Global Policy Forum

By Steven Lee Myers

As the cafes and clubs began to course with night life one recent evening, Andrei V. Bykovsky and Yuliya B. Sokolova cruised around in a white van, patrolling the newest front of Russia's AIDS epidemic.

They stopped first near the Mother of Russia statue, then along Moskovski Prospect, then beneath the Cosmonauts Memorial. They easily found what they were looking for: young women, many in their teens, most racked by drugs or desperation, selling themselves on the street for a trifle — less than $7.

Mr. Bykovsky and Ms. Sokolova passed out condoms from a green backpack and tried to coax the women to visit their basement clinic, which offers exams and advice to slow the spread of H.I.V., the virus that causes AIDS.

In Kaliningrad, as in all of Russia, the virus has spread almost entirely through the use of intravenous drugs. But the next step in the disease's march across Russia, which has one of the fastest-growing AIDS epidemics in the world, is starting to be documented here: a sharp increase in H.I.V. infections through sex."

The figures began to grow in the last year," said Yelena Y. Kozhenkova, a doctor who rides along in the van on its nightly missions. "But we could see it coming even earlier."

What makes Kaliningrad's experience significant is what it forebodes for Russia as a whole. This region of more than 900,000 people, isolated from the Russian mainland and plagued by the social and economic ills that came with the Soviet Union's collapse, was the first hit hard by an explosion of cases among drug addicts and has been a harbinger of the disease's spread ever since.

In 2001, the percentage of new H.I.V. infections in Kaliningrad attributed to sexual contact jumped to nearly 30 percent of the total, compared with only 4 percent when the epidemic struck here with a vengeance in 1996, regional officials said. Prostitution appears to have been the primary source of these infections, but officials now fear that the trend signals the spread of H.I.V. beyond the shadowy world of drugs and criminality.

Tatyana N. Nikitina, the director of the Kaliningrad region's government AIDS center, attributed the increasing numbers to men contracting the virus from prostitutes and then spreading it to their wives and girlfriends.

"The disease has reached beyond the circle of the consumers of sexual services," she said. In all of Russia, sexually transmitted H.I.V. infections accounted for a little more than 5 percent of new cases last year. But if previous patterns hold, officials warn, the number will rise, as it has here.

"The processes under way in Russia now could be observed in the Kaliningrad region five years ago," said Vadim V. Pokrovsky, the country's leading AIDS expert.

AIDS came belatedly to Russia, a fact attributed to the Soviet Union's nearly closed society. The first case was reported in 1987, but infections did not reach epidemic proportions until the mid-1990's, with an explosion of intravenous drug use.

In the last year alone, the total number of registered H.I.V. infections more than doubled to 177,354, from 87,177 in 2000. With screening still fairly limited, officials estimate that the total number of Russians actually infected may have already reached one million.

Dr. Pokrovsky has begun to warn, with some alarm, that AIDS could spread in Russia the way it has in Africa, infecting broad swaths of the population.

For now, drugs remain the leading cause of H.I.V. infections, particularly in Russia's notoriously overcrowded, drug-infested prisons. Some estimates suggest that the country has more than a million hardened drug users, most of them young men, but increasingly young women, as well.

They are also among the most sexually active age group, in which rates of other sexually transmitted diseases, like syphilis, are also high.

"Given the high odds of transmission through needle sharing, the fact that young people are also sexually active, and the high levels of sexually transmitted infections in the wider population, a huge epidemic may be imminent," a report by the United Nations program on H.I.V. and AIDS, or Unaids, warned in December.

In Kaliningrad, the spike in infections through sex has overshadowed some of the progress the region has made in slowing the disease's spread.

The number of new cases each year has dropped from a high of 1,109 in 1997 to 491 last year and only 215 in the first six months of this year, according to the region's AIDS center. To date, there have been 3,763 cases of H.I.V. infection.

Although its rate of infections per capita is higher than in Western Europe, Kaliningrad no longer has the highest rates in Russia, having been surpassed by the regions of Irkutsk and Khanty-Mansi, in Siberia. Officials here have attributed the slowing of the growth to greater awareness of the risks, stricter policing of drugs and to one of the unintended consequences of the United States campaign in Afghanistan: a drop in drug exports that has driven up prices for heroin.

Officials also cite the increased use of clean disposable syringes, which are distributed by the basement clinic, run by a psychologist named Aleksandr A. Dreizin, that sends out the van teams each night.

With the number of cases involving sexual contact increasing, the clinic's mission has evolved from an exclusive focus on addicts, although drugs and prostitution are inseparably intertwined.

Dr. Dreizin has hired a gynecologist to offer women free exams. With money from the World Health Organization and private donors, the center also distributes condoms and pamphlets on safe sex.

An estimated 3,000 women work as prostitutes in Kaliningrad. Dr. Dreizin noted that new clusters of prostitution have appeared on Kaliningrad's borders with Poland and Lithuania, where they serve long lines of motorists waiting to cross. A French organization has donated a bus to help the clinic reach those women more easily.

Of the prostitutes who are reached, Dr. Kozhenkova said, many remain wary even of health authorities. "It's a complex of guilt and shame," she said. "They are afraid even of a gynecological clinic."

Mr. Bykovsky and Ms. Sokolova passed out condoms from a green backpack and tried to coax the women to visit their basement clinic, which offers exams and advice to slow the spread of H.I.V., the virus that causes AIDS.

In Kaliningrad, as in all of Russia, the virus has spread almost entirely through the use of intravenous drugs. But the next step in the disease's march across Russia, which has one of the fastest-growing AIDS epidemics in the world, is starting to be documented here: a sharp increase in H.I.V. infections through sex.

"The figures began to grow in the last year," said Yelena Y. Kozhenkova, a doctor who rides along in the van on its nightly missions. "But we could see it coming even earlier."

What makes Kaliningrad's experience significant is what it forebodes for Russia as a whole. This region of more than 900,000 people, isolated from the Russian mainland and plagued by the social and economic ills that came with the Soviet Union's collapse, was the first hit hard by an explosion of cases among drug addicts and has been a harbinger of the disease's spread ever since.

In 2001, the percentage of new H.I.V. infections in Kaliningrad attributed to sexual contact jumped to nearly 30 percent of the total, compared with only 4 percent when the epidemic struck here with a vengeance in 1996, regional officials said. Prostitution appears to have been the primary source of these infections, but officials now fear that the trend signals the spread of H.I.V. beyond the shadowy world of drugs and criminality.

Tatyana N. Nikitina, the director of the Kaliningrad region's government AIDS center, attributed the increasing numbers to men contracting the virus from prostitutes and then spreading it to their wives and girlfriends.

"The disease has reached beyond the circle of the consumers of sexual services," she said.

In all of Russia, sexually transmitted H.I.V. infections accounted for a little more than 5 percent of new cases last year. But if previous patterns hold, officials warn, the number will rise, as it has here.

"The processes under way in Russia now could be observed in the Kaliningrad region five years ago," said Vadim V. Pokrovsky, the country's leading AIDS expert.

AIDS came belatedly to Russia, a fact attributed to the Soviet Union's nearly closed society. The first case was reported in 1987, but infections did not reach epidemic proportions until the mid-1990's, with an explosion of intravenous drug use.

In the last year alone, the total number of registered H.I.V. infections more than doubled to 177,354, from 87,177 in 2000. With screening still fairly limited, officials estimate that the total number of Russians actually infected may have already reached one million.

Dr. Pokrovsky has begun to warn, with some alarm, that AIDS could spread in Russia the way it has in Africa, infecting broad swaths of the population.

For now, drugs remain the leading cause of H.I.V. infections, particularly in Russia's notoriously overcrowded, drug-infested prisons. Some estimates suggest that the country has more than a million hardened drug users, most of them young men, but increasingly young women, as well.

They are also among the most sexually active age group, in which rates of other sexually transmitted diseases, like syphilis, are also high.

"Given the high odds of transmission through needle sharing, the fact that young people are also sexually active, and the high levels of sexually transmitted infections in the wider population, a huge epidemic may be imminent," a report by the United Nations program on H.I.V. and AIDS, or Unaids, warned in December.

In Kaliningrad, the spike in infections through sex has overshadowed some of the progress the region has made in slowing the disease's spread.

The number of new cases each year has dropped from a high of 1,109 in 1997 to 491 last year and only 215 in the first six months of this year, according to the region's AIDS center. To date, there have been 3,763 cases of H.I.V. infection.

Although its rate of infections per capita is higher than in Western Europe, Kaliningrad no longer has the highest rates in Russia, having been surpassed by the regions of Irkutsk and Khanty-Mansi, in Siberia. Officials here have attributed the slowing of the growth to greater awareness of the risks, stricter policing of drugs and to one of the unintended consequences of the United States campaign in Afghanistan: a drop in drug exports that has driven up prices for heroin.

Officials also cite the increased use of clean disposable syringes, which are distributed by the basement clinic, run by a psychologist named Aleksandr A. Dreizin, that sends out the van teams each night.

With the number of cases involving sexual contact increasing, the clinic's mission has evolved from an exclusive focus on addicts, although drugs and prostitution are inseparably intertwined.

Dr. Dreizin has hired a gynecologist to offer women free exams. With money from the World Health Organization and private donors, the center also distributes condoms and pamphlets on safe sex.

An estimated 3,000 women work as prostitutes in Kaliningrad. Dr. Dreizin noted that new clusters of prostitution have appeared on Kaliningrad's borders with Poland and Lithuania, where they serve long lines of motorists waiting to cross. A French organization has donated a bus to help the clinic reach those women more easily.

Of the prostitutes who are reached, Dr. Kozhenkova said, many remain wary even of health authorities. "It's a complex of guilt and shame," she said. "They are afraid even of a gynecological clinic."

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