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AIDS among injecting drug users in Russia: Opportunities and barriers to scaling-up of harm reduction programmes
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Health Policy 85 (2008) 162–171
Prevention of HIV/AIDS among injecting drug users in Russia: Opportunities and barriers to scaling-up of harm reduction programmes Elena Tkatchenko-Schmidt a,∗ , Adrian Renton a , Ruzanna Gevorgyan b , Ludmila Davydenko c , Rifat Atun d a
Institute for Health and Human Development, University of East London, UK b London Metropolitan University, UK c Volgograd State Medical University, Russian Federation d Imperial College London, UK
Abstract Objectives: to examine attitudes of Russian policy-makers and HIV stakeholders towards harm reduction (HR) scale up, focusing on the factors constraining the scale-up process. Methods: Semi-structured interviews with representatives of 58 government and non-governmental organisations involved in HIV policies and programmes in Volgograd Region, Russian Federation. Results: We found a considerable diversity of opinion on HR scale-up and suggest that Russia is experiencing the situation of power parity between HR supporters and opponents with many stakeholders being indecisive or cautious to express their views. We identified six main factors which constrain policy decisions in favour of HR scale-up: insufficient financial resources; lack of information on HR effectiveness; perception of HR as being culturally unacceptable; reluctance of IDUs to use the services; opposition from law enforcement agencies and the Russian Church; and unclear legal regulations. We demonstrate a complex interplay between these factors, policy-makers’ attitudes and their choices on HR scale-up. Conclusions: A number of actions are needed to achieve a successful scale-up of HR programmes in Russia and similar political contexts: (i) a strategic approach to HR advocacy, targeting neutral and indecisive stakeholders; (ii) more systematic evidence on HR effectiveness and cost-effectiveness in the local context; (iii) HR advocacy targeting law enforcement agencies and the Russian Church; and (iv) aligning best international HR practices with the objectives of local policy-makers, practitioners and service-users. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Harm reduction; HIV/AIDS; Scale-up; Russia; CIS
∗ Corresponding author at: University of East London, Stratford Campus, University House, Romford Road, London E15 4LZ, UK. Tel.: +44 208 223 4081. E-mail address: [email protected] (E. Tkatchenko-Schmidt).
0168-8510/$ – see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2007.07.005
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1. Introduction Harm reduction among injecting drug users (IDUs) is a prevention strategy aimed at reducing the adverse health, social and economic impact of drug use without requiring abstinence from drugs [1]. HR interventions include education about injecting risks, needle and syringe exchange (NSE) and opioid substitution therapy [2,3]. HR has been successfully applied in many settings [4–7] and is recommended as a priority prevention strategy in countries with rapidly developing HIV epidemics driven by IDUs [8–15]. HR has been particularly effective when introduced in the early stages of the HIV epidemic and at substantial scale [8,9]. Although there is no consensus on the scale and/or scope of services needed to contain the spread of HIV/AIDS, the United Nation Joint Programme on HIV/AIDS (UNAIDS) recommends reaching at least 60% of IDUs in a given geographical location [10,11]. HR scale-up is commonly interpreted as reaching larger numbers of IDUs in a given place; coverage of a larger geographical area; increasing the scope and volume of services for IDUs; and reaching other high-risk groups, such as IDU sex workers (SWs) and prisoners [9,12,13]. In Russia, HR interventions began in the mid 1990 s in response to the rapidly growing number of IDUs and a series of explosive outbreaks of HIV among IDUs and IDU SWs [16–18]. Within a decade, over 80 pilot projects were established throughout the country with the support of the Russian Ministry of Health and funding from international donors [12,19,20]. Although a number of local and international studies have shown the effectiveness of these projects in reducing HIV risks among the IDUs they targeted [21–23] HR has neither been formally integrated into the national framework of HIV response nor scaled-up to a level sufficient for significant epidemiological impact [19,20,24,25]. Indeed, a rapid assessment of HR coverage conducted in 15 Russian cities in 2004 found only two sites where 60% of IDUs or more were in contact with HR services. One third of the projects surveyed had reached no more than 10% of IDUs [26]. Similarly, the 2005 analysis of 20 HR sites funded by the Russian Harm Reduction Network found that the average project coverage was 12.5% [27]. Furthermore, although the Russian Ministry of Health nominally supports HR [28,29], the National AIDS Programme for 2002–2006 provided no reference to HR and identified no resources to sup-
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port such activities. Most HR projects have been for years dependent on non-governmental funding, with 70% of resources provided by international donors [19,24]. Also, there are controversies around provision of NSE and opioid substitution therapy [30–32]. Projects, which provide clean needles and syringes to IDUs do so only at the discretion of local authorities and police forces, and have frequently faced threats of closure [24,31,32]. Opioid substitution therapy is prohibited under the Russian legislation and has not been formally established, in spite of methadone and buprenorphine being on the WHO Essential Medicines List [33]. The reluctance of the Russian Government to mainstream HR activities within the national HIV response has been questioned by international donors and local non-governmental organisations (NGOs) [20,24,32,34,35]. However, the reasons behind such apparent resistance to expand the services, which have proven to be effective at small pilot scale, have not been systematically explored. In this paper we examine the attitudes of Russian policy-makers and HIV stakeholders towards HR scaleup. In particular, the study explores the perceptions of local decision-makers of the factors, which impede the scale-up process. The influence of contextual factors on the policy process has been discussed in policy analysis literature [36–38] and in HIV/AIDS [39–41]. By examining this issue in the Russian context, we aim to identify challenges that may be specific to the post-communist transitional environments; challenges that need to be addressed before programmes targeting high-risk populations can be successfully scaled-up in these contexts.
2. Methodology 2.1. Study area The study was conducted in Volgograd region, which is situated in the south-west of Russia and has a population of 2.7 million, of whom 75% live in urban areas. The region covers a territory of 113,000 square kilometres and is administratively divided into 39 municipalities [42]. The first HIV case in the region was registered in 1987. Cumulative notification rates in 2004 were
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157 per 100,000, (22nd highest among 89 Russian regions) [43]. The first and the only HR project in the region was set up in 1998 with funding from the Open Society Institute/Soros Foundation and delivered by the local NGO “Maria: Mothers Against Drugs”. The project operates in the regional capital (Volgograd) and a nearby municipality (Volzhsky); has seven employees and provides services to about 600 IDUs per year [44].
The broader study of the HIV epidemic and response interviewed also senior managers of eight major local enterprises; they however were selected using a different sampling framework. Also, these informants were barely familiar with HR programmes and could not comment on challenges of scaling-up; therefore, the data from these participants were excluded from the analysis. 2.3. Ethics and consent
2.2. Study participants The study was undertaken between February and June 2004 as an integral part of a larger research project which aimed to explore stakeholders’ views on the HIV/AIDS epidemic and response in Russia. We employed a qualitative method of inquiry, comprising one-to-one semi-structured interviews with representatives of 58 organisations that we defined as HIV stakeholders—namely, organisations that influenced or could potentially influence regional policies and actions on HIV/AIDS. We selected organisations by purposive and chain sampling; and informants (one per organisation) by purposive sampling; in all cases informants were either the head or deputy head of the organisation. Organisations were selected in two rounds. We first identified agencies, which were represented on the Regional Interdepartmental Committee on AIDS (ICA)—a governmental body established in the mid 1990 s to develop, co-ordinate and monitor local HIV policies and programmes; and comprising nine governmental departments (health, social care, sports, culture, youth etc), three healthcare services (drug treatment, sexually transmitted infections (STIs); and HIV/AIDS) and two academic institutions. Our approach was based on pluralist theories of policy-making [37,38,45] and theories of organisational interdependency [46,47]. We assumed that when making HIV-related decisions, ICA members interacted with and were influenced by other policy players. To identify these we asked the interviewees in round 1 to nominate regional governmental and non-governmental organisations who, they believed, influenced or could potentially influence decisions and actions on HIV/AIDS. In total, a further 25 governmental organisations and 13 NGOs were nominated. All the organisations approached agreed to participate in the study.
The study was explained to all participants and informed consent was obtained in all cases. Subjects were allowed to withdraw consent before, during, or after interviews. As no ethics committee existed in Volgograd at the time of the study, ethical approval was obtained from the Riverside Research Ethics Committee in the United Kingdom (UK). Official approvals were also obtained from the Volgograd Regional Government and the Regional Health Department. 2.4. Data collection The topic guide included both open-ended and structured questions. In relation to HR, we asked whether the respondents supported HR scale-up with answers given on a five-point Likert scale ranging from 1=“strongly support” to 5=“strongly oppose”; and, why, in their view, scale-up of HR in Russia had been difficult. These answers were provided in respondents’ own words. Interviews were conducted in Russian by two researchers from the regional medical school. Interviews lasted between 45 and 75 minutes; all were audiotaped and transcribed in verbatim. 2.5. Data analysis Transcripts were analysed thematically using the framework approach [48], which involved five stages: familiarisation with the data; identifying a thematic framework; coding the data; creating thematic charts; and searching for patterns, explanations and interpretations. The coding framework was developed using the issues identified a priori during the study design and those emerging in the familiarisation stage. Manual coding was done independently by two local researchers and cross-checked between them for consistency. When differences in coding occurred
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these were resolved with the involvement of a third researcher. The coded textual elements were pasted into compilation sheets; each text unit was given an identification number, which allowed tracing back to the original transcript. Following this, several thematic charts were constructed to allocate data for each theme across all respondents. Marginal remarks were also noted; these were developed into memos and used for explanation and interpretation of the data. We employed several strategies to ensure rigour and to strengthen the validity and reliability of our data: first, the process of data collection and analysis was well documented and supervised both locally and from the UK; second, data coding and interpretation was done by more than one researcher and cross-checked between them for consistency; third, we cross-checked data emerging from different interviews and shared initial interpretation of the data with several informants for respondent validation and feedback [48,49].
3. Results 3.1. Attitudes towards scaling-up About half of the policy-makers interviewed supported HR scale-up, with one third being against it; and another fifth being undecided (Table 1). The majority of the supporters were ICA members. In other stakeholder groups opinions were equally divided with two fifths for and against and one fifth undecided. Five of the 13 local NGOs were “strongly against HR scale-up”; while many neutral stakeholders were among government organisations.
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3.2. Perception of barriers to scaling-up The perceived barriers to scaling-up HR were grouped into six main themes. The most commonly identified barrier was the lack of financial resources in the health system. It was argued that HR interventions were largely supported from international sources. Although some financial and in-kind support was provided by local governments, it was “ad hoc” and “sporadic” and insufficient to sustain HR activities. The second most commonly identified challenge was the lack of evidence on the effectiveness of HR in Russia, with limited or no information on the effectiveness of the existing programmes available to local policy-makers. Many respondents argued that there were no clear criteria for evaluating HR interventions, and the advocacy materials, which promoted HR did so “in general terms” without appropriate data to back up effectiveness statements. As one respondent commented: “Some people say that syringe exchange reduces harm, which means it decreases the number of patients with AIDS . . . But I have not seen a single presentation, [or] a single analysis to support this argument. There are only big beautiful books with quotations from here and there. Nobody has done such analysis; nobody has studied it (Government official, not member of ICA). About a quarter of the stakeholders named cultural barriers to scaling-up. In-depth analysis of the interview accounts identified two distinct patterns in the way stakeholders used the term “Russian culture”. To those who opposed scaling-up, HR was a concept that originated and developed in the West, where traditions and cultural norms, they believed, “were different”. For
Table 1 Attitudes of policy-makers and HIV stakeholders towards scaling-up of harm reduction Stakeholder group Government stakeholders, members of ICA (N = 20) Other government stakeholders (N = 25) NGO stakeholders (N = 13) Total (N = 58)
Strongly support n (%)
Support n (%)
Neither support nor oppose or find difficult to answer n (%)
Oppose n (%)
Strongly oppose n (%)
4 (20.0)
9 (45.0)
4 (20.0)
2 (10.0)
1 (5.0)
6 (24.0)
4 (16.0)
6 (24.0)
3 (12.0)
6 (24.0)
2 (15.4) 12 (20.7)
3 (23.0) 16 (27.6)
2 (15.4) 12 (20.7)
1 (7.7) 6 (10.3)
5 (38.5) 12 (20.7)
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them, HR was “imposed on Russia from outside”, and hence “culturally unacceptable” and “contradictory to the Russian mentality”. As an NGO representative said: “People know and often view these programmes as something that has been imported and imposed by foreign organisations, foreign governments; and it is not clear whether we really need them” (NGO representative). Those in favour of scaling-up used the term “culture” to mean traditions and social norm, where drugs, sex and HIV were taboo issues. Some argued, the root of these traditions and norms lay in the communist past of Russia: “This is because of the culture of our leaders, generally a low culture. For instance, take our former communists. They are so conservative.” (Healthcare manager, member of ICA).
Several stakeholders singled out unclear legislation on HR and particularly NSE as an important constraint. They argued that the current legislation was ambiguous on the legality of providing needles and syringes to IDUs. This ambiguity prevented HR scale-up in three ways: first, it gave an opportunity to law enforcement agencies to disrupt the existing HR projects; second, it created insecurity for those engaged in HR activities; and third, it undermined the support of local decisionmakers and health practitioners who were in favour of HR interventions but feared openly to support the expansion of the services, which could be interpreted as illegal. As one respondent noted: “Today all the documents are of declarative and recommendatory nature. There is no legal support. Therefore it is absolutely unclear what kind of problems one may face in the future.” (Government official, member of ICA)
4. Discussion Several respondents identified unwillingness of IDUs to use HR services as a key barrier to scale-up. Three reasons were offered to explain this. First, little information was available about HR projects, their location and benefits. Second, IDUs found it easier to buy inexpensive syringes from pharmacies. Third, IDUs were concerned that contacts with HR services may lead to their IDU status becoming a common knowledge, leading to stigmatisation in their neighborhoods and prosecution by the local police. Furthermore, as IDUs were often perceived as “evil doers” useless to the society, spending limited public resources on programmes for IDUs was unpopular; and many local policy-makers were reluctant openly to support these. A number of stakeholders believed that HR scaleup was constrained by opposition of powerful political institutions, especially the law enforcement agencies (for example the police, drug control and security services) and the Russian Orthodox Church. Interestingly, many respondents were unable to identify specifically which groups or institutions opposed scaling-up. Instead these respondents used the words “society”, “public” and “public opinion” to denote the sources of opposition. In fact, the view “I personally support harm reduction but the society is against it” was commonly shared among our informants.
HIV/AIDS continues to be a major public health issue in Russia [50]. By May 2007 the Russian authorities had reported 386,141 officially registered HIV cases [51] but the actual figure may be as high as 1.5 million [35,52]. The majority of infections are among IDUs [19,35,51], whose numbers are estimated at 1.5–3.5 million [35]. Needle-sharing practices are widespread, ranging from 36 to 82% depending on the location [53]; and in some cities HIV prevalence amongst IDUs reaches 60% or over [18,19,54]. Given the gravity of the situation, one would expect HR scaleup to be a high priority for the Russian government. But, this does not seem to be the case. In spite of international evidence and the successes of many small-scale HR interventions in Russia, policy-makers have not yet integrated HR into the official framework of HIV response; nor provided support to develop services to a scale sufficient to control the epidemic. This paper has explored the perspectives of local policy-makers and HIV stakeholders on HR and examined the interplay between their attitudes, internal and external influences and policy decisions on HR scale-up. Political theory offers different models to explain why certain policies do not get onto the policy agenda [55,56] or get deliberately restrained by non-decision-
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making [36,57]. These, singly or in combination, may include the dominant societal values, the accepted rules of the game, the existing power relations among stakeholder groups, and the instruments of force used [57]. In order to better understand which factors have constrained the scale-up of HR in Russia and how, we examined the distribution of support and opposition forces to HR and the factors, which determined the position of those who were not in support. Our findings show a considerable diversity of opinion in relation to HR scale-up. The proportions of HR supporters and non-supporters are almost equal in number; while a considerable proportion of stakeholders are either indecisive or reluctant to openly express their views. The finding suggests that Russia is experiencing ‘power parity’ between HR supporters and opponents. This may help to explain why HR services in Russia are neither closing down nor scaling-up. The key factors, which constrain political decisions in favour of HR have been identified as (i) insufficient financial resources to expand services; (ii) lack of information about HR effectiveness; (iii) perception of HR as being contradictory to Russian culture and mentality; (iv) reluctance of IDUs to use services because of unawareness, stigma and fear of prosecution; (v) opposition from law enforcement agencies and the Russian Orthodox Church; and (vi) unclear laws and regulations. Earlier studies have explored how HR practices and the micro (e.g. social norms and rules; IDU relationships and networks) and macro (e.g. legal and policy frameworks; political economy; gender issues) contexts determined IDU behaviour [58]. Other studies, specific to the Russian context, have explored how health systems and broader contexts influenced delivery of HR services [59–61]. Here, we analyse how contextual factors impact on the reasoning of decisionmakers and their policy choices. We tried to assign the factors we identified as macro- and micro-influences, but found the distinction between these two levels to be blurred. Even the legal framework and limited financial resources were not barriers imposed externally by the macro-context but a product of internal influences and powers, which determined policies at the micro level. Thus, lack of financial resources to expand HR services was identified as a key policy constraint by almost all stakeholders we interviewed. Severe underfunding
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of public services, including health and social care, was a major problem for Russia after the dissolution of the Soviet Union [62–65]. HIV/AIDS was particularly neglected with no funds allocated to the HIV programme from the federal budget before 1998 [66,67] and only US$5-7 million per annum between 1998 and 2003 [59]. However, strong growth of the Russian economy in more recent years [68,69] has enabled the government to increase financial commitments to HIV/AIDS to US$175 million by 2006: an unprecedented 30-fold increase [70,71]. Hence, the scarcity of financial resources for HIV/AIDS as a macro factor is not a critical issue any more, but whether the new funding will be used to expand HR interventions remains to be seen. Our findings from 2004 and some recent reports on HR in Russia [72–74] suggest that an increase in financial resources per se does not lead naturally to an expansion of HR interventions. On the contrary, according to the Russian Harm Reduction Network, between 2004 and 2006 (the period when the overall national funding for HIV/AIDS rapidly increased) resources for HR interventions decreased by 27% [73]; and the number of HR projects declined from 80 to 66 [73]. Hence, it is not the lack of financial resources as a macro factor that restrains HR scale-up, it is the choices made by policy-makers not to allocate new funds to interventions targeting IDUs and other marginalised populations. This is a micro factor determined by policy-makers’ preferences and distribution of power on the policy arena. The legal framework regulating HR and NSE is another example of the interplay between macro and micro policy influences. Uncertainties surrounding the NSE legislation had a significant impact on HR scale up. But laws do not exist in isolation from the rest of the political process. They are a product of the process and power [36]. Indeed, the Russian drug legislation is a good illustration of this. The Russian Drug Act has undergone a number of changes in the past few years, firstly from more repressive to more liberal and then backwards [31,75,76], which shows that the uncertain legal framework itself, is not an independent macro factor but a result of the current power balance and continuous struggle between HR supporters and opponents. With regards to the latter, our findings provide some useful insights into the disposition of HR support and opposition forces. Although we demonstrate the views
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on HR scale-up to be almost equally divided, policy change does not depend so much on the number of supporters and opponents but on their power to influence the policy-making process [36,77,78]. Measuring the power of HIV stakeholders was beyond the scope of this study. However our findings provide some understanding of the dynamics of policy-making in Russia. For example, an interesting result was the level of opposition within the NGO community in Volgograd. This is surprising given that the development of HR in Russia had been strongly supported by national and international NGOs [79], and that NGOs ran about half of the existing HR projects [26,80]. In the context of our research the term “NGO” was defined as any non-profit, voluntary, civic or humanitarian organisation. Our results suggest that the NGO sector in Russia as a broad notion is not homogeneous. While some NGOs are critical players in advocacy and delivery of HR interventions others are strongly opposed to HR. This apparent polarisation may be a feature of the post-communist transitional environment, where some NGOs were established relatively recently sometimes with international funding and often as a challenge to local government policies; while others comprise more ‘traditional’ civil society organisations including professional associations, women’s groups or organisations of religious and patriotic nature. In a strict sense, the latter group may not be regarded as fully fledged NGOs, as they are often close to local policy-makers; but they may yield substantial influence on policymakers’ decisions and policy choices. This polarisation needs to be taken into account when planning HR advocacy and interventions at a local level. Further, with respect to the opposition, we identified only two distinct forces perceived to be strongly against HR scale-up, namely the Russian Orthodox Church and the law enforcement agencies. But, interestingly, the view that ‘public opinion’ was resolutely against HR was very common among our respondents. This suggests that in today’s Russia the Russian Church and law enforcement agencies are seen as very influential political players in determining the opinions of stakeholders and the overall public ethos. However, their constituencies and reasons for opposition to HR are likely to be different. Rhodes et al. studied the impact of police practices on IDUs’ behaviour and argued that repressive drug legislation coupled with aggressive street policing undermined the HIV prevention efforts
through increased high-risk practices amongst IDUs [81]. We found these forces to be critical in determining policy-makers’ behaviour and choices. One of the key barriers to HR scale-up identified in this study was as the cultural unacceptability of HR as it was perceived to be contradictory to the Russian mentality. This cultural unacceptability, we find, is related to at least two factors: (a) the legacy of policies of the communist past, where issues of sex and dugs were taboos; and (b) the involvement of international agencies in HR programmes. The denial of HIV/AIDS and behavioural risks contributing to the epidemic are not uncommon in many countries [82,83]. In the Soviet Union and postcommunist Russia this denial has been reinforced by the political discourse of the Soviet ideology aimed at bringing up “ideal” men and women. This ideology left no place for those who were deemed to be “imperfect” (for example IDUs, SWs and men who have sex with men) and who “fell out” of the society [84]. Substantial advocacy and funding from international donors to introduce HR in Russia has had both positive and negative impact on the evolution of HR programmes. While international support has undoubtedly helped the establishment of HR programmes throughout the country and strengthened the position of HR advocates, it also created barriers to scale-up in at least three ways. Firstly, in spite of the presence of large number of international development programmes, the expression “Western influence” still seems to have a more negative than positive connotation with some decisionmakers opposing interventions, which in their views, are ‘imported’ from the West. Although the needs for indigenous approaches and community-specific programmes have been emphasised in the HR literature [85–88], insufficient attention has been paid to these needs when the first HR projects were put in place in Russia. In the society, where east-west polarisation was still fresh memory, the neglect of the local context has created an additional barrier to HR scale up, not on the grounds of the intervention itself but due to the fact that it “came” from the West. More recent positive experiences show that the work through national NGOs including those that developed as spin-offs from international organisations (e.g. Open Health Institute) might be more influential and productive in such contexts.
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Second, significant external funding for HR has ‘crowded out’ local funding and discouraged policymakers to invest in the areas, in which substantial international funds are available. As a result, HR programmes continue being supported through nongovernmental and international funding even when significant national funds are available. Third, as the Russian authorities are not spending their own resources on HR, they do not have much interest in evaluating the effectiveness and efficiency of these programmes. Consequently, many decision-makers have no robust data on HR effectiveness and the interventions are considered on the grounds of personal and moral judgements rather than cost–benefit analysis. Our study has some methodological limitations. We adopted a qualitative method and used purposive rather than random sampling. However, we ensured representativeness of views of a wide range of stakeholders interviewed. Our sample, though not statistically representative, was theoretically informed, relevant to the research questions and hence appropriate to the study objectives. We also maintained a systematic approach to our research rigour at every stage—in design, sampling, analysis and interpretation—with independent reflexive thematic analysis which allowed triangulation between team members. Our findings have a number of policy implications, suggesting actions that need to be taken if HR programmes in Russia (and similar political contexts) are to be successfully scaled-up. First, the future of HR in Russia will, to a large extent, depend on the position of the multiple stakeholders who are currently either neutral or indecisive on HR scale-up. A strategic approach to HR advocacy is needed to target these stakeholders to gain their support. Second, there is a need for more systematic evidence on the effectiveness and cost-effectiveness of HR programmes in the local context, to encourage high-level political debates informed by evidence rather than moral position. Third, given the substantial power of the law enforcement agencies and the Russian Orthodox Church in determining political and public attitudes, these institutions should be essential targets in HR education and advocacy campaigns. Finally, the perception of HR as a “Western” strategy, “owned by international agencies”, but not the Russian authorities needs to be addressed. Internationally adopted HR approaches and objec-
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tives need to be made congruent with those of local policy-makers, healthcare practitioners and serviceusers.
Acknowledgements This work was carried out as part of the Programme “Knowledge for Action in HIV/AIDS in the Russian Federation” funded by the UK Department for International Development (DFID). We would like to thank DFID for the support provided. DFID however is not responsible for the views expressed. We would like also to thank the regional administration, health department, HIV/AIDS centre and medical school in Volgograd for their support in conducting this study; our special thanks are to Dr. Alexander Filippov, Dr. Nedezhda Gorshkova, Professor Natalia Latyshevskaya, Dr. Galina Gerusova; Dr. Ludmila Slivina and Dr. Marina Karpenko. We would like to thank Professor Tim Rhodes from the London School of Hygiene & Tropical Medicine for valuable comments on this paper.
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Health Policy 85 (2008) 162–171
Prevention of HIV/AIDS among injecting drug users in Russia: Opportunities and barriers to scaling-up of harm reduction programmes Elena Tkatchenko-Schmidt a,∗ , Adrian Renton a , Ruzanna Gevorgyan b , Ludmila Davydenko c , Rifat Atun d a
Institute for Health and Human Development, University of East London, UK b London Metropolitan University, UK c Volgograd State Medical University, Russian Federation d Imperial College London, UK
Abstract Objectives: to examine attitudes of Russian policy-makers and HIV stakeholders towards harm reduction (HR) scale up, focusing on the factors constraining the scale-up process. Methods: Semi-structured interviews with representatives of 58 government and non-governmental organisations involved in HIV policies and programmes in Volgograd Region, Russian Federation. Results: We found a considerable diversity of opinion on HR scale-up and suggest that Russia is experiencing the situation of power parity between HR supporters and opponents with many stakeholders being indecisive or cautious to express their views. We identified six main factors which constrain policy decisions in favour of HR scale-up: insufficient financial resources; lack of information on HR effectiveness; perception of HR as being culturally unacceptable; reluctance of IDUs to use the services; opposition from law enforcement agencies and the Russian Church; and unclear legal regulations. We demonstrate a complex interplay between these factors, policy-makers’ attitudes and their choices on HR scale-up. Conclusions: A number of actions are needed to achieve a successful scale-up of HR programmes in Russia and similar political contexts: (i) a strategic approach to HR advocacy, targeting neutral and indecisive stakeholders; (ii) more systematic evidence on HR effectiveness and cost-effectiveness in the local context; (iii) HR advocacy targeting law enforcement agencies and the Russian Church; and (iv) aligning best international HR practices with the objectives of local policy-makers, practitioners and service-users. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Harm reduction; HIV/AIDS; Scale-up; Russia; CIS
∗ Corresponding author at: University of East London, Stratford Campus, University House, Romford Road, London E15 4LZ, UK. Tel.: +44 208 223 4081. E-mail address: [email protected] (E. Tkatchenko-Schmidt).
0168-8510/$ – see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2007.07.005
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1. Introduction Harm reduction among injecting drug users (IDUs) is a prevention strategy aimed at reducing the adverse health, social and economic impact of drug use without requiring abstinence from drugs [1]. HR interventions include education about injecting risks, needle and syringe exchange (NSE) and opioid substitution therapy [2,3]. HR has been successfully applied in many settings [4–7] and is recommended as a priority prevention strategy in countries with rapidly developing HIV epidemics driven by IDUs [8–15]. HR has been particularly effective when introduced in the early stages of the HIV epidemic and at substantial scale [8,9]. Although there is no consensus on the scale and/or scope of services needed to contain the spread of HIV/AIDS, the United Nation Joint Programme on HIV/AIDS (UNAIDS) recommends reaching at least 60% of IDUs in a given geographical location [10,11]. HR scale-up is commonly interpreted as reaching larger numbers of IDUs in a given place; coverage of a larger geographical area; increasing the scope and volume of services for IDUs; and reaching other high-risk groups, such as IDU sex workers (SWs) and prisoners [9,12,13]. In Russia, HR interventions began in the mid 1990 s in response to the rapidly growing number of IDUs and a series of explosive outbreaks of HIV among IDUs and IDU SWs [16–18]. Within a decade, over 80 pilot projects were established throughout the country with the support of the Russian Ministry of Health and funding from international donors [12,19,20]. Although a number of local and international studies have shown the effectiveness of these projects in reducing HIV risks among the IDUs they targeted [21–23] HR has neither been formally integrated into the national framework of HIV response nor scaled-up to a level sufficient for significant epidemiological impact [19,20,24,25]. Indeed, a rapid assessment of HR coverage conducted in 15 Russian cities in 2004 found only two sites where 60% of IDUs or more were in contact with HR services. One third of the projects surveyed had reached no more than 10% of IDUs [26]. Similarly, the 2005 analysis of 20 HR sites funded by the Russian Harm Reduction Network found that the average project coverage was 12.5% [27]. Furthermore, although the Russian Ministry of Health nominally supports HR [28,29], the National AIDS Programme for 2002–2006 provided no reference to HR and identified no resources to sup-
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port such activities. Most HR projects have been for years dependent on non-governmental funding, with 70% of resources provided by international donors [19,24]. Also, there are controversies around provision of NSE and opioid substitution therapy [30–32]. Projects, which provide clean needles and syringes to IDUs do so only at the discretion of local authorities and police forces, and have frequently faced threats of closure [24,31,32]. Opioid substitution therapy is prohibited under the Russian legislation and has not been formally established, in spite of methadone and buprenorphine being on the WHO Essential Medicines List [33]. The reluctance of the Russian Government to mainstream HR activities within the national HIV response has been questioned by international donors and local non-governmental organisations (NGOs) [20,24,32,34,35]. However, the reasons behind such apparent resistance to expand the services, which have proven to be effective at small pilot scale, have not been systematically explored. In this paper we examine the attitudes of Russian policy-makers and HIV stakeholders towards HR scaleup. In particular, the study explores the perceptions of local decision-makers of the factors, which impede the scale-up process. The influence of contextual factors on the policy process has been discussed in policy analysis literature [36–38] and in HIV/AIDS [39–41]. By examining this issue in the Russian context, we aim to identify challenges that may be specific to the post-communist transitional environments; challenges that need to be addressed before programmes targeting high-risk populations can be successfully scaled-up in these contexts.
2. Methodology 2.1. Study area The study was conducted in Volgograd region, which is situated in the south-west of Russia and has a population of 2.7 million, of whom 75% live in urban areas. The region covers a territory of 113,000 square kilometres and is administratively divided into 39 municipalities [42]. The first HIV case in the region was registered in 1987. Cumulative notification rates in 2004 were
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157 per 100,000, (22nd highest among 89 Russian regions) [43]. The first and the only HR project in the region was set up in 1998 with funding from the Open Society Institute/Soros Foundation and delivered by the local NGO “Maria: Mothers Against Drugs”. The project operates in the regional capital (Volgograd) and a nearby municipality (Volzhsky); has seven employees and provides services to about 600 IDUs per year [44].
The broader study of the HIV epidemic and response interviewed also senior managers of eight major local enterprises; they however were selected using a different sampling framework. Also, these informants were barely familiar with HR programmes and could not comment on challenges of scaling-up; therefore, the data from these participants were excluded from the analysis. 2.3. Ethics and consent
2.2. Study participants The study was undertaken between February and June 2004 as an integral part of a larger research project which aimed to explore stakeholders’ views on the HIV/AIDS epidemic and response in Russia. We employed a qualitative method of inquiry, comprising one-to-one semi-structured interviews with representatives of 58 organisations that we defined as HIV stakeholders—namely, organisations that influenced or could potentially influence regional policies and actions on HIV/AIDS. We selected organisations by purposive and chain sampling; and informants (one per organisation) by purposive sampling; in all cases informants were either the head or deputy head of the organisation. Organisations were selected in two rounds. We first identified agencies, which were represented on the Regional Interdepartmental Committee on AIDS (ICA)—a governmental body established in the mid 1990 s to develop, co-ordinate and monitor local HIV policies and programmes; and comprising nine governmental departments (health, social care, sports, culture, youth etc), three healthcare services (drug treatment, sexually transmitted infections (STIs); and HIV/AIDS) and two academic institutions. Our approach was based on pluralist theories of policy-making [37,38,45] and theories of organisational interdependency [46,47]. We assumed that when making HIV-related decisions, ICA members interacted with and were influenced by other policy players. To identify these we asked the interviewees in round 1 to nominate regional governmental and non-governmental organisations who, they believed, influenced or could potentially influence decisions and actions on HIV/AIDS. In total, a further 25 governmental organisations and 13 NGOs were nominated. All the organisations approached agreed to participate in the study.
The study was explained to all participants and informed consent was obtained in all cases. Subjects were allowed to withdraw consent before, during, or after interviews. As no ethics committee existed in Volgograd at the time of the study, ethical approval was obtained from the Riverside Research Ethics Committee in the United Kingdom (UK). Official approvals were also obtained from the Volgograd Regional Government and the Regional Health Department. 2.4. Data collection The topic guide included both open-ended and structured questions. In relation to HR, we asked whether the respondents supported HR scale-up with answers given on a five-point Likert scale ranging from 1=“strongly support” to 5=“strongly oppose”; and, why, in their view, scale-up of HR in Russia had been difficult. These answers were provided in respondents’ own words. Interviews were conducted in Russian by two researchers from the regional medical school. Interviews lasted between 45 and 75 minutes; all were audiotaped and transcribed in verbatim. 2.5. Data analysis Transcripts were analysed thematically using the framework approach [48], which involved five stages: familiarisation with the data; identifying a thematic framework; coding the data; creating thematic charts; and searching for patterns, explanations and interpretations. The coding framework was developed using the issues identified a priori during the study design and those emerging in the familiarisation stage. Manual coding was done independently by two local researchers and cross-checked between them for consistency. When differences in coding occurred
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these were resolved with the involvement of a third researcher. The coded textual elements were pasted into compilation sheets; each text unit was given an identification number, which allowed tracing back to the original transcript. Following this, several thematic charts were constructed to allocate data for each theme across all respondents. Marginal remarks were also noted; these were developed into memos and used for explanation and interpretation of the data. We employed several strategies to ensure rigour and to strengthen the validity and reliability of our data: first, the process of data collection and analysis was well documented and supervised both locally and from the UK; second, data coding and interpretation was done by more than one researcher and cross-checked between them for consistency; third, we cross-checked data emerging from different interviews and shared initial interpretation of the data with several informants for respondent validation and feedback [48,49].
3. Results 3.1. Attitudes towards scaling-up About half of the policy-makers interviewed supported HR scale-up, with one third being against it; and another fifth being undecided (Table 1). The majority of the supporters were ICA members. In other stakeholder groups opinions were equally divided with two fifths for and against and one fifth undecided. Five of the 13 local NGOs were “strongly against HR scale-up”; while many neutral stakeholders were among government organisations.
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3.2. Perception of barriers to scaling-up The perceived barriers to scaling-up HR were grouped into six main themes. The most commonly identified barrier was the lack of financial resources in the health system. It was argued that HR interventions were largely supported from international sources. Although some financial and in-kind support was provided by local governments, it was “ad hoc” and “sporadic” and insufficient to sustain HR activities. The second most commonly identified challenge was the lack of evidence on the effectiveness of HR in Russia, with limited or no information on the effectiveness of the existing programmes available to local policy-makers. Many respondents argued that there were no clear criteria for evaluating HR interventions, and the advocacy materials, which promoted HR did so “in general terms” without appropriate data to back up effectiveness statements. As one respondent commented: “Some people say that syringe exchange reduces harm, which means it decreases the number of patients with AIDS . . . But I have not seen a single presentation, [or] a single analysis to support this argument. There are only big beautiful books with quotations from here and there. Nobody has done such analysis; nobody has studied it (Government official, not member of ICA). About a quarter of the stakeholders named cultural barriers to scaling-up. In-depth analysis of the interview accounts identified two distinct patterns in the way stakeholders used the term “Russian culture”. To those who opposed scaling-up, HR was a concept that originated and developed in the West, where traditions and cultural norms, they believed, “were different”. For
Table 1 Attitudes of policy-makers and HIV stakeholders towards scaling-up of harm reduction Stakeholder group Government stakeholders, members of ICA (N = 20) Other government stakeholders (N = 25) NGO stakeholders (N = 13) Total (N = 58)
Strongly support n (%)
Support n (%)
Neither support nor oppose or find difficult to answer n (%)
Oppose n (%)
Strongly oppose n (%)
4 (20.0)
9 (45.0)
4 (20.0)
2 (10.0)
1 (5.0)
6 (24.0)
4 (16.0)
6 (24.0)
3 (12.0)
6 (24.0)
2 (15.4) 12 (20.7)
3 (23.0) 16 (27.6)
2 (15.4) 12 (20.7)
1 (7.7) 6 (10.3)
5 (38.5) 12 (20.7)
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them, HR was “imposed on Russia from outside”, and hence “culturally unacceptable” and “contradictory to the Russian mentality”. As an NGO representative said: “People know and often view these programmes as something that has been imported and imposed by foreign organisations, foreign governments; and it is not clear whether we really need them” (NGO representative). Those in favour of scaling-up used the term “culture” to mean traditions and social norm, where drugs, sex and HIV were taboo issues. Some argued, the root of these traditions and norms lay in the communist past of Russia: “This is because of the culture of our leaders, generally a low culture. For instance, take our former communists. They are so conservative.” (Healthcare manager, member of ICA).
Several stakeholders singled out unclear legislation on HR and particularly NSE as an important constraint. They argued that the current legislation was ambiguous on the legality of providing needles and syringes to IDUs. This ambiguity prevented HR scale-up in three ways: first, it gave an opportunity to law enforcement agencies to disrupt the existing HR projects; second, it created insecurity for those engaged in HR activities; and third, it undermined the support of local decisionmakers and health practitioners who were in favour of HR interventions but feared openly to support the expansion of the services, which could be interpreted as illegal. As one respondent noted: “Today all the documents are of declarative and recommendatory nature. There is no legal support. Therefore it is absolutely unclear what kind of problems one may face in the future.” (Government official, member of ICA)
4. Discussion Several respondents identified unwillingness of IDUs to use HR services as a key barrier to scale-up. Three reasons were offered to explain this. First, little information was available about HR projects, their location and benefits. Second, IDUs found it easier to buy inexpensive syringes from pharmacies. Third, IDUs were concerned that contacts with HR services may lead to their IDU status becoming a common knowledge, leading to stigmatisation in their neighborhoods and prosecution by the local police. Furthermore, as IDUs were often perceived as “evil doers” useless to the society, spending limited public resources on programmes for IDUs was unpopular; and many local policy-makers were reluctant openly to support these. A number of stakeholders believed that HR scaleup was constrained by opposition of powerful political institutions, especially the law enforcement agencies (for example the police, drug control and security services) and the Russian Orthodox Church. Interestingly, many respondents were unable to identify specifically which groups or institutions opposed scaling-up. Instead these respondents used the words “society”, “public” and “public opinion” to denote the sources of opposition. In fact, the view “I personally support harm reduction but the society is against it” was commonly shared among our informants.
HIV/AIDS continues to be a major public health issue in Russia [50]. By May 2007 the Russian authorities had reported 386,141 officially registered HIV cases [51] but the actual figure may be as high as 1.5 million [35,52]. The majority of infections are among IDUs [19,35,51], whose numbers are estimated at 1.5–3.5 million [35]. Needle-sharing practices are widespread, ranging from 36 to 82% depending on the location [53]; and in some cities HIV prevalence amongst IDUs reaches 60% or over [18,19,54]. Given the gravity of the situation, one would expect HR scaleup to be a high priority for the Russian government. But, this does not seem to be the case. In spite of international evidence and the successes of many small-scale HR interventions in Russia, policy-makers have not yet integrated HR into the official framework of HIV response; nor provided support to develop services to a scale sufficient to control the epidemic. This paper has explored the perspectives of local policy-makers and HIV stakeholders on HR and examined the interplay between their attitudes, internal and external influences and policy decisions on HR scale-up. Political theory offers different models to explain why certain policies do not get onto the policy agenda [55,56] or get deliberately restrained by non-decision-
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making [36,57]. These, singly or in combination, may include the dominant societal values, the accepted rules of the game, the existing power relations among stakeholder groups, and the instruments of force used [57]. In order to better understand which factors have constrained the scale-up of HR in Russia and how, we examined the distribution of support and opposition forces to HR and the factors, which determined the position of those who were not in support. Our findings show a considerable diversity of opinion in relation to HR scale-up. The proportions of HR supporters and non-supporters are almost equal in number; while a considerable proportion of stakeholders are either indecisive or reluctant to openly express their views. The finding suggests that Russia is experiencing ‘power parity’ between HR supporters and opponents. This may help to explain why HR services in Russia are neither closing down nor scaling-up. The key factors, which constrain political decisions in favour of HR have been identified as (i) insufficient financial resources to expand services; (ii) lack of information about HR effectiveness; (iii) perception of HR as being contradictory to Russian culture and mentality; (iv) reluctance of IDUs to use services because of unawareness, stigma and fear of prosecution; (v) opposition from law enforcement agencies and the Russian Orthodox Church; and (vi) unclear laws and regulations. Earlier studies have explored how HR practices and the micro (e.g. social norms and rules; IDU relationships and networks) and macro (e.g. legal and policy frameworks; political economy; gender issues) contexts determined IDU behaviour [58]. Other studies, specific to the Russian context, have explored how health systems and broader contexts influenced delivery of HR services [59–61]. Here, we analyse how contextual factors impact on the reasoning of decisionmakers and their policy choices. We tried to assign the factors we identified as macro- and micro-influences, but found the distinction between these two levels to be blurred. Even the legal framework and limited financial resources were not barriers imposed externally by the macro-context but a product of internal influences and powers, which determined policies at the micro level. Thus, lack of financial resources to expand HR services was identified as a key policy constraint by almost all stakeholders we interviewed. Severe underfunding
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of public services, including health and social care, was a major problem for Russia after the dissolution of the Soviet Union [62–65]. HIV/AIDS was particularly neglected with no funds allocated to the HIV programme from the federal budget before 1998 [66,67] and only US$5-7 million per annum between 1998 and 2003 [59]. However, strong growth of the Russian economy in more recent years [68,69] has enabled the government to increase financial commitments to HIV/AIDS to US$175 million by 2006: an unprecedented 30-fold increase [70,71]. Hence, the scarcity of financial resources for HIV/AIDS as a macro factor is not a critical issue any more, but whether the new funding will be used to expand HR interventions remains to be seen. Our findings from 2004 and some recent reports on HR in Russia [72–74] suggest that an increase in financial resources per se does not lead naturally to an expansion of HR interventions. On the contrary, according to the Russian Harm Reduction Network, between 2004 and 2006 (the period when the overall national funding for HIV/AIDS rapidly increased) resources for HR interventions decreased by 27% [73]; and the number of HR projects declined from 80 to 66 [73]. Hence, it is not the lack of financial resources as a macro factor that restrains HR scale-up, it is the choices made by policy-makers not to allocate new funds to interventions targeting IDUs and other marginalised populations. This is a micro factor determined by policy-makers’ preferences and distribution of power on the policy arena. The legal framework regulating HR and NSE is another example of the interplay between macro and micro policy influences. Uncertainties surrounding the NSE legislation had a significant impact on HR scale up. But laws do not exist in isolation from the rest of the political process. They are a product of the process and power [36]. Indeed, the Russian drug legislation is a good illustration of this. The Russian Drug Act has undergone a number of changes in the past few years, firstly from more repressive to more liberal and then backwards [31,75,76], which shows that the uncertain legal framework itself, is not an independent macro factor but a result of the current power balance and continuous struggle between HR supporters and opponents. With regards to the latter, our findings provide some useful insights into the disposition of HR support and opposition forces. Although we demonstrate the views
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on HR scale-up to be almost equally divided, policy change does not depend so much on the number of supporters and opponents but on their power to influence the policy-making process [36,77,78]. Measuring the power of HIV stakeholders was beyond the scope of this study. However our findings provide some understanding of the dynamics of policy-making in Russia. For example, an interesting result was the level of opposition within the NGO community in Volgograd. This is surprising given that the development of HR in Russia had been strongly supported by national and international NGOs [79], and that NGOs ran about half of the existing HR projects [26,80]. In the context of our research the term “NGO” was defined as any non-profit, voluntary, civic or humanitarian organisation. Our results suggest that the NGO sector in Russia as a broad notion is not homogeneous. While some NGOs are critical players in advocacy and delivery of HR interventions others are strongly opposed to HR. This apparent polarisation may be a feature of the post-communist transitional environment, where some NGOs were established relatively recently sometimes with international funding and often as a challenge to local government policies; while others comprise more ‘traditional’ civil society organisations including professional associations, women’s groups or organisations of religious and patriotic nature. In a strict sense, the latter group may not be regarded as fully fledged NGOs, as they are often close to local policy-makers; but they may yield substantial influence on policymakers’ decisions and policy choices. This polarisation needs to be taken into account when planning HR advocacy and interventions at a local level. Further, with respect to the opposition, we identified only two distinct forces perceived to be strongly against HR scale-up, namely the Russian Orthodox Church and the law enforcement agencies. But, interestingly, the view that ‘public opinion’ was resolutely against HR was very common among our respondents. This suggests that in today’s Russia the Russian Church and law enforcement agencies are seen as very influential political players in determining the opinions of stakeholders and the overall public ethos. However, their constituencies and reasons for opposition to HR are likely to be different. Rhodes et al. studied the impact of police practices on IDUs’ behaviour and argued that repressive drug legislation coupled with aggressive street policing undermined the HIV prevention efforts
through increased high-risk practices amongst IDUs [81]. We found these forces to be critical in determining policy-makers’ behaviour and choices. One of the key barriers to HR scale-up identified in this study was as the cultural unacceptability of HR as it was perceived to be contradictory to the Russian mentality. This cultural unacceptability, we find, is related to at least two factors: (a) the legacy of policies of the communist past, where issues of sex and dugs were taboos; and (b) the involvement of international agencies in HR programmes. The denial of HIV/AIDS and behavioural risks contributing to the epidemic are not uncommon in many countries [82,83]. In the Soviet Union and postcommunist Russia this denial has been reinforced by the political discourse of the Soviet ideology aimed at bringing up “ideal” men and women. This ideology left no place for those who were deemed to be “imperfect” (for example IDUs, SWs and men who have sex with men) and who “fell out” of the society [84]. Substantial advocacy and funding from international donors to introduce HR in Russia has had both positive and negative impact on the evolution of HR programmes. While international support has undoubtedly helped the establishment of HR programmes throughout the country and strengthened the position of HR advocates, it also created barriers to scale-up in at least three ways. Firstly, in spite of the presence of large number of international development programmes, the expression “Western influence” still seems to have a more negative than positive connotation with some decisionmakers opposing interventions, which in their views, are ‘imported’ from the West. Although the needs for indigenous approaches and community-specific programmes have been emphasised in the HR literature [85–88], insufficient attention has been paid to these needs when the first HR projects were put in place in Russia. In the society, where east-west polarisation was still fresh memory, the neglect of the local context has created an additional barrier to HR scale up, not on the grounds of the intervention itself but due to the fact that it “came” from the West. More recent positive experiences show that the work through national NGOs including those that developed as spin-offs from international organisations (e.g. Open Health Institute) might be more influential and productive in such contexts.
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Second, significant external funding for HR has ‘crowded out’ local funding and discouraged policymakers to invest in the areas, in which substantial international funds are available. As a result, HR programmes continue being supported through nongovernmental and international funding even when significant national funds are available. Third, as the Russian authorities are not spending their own resources on HR, they do not have much interest in evaluating the effectiveness and efficiency of these programmes. Consequently, many decision-makers have no robust data on HR effectiveness and the interventions are considered on the grounds of personal and moral judgements rather than cost–benefit analysis. Our study has some methodological limitations. We adopted a qualitative method and used purposive rather than random sampling. However, we ensured representativeness of views of a wide range of stakeholders interviewed. Our sample, though not statistically representative, was theoretically informed, relevant to the research questions and hence appropriate to the study objectives. We also maintained a systematic approach to our research rigour at every stage—in design, sampling, analysis and interpretation—with independent reflexive thematic analysis which allowed triangulation between team members. Our findings have a number of policy implications, suggesting actions that need to be taken if HR programmes in Russia (and similar political contexts) are to be successfully scaled-up. First, the future of HR in Russia will, to a large extent, depend on the position of the multiple stakeholders who are currently either neutral or indecisive on HR scale-up. A strategic approach to HR advocacy is needed to target these stakeholders to gain their support. Second, there is a need for more systematic evidence on the effectiveness and cost-effectiveness of HR programmes in the local context, to encourage high-level political debates informed by evidence rather than moral position. Third, given the substantial power of the law enforcement agencies and the Russian Orthodox Church in determining political and public attitudes, these institutions should be essential targets in HR education and advocacy campaigns. Finally, the perception of HR as a “Western” strategy, “owned by international agencies”, but not the Russian authorities needs to be addressed. Internationally adopted HR approaches and objec-
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tives need to be made congruent with those of local policy-makers, healthcare practitioners and serviceusers.
Acknowledgements This work was carried out as part of the Programme “Knowledge for Action in HIV/AIDS in the Russian Federation” funded by the UK Department for International Development (DFID). We would like to thank DFID for the support provided. DFID however is not responsible for the views expressed. We would like also to thank the regional administration, health department, HIV/AIDS centre and medical school in Volgograd for their support in conducting this study; our special thanks are to Dr. Alexander Filippov, Dr. Nedezhda Gorshkova, Professor Natalia Latyshevskaya, Dr. Galina Gerusova; Dr. Ludmila Slivina and Dr. Marina Karpenko. We would like to thank Professor Tim Rhodes from the London School of Hygiene & Tropical Medicine for valuable comments on this paper.
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