Social Science & Medicine 50 (2000) 1547±1556
www.elsevier.com/locate/socscimed
Social change and HIV in the former USSR: the making
of a new epidemic
Laetitia Atlani a,*, Michel CaraeÈl b, Jean-Baptiste Brunet c, Timothy Frasca d,
Nikolai Chaika e
a
National Centre for Scienti®c Research, Centre National pour la Recherche Scienti®que (CNRS), Laboratoire d'Ethnologie et de
Sociologie Comparative UMR 7535 Paris X-Nanterre University, France
b
Joint United Nations Programme on AIDS (UNAIDS), Geneva, Switzerland
c
European Centre for the Epidemiological Monitoring of AIDS, Saint-Maurice, France
d
Consultant UNDP, New York, USA
e
Pasteur Institute, City Department for STD, St Petersburg, Russia
Abstract
This paper describes the development of the recent HIV epidemic in countries of the former Soviet Union. It
explores the socio±political and economic roots of an injection-drug-driven HIV epidemic associated with a drug
culture that facilitates HIV transmission. This review, based on many unpublished reports, studies and ®eld notes,
discusses the new social and health context in which the epidemic is developing. The evidence of a growing number
of drug users in the region is discussed and drug injection behaviour described. The authors present selected data on
the heterosexual transmission of HIV and linkages between the drug-linked HIV epidemic and its further spread
into the non-injecting population. The potential overlap with the still uncontrolled syphilis epidemic that began in
1990 is probably a key factor in the future of HIV spread in the region. Until now, HIV infection among STD
patients has been extremely low. However, rapid changes in sexual norms and behaviours, the growing commercial
sex industry, and increased mobility soon may a€ect the current situation. The huge economic and socio±political
crises currently a€ecting the region have created a ``risk situation'' for the spread of HIV. Concerns are raised about
the appropriateness and the scope of government and non-governmental approaches to the exploding HIV and STD
epidemics. 7 2000 Elsevier Science Ltd. All rights reserved.
Keywords: HIV; STDs; Social change; Former USSR; IDUs; Sex workers
Introduction
* Corresponding author. CNRS, Laboratoire d'Ethnologie
et de Sociologie Comparative, Universite de Paris X-Nanterre,
MAE 21 Allee de l'Universite, 92023, Nanterre Cedex France.
Tel.: +33-146692511; fax: +33-146692511.
E-mail address: [email protected] (L. Atlani).
If disease is an expression of individual life under
unfavourable conditions, then epidemics must be indicative of mass disturbances of mass life. (Eisenberg, 1984)
0277-9536/00/$ - see front matter 7 2000 Elsevier Science Ltd. All rights reserved.
PII: S 0 2 7 7 - 9 5 3 6 ( 9 9 ) 0 0 4 6 4 - 5
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L. Atlani et al. / Social Science & Medicine 50 (2000) 1547±1556
Our conception of the determinants of an epidemic
changes as the epidemic evolves: at certain times,
pressure arises to track infection and improve access to
health care systems; at other times, the emphasis has
been on individual risk factors, risk-taking or on ``risk
groups''; eventually, rising poverty and social deprivation may ®gure more predominantly in policy making.
The HIV epidemic is a good example of such contrasting views. In the early years of AIDS, medical
authorities tended to view HIV as a communicable
virus to be handled in traditional ways: through identifying the ``carriers'' of the virus, tracking transmission
routes, and heading o€ new infections by patientfocused policies, such as contact tracing and partner
noti®cation. Later, under the in¯uence of psychological
theories of behavioural change, individuals at risk were
the focus, with the underlying assumption that the individuals who receive the intervention will make
rational decisions about their behaviour and that they
have the power to make the necessary changes. Social
and environmental variables were treated as independent.
In recent years, the approach to HIV/AIDS has thus
broadened to focus not only on individual risk-taking
behaviour, but also on the immediate environmental
and societal factors that in¯uence such behaviour,
including the in¯uence of communities on individuals
(Tarantola, 1992; Tawil et al., 1995; Barnett and
Whitesite, 1997; CaraeÈl et al., 1997). The earlier concepts of risk and risk-taking were broadened to include
new concepts such as ``risk situation'' and vulnerability, resulting from societal factors that a€ect
adversely one's ability to exert control over one's own
health.
The case of the new HIV epidemic that recently
emerged in the former Soviet Union is particularly illustrative of these often contradictory views. It may be
an extreme and rare example of a ``risk situation'' in
which economic collapse and the deterioration of the
health-care system coincide with changes in moral
norms and values among many social groups. Not surprisingly, in recent years, all health indicators have
dropped sharply in the countries of the former Soviet
Union, and new epidemics, including HIV and STDs,
are rising.
The e€ects on health of the politico±economic transition that occurred after the collapse of the communist system in the early 1990s have probably few
parallels in history. This transition is characterised by
a rapid decline in gross domestic product (GDP), especially a€ecting industrial production, and high in¯ation. With the beginning of privatisation, the role of
the underground economy expanded, generating severe
economic inequalities (UNDP, 1996, 1997, 1998). Anyone dependent on the state budget, especially pen-
sioners, the disabled, the unemployed, civil servants
and military personnel, experienced a sharp drop in
living standards.
The sudden collapse of the Soviet system disrupted
the very basis of the organisation of production. Previously, the system provided universal human security,
including full employment, controlled prices of essential goods, universal health care, education and a
broad safety net to guarantee residents' minimum
needs. Centralisation often resulted in heavy concentrations of certain industries in particular regions or
cities with heavily dependent communities, comparable
to the ``company town'' phenomenon in the West.
These industries not only provided jobs but also welfare, health and social services.
The disruption caused by the shutdown of these
industries was so severe that people had no time to
adjust materially or psychologically. Poverty became
widespread. In a 1995 opinion poll in Kazakhstan,
75% of those surveyed stated that they had purchased
no consumer goods at all in the previous year (Karavan, 1995). Delays of many months in the payment of
wages have become commonplace.
These dramatic economic changes have been associated with a deterioration in the health of the peoples
of the former Soviet Union. With gross domestic product falling by as much as one-half, real health spending was cut by comparable amounts. The budget
reductions slashed real wages of health workers, capital
investments in the health sector, and purchases of
pharmaceuticals and supplies (Healy and McKee,
1997). In 1960, 6.6% of the USSR's GDP was spent
on public health. By 1985 the ®gure had fallen to
4.6%, and in 1994 to 1.7%. By comparison, spending
on health care in OECD countries averages 7 to 8%
(Powell, 1998). Health costs, which increased due to
the partial privatisation and commercialisation of
many health services, were suddenly transferred from
the state to households.
Macroeconomic decline had broader health consequences as well: heating shortages induced increased
rates of pneumonia, deteriorating water supplies led to
epidemics of infectious diseases such as cholera, and
the interruption of immunisations caused outbreaks of
diphtheria. Inevitably, the region's health indicators
worsened: non-communicable diseases showed such
startling increases that Russian boys born in 1993 are
expected to live 5 years fewer than those born in 1989
(Adeyi et al., 1997). In Ukraine, male life expectancy
was estimated to have dropped from 66 in 1989 to 61
in 1995 (Barnett and Whitesite, 1997).
Some authors link this phenomenon both to deteriorating health care as well as increased alcoholism
and smoking (Bobak et al., 1998). In Russia, Cornia
(1997) has shown a strong correlation between the
decline in life expectancy and the increase in ``psycho-
L. Atlani et al. / Social Science & Medicine 50 (2000) 1547±1556
logical stress'', measured by levels of unemployment
and labour turnover and the increased rate of divorce.
Another indicator of stress is the raising rate of
suicide. Between 1960 and 1993, the ocial number of
suicides per year in Russia increased 43%, from 39,000
to 56,000 and had further risen to 67,000 by 1995
(Powell, 1998). These ®gures include only those deaths
registered as suicides. Bobak et al. (1998) noted that
poor health status in Russia might be related to the
dysfunction of social structures, socio±economic deprivation and lack of perceived control on the environment and one's health.
Linking risk behaviour to social structural change is
still problematic in current behaviour change theories
(Giddens, 1979). In addition, fundamental data and
cross-disciplinary studies in the region are lacking that
might establish the link between social dimensions of
risky behaviour and speci®c aspects of the drastic
changes in organisational, institutional, health and
economic conditions in the former USSR. By these
standards, the data collected for this paper are bare
beginnings. Nonetheless, both the recent second Conference on AIDS and Social Sciences in Europe and
the second International Conference on AIDS held in
1998 expressed a growing concern about determinants
of the HIV epidemic in Eastern Europe and the
countries of the former Soviet Union and o€ered
timely opportunities to assemble relevant literature.
This paper utilises the information assembled at these
events, supplemented by other papers, published and
unpublished reports and ®eld notes from Atlani.1
In this article, we discuss selected aspects of the
determinants and dynamics of the new HIV epidemic
in the countries of the former Soviet Union, where the
societal changes were deepest and most sudden.
An explosive HIV epidemic among injecting drug users
Little attention was paid to the HIV epidemic in the
former USSR during its early years, due to the low
rates persisting in the region and the pressure of more
immediate social upheavals.
From 1988 until about 1994, health ocials from
the region tended to downplay the threat of HIV,
pointing to the extremely low levels of infection. The
isolated outbreak of nosocomial infections among Russian children in 1988 was seen as exceptional. The majority of the few, adult reported cases of HIV infection
1
The ®rst author has regularly visited several countries of
the former Soviet Union (Azerbaijan, Kazakhstan, Kyrgyzstan, Russia and Ukraine) since 1995 to work on HIV prevention. Her work was commissioned by UNDP and Path®nder
International. Additional ®eldwork was funded by the CNRS.
1549
were detected among homosexual men. Even as the
silent epidemics in Russia (1991±95) and the Ukraine
(1993±94) were ending, many local public health
experts concurred that HIV infection in their countries
was ``stable''. It was generally thought that, with a systematic application of a broad range of preventive
measures in health care settings, the situation would
remain unchanged for the foreseeable future.
The assumption that prevention could be concentrated in formal health care settings showed that health
ocials were oblivious to the implications of social
transformations. Indeed, a few years later, the situation has changed dramatically: the HIV epidemic is
now escalating in many of the countries of the former
Soviet Union, with an explosive spread among intravenous drug users (IDUs). In 1997, transmission through
injecting drug use accounted for most of the 100,000
estimated new HIV infections in the region (UNAIDS/
WHO, 1998).
In Ukraine, where some 80% of the estimated
15,000 infections reported in 1997 were among drug
users, half of the noti®cations occurred in 1997
(UNAIDS/WHO, 1998; Scherbinskaya et al., 1998).
The two Ukrainian cities of Odessa and Nykolayev are
the most a€ected. In the ®rst, HIV prevalence among
IDUs was 1.4% in January 1995, 13% in August of
the same year, and 31% in January 1996. In the second city, the ®gures are 0.3% in 1994, 17% in 1995
and 57% in January 1996 (Kobysha et al., 1996; Khodakevich et al., 1997).
In the Russian Federation, more than 60% of the
new HIV cases recorded in 1996 were among IDUs,
compared to 28% for the 1987±1995 period, when sexual transmission predominated. Homosexual contact
then accounted for 29% of the cases, and parental
transmission during medical treatment another 25%
(Danziger, 1996; Ingram, 1997). In 1997, according to
various authors, between 74 and 90% of new infections were among IDUs (Harstock and Kozlov, 1998;
UNAIDS/WHO, 1998; Rhodes et al., 1999).
Kazakhstan is also facing an injecting drug-related
HIV epidemic. Together with its Central Asian neighbours, it has become a major tracking route for
opium and heroin from Afghanistan, the world's largest source. Even if injecting drugs emerged only in
1994, most users began injecting recently and the majority of the estimated 40,000 drug users are unemployed youth (Ellis, 1996; Kumar, 1998). By April
1999, Kazakhstan had recorded 882 cases of HIV
infection and 24 cases of AIDS. Turar Cheklikov,
director of Kazakhstan National AIDS Centre, said
that 80% of the infections are the result of injection
drug use.
It would have been unthinkable a few years ago for
us to suggest that children from 11 to 13 years old
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L. Atlani et al. / Social Science & Medicine 50 (2000) 1547±1556
would take drugs. (quoted by Russia Today Online
04/28/99)
Belarus also faces a sharp increase in registered
cases of HIV infection since 1996, mostly among the
estimated 4000±7000 IDUs in the city of Svetlogorsk.
Before June 1996, six out of 33 (18%) registered IDUs
tested HIV positive in one study. By October 1996,
482 cases of HIV infection had been registered, mostly
among IDUs (Dhene et al., 1999). Moldova is following the same pattern, with 77% of HIV cases in 1997
found to be IDUs (Hamers, 1997).
For several reasons, doubts remain about the validity of these sero-prevalence data based on mass
screening and screening of the so-called high-risk
populations. For a person to be registered as HIVpositive, two tests must be performed as well as clinical
investigation. Many HIV infections may not be registered as people refuse follow-up procedures or health
structures are unable to provide them or ful®l reporting requirements. In Ukraine, for example, Kobysha et
al. (1996) reported that only between 50±80% of drug
users listed in police, drug treatment or prison records
had been tested for HIV.
In addition, registered HIV infections may re¯ect an
over-reporting bias among IDUs. According to
Hamers (1997)
processing is proliferating in former Soviet states, and
trac is being re-routed or newly introduced into the
Balkans and along the Silk Road. Free-market economies and open borders have facilitated the exchange
and transport of drugs, along with other goods.
Opium derivatives are now easily available in these
countries, including heroin recently introduced to new
users as well as home-produced poppy extracts.
In addition, the creation of new convertible currencies has made previously uninteresting markets attractive to international drug trackers. At the same time,
widespread economic collapse makes drug dealing an
attractive career choice. Organised crime groups have
also emerged in many post-communist countries and
have moved into drug production and tracking,
while law enforcement structures are weakened or corrupt (Grund, 1996). Several reports mention the
strengthening of a regional narcotics ma®a with strong
links to the drug-producing and -tracking cartels of
the Golden Crescent and Golden Triangle (UNDCP,
1997).
Increase in drug demand
In Ukraine in 1995 the number of diagnosed HIV
infections among IDUs was exactly the same as the
reported number of HIV infections acquired through
injecting drug use (Hamers, 1997). Finally, people living with HIV may not be recorded, as many are only
detected when diagnosed with AIDS (Barnett and
Whitesite, 1997). All these factors imply that data on
HIV prevalence among IDU should be interpreted
with caution and that trends over time are probably
more signi®cant that absolute numbers.
There are many gaps in the available knowledge on
the characteristics of IDUs and their sub-populations
as well as on the dynamics of viral transmission
among them. However, several factors seem to drive
this new HIV epidemic: a sharp increase in drug
supply, increased demand for drugs, and a shift in the
culture of drug use.
The scale of drug use is impossible to estimate precisely. Ocials and social workers generally agree that
the increase in the last few years is considerable and
that the proportion of users injecting is rising. Alarming anecdotal reports also indicate an increasingly
younger age of initiation and the use of combinations
of drugs that make rehabilitation more dicult.
The number of IDUs found to be HIV-positive also
has climbed at an increasingly rapid rate since 1992,
and these ®gures are likely to represent only around
10% of all drug users, including non-dependent consumers.
In Russia, the ocial estimate of illicit drug users in
treatment rose from 91,000 in 1994 to 350,000 in 1997.
Unocial sources claimed in 1998 that there were as
many as 2.5 million drug users in Russia, of whom
two-thirds are believed to inject. Perhaps 10±15% of
the population has experimented with illegal drugs. In
a recent study among school children in St. Petersburg
(Russia), 21% reported experimentation with illicit
drugs and 5% reported intravenous consumption
(Davidova et al., 1998). Brunet, quoting ocial
sources, reported 200,000 IDUs for that city alone
(Brunet, 1997).
Change in drug supply
Social and cultural factors a€ecting injecting drug use
The world production of heroin quadrupled in the
last decade, creating new markets in the production
areas and along transport routes (Burrow et al., 1998).
Since the collapse of the USSR, opium growing and
No systematic assessments of the determinants of
drug demand have been conducted in the region.
Opium poppies have long been cultivated in the former
USSR, and drug injecting is not an entirely new
Since IDUs tested are those ocially registered as
such by the police, they probably represent a biased
sample of all IDUs.
L. Atlani et al. / Social Science & Medicine 50 (2000) 1547±1556
phenomenon (Rhodes et al., 1999). However, the
recent expansion of drug use is evident, as shown in
Odessa (Ukraine) where one survey among 500 street
IDUs, found that 58% were younger than 25 years of
age and that 66% were neither employed nor studying
(De Jong, 1996).
In the former USSR, the current combination of
socio±economic and political factors has created what
local people call the ``transition trauma''. Apart from
the discontent and hopelessness generated by the current misery, a substantial ``generation gap'' has arisen
in which anything perceived as coming from parents or
traditional institutions Ð including information about
drugs Ð is immediately dismissed. Today, the post
communist economic malaise hits young people especially hard. Many youths have few prospects for
even minimum economic stability. Independent housing for young families is out of reach, as state-backed
mortgages have been abolished.
At the same time, increased travel and access to western media via satellite television provide attractive
images of a variety of alternative lifestyles. It increasingly presents stylish and exciting pictures of youth
and beauty, frequently laced with covert or open references to drug use.
Injecting drug use may appear to some youth subgroups as an expression of ``reactive hedonism''
(Grund, 1996) in which drugs increasingly substitute
for or supplement traditional patterns of heavy alcohol
consumption, but without the natural checks and balances that arise when people have jobs, a minimum of
economic perspectives and associated responsibilities
and security. For other sub-groups, drug consumption
is clearly associated with unemployment and lack of
perspective. Today, many in the younger generation
see no grounds for hope in the future, given the sense
of ``failure'' of the society their parents and elders
worked so hard to build.
Drug culture and consumption
The spread of HIV in the region is also directly
in¯uenced by current methods of drug production and
consumption. Cultivation of poppies is increasing in
the Central Asian Republics and in Russia as well.
Poppy straw produced in the region is probably the
most widely used source of opioids, including Russian
and Ukrainian ``chromie'' (black) or ``himier'' (chemistry), as well as ``hanka'' in Russia and Kazakhstan
2
Field notes from work in the Kyrgyz Republic commissioned by UNDP in 1995, 1997 and 1998 (5 months). Personal communications with key informants in charge of
services for IDUs in both the NGO and governmental sectors,
based in Bishkek and Osh.
1551
(Rhodes et al., 1999). In Ukraine, the main injected
drug is dimethylmorphine, a home-made liquid substance made from poppy straw, and in some countries
of the region, drug users inject ephedrone, a derivative
of ephedrin (De Jong, 1997). Liquid ``amphetaminlike'' drugs, ``vint'' (screw) or ``belie'' (white), are also
produced in the region from ephedra or ephedrin
(Rhodes et al., 1999).
Sharing of equipment, the principal risk factor for
HIV drug injection, is described as common in the
region, with around 60% of regular users reporting
borrowing and lending equipment (Davidova et al.,
1998; Saar et al., 1998). Many potentially risky sharing
behaviours have been reported in the region, and this
sample is probably not complete.
In addition to sharing equipment, speci®c risk practices facilitate the spread of HIV in the four countries
with an explosive HIV drug-related epidemic. These
practices are associated with the preparation and the
distribution of homemade opium where the poppy
straw is processed with the use of a range of chemicals.
A strong group culture exists among IDUs, which
may stimulate the sharing of injection equipment, as
well as the purchasing and preparing of drugs and
avoiding detection. Increased risk is also associated
with the rental of injection equipment in so-called
shooting galleries or parks. As the average age of
IDUs decreases and initiation occurs as early as 13 or
14 years in some countries, young and inexperienced
users tend to buy pre-packaged drugs rather than prepare their own ®xes. These preparations may come in
used or non-sterile syringes. Central Asian professionals working on drug harm reduction call this
phenomenon the ``Odessa syndrome'', referring to the
situation in that Ukrainian city which pre®gured similar experiences elsewhere in the region.2
Opium straw is commonly processed at home for
later consumption elsewhere (kitchen production): or it
may be produced for a larger number of drug addicts
(garage production). Group preparation (2±4 people)
is preferred in order to save on drugs and other processing materials and to generate group solidarity. Producers and dealers may save drugs in contaminated
reservoirs before distribution. IDUs in the region tend
to share homemade drugs through ``backloading'', a
distribution technique in which the syringes of a group
of users are loaded ``at the back'' with a single syringe
(De Jong, 1996, 1997). Even if drug users provide their
own equipment when buying from the dealer Ð who
is quite often a user himself Ð syringes are ®lled from
the dealer's larger syringe or from the container.
Chemicals are used during the drug preparation, and
blood may be added at the end of the process. The
blood is supposed to act as an adsorbent of these
chemicals or as an alternative neutralising agent when
1552
L. Atlani et al. / Social Science & Medicine 50 (2000) 1547±1556
no other is available, or as a way to reduce the acidity
of the preparation. The practice may also be used to
establish the quality of the drug Ð if the blood coagulates quickly, it is a sign of high quality Ð or to provoke a euphoric rush (Reynolds, 1997; Boekham and
Zmushko, 1998). The extent of the practice of adding
blood to the drug during preparation is still unknown,
but it has led several narcotics agencies in former
Soviet Union countries to question the usefulness of
establishing needle and syringe exchange services.
Bridging populations: the key for further HIV spread
``Bridge'' populations can be de®ned as those men
and women who have sex with both high-risk and lowrisk partners. ``Bridging'' risk behaviour involves possible transmission of HIV across di€erent physical
modes of transmission and across di€erent risk behaviour subpopulations (De Jarlais and Padian, 1997).
Morris et al. (1996) suggested that men having sex
with both commercial and non-commercial sex partners in Thailand played a signi®cant role in HIV transmission in Thailand. Barnett and Whitesite (1997)
highlighted in Ukraine the signi®cant ``bridging'' role
of IDUs in spreading HIV from the drug user population to other populations through unprotected heterosexual intercourse. In Ukraine, most IDUs were
described as not aware of the risks of unsafe sex: more
than 50% reported sex with multiple partners, most of
them being non-drug users (De Jong, 1996).
In the context of the social factors described above,
how important is the risk of HIV transmission from
IDUs to the rest of the population? The HIV epidemic
may or may not spread in the region, depending on
the likelihood of expansion from the localised IDU
epidemics to the so-called general population through
sexual contact. Widespread HIV transmission among
sexual partners of IDUs is likely to occur due to their
low level of protected sex, according to behavioural
surveys.
Prostitution and drug use
From the little data available, an increased risk of
HIV transmission from IDUs practising commercial
sex seems likely. Reports from Ukraine, Latvia,
Lithuania, Azerbaijan, Kazakhstan and other countries
of the former USSR suggest that a fraction of both
3
Field notes from work on non-governmental responses to
HIV and AIDS in Kazakhstan, commissioned by UNDP and
Path®nder International in 1995 and 1998 (6 weeks). Personal
communications with local AIDS activists in Almaty.
female and male IDUs practise prostitution. In
Ukraine, 10±20% of IDUs engaged in sex with multiple partners in order to obtain drugs or money, and
most sex workers working on the streets were also
IDUs (Konings, 1996). A similar situation has been
reported in Latvia, with low levels of condom use and
an association between sex workers and opiate use; as
well as in Lithuania, where both male and female
IDUs are reported to be involved in the sex trade
(Konings, 1996).
In Kazakhstan, local AIDS activists report an
increase of IDUs among sex workers, who turn to sex
work to ®nance their ®xes and where the relatively
high cost of drugs is not the only economic incentive
for prostitution among IDUs. They note that police
practices and the legal situation contribute to this link.
An average consumer will need between US$60 and
300 a month for drug purchases. Other costs, such as
bribes, are additional. Prosecution often stimulates
drug tracking and consumption. There are usually
two grounds for drug-related arrest: if caught for consumption, the user may be sent to one of the now
under-budgeted treatment centres and, upon release,
will be watched by police for a year. If arrested for
tracking, the user may be sent to prison. Schools and
health care centres are supposed to identify suspects
and often notify police and treatment centres, which
co-ordinate their activities closely. In practical terms,
treatment centres, health services and the police may
be indistinguishable to drug users.
Once a person is registered as an IDU or simply
known by the police unocially, he/she may be
arrested for presumption of both consumption and
dealing. Under these circumstances, it appears that
police may extort bribes, with the threat of a new
prison term. Some IDUs have reported that they have
then been regularly ``contacted'' by the police and thus
had to generate income to pay the bribes and avoid
imprisonment. Further prostitution or drug tracking
may be the source of these funds.3
According to many anecdotal reports, commercial
sex activities have increased exponentially in the
region, arising both from increased demand, increased
poverty among women, and the opportunities for
quick and sizeable material rewards. However, no data
on the size of the prostitute population are available,
and the extent to which men frequent prostitutes is not
known.
Prostitution in the former USSR is described as an
adaptation strategy for thousands facing loss of their
previous income (Kon and Riordan, 1993; Visser et
al., 1993; Kon, 1995; Lunin et al., 1995). In the Latvian capital of Riga, where an estimated 6000 prostitutes are active, about 1000 of the poorest come from
rural areas or abroad to work on the streets. They are
often adolescents, and child prostitution has also been
L. Atlani et al. / Social Science & Medicine 50 (2000) 1547±1556
reported. Among 107 sex workers surveyed, unemployment and miserable living conditions were the main
reasons for their recruitment to prostitution (Konings,
1996).
Economic crisis also leads to temporary or ``seasonal'' sex work in foreign countries involving women
from the Community of Independent States (CIS).
Women facing severe hardships leave home and
become sex workers to secure the means for their
families' survival. Such situations are common in Central Asia and the Caucasus where poor women travel
abroad for short periods, mainly to Turkey, practice
commercial sex long enough to accumulate a small
amount of capital, buy goods for reselling, and return
home to open a small business.34 Temporary prostitution is also reported in the region particularly among
youth.
A study in St. Petersburg showed that 10% of teenagers and young adults consider prostitution as an
acceptable and legal way of making money (Afanasyev
and Skorobogatov, 1995). In Baku, the capital of
Azerbaijan, underground commercial sex occurs
among young women from well-educated families.
They are often students relying on money from their
families and educated along Muslim principles. The
girls enter prostitution for the luxuries associated with
it, especially when foreigners are involved. At the same
time, they continue to live with their parents, who are
unaware of their daughters' activities. The level of
STDs and abortion among them is quite high, indicating that condoms are rarely used in sexual relations.4
The borderline between this activity and more permanent forms of prostitution may not always be easy to
de®ne and may continue to shift as conditions change.
Knowledge of HIV is high among high-class prostitutes and those working in salons, massage parlours,
saunas and hotels, but condom use depends on the client. Knowledge remains low among those working in
railway stations and on the streets, most of whom do
not visit health services and almost never use condoms
(Kurova et al., 1998).
High-class prostitutes, ``call girls'' or those organised
in apartments or saunas may have more options for
self-protection such as condom use, while street
workers rarely can enjoy this luxury. Even in the
hotel-based sex industry, consistent condom use is
uncommon. Among 78 sex workers in three hotels in
St. Petersburg, only 44% reported using condoms with
every client (Platoshina and Chaika, 1995). A 1997
study in Kyrgyzstan showed that in bathhouses, bars
4
Field notes from visits to Baku, Azerbaijan, from work
commissioned by UNDP and conducted in 1997, 1998 and
1999 (3 months). Personal communications with local AIDS
activists, dermato-venerologists and gynecologists.
1553
and brothel apartments (kvartira), condoms were available and used, while on the street, condom use was
low (Oostvogels, 1997).
In addition, the high mobility among prostitutes in
the region may increase their vulnerability to HIV.
Many sex workers are engaging in prostitution abroad,
especially in Western Europe, for a short period before
returning home. Although many sex workers come
independently, the majority are recruited by international prostitution networks, which may entrap
them with promises of jobs as au pair domestics, nannies or the like. Therefore, although part of a well-organised sex business, these women may have little
awareness of health risks. Those working in Turkish
brothels are reportedly required by pimps to meet the
clients' demands and not use condoms. Furthermore,
many prostitutes operate illegally in rough conditions
characterised by considerable violence and crime. As
such, condom use and STD treatment are not their primary concerns (Konings, 1996).
The HIV±syphilis link
The dynamics of intravenous drug use Ð injection
culture and sexual and contraceptive behaviour Ð are
known to vary over time and over geographic locations. However, given the scope of the rapidly emerging injection-drug HIV epidemic in the region, the
potential exists for further spread of HIV through heterosexual transmission.
Sex workers are at risk of acquiring HIV through
both sexual and drug use behaviour. Wherever condom use is low, they represent one of the groups most
vulnerable to both HIV and STDs and, in a still lowprevalence epidemic, they are among the ®rst hit.
Few data are available on the prevalence of HIV
among prostitutes in the region. Only in the Ukraine
data indicate at national level a slow but persistent
increase of HIV among registered sex workers over
time: from a low 0.004% in 1993 to 0.4% in 1996
(Konings, 1996). A study in Kaliningrad, in the Russian Federation, reported a very high prevalence of
32% among 103 street sex workers; 33 were known to
be injecting drug users (Brunet, 1997; Liitsola et al.,
1998).
Among sex workers and their clients, STD rates
seem to have increased recently, raising a concern
about their potential role as co-factors in driving a second wave of HIV infection. In Lithuania in 1996, half
of 43 sex workers given a medical exam had an STD
(Konings, 1996). In Latvia, no prostitutes were HIVpositive, but rates of gonorrhoea (10.2%) and syphilis
(15.7%) were high (Kurova et al., 1998). In the Ukrainian city of Odessa, syphilis prevalence among a small
group of prostitutes was close to 10% in 1997. In St.
1554
L. Atlani et al. / Social Science & Medicine 50 (2000) 1547±1556
Petersburg, 46% of hotel prostitutes had at least one
STD in the previous year (Afanasyev and Skorobogatov, 1995).
Most of the former USSR countries are currently
experiencing a rapid increase in the incidence of syphilis. Since 1990, for instance, prevalence has increased
in Russia from 5.4 per 100,000 inhabitants to 270 per
100,000 in 1997. Rates of increase are much higher in
speci®c cities such as Kaliningrad where the syphilis
morbidity rate in 1997 was almost 40% higher (365
per 100,000) than in the rest of the country (Chaika,
1998). Similar trends and levels are reported in Belarus
and Kazakhstan, and to a lesser extend in Ukraine.
Other STDs such as gonorrhoea and chlamydia are
also reported to be increasing.
As with HIV, these epidemics appear to be rooted in
a combination of socio±economic factors, including
changes in sexual behaviour and norms (Westho€ et
al., 1996; Chervyakov and Kon, 1998), reduced access
to appropriate health services, and inadequacy of legislation related to STD control (Linglof, 1995; Tichonova et al., 1997). However, there is still no
con®rmation that the two epidemics will overlap and
create a major heterosexually-transmitted HIV epidemic in the future.
Discussion
Although evidence from the region remains limited,
there is certainly cause for alarm about the capacity of
current social conditions in the former USSR to generate an explosive HIV epidemic. Experience elsewhere
in the world, together with initial reports indicate that
injection drug use and commercial sex are increasing
due to the region's social and economic dislocation
and the accompanying psychological stress and alienation, especially among young people. Just as health
and welfare services deteriorate to a clearly inadequate
state, drug pricing and availability patterns are changing dynamically as international producers and traf®ckers take advantage of new opportunities, such as
the newly opened borders between Eastern and Western Europe.
However, an increase in drug consumption does not
necessarily imply an increase in drug injecting everywhere or, more signi®cantly for the HIV epidemic, an
increase in the sharing of injecting equipment and
addiction-related commercial sex activity. While evidence from some countries in the former Soviet Union
suggests that this is indeed the case (Ukraine), it has
not been demonstrated that HIV will reach other
groups through bridge populations as has been seen in
Thailand (Morris et al., 1996).
Sexual transmission patterns also may or may not
follow known routes. Here, the evidence of a dramatic
increase in syphilis and other STDs suggests at least a
potential for a second HIV wave, both for the
increased high-risk sexual behaviour taking place and
for the role of ulcerative STDs in facilitating HIV
transmission.
To forecast the directions of HIV spread in the former Soviet Union, more needs to be known about the
determinants of risk behaviours, the dynamics of the
HIV/STD epidemic, the sexual mixing patterns, and
the response to various interventions in vulnerable
groups. This supposes a shift from a narrow epidemiological perspective to a much broader comprehensive
approach that should include more qualitative and
quantitative work on behaviours and vulnerability factors. Individual behaviours occur in complex socio±
economic and cultural contexts, and analysis that
removes them from their broader settings ignores
essential in¯uences. With the collapse of the Soviet
Union, it is virtually impossible to disengage individual
risk behaviour from environmental and economic factors in determining and understanding vulnerability to
HIV. It is thus important to develop a holistic, ethnographic view of the cultural and economic context in
the region.
This in turn should lead to a focus not only on
interventions aimed at ``persuading'' individuals or
groups to adopt certain behaviours Ð still the most
common approach in the countries of the former
Soviet Union Ð but on interventions ``enabling'' them
to do so, or at least easing the way. Opportunities still
exist to prevent further spread of STD and HIV infections in the region through innovative enabling
approaches such as those implemented in Ukraine and
Kyrgyzstan.
However, experts have expressed concern about governmental policy responses in Russia and in other
countries such as Belarus. In Russia, various attempts
to develop sex education in schools and programs
among men having sex with men were prevented by a
coalition of political forces (Chervyakov and Kon,
1998). In many countries of the region, HIV/AIDS
prevention and care interventions are still impeded by
a social, and sometimes legal and ethical environment
which is not conducive to HIV prevention or to the
care and support of people living with HIV. Outdated
contagious disease laws and discriminatory regulations
remain in force in several countries; names and other
details of persons tested HIV-positive are often
recorded for contact tracing and surveillance; con®dentiality is at times compromised or non-existent; and
discrimination and stigmatisation often follow a positive HIV antibody test.
At the same time, the response from ``civil society''
remains generally weak. For decades, independent
grassroots action was prohibited, and volunteer work
L. Atlani et al. / Social Science & Medicine 50 (2000) 1547±1556
was limited to ocially sanctioned activities carried
out by state-directed mass organisations. This has
inhibited the development of community-based responses among those directly a€ected by the epidemic,
particularly people living with HIV (Atlani and Frasca,
1995). Today, civil society and non-governmental organisations dealing with HIV/AIDS are burgeoning.
However, they often lack capacity, mutual understanding and co-ordination of their activities. As yet, they
have still little in¯uence on national decision-making in
most of the countries of the region and remain isolated
both from the state apparatus and from the most vulnerable populations.
Because enabling approaches may require questioning and eventually challenging current norms regulating the politico±economic sphere and the power
relationships, and be perceived as calls for reforms,
many preventive HIV/STD interventions simply avoid
them in the former Soviet Union.
Acknowledgements
The authors want to thank E. Murat, Z. Takenov
and A. Wilson for help and useful discussions.
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