Thirteen months ago, a young man from Irkutsk’s rough-and-tumble north side appeared at the government railroad workers’ hospital complaining of a head wound suffered in a family fight. A blood work-up soon showed that it was the least of his problems: He was also infected with HIV, the virus that causes AIDS.

This in itself was unusual for the Irkutsk region – a Siberian expanse big enough to accommodate France and England in one gulp. Since health officials started keeping AIDS statistics in 1991 – four years after the country’s first case was officially recorded – the region had seen fewer than 200 HIV infections. But when a second north-side man checked into another hospital for an operation a few days later, only to test positive for HIV, the officials decided to investigate.

What they found is still resounding through Irkutsk. The two men, it turned out, attended Vocational School 44, a training institute for river-transport workers. Further tests uncovered six more HIV cases among their class mates. All eight shared another deadly trait: They were addicted to heroin, which first appeared in the city’s drug subculture only six or seven months earlier.

Today, a region that had hardly heard of AIDS a year ago has recorded 5,000 new cases of HIV infection and registered more than 8,500 drug addicts. Those are the official statistics: The true figures could be 10 times higher, officials say.

Why are the official statistics so much lower? Partly because many of those in the high-risk groups are reluctant to be tested. They are not only afraid of knowing the results, but of the consequences of being targeted as a carrier of HIV. Anonymous testing centers are still few and far between – with only 300 cites throughout the country. In many cases those who obtained positive test results from less than anonymous clinics have been reported to the local authorities.

THE FIRE IN IRKUTSK

Perhaps nowhere else throughout the country have HIV infections grown as explosively as they have in Irkutsk. Heroin has proved to be the deadly catalyst in this epidemic. It has fueled a sharp rise in drug use and encouraged the needle sharing that helps to spread AIDS.

“It’s a fire there,” said Arkadiusz Majszyk, the UN AIDS representative. “And nobody is paying attention.”

If it is a fire, then the rest of the country is surely smoldering. The number of HIV-infected people is small so far – 33,000 by official estimates, perhaps 300,000 by international ones – but the potential for growth is huge.

The United Nations says the virus’ spread is accelerating and could move beyond drug users if preventive measures are not taken. Already 40 percent of the country’s prostitutes, who often use drugs, are HIV-positive.

The growing prevalence of venereal diseases makes sexual transmission of the virus even easier. “Our experience shows that a rise in the infection rate of diseases such as gonorrhea and syphilis is usually an indicator that a jump in HIV infection rates will follow,” said one Moscow doctor who treats prostitutes and their clients for sexually transmitted diseases.

“Many clients are aware of the risk of getting AIDS, but they still prefer not to use a condom when the seek they services of a prostitute,” he said. “And for a little extra cash, the women are willing to engage in unsafe sex.”

“In the regions where the outbreak of the epidemic among intravenous drug users was registered earlier, a new stage of the epidemic is now developing driven by the sexual transmission of the virus,” said Majszyk, explaining that commercial sex workers are the gateway through which the virus that causes AIDS reaches the rest of the population. “Clients, who are generally not drug users, come back home and transmit the disease to their wives and partners.”

AN OUNCE OF PREVENTION

The United Nations recently joined local counterparts to announce a new effort to halt the epidemic. This June the U.N. will support a conference bringing together regional and federal officials along with potential foreign donors to tackle the problem.

“We try to help get people together to speak the same language and attack the HIV-related problems without overlapping,” said Majszyk. “A two-tiered strategy is required, including systemic HIV prevention measures and an adequate response to urgent needs. The most urgent issue to address is the problem of prevention among intravenous drug users and commercial sex workers,” said Majszyk.

“The most effective means of avoiding an epidemic among drug users is harm reduction,” said Majszyk. This technology, which uses syringe exchanges to protect and educate the high-risk population, has proven to be a very effective means of prevention in other parts of the world, said Majszyk.

To date some 30 syringe exchanges have sprung up throughout the country providing information about avoiding HIV infection along with clean needles and syringes – but these efforts have not been able to reach the masses.

“Take the St. Petersburg bus,” said Majszyk, referring to one of the first syringe exchange programs implemented. “Some 150 drug users come to the bus every day, but there are 70,000 people injecting drugs daily throughout the city. Over the next few years we want to reach 60 percent of the drug user population with prevention programs and information.”

But in order for these prevention programs to work, Majszyk says, they take time. And time is in short supply in Irkutsk. Heroin and HIV have already penetrated virtually every corner of this vast region, a hodgepodge of pristine forest and permafrost, dying company towns and smoky industrial cities.

Heroin has surfaced in Bodaibo, a mountain-ringed gold-mining outpost reachable only by small plane, and in Ust-Kut, a northern river port whose shipping business has all but dried up. There is HIV in Mama, a moribund mica-mining village some 640 kilometers north of here, and in Bratsk, a good-sized manufacturing center far down the north-flowing Angara River.

The Irkutsk region is home to about 2 million people. Simple math says the rate of HIV infection is somewhere between one in 40 and one in 400. “But you really have to measure it against the number of youth,” because drug use and HIV are largely confined to the young, said Yelena A. Lyustritskaya, who heads a government commission on drug abuse. “And in the Irkutsk region there are 300,000 people between the ages of 14 and 28. So it turns out that every third or fourth young man at age 18 or 20 takes drugs.”

No one knows the infection rate among those users. But Dr. Maxim Medvedev, who screens addicts for a private rehabilitation program called Siberia Without Drugs, says roughly three of every 10 people he examines have the AIDS virus.

At the government’s principal rehabilitation center, 40 of the 62 inpatients are infected with HIV. Talk to some of the current and reformed addicts at that center, a tidy but rundown and cheerless place, and those numbers do not seem so outlandish.

“We used to be the department for glue sniffers,” one of the center’s doctors said. “There is only one sniffer here now. There are no alcoholics. They are all drug addicts.”

THE NEW DRUG IN TOWN

A buzz-cut 16-year-old who switched from opium to heroin said he believed that he had gotten HIV by sharing his needle late last year. He may understand how the virus is transmitted, but there are many outlandish theories circulating among the infected – a sign that AIDS prevention programs have a long way to go before they reach the high-risk groups. One common theory explaining the rise of the epidemic, said one 17-year-old with HIV and hepatitis, is that outsiders salted the heroin with the ground-up bones of African AIDS victims.

“The countries that supply us don’t have anything, only fruits,” he said. “Siberia’s rich, and they want everybody here to die.”

Natalya Kozhevnikova, a 27-year-old from a small diamond-mining town, said many addicts there began using drugs at age 12 or 13. “There is nothing to do – no movie theaters, no discos, nothing,” she said.

Lelia Starodumova, 23, was a swimming champion and model before she started taking opium four years ago. Now she and her husband are heroin addicts, and she carries HIV. “Ninety-nine percent of drug addicts have HIV,” she said blandly. “The only ones who aren’t sick are the ones who haven’t had their blood tested.”

In a bleak two-room apartment across town, opposite the ramshackle factory that produces the country’s top fighter jet, the Su-30, Andrei Kurnosov, a 30-year-old addict, said he had been on drugs for nine years. When he began, he said, he was among the top five in his law class, hoping for a chance to study in the United States. Now he practices petty thievery and rolls small-time drug sellers for the 150 rubles – about $5 – he needs daily to finance his habit. Kurnosov says he has avoided HIV through blind luck. He has shared needles with other addicts, the last time three months ago, although he knows the dangers. “You don’t care, when you need a dose,” he said. “The fear of remaining sober and in pain overwhelms any fear of sickness.”

Heroin’s death grip on its victims offers some explanation of why HIV has raced through Irkutsk’s addict population. Opium, whose less insistent craving grants a user some time to find a clean syringe, once was the drug of choice. But unlike heroin, which needs only water for it to be injected, opium must be carefully cooked and mixed.

So when heroin suddenly appeared some 18 months ago, addicts switched en masse. It first came in liquid form – in bottles or already-loaded syringes – and groups of users filled their syringes from the same bottle, raising the odds that one infected addict would contaminate many others.

Today heroin comes as a powder wrapped in paper “checks,” Russian slang for the cash-register tapes that they resemble. Fifty-ruble and 100-ruble checks are sold almost brazenly, from newsstands and bread kiosks and by loitering dealers, in any number of open-air drug markets around town.

Addicts say many police officers have been bought off, and this may be true. In one muddy north-side market named Trety Posyolok, or Third Settlement, a militia jeep cruised past knots of dealers and addicts twice in 10 minutes one recent afternoon.

Officially, of course, the police deny being on the take. They claim the heroin trade is ballooning despite their best efforts to stop it.

THE ROUTE TO SIBERIA

The drug comes by truck from Afghanistan and Tajikistan, far to the west of Irkutsk, and is distributed throughout Siberia from the western Siberian city of Novosibirsk.

Irkutsk’s militia seized about 180 kilograms of drugs last year, well ahead of previous years but a pittance in comparison with the total traffic. Smugglers vacuum-pack heroin or hide it in shipments of rotting onions to deter drug sniffing dogs. More and more, the trade has shifted from individual freelancers to organized crime.

“It’s difficult to control the flow,” said the deputy chief of the eastern Siberia militia, Pyotr Kobalchok. “We’ve even arrested members of the Tajikistan special services who were escorting the smugglers. It’s that well organized.”

Beneath such frustration over Irkutsk’s plight runs a subtle but pointed undercurrent: This region never had such problems when the Soviet Union existed. Addiction and AIDS are among the consequences of freedom and capitalism that Westerners neglected to mention when communist rule ended a decade ago.

Indeed, it is not just in Siberia where officials are blaming the spread of AIDS on the country’s open borders. The fear of HIV, which is perceived to be an imported disease, led to the implementation of a controversial law passed in 1995 requiring all foreigners requesting a visa for longer than three months to take an AIDS test. Among the many outspoken critics of the law were medical experts who accused legislators of trying to shut the barn door after the horse was loose.

Law-enforcement officials unanimously blame the drug problem on the opening of Soviet borders and the loosening of government control over ordinary people.

“Back then, there were no charter flights,” said Nikolai Pushkar, chief of the eastern Siberia transport militia, which battles drug smuggling. “Everything was state-owned, and it wasn’t possible to negotiate with the state. In the past only the president could have his own plane. Now anyone with money can have a plane.”

“No matter how much we criticize the Soviet system, there was a certain ideology. We were educated in an absolutely different way,” Pushkar added. “Of course, there were abuses when the state interfered with family life.

“But there were standards then.”

Irkutsk has declared its own war on both of its epidemics, hiring new narcotics police, printing educational brochures and changing the school curriculum to promote what officials call “the healthy way of life.” But beyond telling people to just say no to drugs, officials have not done much to prevent the spread of HIV among addicts and have no immediate plans to do so.

Proven AIDS-preventive measures, like providing drug addicts with sterile needles or bottles of virus-killing bleach, remain on the drawing board – in part, some critics say, because politicians believe they amount to an endorsement of drug use.

Indeed, although prevention is the best method of battling the virus, many regions throughout the country are reluctant to endorse public AIDS awareness campaigns. “In many schools the theme [of sex and drug use] is still taboo,” said Irina Savchenko, the health ministry’s representative to the federal center for AIDS prevention. “They believe that just discussing these subjects will result in greater sexual activity and drug use among pupils.”

“We had contact with different people last year, including people from foreign countries where such programs are implemented,” said Dmitry Piven, the Irkutsk region’s deputy head of health care. “Since there are different schemes, we are choosing an optimal one for ourselves.” Piven said officials would try to put new preventive measures into effect among addicts before year’s end.

The addict Kurnosov – his gaunt, rheumy face a contrast to hands swollen grotesquely by repeated injections – said that would be too late for many addicts. For many others, it already is.

“The generation of the ’70s is dying,” he said. “The generation of the ’80s is already dead – not all, not 100 percent. But 50 percent are killing themselves.”

MAP posted-by: Derek Rea