For activists who hand out clean syringes and HIV tests outside a shop in northern Moscow, the reaction from some of the area's users of injected drugs has become routine: they avert their eyes, either in fear or shame, and quicken their steps to get out of sight.
“They're afraid, they think it's a trap and we're going to call the police or something,” says Maria Preobrazhenskaya, an activist with the Moscow-based Andrey Rylkov Foundation, whose harm reduction activities targeting vulnerable populations do not receive Global Fund support.
The foundation is one of only a handful of groups still able to implement outreach activities as the Russian government has shown itself increasingly unwilling -- or unable -- to shoulder costs for harm reduction, a decision that has carried considerable consequence.
In 2013, Russia's health watchdog Rospotrebnadzor recorded nearly 78,000 new cases of HIV infection: a steady increase from 2011 over the 62,000 cases recorded then. Activists fear that due to new ceilings on the size of their grants from the Global Fund, which has been the main source of funding for harm reduction in the absence of government funds, those numbers could drive higher.
Pavel Aksenov, director of the non-profit partnership Esvero, responsible for harm reduction activities in more than 30 Russian cities, told Aidspan that the government ignores drug users at its peril.
"Right now the government is covering almost the entire spectrum of preventative measures — except for measures among the population most vulnerable to catching the disease. And the one and only source of financing for preventative measures among members of this group is the Global Fund," he said.
Russia began to transition away from being a recipient of Global Fund support in 2010, and disbanded its country coordination mechanism (CCM) in 2013. Since then, activities in Russia that are supported by the Fund have operated through non-governmental organizations.
The Fund's transition away from the earlier rounds-based approach to the new funding model, (NFM) which emphasizes high burden, lower income countries in its allocation of resources means that there will ultimately be less money available for wealthier countries, who should ostensibly be able to fill the gaps in donor support.
This is contributing to what Harm Reduction International warns is a “global funding crisis” driven by “donor retreat and government neglect".
To see the consequences of a withdrawal of support by donors for harm reduction, one must look only to Romania, which became ineligible for Global Fund support through the regular channels in 2012. Romania, like Russia, remains eligible for HIV support under the NGO rule, but only if NGOs can demonstrate that there are political barriers to providing key services (see article here).
In the absence of Global Fund support for prevention activities, however, Romanian NGOs were unable to sustain them, which contributed to a subsequent rise in HIV infection in the country, a report from Harm Reduction International found.
"Everything depends on preventative measures. Treatment of the disease is a fairly structured process; its effectiveness hinges on how well it was planned for and how accurately it was predicted,” Aksenov of Esvero said.
Ilya Lapin, an activist who works with intravenous drug users in Tver, echoed that sentiment.
“To say that Russia will be able to stop the epidemic, I think that's a very strong statement. Because if we don't work on these three areas — preventative measures among drug users, among homosexual men, among sex workers — Russia will remain at the forefront of the HIV epidemic,” he said.
In a minor victory for those trying to stem the spread of the epidemic, Russia's Justice Ministry in mid-August ruled that several NGOs working to fight HIV did not fall into the category of “foreign agents” according to the country's controversial 2012 law on NGOs receiving foreign funding.
Russia was allocated $15.7 million for HIV under the NFM, about 25% of which was already committed to existing grants. This has left some $11.9 million for Fund-supported HIV programming from 2015-2017; country dialogue to develop an NGO-led concept note has concluded with the submission on 8 September of an HIV concept note.
The concept note submitted in September followed a review of an earlier proposal that earned strong objections from among several civil society groups worried that it de-emphasized service delivery in certain key regions in favor of a nationwide advocacy campaign to encourage the federal government to assume a greater share of the costs for prevention programs. In a Russia where some harm reduction activities such as opioid substitution therapy (OST) are not only discouraged but also illegal, there were those who felt that this was not the most effective allocation of limited resources.
However, Aidspan understands that there was an overwhelming consensus behind the transition to a new advocacy focus for the Global Fund grant. The hope is that by using what is likely to be Russia's last HIV grant from the Fund to make a compelling, financially sound case for the effectiveness of HIV prevention programs targeting key populations -- including people who inject drugs -- there will be enough time to develop a financial and political reservoir of support in the country for such programs to continue beyond 2017.
Under the concept note submitted to the Fund, which will be considered in coming weeks by the Technical Review Panel, the proposed breakdown of the funds is roughly as follows: 63% for HIV prevention activities within key populations; 8% to support a legal defense fund; 7% for community system strengthening; 4% for data analysis, monitoring and evaluation; and 18% for program management.
Mikhail Golichenko, a senior policy analyst at the Canadian AIDS Legal Network who leads the organization's research and advocacy work in Russian-speaking countries, said the "meager sum" allocated by the Fund will probably do nothing to improve the battle against HIV -- but it may force the state to engage in a more serious dialogue about national harm-reduction programs.
"In the new model, emphasis is placed on engaging members of the key population in the work of state programs. Thus the key groups are no longer viewed as an object of preventative measures, but as full-fledged participants in the programs and also full-fledged participants in the dialogue with the state," he said. "If the programs are conducted properly, it is precisely the development of the vulnerable groups' potential that will provide the opportunity to ensure the stability of these programs in the future; it is these key, vulnerable groups acting as catalysts for change."
But in practical terms, according to Esvero's Askenov, this means that in addition to layoffs of outreach workers, the proposal would mean an end to assistance for more than 40,000 injected drug users who are current beneficiaries of Global Fund-supported programs.
Among them are people like Nastya, a young HIV-positive drug user who has turned to prostitution to support her habit even as her body deteriorates. Bad experiences with government doctors, who dismissed her without trying to help her, have left her without any consistent access to health care -- beyond limited outreach efforts.
When offered condoms, she demurred, saying her clients "usually don't care" that she is HIV positive.