MOSCOW — They look like addicts anywhere in the world: tattered and vacant-eyed, they circle Moscow pharmacies known to sell prescription drugs illicitly, looking for something to inject for a quick high.
James Hill for The New York Times
Pyotr Nikitenko, right, distributed medical supplies and literature outside a pharmacy in Moscow with a drug outreach center colleague, left. Mr. Nikitenko, a former heroin user, said most of his friends were now H.I.V. positive.
Though public examples of Russia’s problem with heroin are not new and seldom bring even raised eyebrows among locals, the issue has recently come to symbolize a broader failure. The country has become one of the world’s low points in the effort to fight the spread of H.I.V., and unchecked intravenous drug use is the biggest cause, international health officials say.
The epidemic here has defied worldwide trends, expanding more rapidly year by year than almost anywhere else. Nearly 60,000 new cases of H.I.V., the virus that causes AIDS, were documented in Russia in 2009, an 8 percent increase from 2008, according to Unaids, the United Nations H.I.V./AIDS program. Of those new cases, more than 60 percent were believed to have been caused by intravenous drug use, and many of the others were believed to have been infected through sex with addicts.
Though South Africa, with more infections than any other country, far outstripped that total number, with an estimated 390,000 new infections in 2009, the rate of new infections annually has decreased there by nearly half since its peak in the late 1990s.
“I’ve been researching the problem of H.I.V. infection for 25 years, and I must say that the situation has become significantly worse” in Russia, said Dr. Vadim V. Pokrovsky, the head of the country’s Federal AIDS Center.
While in recent years the government has increased its efforts to fight the disease, Dr. Pokrovsky said, current programs almost completely neglect those groups at the heart of it.
Officials estimate that well over a million people abuse drugs intravenously in Russia, often sharing and infecting one another with tainted needles. They are among Russian society’s most marginalized people, more likely to face a few weeks handcuffed to a clinic bed than to receive basic treatment to break their addictions. Meanwhile, officials have treated sex education and other preventative programs with open hostility.
“Which are the main infected groups? Injecting-drug users and sex workers,” said Lev Zohrabyan, the Europe and Central Asia adviser for Unaids. “It turns out that these are the groups where the money must be directed to change the picture. But if you open the budget, you will see that for prevention work among these groups for the next two years there is nothing.”
Top officials have consistently blamed the United States’ failure to eradicate heroin production in Afghanistan for Russia’s intravenous drug problem. About 90 percent of Russian addicts use Afghan heroin, according to the Federal Drug Control Service.
Yet once the drugs pass through Russia’s porous borders with former Soviet republics in Central Asia, dealers find a ready market of addicts with few tools to help them quit. While some regions have experimented with needle-exchange programs, the practice, which has proven effective at reducing the spread of H.I.V. in other countries, has not been adopted on a national level.
The country’s top medical and political officials have roundly condemned drug substitution therapy for heroin addicts — the use of methadone or other narcotics, widely considered an effective way to wean people off the drug — on the basis that it substitutes one form of addiction for another. Doctors who have flouted the official ban on the treatment have faced prosecution and even harassment by Kremlin-backed youth groups.
The Russian Orthodox Church, which has become a significant voice in the country’s political affairs in the past decade, has also expressed strong opposition to such preventative measures.
Even a new antinarcotics strategy ordered by President Dmitri A. Medvedev last summer acknowledges Russia’s failure to adequately confront the problem. “Prophylactic activities, medical aid and rehabilitation of patients with drug addiction are not sufficiently effective,” said the document, posted on Mr. Medvedev’s Web site.
Many of the addicts gathered outside one pharmacy in southern Moscow said they had often tried to stop. “You want to quit, and you don’t,” said a graying 33-year-old named Maxim who had the scarred arms of a dedicated user. Another man, who had quarter-size holes gouged into his body from injection-related infections and would not give his name, said he feared that he would be arrested if he sought treatment — a worry that is not completely unfounded here.
The police often arrest drug users, sending them to special detoxification centers where doctors encourage, and sometimes force, immediate abstinence, which can in some rare cases be fatal. Last summer, organizers of the 18th annual International AIDS Conference held in Vienna issued a declaration — aimed at Russia and the countries of the former Soviet Union, in particular — arguing that such practices drove addicts underground, complicating H.I.V.-prevention efforts.
It is not that the government has failed completely to recognize the gravity of the epidemic. Russia’s national security strategy, approved by Mr. Medvedev, identifies the spread of H.I.V. and AIDS as “one of the main threats to national security in the sphere of medicine and health.”
Russia now has more than 500,000 officially registered cases of H.I.V., though Unaids and other experts have estimated the actual number to be closer to one million, as many as in the United States, which has more than twice the population.
Part of the problem is that the government came late to the fight. The epidemic has been raging since the Soviet collapse two decades ago, but a major government response came only in 2006 when Russia’s obligations as host of the Group of 8 summit meeting pushed officials to take a more active role in fighting the disease. Vladimir V. Putin, who was president at the time and is now prime minister, ordered the largest increase in financing in any area in Russia’s history, and spending has grown annually ever since.
This year, the government plans to nearly double spending on H.I.V. drugs to about $600 million and expand prevention programs focusing on youth, said Galina G. Chistyakova, a Health Ministry official who helps oversee Russia’s H.I.V. and AIDS policies. She denied that Russia was having trouble curbing the epidemic, noting that the ministry had documented a slight dip in the number of new infections in 2010 compared with a year earlier.
Dr. Pokrovsky and others said that government programs often became ensnared in Russia’s large and inefficient bureaucracies. Even efforts to provide AIDS patients with treatment, which constitute the bulk of government financing, have fallen short.
Patients and doctors have complained of frequent shortages of antiretroviral drugs to the point where patients have created online communities, like pereboi.ru, that monitor drug deficits and help those in need of medicines connect with people who have extra supplies. Patients have also held street protests, and others have sued.
Many addicts who become infected do not even know that medicines are available, said Pyotr Nikitenko, 28, a former heroin user who now works for a Moscow-based outreach group called Yasen. He said he was able to wean himself off heroin with the help of his family, escaping the fate of most of his friends, who he said now were H.I.V. positive.
“I continue to bury them,” Mr. Nikitenko said. “They continue to die from AIDS, or rather they are dying more and more frequently.”