Introduction
The Russian HIV crisis is getting worse, found to have the greatest number of people living with HIV (PLWH) in Europe and the fastest increasing number of new cases by 10-15% each year (UNAIDS, 2016), Russia’s epidemic is not improving. The consequence of this is HIV/AIDS now rising to the top ten causes of mortality in Russia (IHME, 2017). In this essay, it will be discussed why this high-income country is far more affected by the virus than many other countries of the same resources and what are the impacts of this on the individual.
Availability of drugs
The cost of the ARV’s available are very high in Russia compared to the generic cost of treatment most other countries pay per person per year (ppy). For first-line treatment, the average generic price is $115 ppy while the Russian pays more than $1000. (Frontline AIDS, 2019). The cause of this is the government sourcing the drugs from originator companies when part or all of the treatment regimen is under patent. As a result, many people cannot access these drugs because they are too expensive for health centres to purchase on government budgets.
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An example of the lack of access to ARVs in Russia is Dolutegravir (DTG) recommended by the World Health Organisation in July 2019. However, ViiV healthcare was granted patents on DTG, meaning exclusive rights on the drug until 2026. However, major donors put forward a price deal of $75 ppy for DTG for many. Yet Russia, who chose not to be involved in the license are still required to pay $1871 (Frontline AIDS, 2019). It is precisely patents like these combined with the lack of involvement of the Russian government that leaves Russian citizens with no treatment, resulting in a growing population of PLWH.
Social mechanisms that contribute to health
The life of someone living with HIV in Russia, looking through the social perspective, is greatly affected by wider society, which sets up multiple social barriers that affect their equality. A study (Amirkhanian Y, et al., 2003) revealed 48% of participants were forced by doctors or police to sign conformation of their HIV positive status, which then may be used for criminal charges. Through the abuse of power by authoritative figures in society, the judgment they display ripples into the general population. The effect of this is individuals face challenges in their life, shown by a follow up 2011 study (Amirkhanian Y, et al.,2011), showing nearly 25% of persons refused health care, 11% refused employment and 6% made to move out of a family home because of their HIV-positive status. It must be taken into account however both the studies by Amirkhanian were only done is St. Petersburg meaning a small sample size in comparison to the whole of Russia but also different experiences in more rural places are not present.
A clear example of the neglectful response by the government is the 2016 budget of $325 million, which is a fifth of what is estimated to improve the epidemic (AVERT,2019). Following this, in January 2017, the Ministry of Health’s request of $1.2 billion to implement the 2017-2020 National HIV/AIDS Strategy was rejected by the government (AIDSpan.org, 3 April 2017). The failings of the government to adequately respond to the epidemic contributes to the increased prevalence of HIV and the general feeling of neglect of PLWH. This lack of funding has led to a lack of specialists in Russia’s healthcare, with only 100 HIV/AIDS centres in the country, which is no longer sufficient for the estimated one million PLWH (AVERT, 2019). This lack of funding also means no change in policy of discrimination in health care and the workplace or campaigns to tackle the stigma that resides in HIV.
Two major groups that are of the highest risk of contracting the virus but also the most targeted by social attitudes and repressive government policy are people who inject drugs (PWID) and men who have sex with men (MSM). PWID are shown to be the most at risk for HIV in Russia due to the culture of sharing needles (UNAIDS, 2016). An example of the damaging Russian government policy is banning opioid substitution therapy (OST), although recommended by UNAIDS and the World Health Organisation. The therapy has been found to reduce drug use and vulnerability to HIV and tuberculosis (UNAIDS, Do No Harm 2016). Without this therapy patients admitted to the hospital, who inject drugs, are unlikely to remain in hospital due to severe withdrawal effects resulting in them returning to the high-risk environment of sharing needles. The power imbalance between the police and PWID also contributes to social inequality, with 60.5% arrests of PWID due to police planting syringes or drugs (Lunze, et al., 2014). This supports the assertion that punitive drug laws contribute to the HIV risk environment of PWID because the more repressed drug users are the more it reinforces the hazardous use of needles. Furthermore, planting drugs on PWID as a pretext for arrest violates their rights. Furthermore, due to Russia reaching a high-income country status, the global fund has been removed and without reinvestment, by the government, the needle exchange programs (NSP’s) have been shut down despite the increasing HIV levels. As of 2018, a very small number of twenty NSP’s are offered in all of Russia (AVERT, 2019).
MSM also have an oppressive environment created by negative social attitudes and unhelpful laws such as the gay propaganda law which has made it difficult to reduce stigma and transmission. Since 2013 the policy has made it illegal to post information about being gay, even if It is strictly informative. The result is a lack of education on safe sex and therefore failure of reduction in transmission or risky behaviour. Akin to this is the code 103 required by all clinics to follow, where if HIV is diagnosed for a male, the patient must disclose how the virus was contracted. If from gay relations it is recorded and can be used by the police for evidence for prosecution. The two major effects of this are the actual number of people with HIV in Russia is unknown as many refuse to go to a clinic out of fear and these people that do not go cannot get the ARV drugs they need to not spread the virus. In Moscow, Russia’s biggest city, only 9% of HIV positive MSM are on ARV therapy (Mogilnyi et al., 2016). Moreover, Pre-exposure prophylaxis is not available in Russia despite numerous studies stating its use in reducing transmission close to zero with no significant side effects (McCormack, S et al.,2014). (Fonner et al., 2016).
Individual mechanisms that affect health
The neglected epidemic in Russia has caused the prevalence of HIV to increase but the population is affected further than this as a result of stigma and discrimination. To look through the individual’s perspective, someone living with HIV are more specifically affected by the stigma and abuse they face in their daily life. This leads to mental health issues and a greater probability they will engage in high-risk behaviour as they feel their actions are taboo and to be done in secret. These negative social attitudes towards the marginalised HIV population only exacerbated by policies that repress their rights, safety, and legal protection, increase one’s vulnerability to discrimination and harm to their psychological needs.
The most recent study done on mental health issues and high-risk behaviour concerning HIV in Russia is by Amirkhanian et al., (2011). The study made a few summary points, the first being out of the people in the sample with HIV, 58% had a sexual relationship with HIV-negative partners, of them, 52% engaged in unprotected intercourse. Of the PWID in the sample, 47% still share needles. It is obvious from these statistics that those who become aware of their status are out of touch with any information to help or guide them and surrounded by stigma the individual is reluctant to reach out. As a result, the risky behaviour which they engaged in is continued which will inevitably cause a spread of HIV possibly to people outside these high-risk groups.
This social suppression of HIV populations is linked to an increase in mental health problems. For the individual this can result in a breakdown of relationships and livelihood. A few examples by The Guardian (Cain, 2017) have shown the effect of stigma on one’s lifestyle, Katia explains “if I told my father I had HIV, he wouldn’t understand. He’d run away from me” or Vladislav, who lost his job when he revealed his status. The breakdown of the individual’s life usually results in isolation and fear of being targeted further and therefore increased risk of developing a mental illness. The same study by Amirkhanian et al., 2011 revealed that those living with HIV in Russia have higher psychological distress levels than normal, 39% with probable clinical depression, and over 37% having anxiety levels similar to psychiatric patients. The devastating effect of a highly stigmatised and discriminated population is shown through such high levels of psychological distress.
Conclusion
Although the HIV crisis in Russia needs immediate attention there is still a lack of recent and accurate figures due to the fear and stigma surrounding the virus, which only impedes further progress. The lack of involvement from the government in multiple spaces means no funding for drugs and new centres to reduce transmission and no campaigns to limit discrimination in the workspace and health care. As a result, we are seeing an increase in both prevalence of HIV but also psychological distress of the sufferers.
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