- Russia has the third-highest number of new HIV infections in the world
- A federal center reported 1.1 million diagnosed cases of HIV in Russia
MoscowAnna Alimova works on the front lines of Russia's growing HIV epidemic.
On a Friday night, the mother of two with a shock of bright pink hair stands outside a 24-hour pharmacy in a leafy Moscow neighborhood. She cheerfully offers plastic bags full of clean syringes to Russians dashing into and out of the store.
"Mostly drug users have hepatitis," she says. "And many of them have HIV."
According to the United Nations' UNAIDS program, Russia had the third-highest number of new HIV infections globally in 2015, behind South Africa and Nigeria.
Russian government statistics show that more than half of new infections are transmitted through intravenous drug use. And the rate of infection is rising.
Injecting eye drops
The street corner where Alimova is conducting her outreach is a makeshift shooting gallery littered with used syringes and empty vials of an eye drop sold over-the-counter in the pharmacy. Some Russian drug abusers inject tropicamide, which doctors normally use to dilate pupils, into their veins to amplify the effects of other substances.
Negative side effects of tropicamide abuse can include hallucinations, kidney pain, hyperthermia, tremors and suicidal feelings.
But it's the sharing of contaminated needles that is a main driver of the HIV epidemic sweeping the world's largest country.
Anna Alimova offers a bag of syringes, bandages and ointments to a man leaving a 24-hour pharmacy.
One man emerging from the pharmacy hesitates and then accepts Alimova's offer of clean needles. She asks about his health. He is strikingly gaunt, with dark shadows under his eyes.
The man, who won't give his name for fear of criminal prosecution for using drugs, tells her he was diagnosed with HIV 20 years ago and believes that's why he recently lost a dramatic amount of weight.
He says he lives with his wife, who is HIV-negative, and their child.
"Would you also like some free condoms?" Alimova asks. She then gives him a business card for the Andrey Rylkov Foundation, the small Moscow-based charity where she works with a handful of others to help protect the health and human rights of drug addicts.
A 'staggering' epidemic
The Russian Federal AIDS Center reports that infection rates grew at an average of 10% annually for the past five years. In December, the center said that there were more than 1.1 million diagnosed cases of HIV in Russia.
"It is staggering," said Dr. Masoud Dara, head of the the World Health Organization's Joint Tuberculosis, HIV/AIDS and Hepatitis Program.
For the past decade, the problem has only been getting worse.
"This is not something that suddenly happened overnight," said Vinay Saldanha, Moscow-based regional director of UNAIDS, the United Nations organization designated with coordinating the fight against HIV and AIDS. "This has been an HIV epidemic that is today quite large, but it has been growing for the better part of the last 15 years in the Russian Federation."
Experts like Saldanha argue that the worsening HIV epidemic in Russia is due to a perfect storm of factors, including questionable government policies and neglected societal problems.
Chances for survival
In the 36 years since cases of the virus were first reported in the United States, health care professionals around the world have amassed a vast amount of research on HIV and AIDS.
The WHO provides a road map for societies to battle against the spread of the disease.
But in Russia, several recommendations with a proven track record for harm reduction have yet to be fully implemented.
Take "Masha" (not her real name), who has been addicted to heroin for nearly 20 years. In 2003, she tested positive for HIV as well as hepatitis C. In the 14 years since, she says, the government-run AIDS clinic she visits for periodic testing has never provided treatment for managing HIV.
"So far, they tell me the status of my virus is considered normal," she says.
In Russia, barely a third of all diagnosed HIV cases are treated with antiretroviral drugs, Dara said.
"This is one of the key areas the World Health Organization is in dialogue with Russia to change," he said. "People with HIV (should) be put on treatment as soon as possible. This would increase their chance of survival and decrease the risk of transmission."
Stigma and discrimination
Masha says she also faces discrimination for having HIV.
When she recently went to a doctor's office to treat the open ulcer on her leg -- a painful consequence of her drug abuse -- he refused to examine her when he learned that she had HIV.
"He said, 'get out of my office,' " Masha recalled, tears streaming down her cheeks.
"We talk about an HIV epidemic, but what we're really seeing is an epidemic of stigma and discrimination," UNAIDS's Saldanha said.
Health experts say the real number of people living with HIV in Russia is probably much higher than the official statistics because many people in vulnerable communities are afraid to come forward for testing.
Requests for comment from the Russian Health Ministry have not been successful.
The search for methadone
International health organizations recommend methadone as a substitute for street drugs.Alternatives like methadone are orally administered, removing the risks associated with needle injections, the cause of so many new infections in Russia.
The Russian government, however, has banned all methadone clinics. Critics argue that legalizing distribution of methadone substitutes for street drugs would simply promote addiction in Russian society.
When she was a drug user, the Rylkov Foundation's Alimova says, she wished she had a legal methadone alternative to help wean her off of a decade-long addiction to heroin.
Though she's been clean for six years, she believes methadone would be an enormous help to many other users who are hopelessly addicted to street drugs.
"They could come back to society," Alimova said. "They could lead a full life."
Health care experts also say clean needle distribution programs have proven successful at helping reduce the spread of HIV.
And yet, the Andrey Rylkov Foundation runs the only needle distribution program in all of Moscow, a city with more than 12 million inhabitants.
Alimova, who kicked her habit years ago with the help of the foundation, is one of only 15 employees.
They take turns each night of the week, taking a small bus equipped with medical supplies to street corners in different neighborhoods.
One night, a steady stream of opioid users walks up to the parked bus. Most of them are strikingly gaunt. One man scratches at the open sore on his leg. Another has two swollen black eyes.
"I was boxing," he mumbles.
"Can I have some twos and threes?" one of the visitors asks, referring to 2- and 3-milligram syringes.
Rylkov Foundation worker Maksim Malishev gives each visitor plastic bags full of syringes, bandages, ointments and doses of naloxone, a medication that can counteract opioid overdose. He also offers secondhand clothing from the back of the bus and used books stacked on a shelf.
"God bless you," one man says before leaving.
"More than half of these people don't have official residence in Moscow," Malishev says. Without this residence permit, known as a propiska, visitors are not entitled to state health care in the Russian capital. Routine medical problems often go untreated until it becomes too late.
Foundation workers are also equipped with a quick HIV test, which they can conduct within minutes through a mouth swab.
Alimova has had to inform several of her "clients" that they are HIV-positive.
"We usually try to support the person and tell the truth about HIV, that it doesn't mean you will die soon. That you can get medical help," she says.
'Every country reaches its tipping point'
Last year, a controversial government decision put the work of the Rylkov Foundation at risk.
The Ministry of Justice labeled the foundation a "foreign agent" because it receives funding from foreign sources and because it has been accused of engaging in political activities.
The organization's main donors include the Levi Strauss Foundation and the Global Fund, two philanthropic groups that focus on battling HIV/AIDS and other communicable diseases.
"There have been, unfortunately, a number of community-based or nongovernmental organizations over the last couple of years that have been designated as foreign agents," said Saldanha of UNAIDS.
He hopes a Russian government strategy against HIV, announced last year, will alleviate pressure on groups like the Rylkov Foundation by providing more direct government funding to homegrown civic organizations.
Saldanha says recognition of the scale of the HIV epidemic has now reached the highest levels of the government. Statistics show that the virus has spread far beyond the most traditionally vulnerable communities, such as intravenous drug users, sex workers and gay men, to the wider population, UNAIDS says.
"Every country reaches its tipping point," Saldanha said. "In the Russian Federation, I think it was the wake-up call that came last year as a million cases of HIV infection were diagnosed.
"This is no longer an issue only for the health sector," he added. "You're starting to see an impact of HIV on demography, on fertility, on the number of children born with HIV, on economic productivity."
A nightly struggle
Outside the 24-hour pharmacy where Alimova is conducting her outreach, traffic picks up as midnight approaches. Cars blaring loud music pull up to the street corner, and passengers dash to and from the pharmacy.
Join the conversation
See the latest news and share your comments with CNN Health on Facebook and Twitter.
A jittery woman named Katya shows up and gives Alimova a hug. In return, she gets a bag full of syringes and bandages.
Before she jumps into a waiting taxi, Katya points to Alimova and says, "these guys are here so that diseases don't spread."
Moments later, a quartet of young men come over to the Rylkov Foundation bus. Two men immediately fill their new syringe with a vial of tropicamide.
Under nearby trees, they jam the stuff into their veins. Then they disappear into the Moscow night.
Journalists Mary Ilyushina and Darya Tarasova contributed to this report.