusiasm isn’t universally shared within ruling circles. Even if the new video’s penetration of the national conversation can be sustained, it butts up against deeply entrenched elements of Russian conservatism. There’s a reason the HIV epidemic in Eastern Europe and Central Asia, driven primarily by what’s happening in Russia, is the fastest-growing in the world . A core element of Putin’s regime-building after retaking the presidency in 2012 has been his reassertion of Russia’s unique great-power status rooted in anti-Western, anti-progressive, traditional “family” values, backed by the increasingly politically powerful Russian Orthodox Church. Support for, or even tolerance of, groups who don’t fit that narrative isn’t in the Putin playbook. The key populations affected by HIV in Russia—drug users, sex workers, men who have sex with men—are highly stigmatized, and their behaviors and even their identities are driven underground and criminalized. These marginalized groups don’t fall through the cracks of HIV prevention and treatment inadvertently.

Russia’s notorious 2013 “anti-gay propaganda” law bans “the promotion of non-traditional sexual relations to minors,” diminishing not only media representation of the LGBT community, but also public access to basic information on sexual identity, reproductive health, and disease prevention among young and old alike. A Pew Research Center poll last fall found that only 14 percent of Russians think that homosexuality should be accepted by society, and the numbers don’t vary too much by generation. Acceptance by young people ages 18-34 reaches only 25 percent. It’s no surprise that men who have sex with men are the key population in Russia about whose HIV knowledge and behaviors we know the least; many are highly reluctant to self-identify even for researchers, let alone government health officials.

Drug users are little better off. Russian law and culture treat drug addiction as a criminal justice rather than public health issue. The law enforcement community exists in a constant state of hypervigilant overreaction to the slightest hint of illicit drug use. Twenty people, for example, are currently facing felony charges for trafficking of the common antidepressant Buproprion (Wellbutrin), despite the Russian Society of Psychiatrists’ insistence that it is not an addictive drug likely to result in abuse. Government policy remains staunchly and obstinately opposed to legalization of opiate substitution therapy (typically methadone or buprenorphine), and although not universally prohibited, needle and syringe exchange programs are few and far between. The civil society groups that used to provide at least some harm reduction services had their wings severely clipped earlier in the decade by a government crackdown on non-governmental organizations; in 2012, NGOs that received foreign funding and engaged in vaguely-defined “political activity” were subject to harassment—or worse—under a new “foreign agents” law. The global health community, the wellspring of most HIV prevention activity in the late 1990s and through the 2000s, has been largely forced out. Only a few home-grown service providers remain.

The government currently spends about $400 million annually on testing and treatment—a number that, according to the head of Russia’s federal AIDS center, should be at least quadrupled. A new pharmaceutical procurement system launched in 2017 cut antiretroviral (ARV) drug prices significantly. However, an official HIV registry set up that same year, ostensibly to make ARV distribution more efficient, has predictably driven away some members of marginalized groups. Lines for treatment are still long, and medications are still expensive. An aggressive import substitution policy has curtailed the availability of many of the more recent-generation Western-produced ARVs. The Russian-made generics are often less effective or produce intolerable side effects. Over the last few years, patients’ groups have resorted to internet-based drug swaps to access new medications or share stocks of people who have died. The inevitable gaps are worrisome, as treatment adherence is vital to maintaining undetectable virus levels. Even under optimal conditions, it can be challenging to follow the strict regimen antiretrovirals require. The higher the barriers to access, the more likely the interruptions to patients’ virally suppressed status.

The response has varied widely across Russia’s 11 time zones. There are bright spots. St. Petersburg’s municipal government has been unique in its sustained collaborations with the western HIV/AIDS research community, and in a set of innovative policy responses like pushing drug treatment services out to the peripheral neighborhoods where users live. A handful of courageous scientists and activists in Kazan, Russia’s sixth largest city lying along the Volga river, stare down civil and criminal penalties for their push to legalize methadone. But on the other side of the spectrum, a regional health ministry investigation in Perm, just west of the Ural mountains, found no fault last month with a local physician’s refusal to treat an HIV patient fear that that he would “infect us all.”

Dud’s documentary has likely gained some level of traction within the Russian government because, while it challenges underlying beliefs about people living with HIV, it lands sparingly on the underlying causes of the epidemic. Dud appropriately skewers public reluctance even to say the word “condom” out loud; Russian officialdom mistakenly fears that condom use undermines their increasingly desperate schemes to increase the birth rate. But on the whole, he presents an unrealistically simple solution in the form of expanded testing and ARV uptake. This approach fits neatly within the incentive structure of a Russian government apparatus that, confronted with an economic downturn and public protests, is looking for ways to demonstrate responsiveness to popular demand for improved social services. The fact that the video’s message comes from a Russian source is, no doubt, appealing for a government and public audience that harbors deep suspicions of Western influence in Russia’s domestic affairs. But expanded mass screening is hardly the primary answer. About 30 percent of the population is already tested annually, and there’s little attention to reaching the key populations most at risk.

While the public reaction to the film is a landmark moment in Russia’s HIV epidemic, reversing the country’s current dangerous trajectory will require an upheaval in government policy and action. The unprecedented uptick in testing interest is a promising sign, but without targeting and adequate access to ARVs, it may be wasted. Much-needed reform of health education, drug treatment, and the criminal code will happen only through confrontation with entrenched power bases within the Russian state. Even small steps toward health-focused sex education in the public school system and the legalization of opiate substitution therapy would be important benchmarks signaling the potential for meaningful change. Putin is reported to have issued recent instructions to his government to increase coverage of ARVs and, remarkably, to come up with a prevention strategy that prioritizes vulnerable populations. Dud’s video will have a lasting impact if it continues to spark the hard conversations that are prerequisite to this type of foundational, structural reform.

Judy Twigg is a senior associate (nonresident) with the Russia and Eurasia Program at the Center for Strategic and International Studies in Washington, D.C. Michael Rendelman is a research assistant with the CSIS Global Health Policy Center.

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Judyth Twigg

Judyth Twigg

Former Senior Associate (Non-Resident), Europe, Russia, and Eurasia Program and Global Health Policy Center

Michael Rendelman