HIV is spreading at a dangerous rate in nations around the Black Sea, passing a record 100,000 new cases yearly.

Hotspots for the HIV rise are Ukraine and Russia - two countries facing economic crisis and armed conflict, factors which could provoke a further surge in the virus.

Student or retired? Then this plan is for you.

Cheap heroin alternative Krokodil is widespread in the ex-USSR, risking HIV spread: image from Georgia (Photo: Michael Bird)

Smaller countries in the region are also recording rises in the numbers, with decade-highs registered in Bulgaria, Armenia, Belarus and Turkey.

Meanwhile Georgia, Azerbaijan, Moldova, Romania and Ukraine have maintained a record post-Soviet rate for the past four years.

None of these nations is experiencing a decreasing trend in new cases.

“We are all concerned about the rise of HIV/AIDS in the region, perhaps the region where HIV is growing fastest,” says the World Bank's Global AIDS Programme Director David Wilson. “Russia faces a large and potentially growing epidemic.”

Due to the low uptake of HIV testing in the region, up to 60 percent of viral carriers are unaware of their infection, according to the World Health Organisation (WHO).

The true figure of new cases per year could be 300,000 per year with over three million people now living with HIV.

HIV rates can be halted by giving drug users access to sterile syringes, to stop them sharing needles containing blood infected with the virus.

Allowing heroin users to switch to taking a substitution drug, methadone, also slows the viral spread.

Medicine readily available to treat carriers of HIV on a regular basis also reduces the chances of further contagion.

"Unfortunately, political opposition and laws in Russia doom all of these approaches," adds Robert Heimer, professor of epidemiology and pharmacology, Yale School of Medicine.

Drugs: Russia seeing record surge

Injecting drug use is the key reason for the rise of HIV in Russia. HIV spreads among this group due to their practice of sharing dirty needles.

However the Russian state will not finance health workers to exchange dirty for clean needles, arguing that this would encourage drug use.

Last year, 58 percent of new HIV cases were due to drug users using infected syringes to inject heroin and its codeine-based home-made alternative Krokodil. This figure is on the rise.

Russia is the centre point of HIV in the region. Its new HIV numbers rose from 58,000 new cases in 2010 to 78,000 in 2013 - accounting for three quarters of cases of the nations under our analysis.

The total number of people living with HIV in November 2014 in Russia was 864,394, although under the WHO’s “iceberg principle” that reported cases are a fraction of reality, this figure could be 2.4 million.

Russia’s method of dealing with the spread of HIV is based on an ultimatum ideology to drug users: give up first, then receive care.

The country bans the medical prescription of methadone, which allows users to extract themselves from drug communities, re-enter civil society and regulate their lives.

In neighbouring Ukraine, the situation is different. NGOs are financed in the millions by foreign donors and there are 8,000 patients on such opioid substitution treatment (OST) as methadone, the largest number in Eurasia.

Half of these patients are HIV positive and Ukrainian experts argue this has been a crucial policy to curb the viral spread.

But Russia prefers to combat HIV by encouraging abstinence and healthy living, with an emphasis on sports and exercise.

“Based on international practice and guidance, the three interventions needle exchange, substitution therapy and treatment for people with HIV would help to check Russia’s epidemic,” says Wilson.

Romania

Romania also witnessed a boom in new cases of HIV among drug users from 2010 to 2011 - when its 20,000-strong injecting drug community was almost free of new cases of the virus.

In 2010, the capital of Bucharest was hit by the spread of legal highs - stimulants which could be bought over the counter as ‘bath salts’ or ‘doll-cleaning powders’, but which contained a spin on the chemical formula for amphetamine.

Users switched from heroin to injecting these cheaper substances, but experienced episodes of paranoia, schizophrenia and paralysis.

To get a faster, quicker high, they also increased the regularity of injections, to up to 15 times per day.

At the same time, the Global Fund ended financing for programmes in Romania which combat HIV, such as vans which travel to drug hotspots to provide users with clean needles.

This double blow allowed the number of cases of HIV among drug users to rise by 200 per cent year-on-year in 2011.

HIV plagues drug users, especially poor communities, many of who belong to the Roma minority, who inject in squats, sewers and crowded flats.

“Users come to these place to shoot up in groups,” says Alina Dumitriu, executive director of Bucharest HIV NGO Sens Positiv.

This makes needle exchange a key factor in limiting the viral spread.

Since then Romania’s Government criminalised the sale of “legal highs”, but powders are still available on the street. And heroin is returning with a vengeance to Bucharest.

Economic collapse: virus spread in the balance

Russia’s currency has been in freefall with the deputy Governor of the central bank Sergey Shvetsov last year calling the situation more serious than his “worst nightmares”.

Meanwhile Ukraine suffers with inflation of 25 percent and an economy propped up by the International Monetary Fund and cash from the west hoping to consolidate Kiev’s western-facing ambitions.

There is strong debate over whether this could lead to a rise in HIV cases, particularly among drug users.

“Much of the drug use that contributes to HIV has its origins in the earlier economic crisis [in the region] following the end of communism and recent data from Greece and Romania shows a sharp spike in HIV infections after the economic crisis in Europe [in 2008],” says the World Bank's David Wilson.

“There are reasons to believe the economic crisis might make things worse by contributing to transgressions and reducing the capacity to respond.”

However the picture may be more nuanced.

"The timing of the 1998 financial crisis in Russia and the beginning of the first wave of HIV among drug injectors is hard to explain as anything more than a coincidence," argues Robert Heimer. "The expansion of drug markets and the replacement of marijuana by heroin in many major Russian cities seems to be at the heart of that HIV epidemic."

Vadim Pokrovskiy, director of Russia's Federal AIDS Centre, also says that so far he has "no evidence" of economic hardship causing a rise in HIV among drug users.

"We have found more HIV cases in regions with better economic situation," he says. "Such regions have been more attractive for drug dealers."

Sex: Taking over as cause of HIV in Ukraine and Moldova

A rise in HIV numbers through sex has overtaken drugs as the main route for new cases in Moldova and Ukraine.

By January 2014 there were 139,573 Ukrainians living with HIV - and estimates assess that AIDS-related complications claim 17,000 lives each year in a country of 45 million people.

An integrated network of associations, funded by money from abroad, has helped stabilise the numbers of new infections to around 21,000 each year.

In 2001, around two-thirds were infected with the virus through sharing dirty syringes and almost one-third through sex.

However by 2013 this was reversed, with two-thirds infected through sex and one-third through needle-sharing.

“Since 2008, the HIV epidemic changed from the route of injecting drug users to sex,” says Pavel Skala, associate director: policy & partnership, Alliance Ukraine. “But injecting drug users are still the major source, through sex, including sex workers.”

Now half of Ukraine’s 310,000 injecting users have access to services, such as clean needles. Around one fifth of them have HIV. This has brought down risky behavior in the last five years.

“The more clients to whom we provide service, the less HIV transmission - in Russia this is another story,” says Skala.

A similar pattern has occurred in Moldova. The ex-Soviet nation saw an HIV boom in the late 1990s due to a surge in the injection of home-grown poppy concoction shirka and heroin. Needles were scarce and sharing was commonplace.

Since then, international funds have pumped millions into promoting harm reduction services - and the number of new cases is stabilising at around 700 per year, of which 92 percent come from sex.

“People believed HIV was due to drugs,” says Roman, a consultant at Chisinau’s Regional Social Centre providing services for people living with HIV. “Now we are more democratic and more libertine. Through the Internet, we can find a partner much faster for sex for two or three days. Sex plays a very large role.”

Both Ukraine and Moldova also see growing numbers of men having sex with men as a cause of HIV.

At present the viral number is around 5.9 percent of the estimated 176,000 male-on-male sexual partners in Ukraine.

“They are not so accessible for prevention services,” says Pavel Skala, “and this is a huge group.”

Money: Fall in funding risks viral spike

Prevention, treatment and care of HIV in the region depends on western financing, mostly from the Washington-based Global Fund to Fight AIDS, Malaria and TB.

"The Global Fund programmes in east Europe were more effective in the region than other [programmes]," argues Russian Federal AIDS Centre's Vadim Pokrovskiy.

But the World Health Organisation says this funding route is “unsustainable” in the long-term.

The Global Fund - which has 14.82 billion USD at its disposal for three years - changed its funding model in 2014 to focus on more countries affected by the diseases, mainly in the southern hemisphere.

It also introduced a new mechanism in which Ukraine was called, confusingly, an “Upper Lower-Middle Income country”.

“The fund considers us a middle income country and we are on the same list as some countries from Latin America and Asia - but this does not take into account the recent crisis in Crimea or the conflict in eastern Ukraine,” says Pavel Skala.

While funding remains constant at 51 million USD per year for Ukraine between 2014 and 2015, NGOs argue that a greater proportion is now going to combating TB, while around 39 percent less is earmarked for HIV elimination.

The Global Fund says there is no breakdown for how this money is differentiated between the diseases.

As countries reach a higher income status, the Global Fund expects to exit their financing to allow local health authorities to take over.

A visit to the Alliance Ukraine offices in Kyiv in November showed the network was in the process of cutting staff.

“It is coming at the worst time, as we have never had such huge decrease in budget with such a huge crisis in government financing, it might be really disastrous,” says Skala.

In 2017, Ukraine is likely to see a halving of its annual financing from the Global Fund from 57 million USD to 27 million USD.

“We are increasing funding in every region, yet we understand that people affected by HIV and TB and malaria in many countries are arguing that they need more. They are right,” says Seth Faison, head of communications at the Global Fund.

In Romania, when the Global Fund stopped financing HIV/AIDS prevention programmes in 2010, the local government did not support the continuity of services such as paying staff to facilitate needle exchange to drug users.

As a result, the number of injecting drug users with HIV boomed. This was in the hundreds in Romania, but in Ukraine a similar pattern could be in the thousands.

Skala says the Romanian lesson taught him “we don’t want same picture in Ukraine".

The state is usually willing to fund treatment for HIV/AIDS carriers. But countries are less open to financing prevention, which is a cheaper and more effective method of curbing HIV.

However this can mean the government giving money to NGOs on the ground - a structure alien to many post-communist states.

“In many cases, when [external financiers] fund NGOs directly, when donors leave, the governments don’t have the tradition, the experience, the confidence or competence to start financing civil society directly,” says the World Bank's David Wilson.

War: Ukraine conflict sees risky behavior up

Conflict in Ukraine’s east and the annexation by Russia of Crimea is causing unemployment, displacement and economic hardship across the country - factors likely to spur the rise of HIV.

NGO Alliance Ukraine has been operating on a national scale for over 14 years, but its services are now under threat in Donetsk and Luhansk, while its operations in Crimea have ended.

The Alliance still has harm reduction projects in Luhansk and Donetsk, a hotbed of HIV in the region. Here users have increased their number of visits to get clean needles and support.

“There is definitely an increase in risky behavior,” says Pavel Skala. “It’s sometimes dangerous for drug users to walk on the street and go to exchange needles - so some users are really stigmatised.”

Users themselves are marginalised by the rebel authorities in the occupied regions, who reportedly enlist drug users as “slaves” to dig trenches for their soldiers.

According to official figures and state services, the level of HIV has started to rise because of dangerous practices in these areas.

“Infections with syphilis, TB and HIV will increase,” says Skala.

A growing number of ‘drug refugees’ from Crimea, Donetsk and Luhansk, who no longer have access to substitution drugs such as methadone, are moving to cities such as Kharkov and Kiev.

These supplies are due to run out in east Ukraine at the beginning of 2015.

Skala believes once the patients run out of methadone, they will be forced to migrate or could regress to taking illegal drugs.

Following the Russian annexation of Crimea, users were left without their regular fix of methadone or buprenorphine.

Many fled to mainland Ukraine for treatment, some detoxed and others returned to injecting illegal drugs.

Unknowns: No certainties on Turkey's recent HIV peak

While countries in the Caucuses and Bulgaria have been witnessing a moderate rise in the numbers of HIV, Turkey, which has never suffered from an HIV epidemic, is witnessing alarming figures.

Turkey has seen a sharp increase in HIV numbers to over 1,000 for the first time in 2012 and with 1,313 cases in 2013, according to the Turkish Ministry of Health.

The official body claims that the source of 52 per cent of cases are “unknown” and that 33 per cent come from heterosexual sex and 14 percent from homosexual sex, and near-zero from injecting drug users.

Experts believe a higher number may be coming from men having sex with men, which is a difficult issue to confront in a country of mostly conservative family values.

While this is still a low prevalence for a major country, Turkey has no harm reduction services for drug users or widespread awareness campaigns, nor are international groups such as UNAIDS present in the country, which is sure to face further scrutiny.

Yet a concerted effort now could head off any potential epidemic.

“My sense is with a bit of international collaboration Turkey has the resources to manage what is likely to be a relatively small epidemic,” says David Wilson, who has worked in the nation.

This article was financed with the Award for Best Initiatives of European Online Investigative Journalism, Robert Schuman Centre for Advanced Studies (European University Institute, Florence, Italy).