On front line of AIDS in Russia

The young Russian woman with hoop earrings and blond hair tucked under her baseball cap, couldn't appear healthier.

Her jeans jacket, blue sweater, and calm demeanor frame the promise of a saleswoman on her way up.

But Irina has been keeping a secret from her parents and all but five intimate friends: Four years ago, on her 18th birthday, she was diagnosed as HIV positive - making her part of the tip of an HIV/AIDS epidemic in Russia that is shifting from high-risk groups like drug users to mainstream society.

Irina, who says she never used drugs, is pregnant, too, with a boyfriend who is also HIV-positive. Her dream, she says, is to have a healthy child and move forward with her life. But the shock of her diagnosis lingers.

"I was so careful about my health ... but nobody has any guarantee," she says, wiping away tears. She believes she became infected by a previous boyfriend when a condom broke. "I never thought I would have HIV. I was 100 percent sure it was something that could never happen to me."

The human cost of Russia's epidemic, which so far counts an estimated 1 million cases of HIV, is growing fast in cities like Tver, 100 miles northwest of Moscow. A wildly overgrown and grungy industrial city of about half a million that sits along the St. Petersburg-Moscow drug-trafficking route, Tver witnessed one of the earliest outbreaks of heroin and opium addiction in Russia - and some of its cases of HIV/AIDS among users who shared needles.

As a result, Tver provides a glimpse into the future of Russia's AIDS crisis - in particular, how HIV has leapt beyond tight circles of drug users. The city also demonstrates how some communities are beginning to respond by reaching out to a broader audience.

"We are trying to explain to the population what this infection means," says Alexander Kolesnik, chief doctor of the Tver Regional AIDS Center. "Some find it difficult to understand: The popular stereotype is that HIV means drug users ... but now it has changed. Even when people know sexual contact is the main way of [HIV] transmission, it is very difficult to change their behavior."

"Many think HIV is not about them," says Tatiana Vinogradova, a doctor at the AIDS Center, which is housed in a battered Soviet-era kindergarten building. "They usually judge people by their appearance: they see a normal person, with normal clothes and no alarm bells, and they think they are a normal [sexual] partner."

In late 1996, the Tver region registered just seven cases of HIV. But the drug trade - combined with bleak futures for youths and heroin that cost less than cigarettes - caused addiction and HIV to surge.

By the end of 2001, Tver had 2,870 diagnosed cases of HIV. Today the official figure stands at more than 4,000, with estimates of the real number soaring to 16,000 cases and beyond.

Drug use has dropped by nearly two-thirds, thanks to higher-priced, poor quality heroin that has made amphetamines and alcohol more fashionable. But HIV continues to spread.

"Even if a miracle happens and the drug problem disappears, the problem of HIV/AIDS will stay," says Dr. Kolesnik. He has directed the center since it was created along with other regional AIDS offices by Soviet health authorities in the late 1980s, in the wake of a scandal in which more than 250 children became infected through blood transfusions.

Today the work has changed completely. The AIDS Center, with the help of local nongovernmental organizations and donors, has distributed 25,000 syringes so far this year to users who inject drugs. Their numbers have dropped from 7,000 in 1998 to some 2,500 today.

But at the same time, the ranks of at-risk groups have grown, expanding the focus to condoms - 50,000 of which are handed out each year, along with health campaigns. Top targets are drug users, prisoners, and those in the sex trade. "This is the echo of past drug problems," says Kolesnik. "In 2000, 63 percent of drug users said they were having regular sexual contact with people who didn't do drugs, so we knew to expect this [epidemic]."

Kolesnik estimates that 200 people have died of HIV-related causes in Tver: 74 from AIDS itself, and the rest from suicides and overdoses.

But the impact is being felt beyond the number of deaths in the community. In recent years, five babies born HIV-positive have been abandoned in the maternity ward by their HIV-positive mothers. A dozen others who were abandoned proved to be HIV negative and have since been adopted.

Nurses who work the maternity ward say they saw one HIV-positive mother in Tver city in 1997; so far this year, the pace is likely to put the 2004 total at 120 - Irina among them.

Specialists here say that appropriate treatment - provided free of charge through Western funding - can limit the likelihood that Irina's baby will be born HIV-positive to 15 percent or far, far less.

The extent of the problem is beginning to register in the public mind.

A June poll of 300 people in Tver found that knowledge of HIV among younger Russians was high. It also found that 55 percent considered using condoms "normal," and that regular condom use had nearly tripled, from 20 percent in 1998 to 59 percent today.

"People are more informed about the problem, but to change their behavior takes time - it could take five years," says Konstantin Gutman, head of the "Your Choice" organization in Tver, which carries out public information campaigns and conducts polls.

"In the past, when it was all about drug users, doctors had an excuse [not to treat HIV patients] because they were marginal and couldn't follow their treatment," says Mr. Gutman. "Now that the epidemic has splashed out onto the population at large, these excuses are gone."

Irina, who has been offered antiretro- viral treatment as her pregnancy progresses, says she is going on with her life.

"We don't think about it every single day - we don't think about it at all," Irina says of her and her boyfriend. "Maybe we should, but we don't.

"I've decided to keep the child, no matter what," she adds with conviction. "It will have a happy ending."

• Second of two parts. The first ran Monday, Aug. 16, 2004.