Andrei Artyomenko can pinpoint the day he believes he became infected. He was 21 years old, a product of a broken family, a school dropout, a junkie living in this Siberian city. By his own account, he looked awful, wearing dirty clothes and weighing just 128 pounds. His mother wouldn't let him come home because he kept stealing from her to pay for his habit.
One day he and a friend retreated into the darkened stairwell of a nine-story apartment building where no one would bother them. "He had just one syringe," Artyomenko recalled. "He warned me. He said, 'I'm not sure, but I think I got bombed,' " meaning infected. But the warning went unheeded.
"All I could think about was the needle," Artyomenko said. "I had to have it."
That spring of 1999 would introduce HIV not only into his own veins but into the Russian national bloodstream as well. It was the spring of "the explosion," as it is called here, the spring this remote Siberian outpost suddenly was no longer so cut off from the rest of the world.
As Afghan liquid heroin arrived, so did AIDS. When a student from a technical school tested positive for HIV, the virus that causes AIDS, panicked local officials began checking his classmates and discovered a hidden epidemic that was just beginning to break out in other cities and would transform Russia.
In the five years since, the country's leadership has done little to stop the infection as it has raced across the country. While international organizations are now rushing to offer assistance and holding back-to-back conferences on how to address the problem, President Vladimir Putin has mentioned AIDS only once in a major speech to the Russian people and then only in a fragment of one sentence. There was no reference to AIDS in his state of the nation address last month.
Russia once was largely free of a disease ravaging the United States, Europe and Africa, but the rate of infection in recent years has been growing faster here than anywhere else in the world, according to the United Nations and other international organizations.
A country that had just a few thousand HIV-positive people before 1999 now has more than 280,000 officially registered cases, and U.N. and Russian experts estimate that 1 million Russians actually have the virus -- more than in the United States, which has twice the population and a much longer history of the disease. Proportionately, the virus has infected six times as many people in Russia as in China, according to current statistics.
Now the infection has broken out of Russia's drug-using community into a society with hidden sexual promiscuity that no one likes to talk about. And with the state still not providing antiretroviral treatment to people like Andrei Artyomenko, the first generation of people infected will soon start dying off in large numbers.
The death toll remains small by the standards of sub-Saharan Africa, where close to 20 million people have succumbed to AIDS. But by 2010, under the most optimistic World Bank forecast, 250,000 Russians will be dying as a result of AIDS each year; under the most pessimistic scenario, the annual toll will reach 650,000, more than all those who have died with AIDS in the United States since 1981.
In Russia, AIDS is striking the world's only major nation where the population is already falling so drastically. Even before AIDS became a factor, the death rate in Russia had soared far beyond the birth rate, reducing the population faster than in any other major industrialized nation in the world. For every 100 babies born in Russia today, 173 people die. The population has already fallen by 5 million since the collapse of the Soviet Union 13 years ago, to 145 million, and government forecasts say it will fall to 102 million or, in the worst case, 77 million by 2050, without accounting for AIDS.
The reasons are myriad. Russians drink more, smoke more and commit suicide more often than practically any other people on earth. They suffer from some of the world's highest rates of heart disease, accidental death, tuberculosis, hepatitis and syphilis. The average lifespan for a Russian man recently fell to 59, below that in Bangladesh, Guatemala or Bosnia.
The advent of AIDS in such an environment threatens to swamp a health system that is already in crisis and, according to some experts, poses a long-term threat to Russia as a nation. The people the disease will afflict will be predominantly young men and women in their child-bearing years, the backbone of a dwindling labor force and the hope for replenishing the population.
"The totality of all this is . . . potentially devastating for the society, economy and social stability," said Murray Feshbach, a specialist at the Woodrow Wilson International Center for Scholars in Washington. Or as Steven L. Solnick, director of the Moscow office of the Ford Foundation, put it, "If you don't stop it now, it'll destroy the country."
Crisis Goes Ignored
As the disease spreads, the Health Ministry is fighting it with just five people closeted in a series of narrow offices in a satellite building far from the center of Moscow. The federal government spends not quite $1 million a year on prevention. Barely 2,000 Russians are receiving antiretroviral medication, and many of those get something less than the full treatment known as a triple cocktail.
"There's a lot of concern about the situation in Russia voiced abroad," Vadim Pokrovsky, director of Russia's Federal Center for AIDS Prevention and Treatment, told reporters last fall. "The concern is much greater than that expressed by our own public and our own government."
The Russian government at first turned down international aid, portraying itself as a donor nation to the Global Fund for AIDS, Tuberculosis and Malaria, so the fund awarded $88 million to a consortium of private groups in a rare bypassing of the host government. That leaves the fight in part in the hands of foreign groups such as the Ford Foundation, the International Committee of the Red Cross, UNAIDS and billionaire financier George Soros's International Harm Reduction Development Program.
"Russia should be one of the success stories because you have universal literacy, because you have a pharmaceutical industry, because you have a television in every home," Solnick said. "There's no reason millions of Russians should die of this disease. And yet it looks extremely likely that millions of Russians will die of this disease."
The reason why can be found in the story of the last five years in Irkutsk.
'Lost Souls Like Me'
A gritty industrial city with snow on the ground and a river frozen as late as May each year, Irkutsk sits on the crossroads between Europe and Asia. Founded in 1661 as a czarist fort on the Angara River, Irkutsk grew into one of the capitals of Siberia, a center of trade, culture and travel, a "thoroughly refined" town, as the playwright Anton Chekhov put it.
Now home to nearly 600,000 people, Irkutsk remains a traditional, unpretentious place where old houses are made of wood, the bars have names like Good Beer and religious icons are sold at sidewalk kiosks.
After the Soviet Union collapsed and Russia opened up, new things arrived in Irkutsk -- including drugs from Central Asia. At first, youngsters experimented with opium that they cooked over stoves and called chernyashka, or black stuff, but in early 1999 liquid heroin arrived in vials, making needle-sharing the new fad.
For many young people, the drugs were a way of dealing with the bewildering changes around them. "I felt myself useless, absolutely useless," recalled Artyomenko, the young man who shared a needle in a stairwell. He was estranged from his violent stepfather. "I needed to share my feelings with somebody, but I couldn't handle what they were telling me," he said. By the time he enrolled at a technical college at 17, he had found chernyashka and the transactional friends who came with it. "I understand they were just lost souls like me," he said. Then came liquid heroin. "AIDS," he said, "came with it."
The American movie "Pulp Fiction" became a cult favorite with some young people here in those days. They idealized its dark mixture of violence and drugs. "I was bringing it to life," recalled Yevgeny Sherbakov, now 21. "I considered myself cool. Later on, when I started selling my clothes off my body, I realized it wasn't fun at all."
The discovery of AIDS at the technical school exposed the consequences for all to see. "The school was just a symptom, the first sign that the infection had crawled into Irkutsk," said Alexei Trutnev, who tested positive in 1999 at age 25.
Trutnev was only the 130th person confirmed with HIV in Irkutsk. Today there are about 17,000 officially registered and probably three or four times that in reality, making Irkutsk proportionately the most infected region in the country.
As in other parts of Russia, authorities in Irkutsk refused to confront the problem at first. The governor and other officials rebuffed activists who demanded action. "We started ringing all the bells that the epidemic had arrived," Igor Vankon, founder of a local drug rehabilitation clinic, recalled. But when activists went to see a top medical official in 2000, "she just opened her arms and said, 'Sorry, we're not doing anything but diagnosis.' When they offered her a harm reduction [prevention] program, she said, 'No, we don't need it.' "
Vankon later tried to start a program aimed at preventing AIDS from spreading among young women. "When I raised the issue," he recalled, "our authorities said, 'There aren't enough syringes for children and you want to give them to prostitutes and drug addicts?' "
Many in Irkutsk thought that the problem was isolated in the drug community and would simply die off with the addicts. "People were stunned and frightened," recalled Artyomenko, whose family made him use separate cups and plates out of fear of infection. "The tension between sick people and drug addicts and the rest of society really escalated."
Battle for Recognition
Eventually the government opened an AIDS center in an unmarked building on a hill far outside the center of town and well out of public view. In 2002, the first needle exchange program began. Last year, the Red Cross opened its own AIDS center on Lenin Avenue in the middle of town with American financing.
But it remains a battle. In April, the local drug enforcement agency sent a letter to the Red Cross ordering it to halt needle exchanges on the ground that they represented "open propaganda of drugs."
The letter came just as the Kremlin was rewriting Russia's drug laws to decriminalize possession of small amounts of drugs, a move activists say will encourage users to get treatment or at least clean syringes. Yet Irkutsk's experience shows how even policy changes at the national level often are not translated to the local level.
"It's scary," said Tanya Yevlampieva, who works at the Red Cross center. "I'm scared mostly by the attitude people have toward it. I don't think anything will change until people start dying" in large numbers.
Little is being done to head that off. Other than pregnant women in the final weeks before childbirth, only three adults and 16 children are receiving antiretroviral treatment in the Irkutsk region. With the triple cocktail still costing between $6,000 and $12,000 a year per person, regional governments can ill afford it even as a growing wave of people will need it in the next two years.
Boris Tsvetkov, director of Irkutsk's AIDS center, maintained that everyone who needs it is getting it now but predicted a real challenge in the immediate future. "The more time passes since the beginning of the disease, the more people are going to need treatment," he said. "It's going to be very big money."
One of the few getting it now is Nastia Cherkashena, a blond 4-year-old in a red dress and pink bow who lives with 47 other abandoned HIV-infected children in a special clinic opened in 2002. Curious when strangers visit, Nastia says little, her eyes heavy with fatigue.
A couple of rooms down at the clinic is Edik Zolotavin, who just turned 8 and stares without comprehension from his bed. Rosa Varnakova, head of the children's AIDS clinic, pulled back his blanket to reveal an emaciated body seeming to belong to a child half his age. His arms and legs were sticks. He is the oldest boy in the clinic, with heart and kidneys so badly damaged that his caretakers do not expect him to live long.
"I think God needs to decide," Varnakova said.
Varnakova and the hospital's chief doctor, Lydia Gubanova, have done what they can to brighten a cold existence for these children, decorating the walls with cartoons, gathering toys and setting up classes for them. "They have everything," Gubanova said. "But they don't have mothers and fathers."
And this is only the beginning. While sexual transmission accounted for fewer than 1 percent of HIV cases in Irkutsk at first, today it represents 30 percent. "Right now, psychologically, we're getting prepared for the moment when something bigger will have to be established," Varnakova said. "We'll come to that point."
'We Do All We Can'
No one knows that better than Alexander Goliusov, who heads the AIDS section at the Health Ministry in Moscow. It falls to him to explain Russia's response to the disease.
Russia's problems with AIDS, and its failure to act, he said, have been exaggerated. While little is spent on prevention, he said that all federal and regional spending on AIDS treatment adds up to nearly $45 million a year, and he noted that Russia the donor nation has now swallowed its pride and applied for $213 million from the global AIDS fund.
"We can talk about whether we do things right or wrong, but we do all we can," Goliusov said. "Of course I'm not saying that things are perfect here and that everything is good and great. But I'm so tired of all the hysteria about Russia."
Still, after venting that frustration, his tone turned dire as he acknowledged that Russia faces a "huge problem" that requires more funding. Within three years, tens of thousands of people will be dying each year and he complains that Russia's pharmaceutical industry isn't rising to the challenge because "in their eyes, it's not worth it."
He sighed as he considered the looming disaster.
"It's breathing down our neck," he said.
"Death's breath," his assistant added.