Important note: Information in this article was accurate in 1997. The state of the art may have changed since the publication date.
CRUMBLED EMPIRE, SHATTERED HEALTH / A Hotbed of HIV.
Newsday - November 4, 1997
Laurie Garrett. Staff Correspondent
ODESSA, Ukraine THE OPIUM concoction he's been shooting into his veins for two years no longer satisfies Sasha, a pale, wiry, 20-year-old laborer. "Even so," he says, "I can't quit. Something keeps drawing me back here." He pauses a moment to watch a cluster of adolescent drug addicts scurry past into Palermo, the city's main drug neighborhood. "It doesn't matter anyway," he adds. "I'm HIV-positive. Whether it's from drugs or AIDS, soon I will die." Many of the friends Sasha grew up with already have died - of overdoses, alcohol and drug-related violence, tuberculosis, AIDS, suicide. Now he is awaiting his turn. "I work as a gravedigger in Municipal Cemetery Number Two," he said, noting the irony with a broad smile and a shrug. "I dig the graves, and then I fill them back up." Five days later, a half-dozen gravediggers stand beside an empty grave site preparing it for the body of Ukrainian drug lord Victor Kulivar. Assassinated downtown in broad daylight, Kulivar is laid to rest amid a sea of 3,000 people after his casket is paraded through the cemetery past a huge marble bust of a Communist Party boss long past. Gangster and gravedigger, standing side-by-side in the receding late afternoon shadows of a monument made moot by time. It is a scene that serves as a particularly fitting symbol of the formidable AIDS crisis looming in the region. For when the Soviets fell in 1991, experts say, men like Kulivar began to rise throughout the region, gangsters who took advantage of the turmoil inherent in the historic change to target a generation of alienated young men and women, people like Sasha. Drugs were suddenly cheap and readily available, prostitution became a huge regional industry, and the stage was set for the birth of a regional AIDS epidemic of Third World proportions. "This isn't just an explosion," suggests Dr. Alla Soloviova, a Ukrainian working for UNICEF in Kiev. "This is an A-bomb." Last year, 7,000 HIV cases were registered in Ukraine, a country of about 50 million people. And one international agency has since projected that by 2001 it will have 20,000 AIDS cases, perhaps a quarter-million cumulative HIV infections and 4,000 new AIDS cases a year after that. These are startling numbers, international experts say, for a country that recorded only 214 HIV cases prior to 1994. "Imagine the impact on the health care system then," said epidemiologist Luis Loures of UNAIDS, the watchdog agency that made the turn-of-the-century prediction. Already the system is reeling throughout the region, Newsday found. Expensive western-style triple-drug therapy is available to only a handful of people in Moscow; most doctors have little or no knowledge of the disease, and no access to more knowledge, and needle exchange programs and public education outreach is virtually nonexistent - even though the disease is being spread with extraordinary rapidity, experts say, through needles shared by drug addicts. In 1995, for instance, only 0.3 percent of Russia's known HIV cases were IV-drug users, according to Dr. Zdenek Jezek of UNAIDS in Moscow. But by December, 1996, he said, "61.2 percent of all HIV was in IV-drug users." In May, Dr. N. F. Gerasimenko of the Russian Academy of Medical Sciences announced that new HIV cases in Russia had risen eightfold from 1995 to 1996, to around 1,500, and the Ministry of Health has since said it expected 800,000 people to be infected by the turn of the century, or about 5 percent of the country's projected population. By comparison, only 0.3 to 0.5 percent of the U.S. population is thought to have contracted HIV or AIDS since 1979. As in Ukraine, the rapid HIV expansion in Russia is occurring in a country that just a few years ago was labeled an "AIDS-free zone" by Russian health officials citing exhaustive state-mandated HIV testing, which failed for years to turn up significant signs of the pandemic. Just 10 years ago, in fact, Yevgeny Chazov, then the Soviet Union's minister of health, told a reporter that HIV was unable to penetrate his country because of a "slavic genetic superiority over the virus." "We are now experiencing a true explosion of HIV in this region," UNAIDS director Dr. Peter Piot said recently. "We see the same potential as we saw in North America 16 years ago, which makes us worry that we're really not learning from our mistakes." And the epidemic is not only growing at an alarming rate, experts say, it also is being passed within many, varied communities. Scientists at UNAIDS in Geneva say they've identified eight of the 10 known HIV subtypes in a region stretching from the republic of Belarus to Vladivostok, Russia, from the Baltic states in the north to the eastern European nations along the Danube and Dneiper Rivers. And this, in turn, has prompted concerns that it is here, in this well-traveled region, that the disease will recombine genetically, taking on new forms. HIV is one of the world's most rapidly mutating viruses, and it responds quickly to changes in its target human population. For example, most infected drug users and gay men in the world carry the B subtype of HIV, while female prostitutes in Africa and Asia predominantly have the C, D and E subtypes. But only a tiny minority of the world's AIDS population moves in social circles that exposes it to widely divergent HIV subtypes, so few people carry two or more subtypes in their bodies at the same time. When such superinfections do occur, HIV has a golden opportunity: It can trade genetic chunks of its RNA from one subtype to another, creating new genetic forms that could include the ability to infect a wider range of cell types, outwit certain drugs or cause more rapid illness. "It's unbelievable," virologist Saladin Osmanov of UNAIDS said during an interview in Geneva. "It now seems that the East will be the mixing pot for all of the elements of the past 15 years of HIV worldwide: subtypes, sex, intravenous-drug users, nosocomial [hospital-spread]. This is it." All this viral diversity implies that HIV has entered the region several times, from different parts of the world. Osmanov says there are at least five epidemics in the region - reflecting five separate times and places in which particular strains were introduced. It's questionable whether all five will continue to develop, but experts say it is clear that beyond the narcotics-driven epidemic that's dominant now is a burgeoning heterosexual epidemic that could be more explosive than any seen elsewhere - including Thailand, which went from a handful of cases in 1989 to a 70 percent infection rate in prostitutes by 1991. "You really need to understand the nature of sex networks in eastern Europe" to understand the potential in the region, explains Loures of UNAIDS. "Clearly the rates of multiple-partner sex are higher than in western Europe. And though no one knows the size of the sex-worker population, it's large and growing . . . It's all very dynamic, and the situation is hard to forecast right now." One reason is that the regional epidemic, despite its frightening dynamics and potential, is only in its infancy. The year 1987 marked a turning point for the Soviet Union. That year a Moscovite returned from a visit to Zanzibar, bringing HIV home with him. He infected five men sexually, who in turn infected several women. And some of those women gave birth to HIV-positive babies. In total, 22 people got HIV in the Soviet Union's first outbreak. At that point, in hopes of maintaining its unique status as an "AIDS-free zone," the Soviet Union immediately initiated the most massive, mandatory HIV-testing program in the world. The effort started slowly, with about 6 million people screened annually in 1987 and 1988, revealing only one additional case. But it soared to 16.5 million tests in 1989, after a second, larger outbreak spilled out of a pediatric hospital in Elista where syringes and catheters were routinely reused. In all, that outbreak prompted about 250 HIV cases, experts have concluded. Eventually, Russian health officials have said, about 165 million tests were done overall by the end of 1995, when 58 new HIV cases were identified. In 1996, the Russian Federation changed its HIV laws, dropping the very expensive large-scale testing program it had begun nearly 10 years earlier while the Soviets were in control and replacing it with laws that allow compelled testing by police and non-medical personnel only in certain circumstances. There were 1,500 new HIV infections recorded that year. The issues surrounding mandatory testing are controversial. In some places, such as the Baltic nation of Estonia, public education and improved infection-control procedures in hospitals and clinics are considered the best approach. But in other parts of the former communist world, top AIDS doctors and politicians claim that only a return to totalitarian control - including full-scale mandatory testing - can stop the virus. "From my point of view, it's necessary to bring back socialism," Dr. Vadim Pokrovsky, who heads all Russian HIV research and clinical care, said in an interview in his Moscow lab. "The psychology of socialism is acceptable for Russians; the so-called democratic way is not realistic. The sense of working for society is very important for young people. In the present moment they don't understand that, and the result is drug addiction, prostitution and so on." On the other side of the issue are doctors such as Dr. Lev Mogilevsky, co-director of the Odessa Plague Station. He proudly displays complete leather-bound works of Marx, Lenin and Engels in his office, yet says he does not support either mandatory testing or patient isolation. "Our main task is to save the younger generation," he said. "If we manage to pull them out of the reach of the mafia structures, we will win the battle. Those structures understand this, of course, and they are trying to attract the youth on their side." In Africa, Thailand and the United States, AIDS experts have seen that the most successful HIV-prevention efforts involve outreach programs in which trained members of high-risk groups, such as prostitutes or young IV-drug users, offer their peers concrete services, including use of sterile needles, sexually transmitted disease clinics, and condoms. But "in the Soviet period, prostitutes and drug users officially didn't exist," said Dr. Jezek of Moscow. "So there was - and still is - no concept of peer education." Dr. Karl Denhe of UNAIDS in Geneva says authorities in Russia, Ukraine and the rest of the region "are aware of the epidemic, and they're scared. Really scared. The problem is they don't know what to do about it. There's no cohesive view." There's also little coordination of health services even within Russia. Consider the case of 27-year-old Nikolai Nedzeski, a Moscow-based AIDS activist who was infected with HIV in 1990. For two years Nedzeski wasn't able to get treatment, because his oblast (or county), where he was registered as a resident, was broke and couldn't afford the drugs and care he required. He traveled to Moscow, but was told that since he wasn't an official resident of the city when he was diagnosed, they wouldn't pay for his care. This health care catch-22 afflicts not only HIV patients, Nedzeski explained, but all Russians who suffer expensive illnesses. "It's a nonfunctioning system . . ." he said. The strongest anti-AIDS program in the region is in Prague, Czech Republic, experts say. There, Dr. Marie Bruckova runs a national AIDS laboratory that collects and analyzes blood from individuals who voluntarily give samples confidentially or anonymously. Those infected get free treatment, counseling and safe-sex education. Meanwhile, on-the-street AIDS education is done through needle-exchange centers, with support from the nation's president, Vaclav Havel, and safe-sex education has been introduced into school curriculums. So far the Czech Republic has identified only 318 citizens with HIV, 95 of whom have developed AIDS, and Bruckova describes the national mood in terms of AIDS as "alert, but not in panic mode." The government of Georgia, which is deeply cash-poor as a result of post-civil war economic decline, can't match the Czech campaign in size, but it follows a similar approach, in intent, said Dr. Tengiv Tsertsvadze, who heads the Caucasus Mountain nation's anti-AIDS efforts, coordinated through a small lab in Tbilisi, the capital city. The Georgian education and voluntary testing program is "based on recommendations from UNAIDS in Geneva" and is done in collaboration with Dr. Jack Dehovitz of Downstate Medical Center in Brooklyn, Tsertsvadze says. "It's a very civilized program." But there are other problems in this war-torn country that doctors like Tsertsvadze must contend with, including a highly questionable public blood supply. In Tbilisi, for instance, fewer than half of all blood transfusions involve serum or plasma that has been screened for HIV contamination. According to Tsertsvadze's staff, only 17,000 of 50,000 blood-bank donors were tested in 1996, and at least half of the nation's emergency blood donations weren't tested all - for HIV, or any other virus. "In old times, we had blood banks [we trusted]," Tsertsvadze said. "But not anymore." In Russia the AIDS battle is in a state of extreme flux. There, Nedzeski explains, "it's still a political disease. Our society says, `Why should we spend our money on prostitutes, homosexuals and drug users?' I asked Mikhail Narkevich last year, `Are we going to provide combination therapy?' and he said, `Why should we? We can't afford to spend money - the people will die sooner.' " For nearly 10 years Narkevich has been in charge of AIDS policy for first the Soviet, and now the Russian Ministry of Health. Ten years ago he supported legislation that made it a capital crime to infect someone sexually with HIV and that gave the police, medical establishment and drug-abuse control departments the right to test both Soviet citizens and visitors for HIV without their consent. "It was a correct strategy. And it was all decreed by the president of the Supreme Soviets in 1987," Narkevich said in his small Moscow office. But times have changed, Narkevich says, and AIDS policies now face a relaxed political environment. The system of mass HIV testing "allowed us in the past to make interesting observations. But the number of tests is decreasing, and we have stopped testing pregnant women. It's too expensive." Last year Russia spent about $1.75 million on testing. But 1997 opened with a smaller HIV/AIDS budget, unpaid doctors and nurses countrywide, and hospitals with empty pharmaceutical shelves. Far from being able to afford $10,000 to $40,000 a year to treat HIV patients in ways that meet U.S. standards, Narkevich says, Russia can't find funding to buy television advertising time to promote AIDS education. The lack of funds for AIDS also is reflected in the treatment strategies offered to HIV patients throughout Russia and in the Ukraine, and in the lack of hope many patients feel, experts say. Today, for instance, only three financially fortunate HIV patients in Russia, and none in Ukraine, receive therapy that is remotely on a par with U.S. treatment. Those are the only three who have managed, Nedzeski says, to find the resources to pay for triple-combination drug therapy with protease inhibitors - the treatment that has revolutionized AIDS care over the past two years in the West. AIDS activists and some doctors say the situation has become nearly unbearable. At the Leningrad Republican Infectious Disease Hospital, for instance, Dr. Paul Sergeyev tenderly strokes the blonde head of plump 9-month-old Natalia. The child beams up at the doctor who has been her surrogate father since the day her HIV-positive, opium-addicted mother abandoned her in the delivery room. "She just showed up, delivered and disappeared," he said. In the crib beside Natalia, 6-month-old Lisa screams for attention. Also abandoned, Lisa has brain damage and seizures. And beyond Lisa is Vadim, who lies motionless staring vacantly from his crib. "We can't know for sure until a child is 3 years old whether he is infected," Sergeyev says as he gently reaches for Lisa, who stops crying with his touch. "We have no money for [polymerase chain reaction] testing. We have no money for anything." At the Odessa Oblast Hospital, which serves the entire region surrounding the city, the impact on the health care system is seen most directly in the pediatric wards, says obstetrician Igor Boychenko. Last year Boychenko's staff delivered about 2,000 babies, 29 of whom were born to HIV-positive mothers and, therefore, stand about a 30 percent chance of eventually developing the disease. This means, Boychenko explains, that as many as 0.5 percent of the babies born in the city last year will develop AIDS. Bad as that sounds, 1997 will end up far worse, he says. Between Jan. 1 and April 1, Boychenko's staff delivered 500 babies, 30 born to HIV-positive moms. So the number of AIDS-fated babies had already jumped to about 2 percent of births. It wasn't until mid-1996 that health experts in Odessa began to truly understand why the HIV "A-bomb" was exploding so dramatically in that city, as well as in the rest of Ukraine. At that point, volunteers such as Odessa attorney Sergei Minov opened several discreet needle-exchange centers and began questioning young people about their habits. What they found, Minov explained, "was a nightmare." Nearly all drug users said they frequently shared needles and syringes and typically pulled some of their own blood into the syringe after the initial injection to flush any remaining narcotics out. It also became clear that the highly organized drug gangsters in the region were selling their "poppy straw" (an opiate) in forms already contaminated, Minov said. This was because the drugs were mass-produced, then checked for potency by young addicts who took free narcotics in trade for these life-threatening tests. To test the samples, the slaves, as these addicts are called, repeatedly dipped their personal syringes into large pots of the drugs, and often pulled the plunger in and out several times. In addition, Minov said, local addicts reported that Gypsy children were ordered by the drug suppliers to collect used syringes. Then, he said, the suppliers would "fill them with narcotics and put them back in circulation." This practice ended, Minov said, when he and other volunteers put the word out among the addicts that he wanted to talk to the "Gypsy Baron," who leads the poppy straw trade in Odessa. Weeks passed. Then one morning last winter, he said, two large limousines drove up to Minov's apartment building, bodyguards leapt out and the lavishly dressed drug lord knocked on his door. Minov told him that selling contaminated opiate and syringes was "bad business" since it would quickly kill off his clientele. The drug lord saw the wisdom of the lawyer's comments and forbade the children from collecting used syringes, he said. One small victory in an "A-bomb" war.
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