BEING A NON-CONFORMIST in Moscow today is not an enviable position – as my first interview there in the summer of 2013 confirmed. It was with a campaigner on gay rights I had contacted from London. He came with an interpreter, but the interpreter wanted to start with an apology. He was standing in at the last minute. The planned interpreter had been taken into hospital. She had been part of a small, twenty-strong demonstration the day before that had protested outside the State Duma against a new law making it a criminal offence to ‘promote’ homosexuality. There they had been set upon by several hundred supporters of the new laws: Orthodox Christian activists and members of pro-Kremlin youth groups. Riot police had moved in and arrests had taken place, almost all of them of gay rights activists. According to the man I was interviewing, it was not the first occasion that violence had been used against the supporters of gay rights. ‘It has happened two or three times before,’ he said. ‘Every time, our demonstrations have been broken up. Every time, people have ended up in hospital. The police do nothing about it. No one is prosecuted.’

Two weeks after I left Russia, a Gay Pride march in St Petersburg was attacked by opponents. Seven of the marchers were taken to hospital with injuries and another sixty were arrested and detained for hours in police stations. This is not a new development. The British campaigner Peter Tatchell was arrested and roughed-up four times for taking part in successive Moscow Gay Pride parades, and other stories of beatings (and worse) come from around Russia. As for the new law itself, it bans ‘the propaganda of non-traditional sexual relations’ to children. The untrue insinuation is, of course, that children stand in particular danger from gay men. This was certainly the excuse that President Putin used in interviews before the Winter Games in Sochi, while his Sports Minister, Vitaly Mutko, told The Guardian that the law was intended to protect the rights of children in the same way that they should be protected from messages promoting alcoholism or drug abuse.

In fact, the laws go beyond even the spurious defence of protecting children. They effectively make it illegal to suggest that gay relationships are equal to heterosexual ones or to distribute material on gay rights; Peter Tatchell believes that even information on safe sex may also cross the legal line. In June 2013 – twenty years after the Stalinist-era law that punished homosexuality with up to five years imprisonment was abolished – the Duma passed the new laws by a majority of 436 votes to nil. We may be in post-Soviet Russia but glasnost has made precious little difference. The opinion surveys show that 90 per cent of the Russian public approve the changes and that almost three quarters say that homosexuality should not be accepted by society. This is truly a homophobic country.2

Gays are not the only minority group who have no effective say in Russia today. If you are concerned with reducing the spread of HIV, which is what this book is all about, then the position of sex workers is crucial in almost every country. There is no easier way for the virus to be transmitted than through women and men who, by definition, have sex frequently with partners they do not know. It is not difficult to prevent transmission. The modest condom is not a revolutionary health promotion aid and, in countries that take sex work seriously, condom use among sex workers is both encouraged and is high. Not so in Russia. Rather than encourage sex workers to carry condoms, the police confiscate them.

One (admittedly small) survey conducted in St Petersburg suggested that four out of five sex workers had had condoms taken from them by the police. In other cases the very possession of condoms has been used in court as evidence of sex work. One 24-year-old woman working in St Petersburg said that the police simply wrote in her arrest report: ‘Had condoms in her possession.’ The police intimidate sex workers to the point that some simply hand over their condoms once the police arrive. An obvious effect is that, rather than discouraging unprotected sex, this policy promotes it. Prostitution remains an offence in Russia although – with a hypocrisy which typifies most other countries – it is tolerated at the price of police corruption and extortion.

Yet, even when taking into account the persecution of the gay population and the exploitation of sex workers, there is no doubt which group is bottom of the Russian pile. Moscow is not like San Francisco where gay men still predominate in the total of HIV casualties. Here there is no question which is the biggest group at risk. Injecting drug users may be a small part of the problem in Western Europe, but in Russia and much of Eastern Europe they dominate the picture. Dirty needles and dirty syringes have spread the virus like wildfire to the point that Russia now has one of the fastest growing epidemics in the world.

In 2011 there were 60,000 new Russian cases of HIV; in 2012 there were over 70,000. Even in most countries of sub-Saharan Africa new cases increase but the rate of increase has reduced. Officially around 700,000 Russians are registered as living with HIV, but no one thinks that is a true measure. For a whole range of reasons many do not come forward for testing. They may fear the stigma in their town or village if the information leaks out – as it may well do. They may not want to come into contact with officialdom. They may not want to go onto the register of drug addicts and face some of the consequences that may result like the loss of a job in a country where unemployment is high. Or they may simply feel reasonably well at an early stage of the disease.

Some think a more accurate figure of the infected would probably be between 1.5 million and 2 million. More moderately, Professor Vadim Pokrovsky, the head of the Russian Federal Aids Centre, estimates the total at 1.3 million. Even that figure puts prevalence in Russia on a par with some sub-Saharan African countries once population is taken into account. According to official figures, about 20,000 Russians died from Aids and Aids-related illness in 2012 – although again the official figures are suspect and the real figure is likely to be at least double that. Where there is no dispute is in isolating the major reason for this continuing tragedy. Around 60 per cent of those living with HIV are injecting drug users. In the last few years heterosexual sex leading to HIV has become a growing part of the problem, but even this is partly because drug users have infected their partners or spouses. In contrast, the difficult-to-believe official figures claim that infection by men having sex with men is almost minimal. Given the prejudice, discrimination and now legal measures directed against them, it is hardly surprising that gay men do not volunteer information on their sexual orientation.

So why do drugs occupy such a dominating position in Russia? The official explanation is that the explosion in drug use dates from ‘the American led invasion’ of Afghanistan in 2001 and the vastly increased cultivation of the opium poppy that followed. One estimate is that opium production increased by no less than four times. The increased supply of heroin certainly did not help Russian efforts to stem the trade, but it is not remotely the whole story. Drug use did not start in 2001, but long before that. It was given particular impetus in the early 1990s after the collapse of the Soviet Union, the opening up of international borders and the political and social turmoil that typified the time. Unemployment and poverty added to the problems, together with young people’s desire to experiment and push the boundaries of their new freedom. The number of drug users referred for the first time to drug treatment centres increased by over six times between 1990 and the start of the Afghanistan action.

Injecting is cheaper than smoking, where the user needs more heroin to produce the same effect, but heroin is not the only problem. If the price of heroin climbs or is limited because of a bad harvest then it will be diluted when sold on the street. The user needs more to get the same ‘high’, and the other option is to turn to cheaper, homemade alternatives which can also be more powerful. A notorious and dangerous example is krokodil (crocodile) named after the way it leads rapidly to scaly skin and much worse. It is made from a series of ingredients including codeine, alkaline used to clear drain blockages, petroleum from lighter fuel, and the red phosphorus from matches. All mixed and injected. To curb its use the authorities have now stopped the over-the-counter sale of codeine, but no one doubts that addicts will find other ingredients and other products.

On the face of it, Russia would seem an open and shut case for harm-reduction policies. The availability of clean needles and syringes would cut off the transmission route of HIV among injecting drug users; the controlled supply of methadone would take drug users off injecting and offer the potential of taking them off drugs altogether. Around the world many other countries, quite apart from Britain, have established beyond any reasonable doubt that clean needles, syringes and methadone is a policy that works and can all but eliminate this method of transmission.

You might think that you don’t need a crystal ball to predict the results of harm-reduction policies when the evidence is so clear. In Russia, however, such policies are rejected out of hand. Dr Sergey Muraviev from the Ministry of Health says: ‘Russia is against methadone treatment. Drug users can’t be treated with drugs. Our aim is to take people off drugs altogether. Methadone leads to the death of patients.’ His words are echoed by Dr Gennady Onischenko, who until very recently was the Chief State Sanitary Physician and who, in spite of this rather strange title (at least to British eyes), had a wide responsibility for public health. He is now an adviser to the Prime Minister, Dmitry Medvedev. His opposition to methadone is absolute. ‘There is not enough evidence it works,’ he says, echoing the words of the Edinburgh police thirty years ago. ‘If we make drugs legal then it will damage the overall position.’ We should not be totally surprised at the Russian approach today. Throughout the twentieth century there was an unequal battle between the traditional psychiatrists, called narcologists, who specialised in alcoholism and drug dependency and believed that addiction was a mental illness best dealt with in an asylum or a labour colony, and a few physicians who supported maintenance as a means to a more or less normal life. The story is set out by a Russian historian, Dr Alisher Latypov, who says that the characteristic response of Communist officialdom to both alcoholism and drug dependence was to back the traditional psychiatrists. The dependent were ‘morally depraved’ and ‘degenerate’ and certainly not the kind of people who should be treated with kid gloves. In the 1920s the main debate was how quickly they could be forced off their addiction – abruptly, rapidly (within one to two weeks) or gradually (one to two months). In Moscow the abrupt method held sway. Among the supporting theories put forward to justify the hard line was that compulsory work inside a labour colony was an effective form of therapy, and had the added advantage that it could be organised on a self-supporting basis without placing a financial burden on the state. Even more optimistically, it was hoped that the Communist state would provide its own inherent solution by establishing human rights and ending the economic exploitation which was common to capitalism, which the Soviets blamed for drug addiction.

There were occasional breaks in this line of repression. For six years at the beginning of the 1930s there was in effect a maintenance programme in what was then Leningrad (now, after a referendum, back to its old name of St Petersburg). Morphine and heroin addicts were maintained on opiates (at a reduced level) on the basis that much of their inherent problem was their constant concern about the cost of obtaining the drugs and the inevitability of ‘an underground life’. The authors of the scheme claimed significant success, including one patient whose case has a total resonance today. He had used morphine and heroin for eighteen years and had been treated unsuccessfully by narcologists three times. He was unemployed and his whole body was covered with sores. Very soon after enrolling on the maintenance programme he found a job and switched from using drugs intravenously to an oral solution of heroin. Other cases were equally successful but then the programme was caught up in a wave of Stalinist repression which could not tolerate the idea of the drug dependent being treated with such ‘generosity’.

A more difficult question for the authorities was what to do with the ‘hero addicts’. These were the men wounded fighting in the Second World War and who became dependent on morphine. The supply of opium was crucial to ease their pain. During the war all the harvest from the Kyrgyz poppy fields had to go to the front and anyone trying to divert the harvest was shot on the spot. Once the war was over the soldiers who had become addicts could hardly be abandoned. Maintenance treatment was continued but, as the narcologists made clear, it was for the ‘soldier heroes’, not the villains and degenerates who began to dominate the addiction figures as the years went by. Today there is no doubt what the policy is: no clean needles, no syringes and, most of all, no methadone.

The theory that you cannot use narcotics to maintain and hopefully withdraw the users from their addiction prevails over alternative claims put forward by the few campaigners brave enough to say that the Russian government’s policy is not only a nonsense, but is also responsible for thousands of unnecessary deaths. In the words of one Russian I met who was working in the field, ‘They persist in looking on drug users as criminals not patients. Their one and only goal is to force them onto abstinence.’ Another told me: ‘The official attitude is that there should not be an easy way to get off drugs.’ The Moscow-based Andrey Rylkov Foundation agrees, saying ‘Russian drug treatment standards are outdated and based on repressive approaches that were in practice during Soviet times.’ The foundation is a grassroots organisation established in 2009 to advocate for humane drug policies, including opioid-substitute treatments like methadone. They quote the view of one official who characterised the official approach as ‘you suffer – and next time you won’t do anything bad’.

The sanctioned treatment is one of withdrawal from opioids altogether. In Moscow I asked a senior doctor how this was organised. He rather wearily mopped his brow. There were, he said, a hundred different programmes. At its best, treatment might consist of three to twelve days of detoxification followed by several months of outpatient supervision or treatment in a rehabilitation centre. The gaping hole in the policy is this: there is no shortage of state-run detoxification centres but, by themselves, they will rarely lead to a drug-free life. So much depends upon rehabilitation and the follow up. Here the facilities do not remotely match the demand, with the effect that the overwhelming majority relapse back into drug taking. ‘The doctors see them coming back and coming back,’ said one researcher. ‘They are clean for twenty days and then go back to the same environment and the same dealers.’

In 2006 one rare independent survey, of almost 1,000 injecting drug users in ten Russian regions, by the Penza Anti Aids Foundation showed that almost 60 per cent of those who had made use of the state treatment system had gone back to using drugs within a month of finishing their treatment course. More than 90 per cent had relapsed within a year. This finding was confirmed by the Russian Federal Drug Control Agency which in a 2009 report said that over 90 per cent of drug treatment patients resumed the use of illegal drugs within a year.

Another survey carried out with injecting drug users in Volgograd and Barnaul showed that, although most users received detoxification, only a third received any kind of rehabilitation. One of the chief fears which prevented drug users coming forward was the effect that this could have on their employment prospects. Those who do come forward are registered as drug users by the local drug treatment service, and the fear is that registration becomes ‘a stamp on the forehead’ which is taken as a sign of degeneracy by both employers and the police. The survey said: ‘Drug users have little trust in the treatment system, perceive the system to be as much a hindrance as a help, and associate treatment with high failure rates, short remissions and continuing drug use.’

One of the main authors of the report, Natalia Bobrova, summarised the position for me:

The opposite view is put by Yevgeny Roizman, a co-founder of City Without Drugs, who in the autumn of 2013 was elected mayor of Russia’s fourth largest city, Yekaterinburg, on the basis of his outspoken views. A 2012 New York Times article described the City Without Drugs approach as ‘kidnap and cold turkey’, quoting one worker as saying, ‘We know we are skirting the edge of the law. We lock people up, but mostly we have a written request from their family. The police couldn’t do this, because it’s against the law.’ Roizman himself explained the principle of his approach to the New York Times. ‘The most important thing is to force them to quit and keep them clean a certain time so that the system cleans itself out. If they behave they can go home.’

Such a defence brings another complaint about the Russian treatment system. Not only is it ineffective, the methods used in the usually unsuccessful attempts to force the dependent off drugs can be brutal. The stories are difficult to substantiate but they come thick and fast – particularly from inside the private sector. There are stories of drug users being handcuffed to their bed frames, undergoing electric shocks and even of mock burials where the patient is put in a coffin and left in the ground for fifteen minutes. The idea of this last form of ‘treatment’, I was told, was to deliver ‘such a profound shock to the drug user that he will reconsider the whole experience of his life’.

More substantiated are two cases quoted in a 2011 report put together by a number of civil society organisations led by the Andrey Rylkov Foundation. One 28-year-old drug user recounted his experience in a state-run clinic:

The second case concerned a private rehabilitation centre. Such centres have sometimes been given carte blanche by relatives who have referred the patient, and conditions can be even worse. A 31-year-old patient described the deliberately violent methods used, particularly against new entrants to the rehabilitation centre who are considered the most likely to be deterred. He described how men were taken to a separate room, stripped to their underclothes and then effectively beaten up by three of the staff with clubs and shovels. ‘They were asked: “So are you going to inject drugs again? Will you?” Everyone shouts – “No, I will not. I am not going to use drugs any more. I swear. Just stop the flogging. Don’t flog me any more please.”’

The International Network of People Who Use Drugs says, ‘In Russia today we are bearing witness to one of the biggest avoidable catastrophes in the history of HIV.’ Human Rights Watch says that the treatment offered at drug treatment clinics in Russia is ‘so poor as to constitute a violation of the right to health’. And so the criticism goes on. There is too much agreement between them all to write it off as some plot from outside to discredit Russia. The Russian authorities seem to be intent on doing that for themselves.

There remains then their argument that methadone treatment simply substitutes one drug for another and brings no long-term benefit. It is an argument that again is rejected by virtually all medical authorities including the World Health Organization and UNAIDS. Methadone is taken orally and doses are given once a day. The very least that it will achieve is to take men and women off injecting and virtually close down this route to HIV and Aids – a massive gain in itself. It is true that methadone is an opioid like heroin, but it works in an entirely different way. It lasts longer in the body and takes away the craving for heroin. The enormous advantage to those who move to methadone is that they can often hold down a job, reunite with their families, and avoid the constant pull of the drugs underworld.

The real complaint against methadone is that it maintains the drug user but it does not automatically lead to a drug-free life. This argument marks a fundamental divide on what the purpose of treatment should be. Politicians (and not just in Russia) hanker for a cure-all: an end to drug dependence and total abstinence. But most physicians would say that this will often not be possible. As one British report says, ‘Recovery is an individual process or journey rather than a pre-determined destination.’ Difficult as it may be for some to accept, the truth is that stabilising a drug user on methadone may be as far as you can get. Nor need that be regarded as failure. It enables the man or woman to live an otherwise normal life and to hold down a job. It also preserves them from the much greater danger of injecting and shared needles – and allows them to avoid not only heroin but the highly damaging drugs cooked at home.

None of this is likely to persuade the Russian authorities any time soon to change their policy, in spite of all the signs of its failure. According to one campaigner I met during my visit to Moscow, the police and the special 40,000-strong federal drug control service pursue a policy not so much of zero tolerance to drugs as ‘zero tolerance to the drug user’. The drug users are easy meat for the police. It is easier to arrest them than the much more dangerous pushers or to break up the criminal gangs. In one case, a well-known addict was followed to his flat by a policeman who then waited for two hours outside on the street. When the addict re-emerged he was arrested, taken to the local station, beaten and left for thirty-two hours in a cell. ‘The trouble is that the police officers don’t feel they are doing anything wrong,’ my informant said. ‘They are repairing an omission in the legal process.’

Corruption in this process is inevitable and it is not always the corruption of organised crime. A notorious case was that of Taisiya Osipova, an opposition activist, who in 2012 was sentenced to eight years’ imprisonment for possessing heroin – and the sentence was twice as long as the prosecutors had sought. The overwhelming number of drug cases that go to trial in Russia (over 90 per cent) result in convictions, and this was no exception. No one suggested that she was a trafficker and all the evidence was that the drugs had been planted on her by the police.

Prison also brings into play the two other killer diseases closely linked with Aids. The first is tuberculosis (as in South Africa), which is often the final cause of death for an Aids patient whose immune system has been destroyed. The other is Hepatitis C, which is caused by shared needles and eventually leads to cirrhosis of the liver. The problems caused are not unique to Russia – they too are worldwide. Nevertheless an overcrowded prison is the perfect incubator for TB and Russia has a massive prison population of over 900,000. As for Hepatitis C, it flourishes when shared needles are the chief way of injecting.

While Russia continues to defend its reactionary approach, elsewhere in the world drug policy is under a new scrutiny. As the years have gone by, we have all heard claims for a single solution to eradicate drug use or listened to a variety of optimistic claims. I remember being in Tehran in the 1960s at an Interpol conference where police chiefs believed the solution was to substitute sunflower for the opium poppy in Afghanistan. That failed, as did the much more recent attempt to persuade opium farmers to grow wheat and guarantee the market price. Some say that the only effect of that was to increase the supply of fertiliser, which was an all too ready ingredient for homemade bombs! As for more bellicose slogans, I remember being given a T-shirt by the Drug Enforcement Agency in the United States embroidered with the words ‘It’s not over until we win’. That was over twenty years ago, and I fear the ‘war on drugs’ has claimed no victory.

In the days before I arrived in Moscow I was at a harm-reduction conference in Vilnius, the capital of Lithuania, a country once a part of the old Soviet Union. There Michel Kazatchkine, the former director of the Global Fund to Fight Aids, succinctly set out the case for reform. Present policies on drugs had failed, he said. ‘No other social policy has attracted such support from the politicians in spite of all the evidence that it is ineffective. We stick to the repressive policies even though there is so little evidence of progress.’ And why? There is a political attraction in the rhetoric of ‘the war against drugs’ and ‘being tough’. A few days after I returned from Moscow I heard a strikingly similar message at Westminster from the Colombian ambassador in London who, speaking on behalf of his government, used almost the same words to support change in his country; Columbia of course has been long regarded as almost a by-word for illicit drugs. Another straw in the wind came a few months later when Gallup in the United States reported that, for the first time in history, a majority of the population supported the legalisation of marijuana.

Michel Kazatchkine is right. We have been mesmerised by the rhetoric and with the thought that with one last push the problem will be over. Now, in the second decade of the twenty-first century and for the first time I can remember, there is a serious movement for change. Politicians are beginning to search for solutions rather than phrases which might go down well with the public. It is not happening everywhere, but there is a movement. Needless to say it is a movement in which the Russians are playing no part. There, the old and unsuccessful policies will continue to be pursued; the war on drugs has become, in the words of the prominent Russian politician, Boris Gryzlov, ‘a total war on drugs’.

As if all this was not bad enough, almost nothing effective is done to warn the Russian public of the dangers of HIV. There are none of the poster campaigns that have been mounted in North America and Britain. Television stations refuse to take advertisements which might offend their viewers. The government devotes a minute part of the health budget to prevention. While this is true of other countries, most of these nations – certainly in the West – do not have a problem of the same scale. The doctors I spoke to in Russia were united in saying that there was a false complacence about the Russian position; that public information was seriously inadequate while sex education in schools could be non-existent.

So are there, then, no bright spots in the dark Russian landscape? There are a few. Antiretroviral treatment in Russia is not remotely adequate, but it is provided. About 120,000 HIV patients currently receive treatment, but that should be compared with the mountainous need. There are promises (budget pressures permitting) that the number of people receiving treatment will increase by 2015. A more certain positive trend is the substantial reduction in mother-to-baby transmission that has been achieved, with the result that many fewer babies today are born with HIV, and at a hospital near St Petersburg there is an example of what can be done for those children who have been unlucky enough to inherit or acquire the virus.

A short drive from the ornate gold of the Winter Palace and the crowds visiting the rooms lined with old masters in the Hermitage there is a hospital built for the poor at the time of Tsar Alexander II. The hospital has developed over the years, surviving revolutions and wars – including the siege of Leningrad, when over 600,000 Russians perished in one of the bravest actions of resistance during the Second World War. The hospital came to treat HIV in the late 1980s when almost 300 children were infected by used syringes, which rapidly spread the virus. This was at a time before antiretroviral drugs and also a time of stigma and ignorance. There was public fear that in some way HIV was infectious merely through touch or proximity. The little children who came to the hospital did not go to local nursery schools because, in the words of the chief medical officer, Professor E. E. Voronin, ‘the nursery schools would not have them’. A petition signed by 2,500 local people was sent to President Yeltsin calling for the clinic to be closed and indeed it was, but for only twenty-four hours, after which wiser heads prevailed.

Today, the hospital operates in calmer but still difficult waters. The HIV orphans are potentially the most heart rending of the HIV casualties. In truth, many of the children are not there because of the deaths of their mothers, but because they have been abandoned by drug-dependent parents. ‘Each of them dreams of a family,’ says Professor Voronin. ‘Many of the children think that their mothers lost them. Our aim is to give the children a future. The medical treatment is only part of that.’

The older children go to school locally – although their condition remains secret – while the younger ones have their own nursery and a dedicated staff try to repair some of the damage that has already been done. Professor Voronin says that in one case a three-year-old girl had been left for months in isolation and when she came to the clinic her face was like a mask. There were no smiles and no reactions. In another case, a child had been sent to an institution for invalids.

Much of this can be put right by the devoted care the children receive at the hospital. Even more hopefully, an increasing number of children are being adopted. Over half of the HIV orphans realise their ambition of a family. The easiest to place are the very young girls of two or three, the most difficult are the children of school age – although that is the common experience of all adoption agencies. Until recently, one possibility was for children to be adopted outside Russia. The nurses all remember a boy adopted by an American couple and who developed into what is regarded in St Petersburg as a typical American teenager. That route has now been closed by the Putin government, which has decreed that there should be no more foreign adoptions – a particularly malevolent restriction when dealing with still hard-to-place children with HIV. Doubtless, the St Petersburg hospital will overcome this obstacle, as they have other obstacles over the past 135 years. What is decidedly less sure is whether Russia will develop successful policies to combat injecting drug use and prevent the HIV infection being spread.

Beyond these small pools of light, the Russian picture remains very dark. The numbers of the infected continue to rise while the government remains hostile to gay people, drug users and sex workers – exactly the groups that can most easily spread the virus. Almost all the signs that have come from the Kremlin have been unhelpful to the cause of reducing HIV. As well as the anti-gay bill that was passed in June 2013, other pieces of legislation have the same baleful impact. Another bill bans so-called foreign agents. USAID, which had provided invaluable support, has already fallen into this category. In the case of USAID you could sympathise perhaps with the Russian doctor who asked me, ‘What would you say if the Americans put a development agency in the middle of London?’ But that does not explain it all. The inevitable result has been that any non-government organisations with any kind of overseas backing fear that the axe will next fall on them – as I saw for myself. In the autumn of 2012 I had been urged by a particular charity to visit them. My visit had to be postponed for six months and in that time their attitude changed. They suddenly needed to know whether I could set out the purpose of my trip and what questions I would be asking. I do not blame the organisation. It simply shows the nervousness that has been engendered among good people who only want to help.

My hope had been to put some of these points to the then chief physician (now prime ministerial adviser) Dr Onischenko, who is reputed also to be close to President Putin. In the event it turned out to be one of the most bizarre interviews I carried out for this book. He had three major points. His first was to ask whether I was writing a work of fiction or non-fiction. It was a point that I (mistakenly) treated as something of a joke. In fact I think he was serious. It was another way of asking whether I was going to tell the truth or make up lies about the position in Russia. This was allied to his second point. Put bluntly, he wanted to know what God-given right had a Conservative politician from Britain to sit in judgement?

Perhaps I could answer that as doubtless others – particularly some of the ministers and officials who I interviewed – had something of the same reaction. This is a book by a politician who used to be a journalist and who regards the standard of fair reporting I was required to meet on the London Times of the 1960s as still being the standard to follow. It is for others to judge whether the fact that I am a Conservative politician has any particular relevance. I certainly do not deny a political intent. Researchers may research, writers may write, but when it comes down to it you need politicians to run with the policies. The truth is that around the world there are policies being pursued which are adding to the already mountainous toll of the dead from Aids. If they can be persuaded to change tack or be helped in what privately they want to do in any event then I would regard that as entirely worthwhile. I have no ‘God-given’ right, but if this little book helps save just one life I will be satisfied. Which brings me back to Dr Onischenko.

His third point was his most complacent and held most danger. The Russian public, he said, were well satisfied with how the government was responding to HIV although, as we have seen, public information is sparse. In his view viruses and diseases came and went. There were others which would afflict us in the future. We had seen off smallpox, cholera and legionella, and we would see off HIV as well. He had no doubt of that. The trouble – the literally fatal flaw – with this argument is: what happens in the meantime? No one realistically believes that a cure is likely to be available overnight or that it could be administered globally and instantaneously even if it was. There are measures that can be taken now to enable people to live successfully with HIV but that is of no comfort if the measures are ignored or only partially implemented.

The truth is that this is all a blue print for inaction. Apart from the promise (budget considerations permitting) to increase antiretroviral treatment nothing much will change in Russia. The drug dependent will continue to become infected. Gay people will continue to be a target for discrimination. Sex workers will continue to be exploited. The public will not be warned of the dangers of Aids – and men, women and children will continue to die from this neglect.

2 Both in intent and effect the new Russian law goes way beyond the Section 28 legislation of the Thatcher years; legislation which I, for one, deeply regret.