MOSCOW (AP) — On a frigid evening on the outskirts of Moscow, two HIV-prevention activists unzip backpacks, pull out packs of hypodermic needles and start discretely approaching people leaving a nearby pharmacy with an offer that could save their lives.
One man, cheeks sunken and behavior jittery, takes a plastic bag full of needles, a tube of ointment for sores and a pamphlet of material about disease prevention. "Thank you," he says, quickly making eye contact before hurrying away.
While the rate of HIV infection is on a global decline as World AIDS Day is marked Tuesday, the number of new infections in Russia continues to rise. By 2016, the country's Federal AIDS Center estimates the total number of those diagnosed with HIV will reach 1 million. The majority of new infections occur among injecting drug users when dirty needles are shared.
So-called harm reduction programs — which distribute clean needles and condoms as well as provide methadone substitution therapy — are shown to reduce the spread of diseases such as HIV. But the Russian government has refused to fund such initiatives, saying this approach to treatment enables addicts to continue living their dangerous lifestyle.
Activists have tried to bridge the gap.
"We know we can't reach everyone and you can't force anyone to stop using, but at least this provides the tools people need to reduce the spread of diseases," said Lena Groznova, who has been participating in the Andrey Rylkov Foundation's outreach program for the past three years. The foundation's activists are out nearly every day in Moscow, waiting around pharmacies that sell non-prescription eye drops used to enhance the effect of opiates.
Though such clean needle distribution programs are allowed to operate, a decline in international funding severely limits the scope of their activity.
In 2009, Russia was supposed to take over the work of one of the major HIV prevention and treatment donors, the Global Fund to Fight AIDS Tuberculosis and Malaria, which operates exclusively in low-income countries and no longer considers Russia eligible based on this criterion.
"We assumed that the government was picking up all the pieces and taking over the treatment component for all of the people in need. However, the treatment that was being done by the community was not being supported by the government," Nicolas Cantau, the Global Fund project manager for Eastern Europe and Central Asia, told The Associated Press. "We were all taken by surprise."
After learning Russia would no longer fund grassroots outreach organizations, the Global Fund decided to continue its work within Russia, but with a fraction of the previous budget. As a result, only 4,300 people have received anti-retroviral drugs this year, compared to 66,000 people in 2009 who had access to the HIV medication with the help of Global Fund aid money. The Fund has again made plans to leave Russia by the end of 2017.
Approximately 30 percent of Russians in need of anti-retroviral drugs currently do not have access to them, according to the Health Ministry.
The U.S. Agency for International Development and the Open Society Foundation, which collectively sponsored over 200 organizations working with HIV, were both forced out of Russia in 2012.
Methadone substitution therapy is widely used globally to wean addicts off intravenous drugs. In Russia, however, the outdated "cold turkey" method is the only available rehabilitation route for addicts; distributing methadone can bring a prison sentence of up to 20 years.
In neighboring Ukraine, whose HIV epidemic has mirrored Russia's, methadone therapy is legal and increasingly prevalent. After years of rapid growth in infection rates, the number of new HIV infections among drug injectors was down in 2013 by 33 percent, according to the HIV/ AIDS Alliance of Ukraine, a decline that has largely been attributed to the introduction of methadone therapy.
Crimea is frequently cited as an example of what happens when methadone therapy is suddenly made unavailable. After the Ukrainian peninsula was annexed by Russia in March 2014 and methadone became illegal, an estimated 80 to 100 of its 12,000 HIV-positive residents died from suicide and overdose, according to UNAIDS.
"Russia decided to come up with its own plan to deal with its drug problem, but 15 years have passed and there is no alternative plan," said Vadim Pokrovsky, the head of the Federal AIDS Center in Moscow, who diagnosed the first HIV case in the Soviet Union in 1987.
In October, Russia announced it would double spending on HIV care and prevention next year to $600 million.
Maxim Malyshev, who runs a clean needle distribution program with the Rylkov Foundation, is skeptical that the increase in government funding will have much positive effect.
"Look at what they are currently doing with their budget. Will we get more signs on the metro telling us HIV doesn't occur in monogamous relationships?" Malyshev said, referring to a current public information campaign on the Moscow subway. The signs read: "Love and loyalty to your partner is your protection from AIDS" and "HIV isn't transferred through friendship."
Bishop Methodius runs purity education programs at Russian Orthodox Churches, advocating a wholesome life to protect against HIV infection. "For us, the lessons of chastity are more important than sexual education," he said.
Sexual education programs in schools, also widely believed to slow the spread of HIV, have also been shot down by conservative government officials who say they promote sexual activity among children.
"I am often asked: When will you have sex education? I say never," Pavel Astakhov, the president's children's rights commissioner, said at a press conference last year. Astakhov has also famously remarked that the best sex education is Russian literature.
"For the last 20 years of the HIV epidemic that I've been involved in the Russian Federation, there was this sense that the epidemic doesn't affect me. It doesn't affect the average Russian. It only affects marginalized groups like injecting drug users and therefore is not something that is relevant or of concern for Russian society, or the average Russian person," Vinay Saldanha, the director of the UNAIDS Regional Support Team for Eastern Europe and Central Asia, told the AP.
Saldanha, however, is hopeful that Prime Minister Dmitry Medvedev's recent remarks on the scale of the HIV epidemic in Russia could signal a change in the way the illness is perceived at the upper levels of the Russian government.
Malyshev was a bit more cautious about what the future might have in store for HIV activists.
"I've stopped making predictions," he said. "There have been too many surprises in the past 20 years."