Roughly one million Russians are HIV-positive and approximately 5 percent of the country's entire youth population is infected. There are more than a million intravenous drug users, but unlike American heroin users, who mainly snort or smoke the drug, Russians inject drugs with syringes, often sharing those syringes and furthering the spread of HIV.
The Russian government under Vladimir Putin has taken very few measures to stop the epidemic. Anti-retroviral (ARV) drugs are given to citizens who are officially registered as having AIDS, but almost no accepted prevention measures — education, drug addiction treatment, clean syringe distribution — are available to the public.
To even be part of the ARV drug distribution system entails some personal risk, as people who confess to being drug users face not only the possibility of imprisonment, but punishments ranging from the loss of a job to having their driver's licenses revoked. So, many people in the core risk groups — intravenous drug users, gay men and sex workers — avoid HIV testing. This too fuels the epidemic.
"The Russian government's strategy of tackling the HIV problem is neglect and denial," Anya Sarang, a Russian public health activist, told me.
In 2012 I spent several weeks in Russia talking to drug users and the activists who wanted to help them. For a Westerner even slightly familiar with the history of drug policy here, the conversations seemed surreal, as though the very worst of our war on drugs had been adopted and the very few things we do right ignored.
An opiate addict in the U.S. has the hope of receiving treatment that the World Health Organization says has a strong empirical basis for actually working. The gold standard of opiate addiction treatment is substitution therapy, meaning the provision of a medically administered drug such as buprenorphine (known the U.S. as the drug Suboxone) or methadone to safely replace heroin.
In Russia, Suboxone and methadone are illegal. The reasons for this relate to culture and politics, not science. Few people with any power speak for people with addiction, and those who do engage in public discussion argue for imprisonment of drug users or ineffective 12-step programs run by the Eastern Orthodox church and funded by the government.
Robert Heimer, an epidemiologist at Yale University who's worked extensively in Russia, described this state of affairs: "If you become registered as a drug user, you can get free treatment. But that treatment doesn't work."
The situation is even more dire for gay men. Russia's anti-gay propaganda law has been widely criticized in the West, and YouTube videos of gay men being attacked has brought to light how precarious life for gay men in Russia can be. But even if violence is not the daily experience of most gay men in Russia, a low level of daily humiliation and the threat of violence certainly is.
I spent an evening conducting interviews at a clandestine meeting of HIV-positive gay men in St. Petersburg. The leader of the group, Ilya, expressed it eloquently:
Prejudice has enormous implications for the country's AIDS crisis. The primary risk group, intravenous drug users, have no real option for getting help to stop using heroin. The secondary risk group, men who have sex with men, live as a pariah class, afraid of living openly and of being tested for HIV.
It was this combination of bad policy from above and antipathy from below that confronted heroin users and gay men in early years of America's AIDS crisis. The national sentiment gradually changed after reaching a low point in the 1980s, but it took years of aggressive political activism and the courage of ordinary people living with AIDS to get us there.
In Russia it's 1987 all over again, only there is no ACT-UP, there are no celebrities coming out, there is no nascent support from public health officials to find solutions, and the rest of the world, when it thinks of Russia's problems, thinks about Putin's military ambitions.
"Our society is not ready to accept people who have these kinds of problems, both drug addiction and HIV," a 33-year-old, HIV-positive former heroin user named Ilya told me.
"They try to forget that we exist."