KALININGRAD, Russia, July 14 ≈ As the cafes and
clubs began to course with night life one recent evening, Andrei V.
Bykovsky and Yuliya B. Sokolova cruised around in a white van, patrolling
the newest front of Russia's AIDS epidemic.
They stopped first near the Mother of Russia statue,
then along Moskovski Prospect, then beneath the Cosmonauts Memorial. They
easily found what they were looking for: young women, many in their teens,
most racked by drugs or desperation, selling themselves on the street for
a trifle ≈ less than $7.
Mr. Bykovsky and Ms. Sokolova passed out condoms from
a green backpack and tried to coax the women to visit their basement
clinic, which offers exams and advice to slow the spread of H.I.V., the
virus that causes AIDS.
In Kaliningrad, as in all of Russia, the virus has
spread almost entirely through the use of intravenous drugs. But the next
step in the disease's march across Russia, which has one of the
fastest-growing AIDS epidemics in the world, is starting to be documented
here: a sharp increase in H.I.V. infections through sex.
"The figures began to grow in the last
year," said Yelena Y. Kozhenkova, a doctor who rides along in the van
on its nightly missions. "But we could see it coming even
earlier."
What makes Kaliningrad's experience significant is
what it forebodes for Russia as a whole. This region of more than 900,000
people, isolated from the Russian mainland and plagued by the social and
economic ills that came with the Soviet Union's collapse, was the first
hit hard by an explosion of cases among drug addicts and has been a
harbinger of the disease's spread ever since.
In 2001, the percentage of new H.I.V. infections in
Kaliningrad attributed to sexual contact jumped to nearly 30 percent of
the total, compared with only 4 percent when the epidemic struck here with
a vengeance in 1996, regional officials said. Prostitution appears to have
been the primary source of these infections, but officials now fear that
the trend signals the spread of H.I.V. beyond the shadowy world of drugs
and criminality.
Tatyana N. Nikitina, the director of the Kaliningrad
region's government AIDS center, attributed the increasing numbers to men
contracting the virus from prostitutes and then spreading it to their
wives and girlfriends.
"The disease has reached beyond the circle of
the consumers of sexual services," she said.
In all of Russia, sexually transmitted H.I.V.
infections accounted for a little more than 5 percent of new cases last
year. But if previous patterns hold, officials warn, the number will rise,
as it has here.
"The processes under way in Russia now could be
observed in the Kaliningrad region five years ago," said Vadim V.
Pokrovsky, the country's leading AIDS expert.
AIDS came belatedly to Russia, a fact attributed to
the Soviet Union's nearly closed society. The first case was reported in
1987, but infections did not reach epidemic proportions until the
mid-1990's, with an explosion of intravenous drug use.
In the last year alone, the total number of
registered H.I.V. infections more than doubled to 177,354, from 87,177 in
2000. With screening still fairly limited, officials estimate that the
total number of Russians actually infected may have already reached one
million.
Dr. Pokrovsky has begun to warn, with some alarm,
that AIDS could spread in Russia the way it has in Africa, infecting broad
swaths of the population.
For now, drugs remain the leading cause of H.I.V.
infections, particularly in Russia's notoriously overcrowded,
drug-infested prisons. Some estimates suggest that the country has more
than a million hardened drug users, most of them young men, but
increasingly young women, as well.
They are also among the most sexually active age
group, in which rates of other sexually transmitted diseases, like
syphilis, are also high.
"Given the high odds of transmission through
needle sharing, the fact that young people are also sexually active, and
the high levels of sexually transmitted infections in the wider
population, a huge epidemic may be imminent," a report by the United
Nations program on H.I.V. and AIDS, or Unaids, warned in December.
In Kaliningrad, the spike in infections through sex
has overshadowed some of the progress the region has made in slowing the
disease's spread.
The number of new cases each year has dropped from a
high of 1,109 in 1997 to 491 last year and only 215 in the first six
months of this year, according to the region's AIDS center. To date, there
have been 3,763 cases of H.I.V. infection.
Although its rate of infections per capita is higher
than in Western Europe, Kaliningrad no longer has the highest rates in
Russia, having been surpassed by the regions of Irkutsk and Khanty-Mansi,
in Siberia. Officials here have attributed the slowing of the growth to
greater awareness of the risks, stricter policing of drugs and to one of
the unintended consequences of the United States campaign in Afghanistan:
a drop in drug exports that has driven up prices for heroin.
Officials also cite the increased use of clean
disposable syringes, which are distributed by the basement clinic, run by
a psychologist named Aleksandr A. Dreizin, that sends out the van teams
each night.
With the number of cases involving sexual contact
increasing, the clinic's mission has evolved from an exclusive focus on
addicts, although drugs and prostitution are inseparably intertwined.
Dr. Dreizin has hired a gynecologist to offer women
free exams. With money from the World Health Organization and private
donors, the center also distributes condoms and pamphlets on safe sex.
An estimated 3,000 women work as prostitutes in
Kaliningrad. Dr. Dreizin noted that new clusters of prostitution have
appeared on Kaliningrad's borders with Poland and Lithuania, where they
serve long lines of motorists waiting to cross. A French organization has
donated a bus to help the clinic reach those women more easily.
Of the prostitutes who are reached, Dr. Kozhenkova
said, many remain wary even of health authorities. "It's a complex of
guilt and shame," she said. "They are afraid even of gynecological clinic."
