MOSCOW -- Every Wednesday afternoon, Petya Nikitenko invites into his office some of the men and women Russia usually tries to ignore. Some have spent time in jail or have sold sex. All have abused drugs. Now that they have come for help, Nikitenko counsels them on the dangers of using intravenous drugs. One of the risks is that, by sharing needles, they will become infected with HIV.
What he does not do - and what HIV-prevention programs in Russia often cannot do without bringing unwelcome attention from the government - is distribute clean needles that could help prevent the spread of the virus.
No one disputes that getting addicts into treatment - and permanently off drugs - is the best response to addiction. But that conflicts with the realities of the disease. Many intravenous drug users aren't ready to quit, and many are unable.
Needle exchange as a "harm reduction" strategy, as the name suggests, tries to reduce the damage from drug use. After 20 years of experience with this approach, the majority of public health experts agree that giving sterile needles to addicts can prevent HIV infections and save lives.
More than 40 countries, from the United States to Kyrgyzstan, allow needle exchanges. The Joint United Nations Programme on HIV/AIDS (UNAIDS), which is coordinating the global fight against AIDS, calls the practice an "essential component" of HIV-prevention efforts. The World Health Organization says there is "no convincing evidence" that needle exchange programs cause unintentional harm; landmark research that followed drug users in Baltimore, where needle exchange was introduced in 1994, found that distributing needles did not encourage drug use. Also, the National Research Council and the Institute of Medicine declared in 1995, based in part on studies in Baltimore, that exchange programs reduced the number of HIV infections without increasing drug use.
But here the thinking is different.
"We tried, but it was a taboo in Moscow," said Nikitenko, whose organization in 1999 launched the only type of needle exchange the city has tolerated - one that authorities didn't know about.
He started small, distributing needles to addicts he knew and trusted, and who trusted him. As word of the exchange spread, a line formed outside his center's front door in a bleak residential neighborhood. After less than two years, he ran out of money and needles. His would-be backers wanted him to get approval from city authorities, but every attempt was rebuffed.
"Knowing the situation," Nikitenko said, "it's better to keep silent now."
Officially, about 342,000 Russians are infected with HIV. Public health experts in Russia and the West estimate that the real number exceeds 1 million, by far the highest figure in Europe. Russia's Federal AIDS Center, meanwhile, projects that the number of HIV infections by 2020 could rise to at least 5 million, and perhaps as many as 15 million - more than 10 percent of Russia's population.
The sharing of dirty needles accounts for at least 70 percent of the officially registered cases. But even as the government prepares to highlight AIDS and other infectious diseases at the Group of Eight summit that opens Saturday in St. Petersburg, the government continues to treat needle exchanges as a problem rather than a solution.
Authorities have refused to promote them, a stand that reflects a deeply rooted stigma surrounding drug use as well as a mistaken belief that needle exchanges encourage it. Officials' lack of support for the programs might also reflect a potentially serious miscalculation about the potential social and economic costs of an AIDS epidemic.
Russia hardly needed an ally for its resistance to needle exchanges. But it found one in the United States.
American public health policy can affect medical policies worldwide, creating a momentum hard to reverse.
In 1988, when needle exchange programs were relatively new, Congress passed legislation banning the use of federal funds for such programs. Its action reflected Congress' uncertainty over two issues: whether exchanges reduced HIV transmission, and whether they might encourage drug use.
By the late 1990s, a wide body of research backed the programs' effectiveness.
A 1997 study published in the British medical journal The Lancet found annual decreases in HIV infection rates among drug users in cities with needle exchange programs. In cities without such programs, infection rates increased by about 6 percent, the researchers at Australia's University of Melbourne reported.
A later survey comparing infection rates in 100 cities in two dozen countries had even more convincing findings: The infection rate declined 19 percent a year in communities with needle exchange programs, while in communities without such programs, infections increased 8 percent.
But Congress, during the Clinton administration, left the ban on federal funds in place, in the belief that providing needles to addicts at taxpayer expense sent the wrong message about drugs.
The Bush administration has taken things further by lobbying to limit access to needle exchanges globally.
In late 2004, for example, the State Department asked the U.N.'s Office on Drugs and Crime not to promote needle exchange programs in any of its work. Antonio Maria Costa, as head of that U.N. office, pledged to review his agency's publications. Its Web site subsequently dropped references to needle exchanges.
The U.S. Agency for International Development, the government's lead agency for foreign aid, has spent nearly $6 billion on HIV/AIDS programs. In February 2005, it asked its offices worldwide to verify that they were complying with the regulation barring grants to programs that include needle exchanges.
A few months later, a U.S. representative at a meeting of the U.N. Commission on Narcotic Drugs lobbied successfully against any mention in the commission's final report of needle exchange or any other "harm reduction" techniques, such as needle sterilization kits.
Russia's official resistance to needle exchange has left many harm reduction programs struggling for money and for support from local officials. About 60 such programs remain open, fewer than in 2002.
"Harm reduction in Russia was difficult to roll out, but it's even more difficult now," said Anna Moshkova, former program officer for the Open Society Institute's International Harm Reduction Development program. Government officials, she said, "are creating lots of obstacles."
Dr. Aleksei Mazus, head of the Moscow AIDS Center, need look no farther than his own hospital to see the link between drugs and AIDS. By his count, three-quarters of his patients are intravenous drug users. The hospital has 150 inpatient beds and an outpatient center that treats 300 clients a day.
Yet Mazus remains deeply skeptical, even scornful, of needle exchange programs.
"Giving out a syringe is just a first step," he said, suggesting that proponents of harm reduction seek to make drugs acceptable. "How far will this lead you?"
'Crisis among crises'
Since 2001, according to government statistics, the number of new HIV infections among drug users has declined, a drop that officials say could be owed in part to addicts' refusing to be tested for fear of arrest on drug charges.
But transmission has moved beyond groups at highest risk. Larger numbers of people are becoming infected through heterosexual sex, and more HIV-positive women are passing the virus on to their infants.
Other health issues, however, generate greater concern.
Russia has one of the world's highest rates of cardiovascular disease, more than triple the rate in the United States and accounting for more than half of all deaths here. Forty thousand people each year die of alcohol poisoning. More than 30,000 each year die of tuberculosis. Russia is also the only industrialized country where life expectancy is falling: A male born today has a life expectancy of 58 years - 12 years less than in the United States and six less than 40 years ago.
So, for Russia, HIV is merely "a crisis among crises among crises," as described by researchers at the University of Wisconsin, Madison and the Center for Strategic and International Studies in Washington. Even among health professionals working with AIDS patients, the researchers found, AIDS is viewed not as the most pressing priority but as one of an overwhelming multitude.
And for a decade, needle exchanges have operated in a legal limbo.
Law enforcement agencies first assumed that the programs were illegal, on the grounds that any action that "inclines" someone to consume illicit drugs was a crime. Changes in the law allowed exchanges if the needles were distributed to prevent infectious disease. But in the past two years, activists have been waiting for new guidelines from the Health Ministry and the Russian Federal Drug Control Service.
"In principle, the Federal Drug Control Service is not against needle exchange programs," Aleksandr Mikhailov, the agency's deputy director, said in an interview. "But these programs must be regulated."
He outlined the agency's requirements: Needle exchanges must operate out of government facilities such as hospitals or drug clinics. Addicts who use the services must register. Only licensed health professionals can distribute the clean needles.
Mobile needle exchange units, which reach addicts on their own turf, would apparently have to shut down. Recovering drug addicts, a critical part of HIV prevention efforts, would be barred from distributing needles. So-called "secondary exchange," in which outreach workers rely on addicts to distribute needles among their networks, would also be banned.
Perhaps most important, activists say, addicts who want to use clean needles might be deterred from seeking them if they can't do so anonymously.
A matter of morality
In St. Petersburg, Russia's second-largest city, municipal health officials openly support harm reduction programs, such as the needle exchanges that a group called Humanitarian Action runs in a hospital and from a bus.
Some days, as many as 60 addicts push open the back door of the bus and climb aboard; other days, as few as a half-dozen. Patience is one of the most important attributes for the health workers inside.
They collect dirty needles, usually dozens at a time, from the addicts. Clean needles are handed out in unmarked plastic bags. Drug users can undergo anonymous blood tests, get information about infectious disease and receive counseling.
Aleksandr Tsekanovich, executive director of Humanitarian Action, has reached out to local police. Some officers said that they understood and appreciated his work, but that he had to understand theirs: The number of drug arrests by a department is a measure of its success.
U.N. experts say needle exchange programs must reach 60 percent of the drug addicts in a given community to have an impact on the spread of the AIDS epidemic. Aleksandr Komarovsky, a young psychiatrist who works on the bus about 30 hours a week, says that as many as 150,000 drug addicts might live in St. Petersburg. Needle exchanges, he says, reach no more than 10 percent.
Moscow, by contrast, does not even allow the exchanges, despite a large network of organizations willing to run them and an indisputable need. The number of drug addicts in 2004 was officially nearly 23,000, but, according to drug specialists, in reality perhaps 10 times that.
The city's campaign against HIV and AIDS focuses on fidelity. It ignores all other behaviors. And this spring, the Moscow City Council proposed banning non-governmental groups that receive money from abroad for HIV prevention work. The tasks that the groups do, the council said, including handing out condoms and clean needles, are "immoral."
Even among doctors, addiction is often viewed less as a medical condition than as a moral flaw best addressed by jail.
In December, on World AIDS Day, Gennady Onishchenko, the nation's chief epidemiologist, estimated that 100 Russians a day become infected with HIV. Asked what role needle exchanges and other harm reduction work could play in slowing the virus' spread, he said, "If you ask me what is the most effective method, I would say, 'Hang pimps on aspen trees.'"
Sun reporters Douglas Birch and Alec MacGillis contributed to this article from Baltimore.