In Russia, the end of Communism brought cheap heroin -- and HIV.

During the 1980s the USSR remained relatively untouched by AIDS. Official statistics suggested only a few hundred people were infected, mostly through unprotected sex, or children who had been infected in hospitals through the use of non-sterile equipment.

But with the fall of the Soviet Union, conditions rapidly deteriorated. The World Bank reported that the post-Soviet economic and social crisis in Russia and other Eastern European countries "is without historic parallel."

To cope, many Russians turned to drugs, particularly cheap heroin which flooded in from Afghanistan and Central Asia. "If you wanted to be fashionable, you had to use drugs," one injection-drug user named Sergei explained to FRONTLINE.

HIV rates among drug users began exploding around 1999, and spread to the general population. Dr. Alexander Kolesnikov, who runs an AIDS center in the city of Tver, says more than half of the people he now diagnoses are outside typical risk groups. "Primarily this has affected women, some of whom are married, some of whom are religious women," he says. "These are frequently women who are planning to have a baby, come to the gynecological center and find out they are HIV-positive. They never used drugs, they never had sexual relations with drug users, and yet they are infected."

Official statistics place the number of HIV-infected Russians at 380,000. But Dr. Vadim Pokrovsky, the head of Russia's Federal AIDS Center, estimates at least 1 million citizens, or nearly 1 percent of the population, are currently infected.

HIV/AIDS currently is not the country's biggest health problem: Russians are far more likely to die from alcoholism or heart disease. It is the only developed nation with a declining population -- the fertility rate has dropped from 2.1 to 1.3 births/woman since the late 1980s and life expectancy has dropped by more than five years during the same period. What effect will HIV have on a nation that is already dying out? This is what Dr. Peter Piot, head of UNAIDS, describes as his "biggest worry."

"There seems to be real denial about the potential for a huge crisis affecting the country, even an economic crisis, in the countries of the former Soviet Union," Dr. Piot says. "Knowing also that there is already a demographic crisis in Russia ... a few percentages of the population infected with HIV is going to have much more serious consequences for the Russian economy, for the health of the nation, the future security..." than in a large country with an expanding population like China or India.

But Russia's AIDS problem has gotten little to no attention from the country's top leadership. President Vladimir Putin did not publicly mention the disease until 2003 when he gave it a passing mention in his annual speech to parliament. In his 2006 state of the union speech, Putin never mentioned AIDS, instead focusing on the country's declining birth rate, calling it "the most acute problem facing our country today," and offering cash incentives for women to have more children.

Russia has spent an estimated $4 million on AIDS prevention and treatment programs at home, but it gave more than $20 million to the Global Fund to Fight AIDS, Tuberculosis and Malaria.

"Russia always tried to be an international power, to present itself like a donor country," explains Dr. Alexei Bobrik, deputy director of Moscow's Open Health Institute. "... We wanted to be among the leaders -- to launch Sputnik, to put the first person in space, to help other developing countries, etc. So basically the commitment of Russia to the Global Fund is in the same role."

Though it initially turned down money from the Global Fund, in 2004 and 2005 Russia accepted funds, including $31 million to stimulate an effective national response, and $34 million for treatment. But Dr. Pokrovsky worries that accepting international money means that the government will be less inclined to spend its money at home. "The logic of our economists is simple," he says smiling. "If you already have money, why do you need more?"

And many experts believe that to successfully combat AIDS, a country must devote its own resources to the battle. "It cannot be underestimated how important it is for national governments to take responsibility and use their own dollars," explains Dr. Chris Beyrer, an AIDS expert at Johns Hopkins University. "If it's just donor-driven, however well intentioned or wherever the money is coming from, it doesn't have the same impact; it's not sustainable."

Dr. Pokrovsky agrees. "Our calculations show that required expenditures for the fight against AIDS may not be all that huge for Russia," he says. "... In reality, Russia can easily handle all the difficulties of fighting the epidemic. The only thing that's needed is the decision by the leadership -- the government, the president, and the parliament -- to direct that money specifically towards the fight against AIDS."

The international HIV/AIDS community received a jolt in late May 2006, when the World Bank reclassified Russia as an "upper middle-income country," meaning that the country could lose tens of millions of dollars in funding from the Global Fund. A Global Fund spokesman told the Associated Press that because of the reclassification, the fund could not approve any additional money after already approved grants expire in 2011.

As Russia gets ready to host the G8 summit in St. Petersburg in July 2006, Putin has begun to speak more about AIDS. He has called for the development of a long-term domestic strategy and pledged to spend $112 million domestically in 2006 to fight the disease. He also placed the issue on the agenda for the G8 meeting and Russia pledged an additional $20 million to the Global Fund, with a deputy foreign minister noting to the Russian press agency Interfax that as the current G8 president, Russia was dedicated to continue the G8's assistance to Africa. Whether Russia is equally committed to fighting AIDS at home once the spotlight of the G8 meeting disappears remains to be seen.

* Note: Figures reflect most recent statistics from UNAIDS and the World Health Organization.

• Related Links
• UNAIDS Country Report: Russia
  This page has UNAIDS statistics on HIV/AIDS in Russia, an epidemiological fact sheet and analysis of the problem. It notes that in Russia, "The epidemic, mainly affecting young people, has already entered a second phase with HIV increasingly transmitted through sexual contact rather than injecting drug use."
• The Devastation
  "AIDS is not a subject that people talk about much in Russia," Michael Specter wrote in The New Yorker in 2004. "Even though the epidemic is spreading here more rapidly than anywhere else in the world, there are virtually no public-service ads on television about it, and the government spends next to nothing on prevention, treatment, education, or care. This year, the entire budget for HIV-related matters is a little more than five rubles per person, less than the cost of a pack of cigarettes."
• Evaluation of the World Bank's Assistance in Responding to the AIDS Epidemic: Russia Case Study
  This 2005 World Bank report, written to assess the bank's programs to combat HIV/AIDS in Russia, outlines the history of the country's epidemic and the government's response.
• Positively Abandoned: Stigma and Discrimination Against HIV-Positive Mothers and their Children in Russia
  "While Russia's HIV/AIDS crisis has received widespread international attention, this particular aspect of the crisis -- abandoned children of HIV-positive mothers -- still remains hidden behind closed doors," according to this June 2005 Human Rights Watch Report.