From the American People? Donors Ignore the Plight of an Imprisoned HIV Educator

Richard Elovich

The US, UK, and Global Fund all funded Maxim Popov's successful HIV-prevention work, for which he was arrested by Ukraine's repressive government. Why have these powerful donors abandoned him and his family?

Rewire is covering global AIDS issues in conjunction with the International AIDS Conference underway this week in Vienna.  A protest held today in Vienna by AIDS activists sought to raise awareness of Popov’s plight.

One person is missing among the 30,000 professionals and representatives of multiple governments gathering in Vienna for the International AIDS Conference this week.  Maxim Popov, a young AIDS doctor from the Central Asian Republic of Uzbekistan, is in prison sentenced to seven years hard labor for his AIDS prevention work funded by the United States, and for charges of fiscal mismanagement that the funders themselves say are baseless. One hopes that Ambassador Eric Goosby, who leads U.S. efforts on AIDS and the U.S. delegation to Vienna, will voice some badly needed public support for Popov and other AIDS workers who have done what is asked of them by the US government, and in the process run afoul of their own.

More than 100 organizations have signed a petition expressing concern about the harsh sentence passed by Uzbekistan on the 29-year-old AIDS worker.  Popov’s alleged offenses include disseminating culturally inappropriate” AIDS education material (that is, publications acknowledging the existence of homosexuality) and handing out clean needles to injecting drug users, which the government termed “misuse of injection equipment.”  In reality, the materials for which Popov was sentenced were produced and vetted by the United Nations, and distributed as part of US HIV-reduction efforts.  The injection equipment was part and parcel of work on needle exchange, an approach whose efficacy is well established to reduce HIV, and which the Uzbek government itself recognized as essential through the establishment of 220 needle exchange points attached to state run clinics across the country. 

To anyone familiar with the situation, the Popov case is more about Uzbekistan’s increasingly paranoid response to any form of independent association organized by its citizens, especially  those receiving international funds, than it is about HIV or the moral well being of the nation.  Many AIDS NGOs, seen as suspect as a result of their foreign support, have been closed in Uzbekistan, and their leaders pressured. 

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But the Popov case is also about the dynamics that find international donors encouraging and incentivizing young health professionals to organize NGOs in repressive societies, and then leaving the NGO staff alone to face the consequences. AIDS work, like other health and development efforts funded by the United States, has always been about HIV prevention on the one hand, and about emphasizing American values of openness and civil society engagement on the other.  The intertwined nature of US AIDS work and US foreign policy is underscored by the fact that contractors are encouraged to ensure that everything that the State Department funds bears a two-by-two inch red, white and blue logo bearing the  phrase “from the American People.”  In a country like Uzbekistan, that logo can become a target on the back of young professionals like Maxim Popov.

So where were the American people, and the US Agency for International Development, when Popov was charged and sentenced for distributing materials as they asked? According to observers, Popov’s wife had to sell their house to pay for his attorney’s fees, and received no support from the local embassy or the US state department during his trial.  The United Kingdom, which had also hired Popov for AIDS work, was similarly silent.  The Global Fund to Fight AIDS, Tuberculosis and Malaria, which emphasizes the importance of NGO engagement the millions it gives to Uzbekistan and was cited in the court documents used to sentence him, also said and did nothing. 

Popov received no visits from ambassadors or international representatives during his prolonged pre-trial detention, in which he was allegedly subject to cruel and inhuman treatment, or after he was transferred to  prison.  His wife and young child are still struggling to survive, and have received no financial support. No foreign donor has subsequently issued a public statement on Popov’s plight. The silence is all the more cruel given that these same international actors routinely tour the non-governrmental organizations like Izis, the one ran by Popov, and use the stories as examples of success and reasons for more funding back in their own capitals.

Uzbekistan, through criminalization of Popov, may make a radical of an ordinary health professional.  Popov was a young psychologist trying to square his knowledge of good HIV prevention with his professional practice, and saw himself neither as an AIDS or human rights activist.  A recently published Russian language account by a friend writing anonymously describes Maksim as frightened and asking for company with the police demanded the names of his needle exchange clients.  At the police interrogation, though, the friend described how Maksim held his fear in check and instead provided rational explanations for why breaching confidentiality would break the trust that permitted him to reach drug users who needed help.

USAID, DFID, and other international donors should engage in a similar review of basic moral principles.  Foreign funded organizations run by idealistic young professionals quickly raise jealousies from local governments. When the US, the UK, or the Global Fund support NGOs to take on AIDS education, the contracts should be two-way agreements—you do the HIV prevention, and we watch your back and help protect you from those who might be angered by your taking our money and doing a good job.

Instead, months after Maxim’s arrest, the U.S. State Department still advises that it is “following the case closely”—no doubt trying to gauge whether raising a forceful argument about Maxim might endanger efforts to secure use of Uzbek military bases for use against Afghanistan and other American interests. 

This kind of diplomatic double speak and do-nothingness is unconscionable.  The US, the UK, and the Global Fund should be speaking with one voice in Vienna to urge freedom for Popov and to reassure other AIDS workers that  if foreign funded AIDS work gets them in political hot water, the donors are there to protect them.  Otherwise, a contract “from the American people,” becomes as tragic and empty as the offices of Maxim Popov’s organization and the others closed by governments that would rather HIV, and people like Maxim, just went away.

Richard Elovich, PhD, is an HIV expert who has worked on US- and UN-funded projects in Central Asia.

Roundups Sexual Health

This Week in Sex: News From the HIV Epidemic

Martha Kempner

This week in sex: Scientists report the first case of HIV transmission to a patient adhering to PrEP protocols, two studies show a new vaginal ring can help women prevent HIV, and young people still aren't getting tested for the virus.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

With the death of Nancy Reagan, the 1980s AIDS crisis is back in the national spotlight. But, of course, HIV and AIDS are still ongoing problems that affect millions of people. This week in sex, we review scientists reporting the first case of HIV transmission to a patient adhering to PrEP protocols, two studies showing a new vaginal ring can help women prevent HIV, and evidence that young people still aren’t getting tested for the virus.

First Case of HIV Transmission While on Truvada

Last week, Canadian scientists reported on what they believe to be the first HIV infection in a patient who was following a PreP (Pre-Exposure Prophylaxis) regimen.

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PrEP is a method of HIV prevention. By taking a daily pill that contains two HIV medicines, sold under the name Truvada, individuals who are HIV-negative but considered to be at high risk of contracting the virus can prevent infection. Studies have found that PrEP is very effective—the Centers for Disease Control and Prevention estimates that people who take the medication every day can reduce their risk of infection by more than 90 percent from sex and by more than 70 percent from injection drug use. One study of men taking PrEP found no infections over a two-and-a-half-year period.

PrEP is less effective when not taken regularly, but the new case of reported PrEP failure involves a 43-year-old man who said that he took his medication daily. His pharmacy records back up that assertion. The man’s partner has HIV, but is on a drug regimen and has an undetectable viral load. The man did report other sexual encounters without condoms with casual partners in the weeks leading up to his diagnosis.

Dr. David Knox, the lead author of this case study, notes that it is difficult to know if a patient really did adhere to the drug regimen, but the evidence in this case suggests that he did. He concluded, “Failure of PrEP in this case was likely due to the transmission of a PrEP-resistant, multi-class resistant strain of HIV 1.”

Experts say, however, that they never expected PrEP to be infallible. As Richard Harrigan of the British Columbia Center for Excellence in HIV/AIDS told Pink News, “I certainly don’t think that this is a situation which calls for panic …. It is an example that demonstrates that PrEP can sometimes be ineffective in the face of drug resistant virus, in the same way that treatment itself can sometimes be ineffective in the face of drug resistant virus.”

Still, some fear that the new study will add to the ongoing debate and apathy that seem to surround PrEP. While some experts see it as a must-have prevention tool, others worry that it will encourage men who have sex with men to forgo using condoms and perhaps increase their risk for other sexually transmitted infections. Still, only 30,000 people in the United States are taking the drug—an estimated one-twentieth of those who could benefit from it.

A New Vaginal Ring Could Help Women Prevent HIV Infection

Researchers have announced promising results from two studies looking at new technology that could help women prevent HIV. The dapivirine ring, named after the drug it contains, was developed by the International Partnership for Microbicides. It looks like the contraceptive ring, Nuvaring, and is similarly inserted high up into the vagina for a month at a time. Instead of releasing hormones to prevent ovulation, however, this ring releases an antiretroviral drug to prevent HIV from reproducing in healthy cells. (A ring that could prevent both pregnancy and HIV is being developed.)

The two studies of the ring are being conducted in Africa. One study recruited about 2,600 women in Malawi, South Africa, Uganda, and Zimbabwe. It found that the ring reduced HIV infection by 27 percent overall and 61 percent for women over age 25. The other study, which is still underway, involves just under 2,000 women in seven sites in South Africa and Uganda. Early results suggest that the ring reduced infection by 31 percent overall when compared to the placebo.

Both studies found that the ring provided little protection to women ages 18-to-21. Researchers are now working to determine how adherence and other biological factors may have impacted such an outcome.

Young People Not Getting Tested for HIV

A study in the February issue of Pediatrics found that HIV testing rates among young people have not increased in the last decade. The researchers looked at data from the Youth Risk Behavior Survey (YRBS), which asks current high school students about sexual behaviors in addition to questions about drugs and alcohol, violence, nutrition, and personal safety (such as using bike helmets and seat belts). Specifically, the YRBS asks students if they’ve ever been tested for HIV.

Using YRBS data collected between 2005 and 2013, the researchers estimated that 22 percent of teens who had ever had sex had been tested for HIV. The percent who had received HIV tests was higher (34 percent) among those who reported four or more lifetime partners. Overall, male teens (17 percent) were less likely than their female peers (27 percent) to have been tested.

Researchers also looked at data from the Behavioral Risk Factor Surveillance System, which asks similar questions to young adults ages 18 to 24. Among people in this age group, between the years of 2011 to 2013, an average of 33 percent had ever been tested. This review of data also found that the percentage of young women who get tested for HIV has been decreasing in recent years—from 42.4 percent in 2011 to 39.5 percent in 2013.

The authors simply conclude, “HIV testing programs do not appear to be successfully reaching high school students and young adults.” They go on to suggest, “Multipronged testing strategies, including provider education, system-level interventions in clinical settings, adolescent-friendly testing services, and sexual health education will likely be needed to increase testing and reduce the percentage of adolescents and young adults living with HIV infection.”

Analysis Sexual Health

The Ban on Federal Funding for Needle Exchanges Puts Poor Women in Danger

Jonathan Neeley

Thanks to restrictive laws and limited health-care options, halting the spread of HIV and hepatitis C is often a losing battle—one that puts women substance users in particularly high danger.

Intravenous drug use has surged in the United States over the last decade. Though media narratives around the uptick tend to focus on crime rates or overdose, the risk of contracting HIV or hepatitis C through used needles is also a major public health concern. And thanks to restrictive laws and limited health-care options, halting the spread of these infections is often a losing battle—one that puts poor women in particularly high danger. Yet Congress still refuses to provide the federal funding that could be key to combating this crisis.

Many intravenous substance users are at heightened risk of contracting HIV or hepatitis C from sex work or sexual violence. According to a 2010 study by the Reference Group to the United Nations on HIV and Injecting Drug Use, between 15 and 66 percent who use injection drugs engage in sex work. Daniel Raymond, the policy director at the Oakland, California-based Harm Reduction Coalition, noted that clients often offer to pay sex workers more for unprotected sex. He also added that in some places, law enforcement can point to condoms as evidence of prostitution, which discourages sex workers from carrying them.

The UN report also stated that women who use intravenous drugs are subjected to higher levels of violence, including sexual abuse. Among other mental, emotional, and physical consequences, these assaults can also lead to sexually transmitted infections.

For poor or homeless women with HIV or hepatitis C, accessing care options at all can be nearly impossible. In some states—California, for example—Medicaid doesn’t cover hepatitis C treatments unless a patient has very advanced liver disease and can prove either six months of substance abstinence or is in a treatment program.

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And if those women become pregnant, that can lead to serious ramifications for their children, too. Pregnant women with untreated HIV have a 25 percent chance of passing the virus on to their babies during gestation or delivery. Meanwhile, according to Emalie Huriaux, the director of federal and state affairs at the San Francisco-based advocacy group Project Inform, only about 5 percent of women with hepatitis C transmit the virus to their baby—but infants who do contract it are at risk for developing cirrhosis or liver cancer as adults. This is not to mention the hardships that come from trying to raise an infant as a parent with an expensive, often debilitating disease.

In order to combat this cycle of complications, many grant-funded centers across the country provide free resources that promote healthy living for women, including condoms and other contraceptives, referrals to prenatal care, and lists of people potentially dangerous to sex workers. Many also offer treatment for HIV and hepatitis C; the former can help drive down a pregnant woman’s viral load before birth and protect babies from infection during breastfeeding, and the latter can help women keep from spreading the infection further. Additionally, evidence shows that even when infections are not a factor, prenatal care can reduce the effects of substance use on perinatal outcomes.

Unfortunately, care providers say, drug users are often met with suspicion or even punishment when they need medical care. As a result, they are often hesitant to seek out help when they need reproductive services.

“There’s such a tremendous amount of stigma within the health care system around people who use drugs,” said Whitney O’Neill Englander, government relations manager for the Harm Reduction Coalition. “And women who use who have children or are pregnant have the highest amount. You see it play out in people taking women’s children away from them based on no evidence they’ve harmed them. You hear a lot about people calling child protective services if there are children involved. It’s pretty routine in terms of if a mother says she has used drugs while pregnant.”

This understandable fear of going to the doctor, or being honest about their drug use if they do go, puts mothers’ health—and the well-being of their fetuses, children, and communities—in further jeopardy.

One way to overcome this reluctance among substance users, advocates say, is to combine reproductive health care with needle exchanges, which provide individuals with sterilized syringes in exchange for ones that could be contaminated.

“Needle exchanges are among the only way to get women who are at high risk in the door,” Mary Wheeler, outreach program director at Randolph, Massachusetts-based Healthy Streets, told Rewire. “When you’re using, you need needles on a daily basis. Syringe exchange programs get more people involved in health-care treatment.”

Needle exchange programs, which became popular in the 1980s, have proved to be key in driving down HIV and hepatitis C infection rates; they also offer counseling services to users trying to curb the habit. Unfortunately, the practice has regularly faced controversy from both law enforcement and policy-makers. In many states, the vague wording around exchange legality can leave advocates vulnerable to arrest. The Obama administration lifted a ban on federal funding for exchange programs in 2009; in 2011, Republicans in Congress reinstated it. As of now, there are only 227 reported programs total in the United States.

Many groups around the country, such as Wheeler’s Healthy Streets, use their syringe exchange programs to connect users to other health services like prenatal care. They label themselves as “harm reduction organizations,” meaning that in addition to such referrals, they prioritize giving drug users and sex workers tools to keep them safe, such as clean needles, filters, and antiseptic towelettes. This positions them as a partner in preserving women’s health, advocates say, rather than a foe.

“Syringe exchange programs are vital for these women in order to have an ally who has the mother’s best interest in mind,” said Catherine Paquette, mobile services manager at the Washington, D.C., harm reduction service HIPS.

Harm reduction as an approach is controversial because many legislators and members of the public make the knee-jerk assumption that it signifies approval of drug use. But it’s worth stating clearly that syringe exchange programs are not federally illegal; they just can’t be paid for by federal dollars. Aside from keeping programs from using money they’re already receiving (for HIV testing from the Centers for Disease Control and Prevention, for instance) that limitation also bottlenecks funds that could be coming from state and local sources.

“States are not undertaking syringe programs because they see the federal ban as sort of a scarlet letter,” Michael Collins, policy manager at the Drug Policy Alliance, told Rewire. “When the ban was lifted during the Obama administration’s first two years, we did see an uptick in states’ interest and funding. When we have the ban in place, it’s incredibly counterproductive for states having syringe programs.”

In Massachusetts, for instance, only ten syringe exchange programs can receive funding from the state’s health department, and each needs approval from its respective local government. Wheeler’s organization, Healthy Streets, is limited to running a voucher program that routes clients to pharmacies where they can receive clean needles because the city Randolph doesn’t allow exchange programs.

“I think people are still unwilling to look at substance use as a public health issue,” said Wheeler. “People are scared of folks who inject drugs. The idea in Massachusetts is still pretty strong that if you have a needle exchange in your community, drug use and crime increases, despite all the evidence that that’s not true.”

Meanwhile, in Washington, D.C., Paquette’s organization, HIPS, started its syringe exchange program in 2007 after Congress lifted a rider that kept the district from funding the group. Using money from the D.C. Health Department, the MAC AIDS FUND, and the Syringe Access Fund, the group’s syringe exchange program reaches not only intravenous drug users but also transgender women who use needles to inject hormones. It also provides ancillary supplies that make injecting safer, like cookers and cotton swabs.

Since D.C. first allowed needle exchanges, there’s been an 80 percent drop in HIV rates among drug users. Still, HIPS could do more if the federal funding ban was not in place, like apply for federal grants to expand and enrich syringe exchange programming. Also, employees whose salary is even partially supported by one of the CDC grants that funds HIPS’ HIV prevention services cannot help with the organization’s syringe exchange branch. In practical terms, that means that while certain HIPS workers can administer an HIV test, lead a support group, or hand out condoms to clients, they have to stop what they’re doing and go get a colleague if those same clients want trade dirty needles for clean ones.

“It’s an administrative annoyance,” said HIPS Executive Director Cyndee Clay. “It takes up time and resources that without the federal ban we wouldn’t have to worry about. The CDC is all about high-impact prevention but can’t talk syringe exchanges. It’s just silly.”

It doesn’t look like the ban will be lifted any time soon, particularly now that Congress is wholly under Republican control. Because it needed compromise on a number of controversial issues in order to reach an agreement in final negotiations, Congress passed the 2014 budget as an omnibus appropriations bill. And since the exchange funding ban is packaged alongside the Affordable Care Act and a number of abortion laws in the Departments of Labor, Health and Human Services, and Education appropriations bill, Democrats did not make rescinding it a priority.

Advocates anticipate that rolling back the ban would require a focus on the issue that many Democrats may not be willing to give. Among many Republicans, Collins says, syringe exchange funding is frequently conflated with government support for drug use.

“The nuances of harm reduction and what harm reduction is not are often present in those offices,” said Collins. “There are a number of Republicans in positions of power, mainly Hal Rogers, who want this ban to remain in place, and I think part of it is a belief that states and local authorities can fund this out of their own pocket, and part is this misguided notion that syringe programs encourage heroin use.”

In reality, harm reduction through syringe exchange benefits the general public as well as injection drug users. In August 2013, then Seattle police chief Jim Pugel wrote a well-circulated op-ed calling Washington “healthier and safer” thanks to the state’s exchange programs.

Syringe exchange programs also save taxpayers money because the costs of HIV and hepatitis C prevention are far less than the costs of treatment: A CDC study found the average cost of a prevented HIV infection by way of a syringe exchange program to be between $4,000 and $12,000. The cost to treat a person infected with HIV? $190,000. With the cure for hepatitis C being marketed at $1,000 per pill, or $80,000 total, the cost comparison is similar. This is not to mention the indirect benefits that come from connecting users with preventive care, including reproductive services.

Perhaps the best reason to re-examine the federal ban on needle exchange funding, however, is to remember the death toll caused by the diseases that exchanges help fight. According to AVERT, an international AIDS and HIV charity, 2011 saw more than 20,000 AIDS-related deaths in children and adults in North America; the CDC reports that hepatitis claims the lives of up to 15,000 people in the United States annually. Given what we know about syringe exchange programs, Congress could be doing more to curb these numbers.

“I work for a number of different issues and this is probably the most frustrating because it’s the most common-sense policy,” said Englander. “You save lives, connect people to treatment, have support of law enforcement. It’s really not acceptable that it’s not utilized because of political reasons. We’re breeding a very expensive health problem.”

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