The Future of AIDS

Nicholas Eberstadt

From Foreign Affairs, November/December 2002

Summary:  In the decades ahead, the center of the global HIV/AIDS pandemic is set to shift from Africa to Eurasia. The death toll in that region's three pivotal countries--Russia, India, and China--could be staggering. This will assuredly be a humanitarian tragedy, but it will be much more than that. The disease will alter the economic potential of the region's major states and the global balance of power. Moscow, New Delhi, and Beijing could take steps to mitigate the disaster--but so far they have not.

Nicholas Eberstadt holds the Henry Wendt Chair in Political Economy at the American Enterprise Institute and is Senior Adviser to the National Bureau of Asian Research. This essay draws on a longer study prepared with the assistance of Lisa Howie; for more detailed results see www.AEI.org/scholars/eberstadt.htm.

The spread of HIV/AIDS through Eurasia, in short, will assuredly qualify as a humanitarian tragedy -- but it will be much more than that. The pandemic there stands to affect, and alter, the economic potential -- and by extension, the military power -- of the region's major states. And the disease will do more damage to some big countries than to others. Over the decades ahead, in other words, HIV/AIDS is set to be a factor in the very balance of power within Eurasia -- and thus in the relationship between Eurasian states and the rest of the world.

THE NEW RUSSIAN ROULETTE

To assess the implications of HIV/AIDS for Russia, India, and China in the years ahead, one must begin by getting a clear sense of the situation today. Unfortunately, the available data on HIV infection in these countries are somewhat tentative, in large part because the highest authorities in Moscow, New Delhi, and Beijing are unable (and unwilling) to monitor their respective HIV epidemics closely and continuously. Even UNAIDS figures are vetted by host governments, raising the possibility that the results have been negotiated downward. Nevertheless, thumbnail sketches of the HIV situation in each country are still possible.

By all accounts, Russia's HIV/AIDS epidemic has exploded in recent years; the only dispute is over how much. Over the past 15 years, Russian medical authorities have registered a cumulative total of about 200,000 HIV-positive patients. Independent estimates, however, are much higher -- ranging from a UNAIDS figure of 700,000 carriers in 2001 to the Russian Academy of Medicine's total of one million in mid-2002, to U.S. intelligence sources' approximation of one to two million carriers today. These latter figures imply an infection rate two to three times that of the United States.

Although the first HIV infections within the Russian Federation occurred before the end of communist rule, the demise of the Soviet state set the stage for the disease's rapid spread. The upheavals of Russia's ongoing transition -- economic and social dislocation, increased poverty, new freedoms (including greater opportunities for geographic mobility, extramarital sex, prostitution, and drug use) -- transformed the country into a far more conducive setting for the spread of HIV/AIDS. Health authorities first noted HIV in port cities such as Kaliningrad and St. Petersburg, but the infection apparently then rapidly made its way to other urban centers, including Siberian cities such as Irkutsk. Current indications are that it is now a truly nationwide phenomenon.

Russia's HIV/AIDS epidemic can be understood by looking at those groups at highest risk. As in most Western countries, there is a homosexual component to the spread of the disease, with men who have sex with other men emerging as an identifiable vector of HIV transmission. There is also a drug-use vector, in which intravenous (iv) drug users contaminate other users or their own sexual partners. This method of transmission appears to be particularly important in Russia: current press reports, for example, suggest that Moscow alone may contain almost one million drug users, including perhaps 150,000 needle-using heroin and cocaine addicts.

The infection appears to be spreading rapidly through these populations, but the scope of an HIV/AIDS "breakout" into the general population will depend to a large degree on risk behavior in the non-drug-using heterosexual population. Although accurate figures about sexual practices are hard to procure, basic demographic data suggest that previous constraints on behavior are eroding: the proportion of out-of-wedlock births, for example, has soared since the collapse of communism. Russia has also experienced an explosive increase in the incidence of curable sexually transmitted infections: official figures point to a 33-fold jump over the course of the 1990s. (This figure should not be taken literally, owing to the unreliability of both past and present health reporting, but it is nonetheless indicative.) Beyond this, Russia's flourishing level of prostitution factors importantly in the spread of HIV/AIDS among heterosexuals, particularly due to the substantial overlap between commercial sex workers and IV drug users.

Russia's transition from communism to capitalism has also coincided with a tremendous increase in criminal activity, a trend with important implications for the future of the HIV/AIDS epidemic. One factor is the spread of behavioral risk through small-scale crime, such as prostitution and IV drug use. At least as important, however, is the Russian Federation's prison system. Currently Russia incarcerates almost one million convicts at any given moment. Public health care, however, is notably absent in the Russian penal system; prison camps are consequently virtual incubation dishes for diseases such as drug-resistant tuberculosis and HIV. Unlike under the communist-era gulag, moreover, nowadays prisoners are released on a regular basis: in 2000, about 300,000 convicts were granted liberty. Most of them head back to their native towns, and a significant proportion of these former convicts are HIV positive. Russia's prison system, in other words, functions like a carburetor for HIV -- pumping a highly concentrated variant of the infection back through the general population.

The immediate prognosis for the Russian HIV/AIDS epidemic depends largely on the preventive policies the government pursues. Unfortunately, it is only a slight caricature to say that Moscow seems to have settled on a posture of malign neglect toward the gathering problem. The Russian government is spending only $6 million a year of its own resources on HIV/AIDS programs. That sum pales in comparison to the more than $6 billion the United States devotes each year to its HIV problem, and surreal as this may sound, the Russian total is less than a third of the $20 million that Moscow pledged just this past summer to the UN's worldwide campaign against HIV. Much of the anti-HIV work in Russia today is being funded not by Russians, but by foreign nongovernmental organizations such as Medicins Sans Frontieres and George Soros' Open Society Institute.

Beyond its own seeming lack of interest in tackling HIV/AIDS, the Russian government has also prevented outside organizations from financing related health activities -- most conspicuously, World Bank-proposed programs to combat tuberculosis, a disease associated with HIV infection that is now endemic throughout the country. Further complicating the struggle is Moscow's insistence that legal authorities have access to HIV test results. People who test positive for HIV and are thought to have contracted the illness through illegal drug use are subject to prosecution. This rule creates a powerful incentive among citizens to conceal and misrepresent their HIV status -- and further fans the spread of the disease.