Rospotrebnadzor epidemic situation with the spread of HIV in Russia. According to official data, about 1% of Russians live with this disease, while 30% of those infected do not know about it. Earlier, Health Minister Veronika Skvortsova said that the HIV epidemic in our country could get out of control by 2020, and Prime Minister Dmitry Medvedev admitted that in some regions of the country there are interruptions in the supply of medicines and test systems. Today, December 1, the world celebrates AIDS Day. The Village learned from the director of the Federal Center for the Prevention and Control of AIDS, Vadim Pokrovsky, why many Russians do not know about their diagnosis, how young girls ended up at risk, and for what reason in Russia it is not customary to talk about a condom as a method of protection.
How Russians become infected with HIV
You recently reported on the situation with the spread of HIV and reported that almost one million infected people have already been registered in Russia. In addition, according to your estimates, more than 20 thousand patients have died since the beginning of 2015 (this is almost 17% more than in the same period in 2014), and new cases of infection in the first ten months of this year were 12% more than for the same period in 2014. What is causing the worsening situation?
The situation with the spread of HIV is constantly deteriorating. It's just that now the number of registered cases is approaching a million, and this figure is impressive. When I said last year that there were already more than 900 thousand cases, it attracted little attention. But the situation is worsening progressively: 10% of HIV-infected people appear every year, 10% of 900 thousand is 90 thousand, of a million is already 100 thousand. The percentage remains the same, but the absolute numbers are growing.
This is due to the fact that the virus from drug users, who until recently were the main group of patients, passes into general group population. Women are especially at risk now. They do not know whether their sexual partner has taken drugs before, and they even become infected from their husband or regular friend.
- Almost a million HIV-infected people in Russia are just official statistics. How much higher could the actual data be?
In fact, 200 thousand sick people have already died, so about 750 thousand remain alive. About the same number, about 800 thousand, are not yet registered. They don't know they are infected and have never been tested.
- Why do people get infected? They just don't know that they need to protect themselves?
Yes, they are not aware. You’ve probably never published anything about HIV infection, isn’t your conscience tormenting you? When people see numbers - 900 thousand, a million - they do not think that they are also at risk, and do not associate this with their behavior. Many people do not know whether their partner has been tested for HIV infection or not, or whether he could have been infected in the past. Therefore, now our recommendations apply to everyone. For example, until you know your partner’s HIV status, use a condom, otherwise the risk of infection is very high. Every 40th man aged 30–35 years is infected with HIV. The likelihood that he will be your partner is very high.
- Do men, in turn, become infected because they are also not sufficiently aware, or more often due to drug use?
So far, men are more likely to become infected through drugs. But, of course, sexually transmitted infections are also possible. Now there are slightly fewer women among the sick. This suggests that the transmission route is working among drug addicts, and their percentage among those infected is increasing all the time. At the same time, in age group Under 25 years of age, there are even more infected women than men. This is due to the fact that often the male sexual partner is older than the woman. Older partners - 30-35 years old - infect 20-25 year olds, so at this age the sexual route of transmission clearly predominates.
Every fortieth man aged
30–35 years old infected with HIV. The probability that he will be your partner, very big
- But so far the most common way of contracting HIV in Russia is through drug use?
Statistics should not mislead you: 55% of new cases of infection occur through drug use, but the remaining 45% are sexually transmitted, that is, almost the same. Those who contract HIV through sexual contact are more difficult to identify. In the case of drugs, the risk factor is clear, and people usually are not examined after unprotected sex. They think: “What do I have to do with HIV infection?” In Europe, the transmission of HIV through drug use has now practically ceased, and the sexual route has become almost dominant. Adults are being discovered who were once infected during sex, but never thought they were at risk. Therefore, everyone is recommended to be tested for HIV.
- As a rule, in Russia people become infected with HIV through heterosexual contacts? There used to be a myth that HIV was a disease of homosexuals.
They remain the main risk group in Western Europe: homosexuals think that there is a cure, and therefore do not use protection. They now want to treat everyone: both those who are sick and those who are not yet sick. Treatment as prevention - give everyone antiretroviral drugs: take a pill in the morning and you can go all out. Our epidemic is of a generalized nature, and since there are not very many sexual minorities among the entire population, there are also few of them among HIV-infected people - 1–2%. By the way, the infection is not transmitted during female homosexual contacts, so lesbians can rest easy.
- What country can Russia be compared to in terms of the spread of HIV?
The Russian scenario is closer to that of Spain and Italy 20 years ago, and is already gravitating towards the African one, where the main route of transmission is heterosexual sexual contact. We have surpassed all European countries, where in total there are approximately the same number of HIV-infected people as we have. That is, if we classify our country as a European power, then half of all sick people in Europe live with us. We have also surpassed the United States, which has traditionally been considered a very vulnerable territory. There are about the same number of living HIV-infected people there as we have, but they register 50 thousand new cases a year, while we have about 100 thousand, and the population there is more than twice ours. Although there are still more deaths in the United States: about 600 thousand people have died from AIDS, in Russia - 200 thousand, so we still have a long way to go. If treatment is organized as poorly as it is now, we can catch up with this indicator: out of 800 thousand HIV-infected people in Russia, only 200 thousand receive appropriate treatment.
- Why?
Because little attention is paid to this problem, and for the last five years funding has not increased, but the number of patients has grown.
- So in Russia there is simply no money to treat everyone?
Well, yes, this is not provided for funding. The government is hinting that it will double funding in 2016. We haven’t seen this money yet, but there is a promise.
- How much money does the state give now to solve this problem?
Currently, about 18 billion rubles a year are allocated to fight HIV. In 2016, they promise to increase this amount by another 20 billion, that is, if the promise is kept, we will have about 40 billion rubles.
- How much is needed, according to your estimates?
To turn the situation around, it will take more than 100 billion rubles.
- Will this money primarily go towards treatment?
Complex issue. In my opinion, more needs to be spent on informing and educating the population so that people do not become infected. Treatment is always worse than prevention. But now the world is dominated by the concept of “Treatment as Prevention”: this concept is that if all HIV-infected people are given a medicine and they constantly take it, then those who are sick will have a very low level of the virus and even their genitals will not become infected from them partners. In my opinion, this is a very controversial approach, because we must first identify everyone who is infected and provide them with medicines, but we are still very far from this. In Russia, we must simultaneously deal with preventing new cases and treating patients: we cannot focus on any one approach.
About why in Russia they treat patients when it’s too late
We recently published a story about an HIV-infected person, here’s what he said: “If in Europe they start dispensing medications for prevention when the immune status is 500 T-lymphocytes per milliliter of blood (there are 1200 T-lymphocytes in a milliliter of blood from a healthy person. - Ed.), then in Moscow they start dispensing medications at status 350, when you already have a lot of secondary diseases, and your immune system cannot resist anything at all. To be treated in Moscow, you must already be very sick - at the stage when HIV turns into AIDS.” This is true?
Everything is correct, because for now there is only enough money for this. And this is one of the reasons why mortality is rising: treatment is started too late. They say: “Wait, you still have 360 cells, when there are 350, we’ll start treating.” The patient comes a year later, and he already has 200 T-lymphocytes - this is equivalent to AIDS.
- What medications do patients receive in Russia?
These are drugs that were developed a long time ago and their license has expired. They are made in India and Russia, these are the so-called generics - they are much cheaper than the original drugs. There is analgin for 10 rubles, and there is for 100. These are not bad medicines, but, of course, all the new ones are better. For example, if you use a modern drug, you need to take one tablet a day, and if you use an old one, then you have to take 12 tablets a day. This is a significant difference for both the patient and the state, because the Russian version costs ten times less.
- That is, in recent years, treatment methods have changed and we are only talking about money?
Well, of course! If you take good medications, even with HIV you can live to a ripe old age and die of cancer or a heart attack. Young people die from HIV, so the state’s task is, firstly, to ensure that they do not become infected, and secondly, if infected, to provide them with treatment so that they do not die young. The main problem of HIV infection for us is the decrease in the working-age population.
- Recently it was reported about the development of certain Russian vaccines against HIV. What do you think of it?
It is very difficult to develop a vaccine against HIV: there is no natural immunity after an infection, because no one has yet recovered. For example, if a person is cured of smallpox, he will never get sick again, so it turned out to be easy to create a vaccine against it. It is quite possible that a vaccine against HIV will never be invented. It has been developed for syphilis and malaria for a hundred years, and nothing works.
- At the same time, there are drugs that can maintain a normal quality of life and allow a person not even to infect his partner?
Quality of life is a controversial issue, because all drugs have side effects. That's why I say: it's better not to get infected. People with HIV on antiretroviral therapy, and even without it, age ten years faster: they often look like old people. This suggests that medications do not kill HIV - it continues its destructive work, inflammatory processes occur that lead to premature aging.
On the role of the state in the HIV epidemic
- Do you blame the media for the lack of awareness among Russians about HIV infection?
Responsibility for this lies with everyone, including the media, but to a large extent with our government, which pays little attention to this problem. Rules traffic We change it every day, it’s relevant, everyone is discussing it. But the problem of HIV infection is not. Although we have as many people dying from HIV as in road accidents.
- Recently, Prime Minister Dmitry Medvedev ordered to accelerate the development of a state strategy to combat the spread of HIV. Are you involved in its development?
Involved as the main critic. There is no strategy as such; they still can’t understand what to focus on: prevention or treatment. We now have very strong conservative approaches, there is even such an opinion: “We should ban having sex.” And the population says: “Yes, yes, we are Orthodox,” but they do not know that Orthodox Christians can only have sex with their wife and only 2.5 days a week, if there is no fasting, and everything else is a sin. In reality, it will be very difficult to accustom our population to conservative principles, which is why HIV is spreading. I believe that people should be offered variety: if you want, use the Orthodox concept, and if you don’t like it, we recommend using a condom.
But the most a big problem- This is prevention among drug users. We think that they can be cured and thus interrupt the transmission of HIV through drug use. Abroad, another approach is the so-called replacement therapy. Those who inject drugs are offered to take them orally: in medical institutions they give out the same opioids in syrup form, so that later there is no need to inject. In Spain, Italy and France, the therapy is believed to have resulted in HIV no longer being transmitted through drug use. Our colleagues say: “This does not cure drug addiction!” We object: “This prevents the spread of HIV!” For now, the prevailing opinion is that of those who hope to cure all drug addicts. 15 years have already passed since they promised this, but the number of drug users has not decreased.
It is believed that a condom gives indulgence for immoral behavior. It's worse when they spread the data that condoms do not protect against HIV
- Do you have an explanation why the Russian authorities pay so little attention to this problem?
This is apparently due to the fact that we have an attitude towards HIV as a disease of homosexuals. For some reason, the fact that in developing countries the disease is spread through sexual contact among the heterosexual population is ignored. You talk to State Duma deputies, and you get the feeling that they know nothing about this problem. Everyone still thinks that homosexuals are the main risk group.
- Why is the use of condoms not promoted in Russia as one of the mechanisms of protection against HIV?
It is believed that a condom gives indulgence to immoral behavior. It’s worse when they spread data that condoms do not protect against HIV. Then the “immoral behavior” is carried out without a condom.
- In Russia, many people generally believe that HIV does not exist.
- Or from bad behavior.
It is believed that some other factors played a role, but for some reason all the dead had HIV infection. Now they say that HIV and AIDS are not related, but this is data from the 80s. Since that time, science has advanced so much that there is no doubt about the connection between these phenomena.
- Recently, the Minister of Health Veronika Skvortsova said that by 2020 the HIV epidemic in Russia could get out of control. What do you think of this forecast?
In my opinion, the epidemic has long been out of control.
photos: Yasya Vogelgardt
V.V. Pokrovsky
Vadim Valentinovich Pokrovsky(born 1955) - a leading Russian scientist who devoted 20 years to his scientific activity problems of HIV infection. Since 1988, he has headed the Specialized Research Laboratory of AIDS Epidemiology of the Central Research Institute of Epidemiology of the Ministry of Health of the Russian Federation. Activities of Pokrovsky V.V. is dedicated to organizational and methodological work in the implementation of the state strategy to combat the HIV epidemic in the territory Russian Federation, as well as scientific research in the field of epidemiology, clinical picture and prevention of HIV infection in Russia.
By order of the USSR Ministry of Health No. 239 (1989), he was included in the Committee to Combat AIDS under the USSR Ministry of Health.
By Order of the Ministry of Health of the Russian Federation No. 299/220, he was included in the Coordination Council for the implementation of the Federal Target Program for preventing the spread in the Russian Federation of the disease caused by the human immunodeficiency virus (HIV infection) for 1996–1997 and for the period until 2000 “Anti-HIV/ AIDS".
With his participation, about 24 regulatory documents Ministry of Health on HIV infection (7 methodological recommendations, 6 rules and instructions, 11 orders). Took part in the preparation of " Federal Law on the sanitary and epidemiological welfare of the population" and the Federal Law on Preventing the Spread of HIV Infection in the Russian Federation.
In 2000, Pokrovsky V.V. was awarded the State Prize of the Russian Federation for the introduction of the domestic drug “Phosphazide” into medical practice for the treatment of HIV infection.
Pokrovsky V.V. takes an active part in the development of international relations, collaborates with the European Center for Epidemiology and AIDS Monitoring, was one of the leaders of the Canadian-Russian project “Russian Network to Combat HIV Infection”, collaborates with TACIS IMC on the project “Prevention and Control” with HIV/AIDS, Phase I”, with the International Labor Organization UNDP, with the UNICEF Children's Fund (UN). with the US Agency for International Development USAID, with the UK Department for International Development DIFID on the project “Comprehensive demonstration project for the prevention and control of HIV in target populations in the Russian Federation”, with Imperial College (London) on the program “Knowledge to combat HIV/AIDS in Russian Federation, with the World Bank - Russian Healthcare Foundation on the project “Prevention, diagnosis, treatment of tuberculosis and AIDS”.
In 2003, by order of the Russian Academy of Medical Sciences and the Ministry of Health of the Russian Federation, a Problem Commission “HIV Infection” was created on the basis of the Center under the leadership of V.V. Pokrovsky.
He has published more than 300 scientific works, 2 monographs, 2 books and 4 teaching aids, trained 6 doctors and 15 candidates of science, is the author of 6 inventions. In the laboratory he directs, 9 test systems have been developed and put into practice for diagnosing diseases such as HIV, hepatitis B, C, D.
By the end of January, a million HIV-infected people were officially registered in Russia. Doctors say that at least 500 thousand people simply do not know that they are also affected by the virus. Illness is no longer considered the preserve of marginalized people. HIV has spread beyond the so-called risk groups, and now even those who do not use drugs and remain faithful to their sexual partners can get it. Is it possible to defeat AIDS by fighting for morality, or is it time to legalize prostitution? How effective are the medications and is there a high chance of catching the virus in the hospital? The head of the Federal Scientific and Methodological Center for the Prevention and Control of AIDS, Academician of the Russian Academy of Sciences, Professor Vadim Pokrovsky answered these and other questions to Lenta.ru.
“Lenta.ru”: Is it true that Russia has overtaken European countries in the number of HIV-infected people?
Yes. The percentage of people infected in our country is three times higher than in the European Union. Twice as much as in France, and ten times as much as in Germany.
Photo: Mikhail Voskresensky / RIA Novosti
Good pace, considering that we started later?
In Russia, the HIV problem was seriously addressed until about 2011. And then funding stopped, and there was barely enough money to treat only a small part of HIV-positive people. As a result, over the past five years the number of infected people has almost doubled. Today, depending on the region, every twentieth man aged 21-40 is infected. Just now they perked up. Apparently, the magic figure of a million infected people frightened us. This year it is planned to double budget spending on HIV/AIDS - up to 41 billion rubles.
Is it just a question of funding?
Unfortunately no. Someone decided that it was enough simply to strengthen morality, to lead healthy image life, and everything will pass on its own. But they did not go into details, for example, what a “healthy lifestyle” is for a 30-year-old unmarried man. It is in this group that sexual activity is considered a sign of health. Or what kind of morality can a drug addict have, who is only concerned about where to get a dose?
Is it true that HIV has moved beyond risk groups and is now available to everyone, like the flu?
The only difference is that you can recover from the flu, but not yet from AIDS. But the disease has indeed ceased to concentrate in any one group and is spreading to wider layers. Now about 20 percent of drug addicts and about 10 percent of homosexual men have HIV. The spread of infection among them did not cause much concern among “decent” people. They say they will die, less problems. But drug addicts are sexually active. And quite intense. At the end of last year, up to 95 thousand new cases of HIV infection were registered. And only half of them are associated with drug use, the rest were infected through sexual intercourse through heterosexual relationships. Only one and a half percent are homosexuals.
Photo: Evgeny Asmolov / Interpress / TASS
Where are the most infected people?
Where money circulated in the 90s, where large enterprises operated successfully. In such regions, drug dealers were more active: Irkutsk, Yekaterinburg, Samara. Tolyatti with its automobile plant was very profitable. Now up to three percent of the population is infected there - one of the most high levels infections in the country. There are “hot spots” in the Urals, Siberia, the Volga region, St. Petersburg and the Leningrad region.
Do the leaders of these regions know about HIV?
Many only heard unpleasant news last fall at a meeting with Dmitry Medvedev. This is due to the mentality of officials. Going from bottom to top through their reports, the situation should improve. In order not to upset managers, they are informed mainly in a positive way.
There is also the opposite effect. Tomsk had good prevention programs and was constantly being held up as an example. But since there was no infection, this work was stopped. As a result, about two years ago there was a major outbreak of HIV infection there.
Is Moscow not on the “black” list? There was always a lot of money here.
We don't know exactly what's happening in the capital. We maintain a personalized database that includes complete information about each patient to avoid repetition and more accurately calculate costs. But Moscow has not provided us with such data for three years now. Apparently, the collection of information in the city is poorly organized.
Do city officials claim that the city has managed to stabilize the number of HIV-infected people?
According to monitoring data from Rospotrebnadzor, 4,800 new HIV-infected Muscovites were identified in 2013, and another 5,200 in 2014. That is, the number is increasing. In comparison, the whole of the United Kingdom (England, Scotland, Wales and Northern Ireland) in 2014, 6150 patients were detected. By the end of last year, 52,700 HIV-positive citizens were registered in Moscow. Many of them arrive at the hospital already in extreme distress. in serious condition. And besides Muscovites, up to 50 thousand non-resident HIV-positive people were registered in the city. And most of them probably never left. Therefore, I personally consider the situation with HIV in Moscow to be explosive.
Can all infected people receive free medicine?
The main indicator is the number of lymphocytes in the blood with the CD4 marker. According to the recommendations in force in our country, treatment begins at a level of less than 350 cells. But now, due to a shortage of funds, therapy is prescribed when there are about 200 CD4 lymphocytes. That is, when an HIV-infected person has a direct threat of developing AIDS.
Is it different in the West?
This is now the most fashionable theory in the world - to identify all infected people and treat them from the moment of infection. After all, those who receive proper treatment are practically not contagious to sexual partners. The offer is good. But in practice it is difficult to implement.
No money?
It's not just about money. It is necessary that the entire population be examined, and this is not easy. After all, you can’t raid people without a certificate. And young, strong people rarely turn to doctors because they think that they are not at risk. The next question is: how to keep everyone on treatment for the rest of their lives, that is, decades? If they take medications poorly, the virus will develop resistance to them. But the most the main problem for Russia - what to do with drug users? They make up up to 60 percent of all infected people.
You have been talking about the need for replacement therapy for a long time, but many consider this almost propaganda for drug addiction.
Replacement therapy is approved by WHO and is used everywhere, including such tough countries as China and Belarus. For us, it is interesting because it reduces the transmission of HIV. If the drug is taken orally and not injected, then it does not play any role in the transmission of the virus. In Spain, Italy and France, this technique is believed to have resulted in HIV no longer being transmitted through drug use.
Does the Ministry of Health have its own alternatives to replacement therapy?
Narcologists develop their own, as they say, creative methods addiction treatment. So far, after such a course, only 50 percent remain drug-free for a year, and very few remain drug-free for five years. The Federal Drug Control Service proposes to create a network of camps similar to the labor treatment centers that existed in the USSR. But we are talking about coercion, which reduces efficiency. According to Federal Drug Control Service estimates, there are at least 1.5 million heroin users alone. How to look for them? Substitution therapy can provide greater coverage, since they themselves will come for free drugs.
But the main obstacle to substitution therapy is not moral fighters at all, but the heroin mafia. This will hurt their market.
Have the crisis and import substitution somehow affected HIV-infected people?
But what? Since 2011, the budget for therapy has not increased, but the number of people receiving treatment has almost quadrupled. The transition to cheaper drugs - generics from India, Southeast Asian countries and those produced in Russia - is also having an impact.
In France and Switzerland, where only original drugs are used, treatment costs 5-7 thousand euros per year. Our cheapest scheme now costs 20 thousand rubles, the average - 80-90 thousand.
Photo: Gennady Gulyaev / Kommersant
Are the substituted tablets worse in quality than the originals?
They suppress the virus. But direct comparisons with the originals regarding the frequency of side effects have not been carried out. In addition, combination medications are widely used abroad - several active ingredients in one pill. A person swallows only one tablet a day. But our patients have to take ten, because the combined ones are expensive.
And the medications also need to be changed. The fact is that HIV gradually gets used to the drugs. We need to look for a replacement for them. And this requires a wide choice. But providing diversity is, again, expensive.
The national strategy to combat AIDS will be presented in March. Will there be anything there that hasn't been offered before?
For us, not only replacement therapy, even prevention among sex workers will be a non-standard approach. According to the police, we have about a million prostitutes. And for their business to be profitable, at least 10 million people must use their services. Many prostitutes use drugs and offer sex without a condom for an additional fee. They themselves risk becoming infected and can infect their clients. It is necessary to educate them for the public good.
Oh! So we are not far from legalizing prostitution.
Not necessary. In many countries, prostitution is formally prohibited, but training programs for prostitutes are intensive. Legalization is another level. In Germany, for example, to engage in this business, you need to obtain a license, pay taxes, and follow the rules. In particular, be sure to use condoms. In Germany there are generally a lot of rational decisions. Let's say, such an everyday question is the sexual needs of disabled people. This is an integral part of a healthy lifestyle. The Germans pay them for the services of sex workers. But in our country, a healthy lifestyle is represented in a completely different way: fasting and sports.
Photo: Sergey Kulikov / Interpress / TASS
Previously, condoms were advertised as the main means of combating the spread of infections, not just HIV. Why did you stop?
The condom does not fit into the concept of morality. He gives indulgence for extramarital sex. But I strongly recommend: until you know your partner’s status, be sure to use a condom. If you want to continue the relationship, get examined together. After all, it is believed that we have many sexual partners, which means having three at the same time. But when it’s just the two of us, it doesn’t seem dangerous. They will live with one for three years, with another for five years, and by the age of 40 there have been a dozen monogamous relationships. If one person with HIV gets into this chain, then all subsequent partners are at risk of infection.
State Duma deputies propose not to accept applications at the registry office without a certificate of HIV status. Will help?
I'm afraid there will be fewer weddings. Young people already believe that it is not necessary to formalize a relationship. And here are new bureaucratic obstacles. Dragging somewhere to donate blood? Or buy a HIV-free certificate? On the Internet they ask for 3200 rubles with delivery.
By the way, about analyses. How likely is it to become infected in a medical facility?
Over the past five years, we have data on more than ten cases of hospital-acquired infections. I am not naming regions, since these incidents are possible everywhere. We are talking about the repeated use of syringes and other medical equipment that must be sterilized before use. All detected cases are associated with children, but we do not exclude that adults could also become infected. It's just easier to rule out sexual transmission in children. A major outbreak of nosocomial infection occurred in 1988 in Elista. After this, security measures in medical institutions were strengthened. But the doctors of the old school have changed, there is no alertness, and the number of HIV-infected people has increased hundreds of times. And if now the medical staff starts skimping on safety or just being lazy, we’ll get a new outbreak.
Vadim Valentinovich Pokrovsky is an academician, head of the Federal Scientific and Methodological Center for the Prevention and Control of AIDS of the Central Research Institute of Epidemiology of the Russian Federation, a leading Russian scientist who has devoted more than thirty years of his scientific activity to the problems of HIV infection. Today he is engaged in organizational and methodological work in the implementation of the Russian Federation state strategy on HIV/AIDS, as well as scientific research in the field of epidemiology, treatment and prevention of HIV infection in Russia.
Despite the very busy schedule of attending the VI International Conference on HIV/AIDS (EECAAC 2018), Vadim Pokrovsky took the time to tell MinusVirus about why the Russian Federation has not yet managed to stop the HIV/AIDS epidemic, about CCR5, about the problems of cooperation between the state and NGOs, volunteering and activism, as well as about his attitude towards public actions and when the HIV epidemic /AIDS will be eliminated.
EECAAC 2018 received a record number of participants, abstracts, and reports. Involvement in HIV/AIDS issues is increasing, but, nevertheless, the virus is spreading in Russia at an even faster rate. What do you think is the main problem?
The problem is that the virus naturally wants to spread, and we are not fighting it enough. That is, the activities that we carry out are insufficient, this is obvious. If they were sufficient, there would not be an increase in the number of new cases of HIV infection. You can’t get hung up on one thing, not just one treatment. Therefore, it is necessary to strengthen both prevention and treatment, and at the same time treatment as prevention. The more people we reach, the greater the preventive effect will be.
I doubt that the number of people needing HIV treatment will not increase unless we stop new cases. Therefore, if possible, we must use all available methods, only then will we stop HIV/AIDS. After all, he very easily finds loopholes that we ourselves create for him.
What needs to be changed in the current format of cooperation between NGOs and government agencies?
The main problem now is the complex bureaucratic mechanisms for transferring public money to NGOs. We need to make this process easier.
Is it a matter of controlling the use of funds, or is it a matter of the complexity of the bureaucratic organisms themselves?
Yes, the point is in the bureaucratic mechanisms themselves. Even if we have developed mechanisms, everyone is still afraid of them and does not trust them. If possible, this process should be facilitated and simplified so that people perceive it as normal. In principle, everyone understands the need for this. The question is how to support non-governmental organizations, because at one time, one might say, we ruined them. We are talking about organizations that were created by the Global Fund. We have not found a way or resource to support them. As a result, we lost both organizations and people, many of whom went to other areas, dispersed, fled, and now much needs to be restored anew.
Are you talking about mutually beneficial cooperation between the state and NGOs? What should be the conditions for such a partnership?
Mutual support is needed here, mutual interest is important. And if there is no mutual interest, it will only be as it is now. So that NGOs would help solve the problems of government agencies, for example, AIDS Centers, etc., and these Centers, in turn, would support NGOs, including financially. Some people think that NGOs should work for free. This is completely wrong. People should also receive adequate salaries for their work.
Do you mean professional volunteering, activism?
I don’t really like this word “volunteering”, it’s more like activism. Because volunteers are those people who do something for free, for the sake of an idea, not necessarily professionally. And here it is necessary that these are professionals who work in those areas in which State organizations They can’t for one reason or another.
Perhaps something is already working out. At the end of last year, quite a lot of funding was allocated for NGOs in the Russian Federation.
Yes, gradually the experience of interaction comes. Funding is starting to increase. We are already achieving something, or at least, it is starting to work out.
Do you think public actions are effective or pointless? For example, at the conference, drawing attention to the reduction in funding in the country, activists of the patient movement stood up together during a speech with the inscription “stop interruptions” on their T-shirts, and people walked near the building where the conference was taking place with protest inscriptions on posters, etc. d.
SR action at the EECAAC 2018 conference. Photo: Oksana Malakhova
They just draw attention to problems. Even that one person who stood near the entrance and spoke against the conference. In fact, this only fuels interest in the conference. Therefore, all this must be used, because even the most unexpected options for attracting attention to the problem can be useful.
Do you share the point of view that overcoming the HIV/AIDS epidemic in Russia is only possible if budgetary funds are allocated? If there is funding, there will be success.
As the American philosopher Francis Fukuyama says, “The issue of fighting AIDS is not only a matter of financing, but also a matter of the government’s ability to solve a particular problem.”
And the government's readiness?
Yes. This is the ability to show political will. Whether you want it or not, you have to decide.
On the issue of HIV vaccines, what problems are there today?
The problem with vaccines is simple. Acquired immunity develops to HIV infection. It is clear that if a person becomes infected with HIV, then he remains infected for life and lives with HIV. Some die from causes other than AIDS. This means their acquired immunity is very low. That's where people say that there are some opportunities to increase it. It is impossible to solve the vaccine problem in the traditional way, as we do, but there is innate immunity. But using the mechanisms of innate immunity is another matter.
Today we can even transfer genes from one person to another for resistance to HIV infection. In most cases, we call it gene therapy because it is a healing process. Using the same principle, we can do prevention. Some people have altered CCR5-Δ32 receptors and are not susceptible to HIV. Why not move it?
A very interesting direction, in fact. We are interfering with the human genome...
This of course sounds scary, but we are involved in everything and, as they say, so far it has been very successful. But time will tell.
The logical question is: when will HIV/AIDS be defeated?
When will the last HIV-infected person die? This is absolutely clear.
By “defeated,” I meant when will there be a cure that will cure HIV once and for all?
No, no, we will be able to say that the epidemic has been eliminated when exactly what I have already said happens. It is then that we will be able to say with complete confidence that the epidemic has been defeated. The idea of treatment now is based on this. We treat everyone, and people live happily ever after, but with the death of the last of them, the epidemic ends.
Very interesting, I haven’t heard this interpretation before...
They simply haven’t fully thought through what’s happening yet. What will happen next? So we will provide everyone with treatment and then what? Of course, we all, unfortunately, do not eternal people. Therefore, even if we do not learn to cure HIV infection, today we can live with a suppressed virus.
Text: Inna Gavrilova
The interview was recorded as part of the VI International Conference on HIV/AIDS 2018, which took place in Moscow.
Post Views: 1,062
AIDS. In Moscow in 2017, 20% more HIV-infected people were identified than last year. And in the regions this figure is much higher. Prevention alone is clearly not enough, experts admit. How should the state protect Russians from HIV? We ask the head of the laboratory of epidemiology and AIDS prevention of the Central Research Institute of Epidemiology and the Federal Scientific and Methodological Center for the Prevention and Control of AIDS Vadim Pokrovsky.
Olga Arslanova: Well, we continue. Russian HIV-infected citizens complained to the UN about torture and discrimination. The report states: “Patients in Russia are denied antiretroviral therapy, immune status and viral load testing.” Most often, refusals are faced by people who are in custody and do not have permanent registration in the city of residence. The authors of the report note: denial of treatment and testing for HIV is contrary to the articles of the Convention against Torture. The report will be considered at a UN conference in Geneva this summer.
Yuri Kovalenko: Well, now let's look at the general statistics of this difficult disease. According to the Ministry of Health, in the last two years the number of HIV-infected people in the country has not been growing and is about 86 thousand people a year. But in some regions growth is still happening. For example, in Moscow in 2017, 20% more cases of infection with the human immunodeficiency virus were registered than in 2016. In 2016, 2.4 thousand cases of disease were identified, and in 2017 - 2.9 thousand. True, the certificate does not contain statistics on total number infected with HIV.
Olga Arslanova: Let's look at the picture for other regions. In two regions, the increase in cases of the disease was more than 100% - in the Chukotka Autonomous Okrug and the Republic of Tyva. But we must take into account that the population there is small, and this is rather a low base effect. In the Tambov region, in the republics of Mari El, Karelia, and in the Ivanovo region, the increase ranged from 50% to 66%. Serious growth The Ministry of Health detected morbidity in the Rostov, Irkutsk, and Novosibirsk regions. And the number of people infected with HIV has also increased Perm region and Moscow region. This growth can be called significant. In another traditionally problematic region - the Sverdlovsk region - the number of new infections has not increased.
Yuri Kovalenko: Well, the total number of people infected with HIV in Russia exceeds 1 million 221 thousand people. Only every third person in the country receives antiretroviral therapy. The ministry also reported that 10 people become infected with the infection every hour.
Olga Arslanova: So, the HIV epidemic in Russia is becoming increasingly serious. According to UNAIDS, Russia has become the third country in the world in the number of new cases of HIV infection after South Africa and Nigeria. This is the kind of company we have. In Europe, the USA and other advanced countries, the number of infected people has been gradually decreasing in recent years, but growth is still observed in Africa (about 8% per year) and in our country, Russia.
Let's discuss what's happening right now. We welcome Vadim Pokrovsky, Academician of the Russian Academy of Sciences, head of the Laboratory of Epidemiology and AIDS Prevention of the Central Research Institute of Epidemiology of the Federal Scientific and Methodological Center for the Prevention and Control of AIDS, to the studio. Vadim Valentinovich, hello.
Yuri Kovalenko: Hello.
Vadim Pokrovsky: Good day.
Olga Arslanova: Let's start with the news that came just in time. last days, about the complaint of HIV-infected people that they do not have actual access to medicines. How can you comment on this?
Vadim Pokrovsky: Well, here, of course, these facts need to be verified, but there is no smoke without fire. Taking into account the fact that in our country approximately a third of the number of registered HIV patients receive therapy, then, of course, there must be cases when there is not enough medicine. If this happens in the Federal Penitentiary Service, then, of course, this can be regarded as discrimination against these people, specifically among prisoners. But I repeat: all facts need to be verified. Although they are theoretically possible, the country is very large, and medicines may not arrive somewhere on time. Well, in connection with this, a person does not receive medications and may even die if he does not receive them on time.
Olga Arslanova: Nevertheless, in regions where there is now growth, where the epidemic has not been stopped, where it is multiplying and developing, probably the reason is the same - people are not being treated, are not stopping?
Vadim Pokrovsky: The position is completely wrong. The number of HIV-infected people is growing in our country. The fact is that people do not recover from HIV infection. And if 100 thousand people become infected, then this is added to the 900 thousand that already existed. And only people who died are subtracted from this number.
Olga Arslanova: As I understand it, the Ministry of Health says that it is simply distributed across regions, but overall the growth...
Vadim Pokrovsky: No, we are talking about new cases, new ones only. This is sometimes called the incidence rate, but it is the number of new cases. And the Ministry of Health names only those cases that are registered in medical institutions.
Yuri Kovalenko: By the way, regarding official and unofficial statistics. Is it possible to understand how much we have unofficially?
Vadim Pokrovsky: Our official statistics belong to Rospotrebnadzor, not the Ministry of Health, because Rospotrebnadzor is responsible for infectious diseases and supervision. And here is Rospotrebnadzor... By the way, Deputy Prime Minister Golodets announced this figure at the beginning of the year - last year 104 thousand new cases of HIV infection were identified. The Ministry of Health says - 86 thousand. This seems to contradict. Actually, no. That is, if we subtract 86 from 104, then we get about 30 thousand - these are the people who did not come to medical institutions. And this is very important, because there are people with HIV infection who, perhaps, do not know about their diagnosis, but are afraid to come to the doctors.
Olga Arslanova: Where does Rospotrebnadzor get its information from then?
Vadim Pokrovsky: From Rospotrebnadzor? If a case of HIV infection is detected somewhere in any medical institution, information about the case of HIV infection, like any infection, must be reported to Rospotrebnadzor. And this difference, of course, is also very important, because we need to find these people and immediately provide them with treatment, because they, naturally, are also involved in the epidemic.
Olga Arslanova: Do I understand you correctly? It is in principle impossible to stop this growth; new infected people will always appear, and the question is in quantity?
Vadim Pokrovsky: Yes. We are now talking about the fact that growth is underway, growth is underway. Well, it is, in principle, possible to stop. Therefore, the goals set by international organizations (WHO, UN AIDS) are zero new cases. That is, if we have 104 thousand new cases, then we need to bring the number of new cases to zero. This is the task for the next five years.
Olga Arslanova: Why so many? That is, we see that in Moscow the growth is 20%. It is clear that there is a diagnosis...
Vadim Pokrovsky: These are just new cases, of course.
Olga Arslanova: Yes. But why are these new cases appearing even though treatment is supposedly being provided?
Vadim Pokrovsky: The fact is that the virus continues to spread. Initially, our epidemic was mainly associated with the fact that people became infected when they injected drugs intravenously with one syringe. And then these people began to become infected through sexual contact. And now approximately 55% of new cases are sexually transmitted infections, and only 45% are infections through drugs.
Yuri Kovalenko: But there is propaganda going on.
Olga Arslanova: It is practically impossible to become infected from a person who is taking antiviral therapy. Accordingly, people who infect other people, for some reason...
Vadim Pokrovsky: Well, you can still get infected if a person, for example, doesn’t take the medicine well.
Olga Arslanova: And yet, what is the root of the problem, I’m trying to understand?
Vadim Pokrovsky: Well, only a third of those identified as HIV-infected receive medications. 380 thousand are now receiving out of 975 thousand living HIV-infected people. And we have another 280 thousand dead. That's where the figure comes from - 1 million 200 thousand. But you asked how much actually. Well, approximately 300 to 500 thousand still do not know that they are infected, that is, they have not been tested. Therefore, we are now talking about 1.3-1.5 million. And of course, from all these people someone can become infected with HIV. This is why the epidemic continues.
Yuri Kovalenko: But there are also subtleties of diagnosing HIV: it may not be diagnosed now, but it will come out in the analysis in six months, or maybe in a year.
Olga Arslanova: Up to six months.
Vadim Pokrovsky: Yes, this is a small percentage of the number of as yet unregistered cases. And these people, of course, also transmit HIV infection. Why the approach: “Let’s identify everyone who is HIV-infected and prescribe them treatment - and this will solve all the problems”? Of course not. As you correctly said...
Olga Arslanova: This will solve part of the problem.
Vadim Pokrovsky: Yes. We need to promote safe sexual behavior, work with drug users, and distribute syringes to them. But that's not the main thing. Teach them: “Even if you cannot refuse to administer a drug, do it in such a way as not to become infected.”
Olga Arslanova: But nevertheless, we have absolutely...
Vadim Pokrovsky: This is not what we do.
Olga Arslanova: Here! We have absolutely closed the issue of substitution therapy - methadone for drug addicts.
Vadim Pokrovsky: In addition to syringes, there is also replacement therapy.
Olga Arslanova: But we don’t want to talk about it.
Vadim Pokrovsky: Do you know what this is?
Olga Arslanova: Tablet?
Vadim Pokrovsky: Yes. If he injects, but if you offer to take the same drug in a tablet, then maybe he will not inject, or at least he will inject less? This means that the virus will spread less.
Olga Arslanova: And most importantly, he will receive it for free.
Vadim Pokrovsky: Yes, he will come to medical workers. And now you can lure him into drug addiction treatment. That is, this method works very effectively in Europe.
Olga Arslanova: Why aren’t we discussing this seriously?
Vadim Pokrovsky: Well, here comes the resistance. I think, of course, maybe there is hidden resistance from the heroin mafia here, because then they will lose income from the sale of heroin. Well, many of our narcologists say: “Our methods are better than replacement therapy, we will cure everyone.” But, unfortunately, the effectiveness of their methods is still insufficient.
Olga Arslanova: Well, with drug addicts...
Yuri Kovalenko: Here are the numbers for last year...
Olga Arslanova: I'm sorry. We've dealt with drug addicts, let's talk then about promoting some kind of correct sexual behavior. In the same way, we have closed the issue of sex education for teenagers. We have closed the issue of free contraceptives for risk groups. Again, it seems simple and inexpensive, and it works in other countries. Why isn't anyone looking at this?
Vadim Pokrovsky: Well, about five years ago, conservative thinking prevailed in our country, so to speak: if we ban everything and stop teaching schoolchildren safe sexual behavior, then they will not have sex at all, but only after a wedding in church, under the supervision of a priest, will they have sex . Well, this is ridiculous, because it didn’t work in the Middle Ages either, people still participated in the spread of infectious diseases, so to speak, despite the fact that everyone supposedly adhered to the necessary rules. Therefore, of course, it is training that is effective.
And here the indicative experience of Germany is very important, where, well, 5 thousand new cases are registered per year. Compared to our 100 thousand, you see, this is a big difference. But there this training in safe sexual behavior is mandatory, and students cannot even refuse it.
Yuri Kovalenko: And yet for Last year the numbers tell a different story. And if we take five years of this conservatism, the ban and everything else, and if we look at the statistics of young people engaging in sexual relations, we will see how much younger people have become - from 12 to 15 years.
Vadim Pokrovsky: It `s naturally. That is, the methods that are currently used are ineffective, so we need to implement training more effectively.
Yuri Kovalenko: What else?
Vadim Pokrovsky: It's prohibited at school. But here it turned out interesting thing, completely unexpected: in our country people become infected more often at the age of over 25, up to 40 and up to 80 years, because after graduating from college they leave the control of their parents. This strict control disappears, and many people indulge in all sorts of crimes by this time, by the age of 30, and become infected most often.
Olga Arslanova: Tell me, please, does morbidity correlate with living standards? There is an opinion that in countries where people do not really imagine their future, citizens more often engage in risky behavior for the sake of momentary pleasures - simply because they do not really understand what it is for to live long and safely. Hence alcoholism - due to these social factors. Hence HIV.
Vadim Pokrovsky: We also believed that this should be the case. But for the first time, HIV infection has spread more in those areas where it was in the 90s economic situation better than others. Let's say, Tolyatti, where the car plant worked, now up to 3% of the population there are infected with HIV. And also many areas of industrial Siberia where production operated. Well, it was precisely related to drug addiction. The same drug mafia preferred to take drugs to where the money is.
Olga Arslanova: Where can they buy it?
Vadim Pokrovsky: So naturally there more people involved in drug use. And when the virus spread among drug addicts, it was these areas that suffered. That is, all this can be explained. But now is an unpleasant moment. Now the increase in the number of new cases among the rural population is even higher than among the urban population. This is not very clear, because HIV infection is a disease of cities. But this may be due precisely to the fact that in rural areas no preventive work is carried out, and the information supply in these regions is worse, and medical care is less well provided. That is, we also need to work with the rural population. We, unfortunately, have started this issue.
Olga Arslanova: Let's listen to our viewers. We have Tamara in touch from Volgograd. Good evening.
Viewer: Good evening. I want to say what the main reason is. This is the price of condoms. If young people earn an average of 20 thousand, and a condom costs from 100 rubles, then how many will he buy? And the second reason. When this disease began in our country, I was already quite an adult lady. And there was a lot educational work, Very. Now practically nothing is being done, young people are not told anything on TV, they don’t hear anything anywhere. This is the main thing... I live in a city, not in a village, but I don’t see any work. Thank you.
Olga Arslanova: Thank you very much. It would seem that the measures are not the most expensive.
Vadim Pokrovsky: I agree one hundred percent with our viewer. Why? That is, preventive measures - this, of course, did not just come out and say: “Comrades, use condoms.” Of course, care must be taken to ensure that they are accessible. Use them, but they are not in the store. Well, they have now appeared in stores, there are quite a lot of them compared to previous years, but the price, I would say, has even increased. And of course, some vocational school student or even a student will think: should I buy a condom or a bottle of beer? And here it seems that the condom is not in favor...
Yuri Kovalenko: But these are the rules of the market. The state cannot legally make it cheaper.
Vadim Pokrovsky: Maybe. Of course it can.
Olga Arslanova: Maybe at least buy it.
Vadim Pokrovsky: Because in all countries except Russia they do this.
Olga Arslanova: Is this what the state is doing? Or are foundations doing this?
Vadim Pokrovsky: This is, of course, done by the state. And it is pursuing a policy of reducing prices: perhaps a reduction in customs tariffs for imports, and also some reductions for domestic ones tax benefits. Or maybe, yes, some special purchases for low prices and distribution to some threatened categories.
Yuri Kovalenko: Everything is relative. If we say that a condom costs 100 rubles, then how much does it cost to treat one HIV-infected person? Approximately how much do you know?
Vadim Pokrovsky: And treatment for an HIV-infected person is lifelong. We want and hope that these people will live to old age. And per year it costs an average of 85 thousand rubles.
Yuri Kovalenko: That is, roughly speaking, per year, if you say 30 years... Well, let's add 40 years. And at 85... Those are crazy millions!
Vadim Pokrovsky: Undoubtedly.
Yuri Kovalenko: It's much more expensive than condoms.
Vadim Pokrovsky: And now we already have, in my opinion, 21 or 22 million... billion in our budget for this year - a solid figure. But nothing was added for prevention - 300 million. 1.5...2 rubles per person - this, of course, is very little. And we cannot organize anything here, any serious everyday prevention that the situation requires.
Olga Arslanova: Do I understand correctly that according to compulsory medical insurance, any HIV-infected person has the right to receive therapy? Now we will not talk about its quality, what generation these drugs are. But he must get it in his region. Why doesn't this work in practice?
Vadim Pokrovsky: While these 22-23 billion are not enough for everyone, not even half enough, so naturally the budget for therapy must be increased.
Olga Arslanova: Let's listen to Lyudmila from St. Petersburg. Good evening.
Viewer: Hello.
Yuri Kovalenko: Hello.
Olga Arslanova: Hello.
Viewer: The fact is that my son is in prison - Leningrad region, Fornosovo village, colony IK-4. They constantly test for HIV there, but for some reason the test does not arrive, that is, there is no one to carry it, or the blood has clotted. In general, there have been no analyzes for several years. He has been in jail for 10 years and has received absolutely no treatment. They don't even have headache pills. How is this even possible? And when I said, I called the center, they told me this: “If he had received it right away, then they would have given him the medicine. And since he didn’t receive the medicine, that means we can’t give him the medicine.” So, these people should just rot there?
Yuri Kovalenko: Some kind of bureaucratic failure.
Olga Arslanova: Thank you. In general, where can you complain if a person does not receive therapy?
Vadim Pokrovsky: Well, here important point affected. The fact is that not only does medicine cost money, but it is also necessary to invest in infrastructure that would ensure that medicine and diagnostics are provided in any region of the country. You see, they don’t deliver here, something gets spoiled on the way, because there is no infrastructure. Therefore, not only, of course, medicines, not only prevention, but also serious infrastructure. Here's what you need.
And you need to complain to Rospotrebnadzor. He is now in the FSIN system. Complain to the leadership of the FSIN, because we have a special program to combat HIV infection in the penal system. Well, you can always complain to the prosecutor, you need to remember this.
Yuri Kovalenko: But you can complain about this for years, but this problem is already systemic long years.
Vadim Pokrovsky: More is needed - in addition to the pure allocation of money for some events, to create infrastructure. And in our country there is still one big failure in the infrastructure - there is no leader who manages all these programs taken together. You see, the statistics seem to be different. And this is due to the fact that no one has specifically appointed a person responsible for the fight against HIV infection.
Olga Arslanova: Well, the last, probably, very important question from our viewers. We understand that, yes, the disease is incurable, but you can live with it, and live a quality life. It is important to recognize and find out in time that you are infected. They ask: “Is it now possible to test for HIV cheaply, or better yet for free, preferably anonymously?”
Vadim Pokrovsky: We provide free testing even in local clinics.
Olga Arslanova: But it is not anonymous.
Vadim Pokrovsky: Yes. But this is just a money issue. If suddenly a non-Russian citizen comes, you need to make sure that he is a Russian citizen. And that's why anonymous for money. If you want it for free, they still require a passport for reporting to our fiscal authorities.
Yuri Kovalenko: This is deceit. If a person, say, has a positive HIV status, and he ordered anonymously, then the doctor should...
Olga Arslanova: No, he shouldn’t, he gave it up anonymously.
Vadim Pokrovsky: No, our law even says that he can be examined and treated anonymously, but at his own expense.
Yuri Kovalenko: Or it may not be treated.
Vadim Pokrovsky: Yes maybe. And we even have a private clinic in Moscow that provides treatment. And in many regions you can also get treatment for free, but you have to pay for everything.
Olga Arslanova: Thank you very much for answering our questions. We remind you that our guest was Vadim Pokrovsky, academician of the Russian Academy of Sciences, head of the Federal Scientific and Methodological Center for the Prevention and Control of AIDS. Thank you very much.
Yuri Kovalenko: Thanks a lot.
Vadim Pokrovsky: All the best!