Awash in AIDS

How Russia's economic crisis is skyrocketing HIV infections again

Over the past two years, tens of thousands of HIV-positive patients in Russia have been left without medication, due to shortages and bureaucratic mistakes. Some patients are undergoing the risky transition from foreign drugs to domestically-made Russian medicine. Against the backdrop of an economic crisis and unstable exchange rate, many hospitals and patients can no longer afford the necessary treatment. Ilya Rozhdestvensky takes a look at how the lives of HIV-positive patients have changed since the economic crisis set in.

Treatment slowing the progression of HIV was developed back in the late 1980s. Since then, the US and Europe have been able to curtail significantly the spread of HIV and AIDS. In Russia, HIV rates stabilized in the early 2000s, but they began to rise again dramatically in 2007. As numbers of HIV/AIDS cases rose over the past year, Russia has also witnessed soaring prices for treatment, and patients have struggled to get access to pills on time. On top of this, the Russian government has been attempting to phase out imports to the Russian medical market and replace them with domestically-made products—a process ridden with bureaucratic mistakes, medical risks for patients, and new hurdles for both suppliers and customers.

Between the early 1990s and July 2015, almost 950,000 individuals were registered as HIV-positive in Russia. This includes 192,000 people who died of the disease. In the first half of 2015, 41,707 people were registered as HIV-positive. This means there are 200 new HIV cases every day this year in Russia. At this rate, by 2016, there will be more than 1 million HIV-positive individuals in Russia.

According to Vadim Pokrovsky, the head of Russia’s Federal AIDS Center, Russia could be facing about 2 million HIV cases by 2020. In several regions, HIV-positive patients already make up more than 1 percent of the population (this includes Irkutsk, Samara, Sverdlovsk, and the city of St. Petersburg). The numbers point to an AIDS crisis.

Amid the crisis, medicine shortages abound. According to a website called Pereboi.ru, which monitors the market for HIV medications, even Moscow faces shortages of prezista, kivexa, and other protease inhibitors that help stunt the HIV virus.

HIV treatment is usually a complicated set of at least three separate medications that must be taken at specific hours throughout the day, and any disruption can be extremely dangerous for the patient. There are also shortages of materials necessary for HIV-testing and monitoring, which patients must undergo on a regular basis in order to adjust treatment for maximum effect. Some regions suffer more than others: in Crimea, for example, 22,000 HIV-positive patients have been left without medication because of delays with purchasing and procuring the drugs, following the region’s change in legal status (Crimea seceded from Ukraine and joined Russia in 2014).

In some regions, including Tatarstan, doctors have started giving Russian drugs to patients who had been treated with foreign drugs before. Some patients and advocates have expressed concern about the quality of these new pills. Alexei Burlak, a member of the coordinating council of the “Union of people with HIV,” told Meduza that doctors often simply have to ignore the negative side effects of the new drugs because pharmacies simply don’t have alternatives in stock. “We have started to get complaints from HIV patients who have been transferred fully to Russian drugs… Some are experiencing side effects they had before they started treatment, and this is a serious issue. People have said that these might not even be side effects, but rather the drugs might not be effective at all. People are starting to get infections, for example, herpes,” said the Health Ministry’s Public Council member Alexei Starchenko in an interview with Russian radio station RSN.

According to UNAIDS, Russia ranks alongside the Democratic Republic of Congo, Nigeria, South Sudan, and Indonesia in terms of HIV prevalence and HIV treatment methods. These countries all face growing numbers of new infections against the backdrop of high HIV prevalence, and they also grapple with a shortage of necessary medications.

Vadim Pokrovsky of the Federal AIDS Center is pessimistic. He says HIV rates will continue to rise in Russia. According to Pokrovsky, in order to slow the the spread of HIV, at least 70 percent of patients must undergo regular treatment. In Russia, only 157,000 out of 516,000 registered patients are treated regularly, which is barely over 30 percent of those infected.

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According to Evgeny Alekseyev, the director of the healthcare development foundation “Focus-Media,” Russia lacks HIV/AIDS education programs. The state has allocated only 200 million rubles ($2.9 million) for HIV/AIDS education for the upcoming year, which amounts to about 1.5 ($0.02) rubles per person in Russia. And due to the latest laws restricting foreign funding and foreign NGO activities in Russia, programs for HIV/AIDS education have been cut off from foreign grants.

Pokrovsky says Russia needs a new approach to HIV and AIDS. He has proposed opioid replacement therapy for drug addicts (a medical treatment that replaces illegal drugs with less harmful drugs under medical supervision) and mandatory sex education in schools, but both the Health Ministry and Russian parliament members staunchly oppose such measures.

The Health Ministry has recognized the crisis and has its own plan in place. In February, Health Ministry officials revealed their five-year strategy for fighting the spread of HIV. The plan includes introducing HIV/AIDS education, promoting international collaboration, increasing the effectiveness of HIV testing and treatment, as well as the “stimulation of development of original domestic anti-retroviral drugs with required strict quality control.”

The five-year strategy is currently under review by state agencies, but the plan still looks very raw: there is no information about how much money should be allocated for any part of the project, or how the proposed import substitution will take place. Another major problem entirely ignored in the strategy is the issue of centralized medication procurement. According to Alexei Mikhailov, a specialist in drug procurement for HIV patients, when Russia’s regions started to take over responsibility for buying drugs for local patients, many regions ended up facing shortages. Mikhailov says Russia must return to a centralized system of ordering and distributing drugs, otherwise the shortages will continue.

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Problems with medical suppliers began back in 2013, when the Health Ministry stopped buying medications at the federal level and transferred this responsibility to the local authorities. Local authorities had lobbied for this move because they claimed that the centralized system of was unable to take into account the local specificity of patients and their needs. But the transition to the local level did not go smoothly.

Starting in 2013, each region had to hold its own call for tenders on the medicine market. This resulted in a huge differentiation in prices across the country. For example, the company R-Pharm sold a drug to an AIDS center in Samara region for 33,987.83 rubles ($501), and sold the same drug to a center in Perm region for 31,302.77 rubles ($462). As a result, some local AIDS centers could no longer afford the drugs they needed, and patients were left without care.

Moreover, local officials had not been trained in how to prepare documents for medical tenders, and some regions were late to order the drugs. Many officials who were charged with ordering the medicine simply refused to carry out this new responsibility. In Vladivostok, for example, the HIV/AIDS medication tender was put off three times because local officials could not place the orders correctly. As a result, tens of thousands of people ended up skipping pills and foregoing treatment.

Decentralization also meant that patients became dependent on the specific regions where they were initially registered. Authorities in Moscow, for example, started turning away patients whose permanent address was outside the city.

In February 2014, experts and advocates asked the Health Ministry to increase financial support for regional AIDS centers struggling under the weight of the new decentralized system.

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But 2014 also brought the economic crisis, and the catastrophic situation for HIV patients got even worse. Against the backdrop of a falling ruble, the cost of HIV medications rose by 20-to-30 percent. Prices of imported drugs soared because of the exchange rate. Even domestically produced drugs, which are made from imported components, became more expensive. As a result, the amount of drugs the state could purchase also fell by 20-to-30 percent.

Other BRICS countries, for example, have dealt with similar problems by supplying cheaper generic medications. According to Denis Godlevsky, the Russia program manager of the AIDS Healthcare Foundation, Brazil, China, and India increased the availability of HIV medicine by producing generic drugs domestically. The same strategy allowed South Africa to start treating 3 million patients, compared with just 300,000 patients ten years before.

Russia could take this path, and the WTO even allows for the generic production of patented drugs in the event of an epidemic. This would bring the prices of HIV medicines down drastically. But according to the International Treatment Preparedness Coalition, the Russian government is unable even to switch to foreign-made generic medicines because Russia’s federal regulations do not include drug compatibility lists at all.

For this reason, there is almost no competition in Russian markets. Only single companies participated in 1,618 contract tenders in Russia. Medtekhpharm, for instance, won over half the contracts in Chechnya, and the company ArkhiMed is virtually the only medicine distributor in Ingushetia. Godlevsky believes that producers could bring prices down: “We always believed that producers have a certain price margin, and they could bring prices down without losing money. At the end of the day, the only things more lucrative than HIV medicines are probably weapons and drugs.”

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Activists called for domestic production of HIV medication long before the economic crisis set in. But as the EU and the US imposed sanctions on Russia in 2014 and 2015 in retaliation for Russia’s role in the Ukraine crisis, import substitution became a hot topic among government employees and parliament members, too.

In July, the Russian newspaper RBC reported that Rostec CEO Sergey Chemezov, who is also an old friend of Russian President Vladimir Putin, appealed to the President with a proposal to set up a subsidiary company of Rostec (a state corporation) called the “National Immunobiological Company.” This company would become the only supplier of medicine for treating HIV, tuberculosis, and hepatitis to state medical facilities in Russia. The letter addressed to Putin states that this company could meet as much as 90 percent of Russia’s demand for such medications. Chemezov explained that the initiative is driven by the “necessity to provide sovereignty to the Russian Federation in the sphere of medical production and import substitution.”

But Denis Godlevsky is not so sure about this idea. At the moment, Rostec only produces a small amount of drugs for treating HIV, tuberculosis, and hepatitis. Godlevsky says that Chemezov’s company is likely to become a monopolist in Russia: “A guy came [to Putin], asked his old buddy to set up a monopoly, and he got one. But he doesn’t have the factories, the technologies, or the logistics for it,” says Godlevsky. “Something seems to be moving along, but not at all in the right direction.” In the meantime, the number of patients with HIV in Russia is set to grow by 10-to-12 percent annually.

Ilya Rozhdestvensky

Moscow