Our reporter joins the St.Petersburg-based Humanitarian Action Fund on an outreach to learn how people who are not usually supposed to be saved from the epidemic: commercial sex workers and injecting drug users, are rescued.
The Outskirts of St.Petersburg. Evening time. Ordinary bedroom suburb: faceless high-rise buildings, shopping malls. About a kilometre away is an abandoned building formerly used as a cinema. A battered blue bus is parked nearby. From time to time, some people get in through the rear doors.
– Hi! What "guns" do you need? 2 ml, 1 ml? You got any dirty ones? Throw them in the basket.
The man pulls out several syringes and needles out of his plastic bag and places them in a special bucket. Just like in a drug store; he explains that he needs some ointment, wipes and new syringes.
Explosions and Cop Hats
This is the bus of the charitable fund Humanitarian Action — an organisation engaged in an HIV preventive treatment and harm-reduction programme in St. Petersburg since 1997.
The non-profit organization now owns three similar buses: two minibuses for outreaching drug users and sex workers by moving from one location to another and offering HIV tests to the wider population; and one larger (blue) bus that patrols areas that have the largest number of drug addicts. As a rule, their regular offtakers help them find their "clients".
In addition to the "reception desk", the blue bus also has two offices where you can talk to a psychologist, get tested and consult a doctor.
The bus kitchen includes: a table, a few chairs, a stove with a gas bottle, a heating system, hangers, and even a toilet. All this was done by the Fund's employees themselves.
Helen is a local old-timer who's been working at the Fund for more than twenty years since it was founded. She shows a badge with a picture of a half-burnt bus – the Fund's very first bus (the current bus is already its third), with the date stamped just like on a memorial board: 20/01/1997 – 11/05/1999.
While parked next to a building one night in 1999, the bus was set on fire. However, it didn't burn to ashes that time. The next morning, they trailed it to the nearest parking lot; the next day, some unidentified thugs attacked the bus again, blowing it up.
During the first several years, the police regularly attempted to prevent the bus team from working, and the traffic police kept on stopping the bus. Then the employees parked the bus, removed the number plates and lived in it for a month. In another instance, the police broke in with machine guns.
This is how they worked
Olga enters the bus. She looks about 50 years old, with an open and relaxed face, wearing a cute casual jacket. She announces that she is going to tell "everything as it is, no lies", but begins with hiding her hands with blood-red swollen fingers — a common identifier of a drug addict.
She is 43 now, and has been on the junk since 16. She has been coming to the bus for over a year since she first heard about it. She lives nearby, right off the street, and it's convenient for her. She first receives psychological help in the bus:
"You may grab brochures on HIV and AIDS, then we can help you go through rehab, and you can be supported in court. Well, you may also take syringes, vitamins, sterile wipes, ointments and water for injections. And of course, naloxone (the antidote that blocks opioid receptors during an overdosage — editor's note)."
However, she has never taken naloxone herself. But she has resuscitated her friends before. First aid courses were held here, in the bus. "I've performed artificial resuscitation before, and thank heavens I managed to save that person. It was still heroin back in the day. Now everyone's hooked on methadone, it's a violent drug." She stopped being shy and hiding her hands. "Of course, it's easier for me to come on the bus. Because the hospital is far away, it takes time to go there and bother about it. And here, within a walking distance, one can get everything, even common advice."
Olga's story is just like any other: in high school, she went on a summer vacation out of town. Poppy straw was growing there, so it was processed into drugs.
"Everything was new and interesting," she recalls with regret. "You get high, sleep, eat sweets, and don't understand anything. Then I began to buy dope." Olga still wonders why she started taking it. She finds only one explanation — all her friends did it: at a party, everyone was given a syringe, and they said: "Press your hand", and got everyone dosed. She says it was not that pleasant, and she never felt high in a “fantasy world”.
At a party, everyone was given a syringe, and they said: "Press your hand", and got everyone dosed. She says it was not that pleasant and she never felt high in a “fantasy world”.
But as time went on, it got worse and worse. I started shooting up every day, and got seriously addicted. In the end – hospitals, rehabs, escapes. Four times I was sent for "occupational therapy" – it's when dope addicts are put in a religious community where they try to recover from the addiction through some type of work, for example, in the garden or by reading the Bible. Nothing worked. Then I served two years and eight months in prison under Article 228 Part 2 of the Criminal Code (Illegal Acquisition, Storage, Processing of Psychotropic Substances without the Intent to Sale on a Large Scale") — I was caught while buying the stuff.
According to Olga, she managed to swallow her dose, but the cops still planted some evidence to have a cause to arrest her. In prison, she did not take any drugs, but "reconsidered everything." She was finally released and proceeded to live a normal life. And then a quarrel with her husband threw her off-balance – and it all started again... She was now injecting herself with drugs every two days. "It becomes like an everyday chore. Last winter, I stayed at a detoxication hospital four times, but that did not help."
"Waving" and "Surfing"
Humanitarian Action continues the work started by French "Doctors of the World", namely: outreach, syringe exchange, case management," the Fund's Deputy Director Alexey Lakhov explains.
In 1997, the first Russian bus hit the road to help drug users. Then in 2001, we began helping sex workers and launched a mobile office especially for them (a "mini bus").
Now, an average of about 20 to 40 people drop into the big bus each day. However, in the late 1990s, the situation was much tougher.
"Right up until 1999, two prominent markets in the city sold and bought drugs," Elena narrates. "When a drug addict would visit, the sellers would literally pull him or her apart, both asking him or her to buy their drugs. We'd park the bus right next to the market, and 200-250 drug users would pass by this mobile office every day, from morning till eleven in the evening. We hardly had time to keep records. The visitor's cards had no codes, just numbers: one, two, three…"
Back then, many of the drug users lived in the basements of the residential complexes on Dybenko St., where one of the markets was located. Almost every basement had an occupant: they bought their stuff right there and got injected right away.
Then someone overbought the market and drove all the drug dealers out. At the same time, heroin then took over the city, pushing out the hunks (poppy-based home-made opiates). Centralised dealing became a thing of the past; they were all now dispersed across the city, and began selling and buying through the hucksters in apartments and yards. Elena compares it with sepsis and explosion. She says these were very tough times.
"That's when the first wave of the HIV epidemic in the city broke out," Alexey Pirumov, another employee of the Fund, picks up. "Those who had never taken drugs through the syringe before the arrival of heroin said they would never try it. But they began by taking the heroin through the nose first, and then later – started injecting it. They all shared their syringes, the so-called "accordeons", and also their injection needles, using their nails to check if they were sharp enough ... Almost no-one from that time is left."
Evgeny Orlov, a social worker at Humanitarian Action who also works part-time as the bus driver, agrees with them, continuing the sea metaphor: if those years it was like a "wave", now it is rather like a "swash" that sometimes brings ashore new drugs, and people "transship" to them. However, heroin has almost completely disappeared from the city. Today, everyone's using the so-called street methadone.
"It's now quite rare to hear that someone is on heroin," confirms drug user Olga. "Most are now using methadone. It is much more expensive, but stronger in concentration. It has a longer-lasting effect." Olga herself uses street methadone.
The amount of methadone that has invaded the streets of St. Petersburg is like no other anywhere else in Russia. Recently, the local chief narcologist presented the figures on the number of the overdoses. He confirmed that St. Petersburg comes out right at the top. "But then the smoking mixtures ("salts") appeared in the city," Lakhov remarks with regret. "We hoped at least this would pass us by."
He explains that there are several problems with the salts: firstly, they hit the phyche extremely hard and destroy the brain, and secondly, nobody knows how to cope with the overdose. Naloxone is used to counter the effects of opioid drugs (all poppy straw derivatives, including heroin and methadone), however, nobody really knows how to bring those who take the salts back to their senses.
Darknet and New Challenges
Now only the drugs themselves, but also their sales mechanisms, are changing. Hucksters have become a thing of the past, and nobody buys from them any more; you can now buy everything online, or get your stash of drugs on the street.
Moreover, the authorities have clamped down on chemist shops, and they no longer sell drug-containing substances through the back door. This has all led to changes in the outreach methods employed.
Humanitarian Action is already changing its aid-lending format: its outreach team has begun to carry out its mission in health-care facilities, including hospitals, dispensaries and correction centers more frequently. They park their mobile office near the facilities, or work directly inside the premises.
Additionally, there are almost no more sex workers offering their services on the streets. Almost all of them work from parlour houses where the owners do not allow them to take drugs and if caught, may kick them out. Some choose to simply rent their own apartments and flag their clients online. In fact, all those who offer their services from the streets are drug addicts who simply want to earn a dose. Hooking on the roadside is the most extreme kind of sex work. You are exposed to all sorts of things. Among other things, there is a great risk of falling in the hands of sadists or the police.
"There've been cases where the clients steal their money, film them secretly, rape them, beat them or cut them with knives," explains Olga Shakirova, an employee of the Fund dealing specifically with sex work. "I wouldn't even call the street girls "sex workers" in the proper sense of the word. They make money to be able to get drugs."
"I can easily live without it."
While we're chatting, a group comprising of several people enters the bus. They must all be 35-40 years old. Everyone's casually dressed, just like every other man or woman. Anyone with an "untrained eye" would never be able to tell that they are actually drug users. Someone is coming here for the second time, and they've brought their friends.
They trust Elena and her colleagues: they are friends, not foes. They speak the same language, without preachment or moralization.
They each collect a package with everything they need.
"Need some ointment?" Elena asks.
"Yes, that red one, against thickening," answers Irina (she asked to use a pseudonym).
"You can also be tested here," Irina addresses her friend Ksenia (she asked to use a pseudonym) who's come along with her. "I, for instance, didn't know that I had hepatitis.
I've been living with it since the 1980s... No, I'm not gonna get tested. I recently got tested for HIV. Everything's fine.
Two from the group, Ivan (he asked to use a pseudonym) and Irina, are married. They both look 35 years old. They are here for the second time. They say it's not always possible to buy syringes from the chemist stores, as there are very few 24-hour chemist stores, and some stores just don’t sell syringes.
Ivan has been living with HIV and hepatitis C for more than ten years. He's brought a plastic bag of used syringes for exchange. He explains why: "I can share my clean [syringes] with friends. I don’t need to mark my injector all the time. I remember how it used to be. We bought the heroin on wholesale, and we all used the same syringe and we shot up one by one. And now it's cool; you can inject yourself, bring the used injectors here and get the new ones."
His path to hard drugs lay through club drugs. He for many years hung out and "rocked hard" at the clubs, where one can easily buy ecstasy and amphetamines.
He remembers how he once had a 7-day marathon on drugs without any sleep. It was not really easy to comedown after those drugs, and he began visiting a friend who was on heroin. When he once had a "hangover", he decided to try some heroin. "It worked like magic." The effect was pleasant, so this is how I got hooked. "And now I am on methadone."
"It's all nonsense – all these stories about stealing stuff from your parents, taking things out of the house... If a person is normal, he or she will be sane anyway"
While examining the posters in the bus (one has instructions on how to react in case of an overdose, the other depicts the problems associated with drug abuse and how to pass rehabilitation), Irina joins the conversation: "It's all nonsense – all these stories about stealing stuff from your parents, taking things out of the house... If a person is normal, he or she will stay sane, no matter what he or she is on." She assures that she herself uses drugs "as a light doping" tool and, of course, she "can easily do without them."
In October, it was reported that the Ministry of Health had compiled guidelines for the "Development of a Standard Interdisciplinary Programme for HIV Prevention in Key Population Groups." The new guidelines not only contain neutral terminology in relation to key groups, but also mention effective assistance methods, such as a "harm reduction" programme involving the distribution of syringes, healing ointments, needles and alcohol wipes. Moreover, the new recommendations suggest active cooperation between the Government and non-profit organizations.
According to Lakhov, the Guidelines document is "excellent". But it brings up a number of questions, in particular, to do with how this programme will be implemented. "It would be nice to understand how such programmes can be implemented and managed at the regional level. How to build cooperation? Who's responsible, and to what extend? How is efficiency calculated?"
"We'll soon have a mobile team that will be visiting people with limited mobility living with HIV," the Fund's Deputy Director announces. "The team will consists of a doctor from the AIDS facility, a nurse, our social worker and a psychologist. We'll visit not only those who find it difficult to get to the AIDS facility because of disease, but also, for example, mothers with small children who simply cannot get to the health center." We plan to make 300 visits per year. The nurse will conduct the tests, the doctor will conduct the medical checkup, and the social worker will bring antiretroviral therapy "by-procuration".
The St. Petersburg's AIDS facility and Botkin Hospital now have low-threshold centers with employees who previously worked at Humanitarian Action. The Fund's position is simple: if the government is obliged to provide free therapy, then people should be directed to the governmental institutions. The more constructive the relations with the medical institutions are, the more loyal they will be to the patients. Drug users are very "specific" patients who are prone to skip both therapy and the visits to the doctors.
Anxiety, Timidity, Stigma
I was going to join another team for a new outreach location in Otradnoye, a city half-hour's drive from St. Petersburg. However, the Fund team decided not to take me along.
It's so risky to bring a reporter along; the place is not mature yet, and those bus visitors who are not used to it may run away.
"We parked in the city's central square, and then moved to the railway station," Olga Shakirova narrated the next day. "There was a total of 13 drug users and a few common people who just came in for a test. All of them over 30 years old. While the bus was parked, my team-mate and I walked through the neighbouring yards looking for people and inviting them to our bus."
It was the third time that Humanitarian Action came to Otradnoye. The locals have not got used to it yet, and many of them think it can be a set-up. And someone just does not believe that this could be real. So I literally had to call people and ask them to come and to also bring their friends.
So far, the outreach workers have failed to reach out to sex workers in the city; no one talks about them, including taxi drivers who usually know everything.
It is extremely difficult to establish contact and build trust with drug addicts.
"People come in for the first time, and we just start to communicate with them, asking them about their health, problems, activity status. We always encourage them to not be shy to ask for help whenever they need it", says Alexey Pirumov. "They are very sensitive, and always understand that we sincerely want to help. We are probably one of the few organizations that sincerely ask: "How are you?"
He clarifies that one of the key points in the communication process is "not to blow the brain out."
"I don't have any education; in my life, the medical syringe is the heaviest thing I've ever held in my hands. I not only earn money here, but also meet guys who are just like me. I try to help them as much as I can," says Alexey.
He's been with the Fund for 10 years. One day, his wife, also an addict, brought him here. He had serious health problems, and almost couldn't walk. He was "all rotted and flaked off." The Fund helped him. The girl's mother and stepfather were also drug users. He finally decided to give up drugs, and got a job at Humanitarian Action. "The result: his wife became paralysed. Stepfather died. Well, but I'm still here. A good end to a bad story," he says.
There's an old joke. A politically incorrect one. It goes: "Any addict will finally quit drugs. But some can take their entire lifetimes to do it." The harm-reduction logic discussed above is actually meant to "help survive the day." For each of them. Not demanding to immediately give up drugs or a dangerous lifestyle.
Alexey survived and lived the day. Many drug users and sex workers from his generation did not. Had the bus picked them up, they would have survived. Fortunately, there are three such buses in St. Petersburg. No such mobile service exists in many other regions of the country. And so, the "good end" to the "bad story" in those regions is much like a black swan compared to the northern capital.
Key performance results of the Fund for 2017
• 12,609 people received preventive treatment.
• 7,585 examinees were tested for HIV (with 187 HIV positives, which is 2.35 %).
• 1,777 representatives from key groups were tested for HIV (with 749 HIV positives, which is 42.15 %).
• 727 out of 936 (77 %) examinees were monitored up to their visit to the St.Petersburg AIDS facility.
• 309 patients were monitored up to their visit to Hospital for Tuberculosis No. 2.
• A total of 1,069 people are being assisted on a permanent basis.
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