Despite the heroic efforts of some small nongovernmental organizations (NGOs), Russia has one of the fastest growing HIV/AIDS epidemics in the world: An estimated 100 people a day, most between the ages of 20 and 30, were being diagnosed with in 2000 in Moscow and across the country.
Yet, according to one participant in Family Health International's (FHI's) "Mobilizing Resources for HIV/AIDS/STD Prevention" training program for Russian NGO leaders, held in Moscow in February 2000, "politicians are ignorant of the HIV problem."
The FHI training program was part of an effort to build the capacity of a small but talented and committed cadre of Russian HIV/AIDS NGOs to leverage a greater national response. By strengthening the ability of these organizations to share information with policymakers, the public and each other, and by linking them to potential donors, FHI is helping to build effective partnerships for HIV/AIDS and sexually transmitted disease (STD) prevention in Russia.
An Explosive Epidemic
Following a trend seen in other countries when HIV transmission occurs through the sharing of infected needles by a community of injecting drug users (IDUs), the number of HIV infections in Moscow rose twelvefold in the first six months of 1999. As a result, Russia's capital city became the epicenter of its HIV/AIDS epidemic for the first time, overtaking the country's far western city of Kaliningrad, a Baltic seaport housing a large population of sex workers, IDUs and HIV-positive prisoners.
Nationwide, a total of 15,652 HIV infections were reported in 1999, nearly a fourfold increase over the 3,947 HIV infections reported in Russia the year before. Moreover, in just one year--from 1999 to 2000--the total number of HIV infections reported in the country since the beginning of Russia's epidemic in 1987 nearly doubled.
Despite these soaring HIV infection numbers, Russia still lags far behind many other countries in responding to HIV/AIDS. The ten-year period between the first diagnosis of HIV in 1987 and the start of Russia's explosive epidemic among young IDUs in 1996--nearly a decade-long window of opportunity--was not, unfortunately, used for prevention.
Instead, for nearly ten years the government, through the district "AIDS centers" established throughout the country when it was still part of the Soviet Union in the late 1980s, performed an estimated 150 to 200 million mandatory HIV tests -- roughly the equivalent of one test per person in Russia's population of approximately 150 million people. Individuals considered to be at high risk of HIV infection, such as drug users, people with STDs, blood donors, prisoners, soldiers, gays, pregnant women and people who had lived abroad, were tested without pre- or post-test counseling.
Russia's 87 district AIDS centers ended their mandatory HIV testing of high-risk groups in 1995 (except for prisoners and health professionals potentially infected through a needle-stick accident). By the end of that year, just over 1,000 individuals who had been screened had tested positive for HIV. Since then, Russia has encountered significant difficulties in launching any other national response to what has become a much more extensive epidemic, estimated by Moscow-based health authorities to be ten times more advanced than its reported size. Even greater is the U.S. National Intelligence Council's 1999 estimate of a possible 1 million HIV infections in Russia by the end of 2000.
To be sure, Russia's lack of political will in building a greater response to its HIV/AIDS epidemic is relatively understandable given the other formidable problems the country faces. In the last decade Russia's challenges have included forming a new democracy after 70 years of communism, frequent changes and instability in national leadership, a high crime rate and an internationally powerful mafia, a breakdown in social mores, prompting what some have called a "sexual revolution," a languishing health infrastructure, and a constant struggle to become a market economy, with a devastating national economic collapse in August 1998.
In fact, the potent combination of these circumstances fuels the spread of HIV. Poverty continues to increase, and rates of injecting drug use among young Russians have soared. The ubiquitous mafia (whose members frequently are local government officials and street cops) contributes to the spread of the virus through its control of both heroin distribution and hundreds of firms providing sex services by young girls.
Beyond Marginalization
Because of their struggle with a myriad of other problems, most Russian politicians may indeed be unaware of the severity of the HIV/AIDS epidemic in their country, or they may not understand its implications. Some undoubtedly see the HIV/AIDS epidemic as a problem still contained in population subgroups, such as gays, prisoners and sex workers, generally marginalized by and in some cases separated from the Russian population as a whole.
Even though this rationalization may be common among Russian policymakers in 2000, a period of enlightenment and political will at the highest levels of government was inaugurated less than three years ago. In September 1997, the United States and Russia began holding semiannual joint cooperation meetings on a number of important bilateral issues, including HIV/AIDS and other health issues of international concern.
Targeting ways the United States could help Russia build democratic reform and rebuild its crumbling infrastructure, the "Gore-Chernomyrdin Commission"--chaired by U.S. Vice President Al Gore and then Russian Prime Minister Viktor Chernomyrdin--identified the dissemination of HIV/AIDS prevention information as a priority in the health arena. At least some high-level government officials in the country recognized, based on the rapid rise in HIV infections starting in 1997, just how quickly the expanding epidemic might grow.
Responding to the Gore-Chernomyrdin initiative was precisely what lay behind FHI's visit to Russia in the fall of 1998, at the invitation of the Russian Ministry of Health and the U.S. Agency for International Development's (USAID's) Moscow mission. Based on the need identified by the commission and a USAID assessment team, FHI's USAID-funded Implementing AIDS Prevention and Care (IMPACT) Project was asked to help NGOs build their capacity to disseminate HIV/AIDS prevention information to the general public. AIDS infoshare, a Moscow-based NGO formed in 1993 that has since become the largest HIV/AIDS-focused NGO in the country, was targeted by USAID as FHI's local partner.
FHI's mandate for working with AIDS infoshare since late 1998 has been to support the group's evolution as a young NGO in the center of both a fledgling democracy and one of the world's most expensive and difficult cities in which to operate. The overall objective of FHI's technical assistance has been to strengthen the group's internal capacity to thrive through organizational development assistance, while expanding its ability to provide HIV/AIDS information and additional support to its NGO partners throughout the country.
Disseminating more prevention information more widely through a cadre of NGOs across the country will not only foster greater awareness among Russians about the HIV/AIDS epidemic in their country, but also will help individuals understand their own risk of HIV infection. At the same time, increasing information dissemination and advocacy to the political sector will build the awareness of policymakers and bolster their political will to respond to the expanding national threat of HIV.
In July and August 1999, a two-person FHI team worked with the AIDS infoshare staff for two weeks, first in the group's Moscow office and then through a three-day workshop held outside the city. This technical assistance focused on team building, addressing the organizational development issues AIDS infoshare faces as the leading HIV/AIDS NGO in Russia, and advancing staff members' skills in evaluating information dissemination initiatives.
The trainers used a working-group approach to review AIDS infoshare's organizational mission and current projects and to discuss its main objectives for the next two years. This opened the floor to recognizing the substantial progress the organization of 15 people had made in five years, as well as sharing some newly emerging individual goals.
A variety of exercises helped strengthen AIDS infoshare staff members' ability to work together as a team while group discussions allowed them to examine individual roles and responsibilities. Participants identified a need to spend more time talking through the necessary steps in project implementation and learned state-of-the-art evaluation methodologies that helped them better define what the additional steps should be.
This training in monitoring and evaluation also laid the groundwork for an enriched understanding of the need for quantifiable project results to ensure community support and programmatic sustainability, a democratic, market-driven concept new in Russia.
The Tver Example
Just prior to the three-day workshop, a small team composed of FHI, AIDS infoshare and USAID/Moscow staff and consultants visited one of AIDS infoshare's regional NGO partners, We and AIDS, and the district AIDS center in Tver. Their goal was to gain a better understanding of regional NGO and AIDS center needs for HIV/AIDS prevention and care information. What they found there was an ominous foreshadowing of the future path of Moscow's epidemic.
Tver, a city a few hours northwest of Moscow by car on the main road and major transshipment route to St. Petersburg, has the seventh highest number of HIV infections reported in Russia to date. The situation in Moscow in 1999 almost exactly mirrored what happened in Tver starting in 1997: until that year, only five people in Tver had been diagnosed as HIV-positive. In 1997, that number grew to between 20 and 90 people testing HIV-positive in Tver each month. By the year's end, 557 people were living with HIV in Tver, 90 percent of them local residents and 90 percent injecting drug users.
Eighteen months later, IDUs accounted for only 76 percent of new HIV cases in Tver, with 24 percent infected through sexual transmission. Noting the growing number of heterosexually transmitted infections in July 1999, Tver AIDS Center Director Dr. Aleksandr Nikolaevich Kolesnik said, "The epidemic in Tver is a general population epidemic already."
As seen in Moscow in 1999, injecting drug users in Tver also switched from injecting opiates (prepared by boiling a mixture of blood and poppy straw) to injecting heroin. Thus, Tver's experience serves as a stark warning to Moscow, where such rapid spread of HIV in a metropolitan population of some 11 million people would have devastating consequences, not only for Russia's capital city, but for the country as a whole.
Identifying Models
In November 1999, FHI expanded its HIV/AIDS/STD training effort to 12 other Russian NGOs from all over the country, as well as AIDS infoshare, by organizing the first of two training workshops supported by USAID/Moscow through the Academy for Educational Development's Global Training for Development (GTD) program.
In the first GTD workshop, FHI trained 13 leaders from Russian NGOs (some of which were started to augment AIDS centers' programmatic funds, since little federal funding is available), as well as the chief medical officer in the HIV/AIDS prevention unit at the Russian Ministry of Health, in designing, implementing and evaluating HIV/AIDS/STD programs. Held at FHI's suburban Washington office in Arlington, Virginia, this program marked the first time this type of in-depth HIV/AIDS/STD prevention training was ever provided to Russian NGO leaders.
The training program was designed to transfer global best practices in strategic planning, behavior change interventions, policy and program advocacy, mass media outreach, condom social marketing and support for people living with HIV, among other topics. Conducted by FHI staff with colleagues from IMPACT partner organizations, such as Population Services International and the Program for Appropriate Technology in Health, the program drew mainly on the most important lessons FHI has learned in its nearly 15 years of experience in designing, implementing and evaluating more than 1,300 HIV/AIDS/STD projects in 60 countries.
Holding the training program in the United States made it possible for the participants to see several NGO projects in action as well as meet with recognized experts and organizations influential in HIV/AIDS research, prevention and care. Among the organizations the participants visited were the U.S. Agency for International Development (the world's leading donor to international HIV/AIDS prevention and care programs, including FHI's IMPACT Project), the U.S. National Institutes of Health, the Washington Hospital Center and the Johns Hopkins School of Hygiene and Public Health.
Even more important than the institutional meetings, though, were the opportunities for the participants to observe U.S. HIV/AIDS prevention and care efforts firsthand through visits FHI arranged with some of the Washington area's most respected programs. These included the Whitman-Walker Clinic (one of the leading HIV/AIDS clinics in the United States), the Prevention Works! program for IDUs, MetroTeen AIDS, which reaches out to young people and provides a drop-in center, and Food & Friends, which delivers meals to people living with HIV.
Participants were enthusiastic about all the site visits, but many found the visit to Food & Friends particularly inspiring. "I would like to use Food & Friends as a model for a program in the future, and to provide social support for people living with HIV as well as impoverished families and the NGOs who support these families," said one participant, Dr. Vera Utugova of the NGO Let's Stop AIDS in Arkhangel'sk.
Knowledge to Action
The FHI training program was designed to balance exposure to U.S. prevention programs with formal presentations on topics such as state-of-the art strategic planning and evaluation methodologies. These sessions were interspersed with working-group discussions that gave the participants a chance to address key crosscutting issues, such as involving people living with HIV in program design and advocacy.
Participants were also given time to work on programmatic action plans. The FHI trainers were impressed with the comprehensive plans the 14 participants had developed at the end of the two weeks, and with their energy in sharing these plans with each other on the last day of the training.
Because programmatic funds in Russia are extremely limited and funding to carry out most of the action plans had not yet been identified, the participants targeted training in fundraising as one of their priorities for future technical assistance. Also identified as a priority by both the Russian participants and the U.S. trainers was their mutual interest in continuing to work together, each vowing to maintain the valuable information sharing and support network they had developed.
Starting to Mobilize
Two FHI staff members returned to Moscow in February 2000 to conduct a second workshop, also funded through AED's GTD program. This training workshop brought together 11 members of the original training group (three of them, unfortunately, were unable to participate), including AIDS infoshare, to focus on resource mobilization for HIV/AIDS/STD prevention programs. While the available resources only allowed support for a compressed two-day training on this crucial topic, the time proved to be well spent.
The two-day workshop focused on ways to identify local resources and mobilize Russian communities through client-centered marketing, proactive information and communication initiatives, and policy and media advocacy. Participants also had an opportunity to share problems they were encountering in carrying out HIV/AIDS programs, including the action plans they had developed at FHI in November. Many of the examples given centered on not having enough resources, such as funding, outreach materials and condoms, to expand coverage to the extent needed by all the target groups. Others outlined a lack of the local judicial and political support needed to speed program implementation.
During the workshop, participants drafted action plans for mobilizing resources within their communities and identified the resources they would have to find externally. Among the topics each addressed were: support from regulatory agencies, skills and staffing, equipment, materials, special supplies (condoms and drugs), training, transportation and administrative needs. This session proved to be a moving one for the participants and the trainers, as it became painfully clear that while the participants had gained a new outlook and additional skills in seeking local resources, there was a much greater programmatic need than local funding and supplies could support.
Just in Time Response
The last session of the training seemed to arrive just when it was most needed. To help participants identify potential sources of external support, FHI convened for the first time in Russia a panel of seven international donor representatives to share their priority programming needs for HIV/AIDS grants or services in kind. Included on the panel for this Donors Roundtable were representatives of USAID's Moscow mission, the U.S. Chamber of Commerce Moscow Health Committee co-chair, the UNAIDS Russia country programme adviser, the Moscow-based public health programme coordinator from the George Soros-funded Open Society Institute, the Moscow-based health operations officer from the World Bank, the Royal Netherlands Embassy's social policy department officer, and the Moscow-based franchise manager for the pharmaceutical company Bristol Myers-Squibb.
What was particularly important about this panel's discussion was the announcement by two presenters of upcoming grant deadlines to which each of the NGO participants was in a position to respond in the next few months. Also, the World Bank representative presented an update on a proposed $150 million loan to Russia for HIV/AIDS prevention to start in 2001, which may include a mechanism for supporting NGOs.
FHI's outreach to the various donors on behalf of the training participants gave donor representatives an opportunity to meet with leaders of prominent HIV/AIDS NGOs and AIDS centers in a different and mutually advantageous setting. Several donor panel members told the FHI trainers they were impressed with the talent and growing set of prevention skills among NGO leaders in Russia.
The presentation by World Bank Health Operations Officer Tatyana Loginova left participants with hope that additional prevention resources might be available next year. "As representatives of the regional AIDS centers, you are very important, as you will probably work with our project," she said.
The NGO participants were encouraged to hear this and to learn of other new opportunities for obtaining donor funding that could help them leverage more local support for their HIV/AIDS prevention efforts and fill some of the current resource gaps.
On the last night of the workshop, all the participants in the Donors Roundtable celebrated the important linkages that had been made that afternoon, adding a number of new "partners in prevention" to the budding NGO network for HIV/AIDS in Russia.
Staunching the Flow
The opportunity to stem HIV before it becomes a generalized epidemic throughout Russia still exists. But not for long. Given the near doubling of the HIV/AIDS epidemic in Russia in just over a year, the local and international response also needs to at least double, and quickly.
FHI hopes to help strengthen this response to HIV/AIDS in Russia by harnessing the talents and the substantial skills of its Russian "partners in prevention" and by quickly meeting their specific training needs through participatory transfer of state-of-the-art information and technical skills.
"Working with FHI has helped us move along the continuum of change," said Dr. Igor Tadjiev, the supervisor of Youth Center Doverie in Astrakhan, during the February workshop in Moscow. FHI hopes that this continuum is now on a much faster trajectory, and that it will garner the much wider support needed to stave the exponential growth of the HIV/AIDS epidemic in the world's largest country, spanning 12 time zones.
--Mary O'Grady
