JAILED DRUG USERS ARE AT EPICENTER OF RUSSIA'S GROWING AIDS SCOURGE

St. PETERSBURG -- When Alexander Multanovskiy was locked up in Kresty jail,
a squalid, overcrowded brick complex built in the late 19th century, he
blocked out the misery with heroin.

The 25-year-old Russian believes that's how he contracted HIV, the AIDS
virus, from one of his fellow inmates. "We were using the same needle," he
says.

Prisoners like Mr. Multanovskiy are helping make the former Soviet bloc
home to the world's fastest-growing HIV epidemic, according to a report
last year from the United Nations' AIDS program and the World Health
Organization. Between 1996 and 2001, the number of registered new HIV
infections in Russia annually surged to more than 87,000 from about 1,500.

The rapid increase in infections and the huge number of Russians using
injection drugs have fueled concern that the country could soon be host to
one of the world's worst AIDS crises. But Russia faces an enormous
challenge to containing the disease, as harsh drug laws send droves of
HIV-positive patients into prisons, where treatment is minimal and the
disease spreads through shared needles and sexual contact.

Drug use soared in Russia amid the social disintegration following the
collapse of the Soviet Union. Enforcement of harsh drug laws, largely
unchanged since Soviet times, has helped flood Russia's jails and prisons
with HIV carriers. About a sixth of the country's roughly 195,000
registered people with HIV are currently in jail, and many others who are
now free have previously been incarcerated. At Kresty, which had fewer than
10 inmates with HIV in 1997, more than 1,000 have the AIDS virus today, out
of a total of about 7,800 prisoners.

HIV prevalence is far higher in prisons than in the general population, but
health officials fear the figures are poised to rise both inside and
outside prison. Russia's drug users number as high as four million of the
country's 145 million people, according to some estimates. Intravenous drug
use is the principal source of HIV infection in the country. Draconian drug
statutes mean possession of even a minute amount of heroin can bring years
behind bars. With the prevalence of needle-sharing in prison and the
tendency of drug users to be jailed more than once, some experts project
ever-rising infection rates across Russia through infected drug users
moving in and out of prison.

Andrei Kozlov and Vadim Pokrovskiy, two of Russia's leading HIV
researchers, fear the infected prison and drug-using populations could
provide the opening the virus needs to work its way into the general
population. Judging from Russia's high rates of sexually transmitted
diseases such as syphilis and gonorrhea, HIV could spread rapidly from drug
users through sexual contact.

Prison officials acknowledge that the disease could spread unnoticed.
Usually, inmates are tested only when they enter prison or if they get
sick. Prison officials say they have no reliable estimate for how often HIV
is transmitted in prisons.

The Ministry of Justice, which runs the country's prisons, has pushed to
reduce overcrowding and to reform the legal code so that fewer addicts are
sent to prison. "We want to improve our legislation to protect young people
committing their first, not-very-serious crime," says Yuri Kalinin, deputy
justice minister. The prison leadership has won praise from AIDS advocates
for piloting new approaches to HIV control. But change has been slow and
piecemeal.

A visit to Kresty reveals the magnitude of the problem and the obstacles to
solving it. Located on the Neva River in St. Petersburg, Kresty is the
largest of the country's SIZOs, from the Russian for "pre-trial detention
center." With the surge in drug crimes, these jails have become severely
overcrowded in recent years because all suspects, innocent and guilty, are
held in SIZOs until their trial verdict -- a process that usually takes
months and can take more than a year.

Each cell measures about 10 square yards. Crammed into that space are two
three-tier bunk beds and as many as 10 prisoners. They sleep in shifts.
Inmates and even some prison officials say the crowding makes controlling
contraband such as drugs and syringes nearly impossible. Guards are
underpaid and susceptible to bribery. Inmates pass drugs and syringes,
along with innocuous messages and cigarettes, through what they call the
"internet": black ropes they dangle down the exterior brick walls or fling
from one barred window to another.

Like most Russian prisons, Kresty tightly restricts access to condoms,
because sex isn't allowed. It also restricts bleach, which can sterilize
needles and tattooing instruments but can also be used to attempt suicide
or attack other prisoners, officials say.

Prisoners are supposed to be given an HIV test when they arrive. As in most
Russian penitentiaries, Kresty's main defense against the spread of HIV is
keeping infected inmates and uninfected ones in separate cellblocks. But as
the case of Mr. Multanovskiy shows, segregation doesn't always work, and it
can even promote the spread of the disease by making inmates feel they know
who is infected and who isn't.

Mr. Multanovskiy, broad-shouldered and blond, offers an incongruously
clean-cut appearance in his black prison uniform. A drug user before he
came to the SIZO, he says he tested negative for HIV upon arrival in March
of last year. A senior prison doctor, who reviewed his medical record,
could only confirm that Mr. Multanovskiy was placed in a cell with inmates
who were all supposed to be free of HIV infection.

After eight months, during which time Mr. Multanovskiy says he and his
cellmates thought it was safe to share needles, he tested positive for the
AIDS virus and was transferred to the block for infected prisoners.

Prison medical authorities say lapses are rare. But evidence of mistakes
isn't hard to find. Penal Colony Three in the small town of Dimitrograd
conducts its own HIV tests on all prisoners arriving from SIZOs, because
officials of the institution say the SIZOs often run out of money to
perform the tests. Through June 7 of this year, the tests turned up five
previously undetected HIV carriers, according to Sergei Tskhmistrenko,
chief of the colony. Eight such cases turned up last year and three the
year before. All of these inmates were probably held with HIV-negative
prisoners in SIZOs, Mr. Tskhmistrenko says.

In interviews, four HIV-infected prisoners who stayed in various SIZOs said
they spent from one month to six months incarcerated with prisoners who
weren't supposed to have the AIDS virus -- a fact confirmed by prison
officials. One of the four prisoners said he knew he was HIV-positive and
told fellow inmates but not prison authorities, for fear they might
mistreat him. But the other three said they didn't know they were infected.
One of these men admitted to sharing needles with his cellmates, and
another said he shared his shaving razor.

At Kresty, two HIV-negative prisoners -- Dmitri Vasiliev and Alexander
Lotzman -- said three infected prisoners were plucked from their midst at
various times. These cases weren't confirmed by Kresty officials, but they
acknowledged that HIV testing was sometimes delayed for lack of money,
syringes, test tubes or fuel for the car used to deliver blood samples to
the laboratory.

Infected inmates also can slip through a biological hole in the net. The
test detects antibodies to HIV, not HIV itself. Since it can take the
immune system as much as several months to generate those antibodies,
inmates can test negative when they actually have an HIV infection.

Perhaps the most dangerous aspect of the segregation policy is that it
encourages prisoners to believe they can safely share needles. A 2000
survey of 1,200 Russian prisoners conducted by the humanitarian group
Doctors Without Borders found that about 8% of inmates admitted to
injecting drugs in prison. Of those, almost two-thirds said they shared
syringes.

"The striking thing is the risk-taking behavior," says Murdo Bijl, director
of AIDS Foundation East West, an organization created by Doctors Without
Borders to deal with AIDS in Russia. "If there is HIV in this group, it
will be fairly quickly transmitted."

Change Outside Jails

Some critics say change must begin outside the jails, with Russia's tough
criminal code and its hard-line medical establishment. The drug laws
practically guarantee that anyone caught with any quantity of heroin, the
most popular injection drug in Russia, can expect to spend a long time
behind bars. Possession of up to five one-thousandths of a gram -- a gram
is 1/28 of an ounce -- can draw as much as three years' imprisonment.
Possession with intent to sell or process, a charge that nets many addicts
who sell small amounts to support their habit, can bring a decade in prison.

Russia's medical establishment has largely opposed reforming the penal
system and treatment of drug addiction. Many doctors who hold influential
positions today were educated under the authoritarian Soviet public-health
system. They disagree with Western methods of treating heroin addiction and
controlling HIV, especially needle-exchange programs, which provide addicts
with free clean syringes, and methadone therapy.

Some doctors, such as Alexei Mazus, director of the Moscow AIDS Center and
one of the most prominent AIDS physicians in Russia, oppose needle-exchange
programs. They fear the practice lures youths into addiction. Studies show
that such programs have been effective in other countries in reducing HIV
infection without encouraging drug use.

Methadone is illegal in Russia. Prisoners suffering from withdrawal rarely
receive any treatment and may resort to used needles and whatever is
available to cope with the wrenching physical and psychological stress of
withdrawal. "Unfortunately, we don't have methadone, so [prisoners] use
home-made drugs ," says Pytor Prokopenko, commander of Matrosskaya Tishina,
Moscow's main SIZO.

An alliance of prison authorities, the Russian drug-control police and
human-rights advocates has put forward a bill to overhaul the drug law. It
would increase penalties for big-time dealers but reduce them for
small-time users. One major change would be to raise the official
recommendation on the amount of heroin that could lead to a serious prison
term. The earliest this bill could take effect, however, would be the end
of this year.

Russian prison reform has been fitful, as well. Last year, a law took
effect that limited to six months the time suspects could be held in a SIZO
after their trials began. But on July 1, that reform will be stricken from
the books, allowing authorities to hold prisoners for the duration of their
trial. SIZO overcrowding is likely to worsen.

Under U.S. federal law, possession of 100 grams of heroin will earn a
first-time offender a mandatory five-year sentence. It's unlikely that a
federal prosecutor would take a case involving five one-thousandths of a
gram, and a state court probably wouldn't sentence a first-time offender to
jail for that amount. In the U.S., many experts consider the incarceration
of drug users one of the main contributing factors to the spread of HIV
among African-Americans, the hardest-hit group in America. Most U.S.
prisons also don't distribute condoms or needles in prison.

A few of Russia's penal colonies have started selling condoms. In an effort
to improve its AIDS prevention programs, the Ministry of Justice is
collaborating with various Western aid organizations, such as the French
doctors' group Medecins du Monde and the Open Society Institute, funded by
financier George Soros. There are some signs of progress: Education has
reduced HIV risk behavior among inmates, according to surveys by AIDS
Foundation East West. The foundation has also started a pilot program with
the Justice Ministry to distribute bleach and condoms. But the program
began only this spring and doesn't operate in all prisons.

These efforts could help limit the spread of the virus, but they can't help
those already infected.

Last to Get Drugs

The vast majority of Russians with HIV were infected in the past few years.
But because HIV typically takes more than five years to reach full-blown
AIDS, the country has not yet been hit with an onslaught of sick people who
require the expensive cocktails of so-called antiretroviral AIDS drugs .

Despite their high numbers among the infected, prisoners will almost
certainly be the last to get those drugs . The prison system can barely
afford the most basic health measures. Prison officials recently reported
that almost a quarter of inmates in St. Petersburg SIZOs lacked their own
bedsheets. Released prisoners are referred to specialized AIDS Centers, but
they also are strapped for funds. The richest, in Moscow, has funds to give
antiretroviral drugs to just 500 patients.

Some leading AIDS doctors frankly say they won't treat HIV-infected
addicts, whom they see as unlikely to stick with the demanding regimen of
antiretroviral pills. Since prisoners overwhelmingly acquire the virus by
injecting illegal drugs , many won't qualify for treatment. "Homeless
people and drug addicts will be at the end of the list," says Dr. Mazus, of
the Moscow AIDS Center.

AIDS activists say the Russian health establishment has stacked the deck
against drug users by denying them methadone and other therapies that could
stabilize their lives and help them adhere to the complex AIDS regimens.
The prevailing attitude, charges Kasia Malinowska-Sempruch, who coordinates
AIDS-prevention programs for drug users in the former Soviet bloc for the
Open Society Institute, is that "HIV and drug use will take care of each other."