“Challenges Drive Us Forward”—Harm Reduction in St. Petersburg, Russia

    It’s been a hell of a month,” said Alesya Shagina, a peer outreach coordinator for Humanitarian Action, of their recent work in St. Petersburg. “But we’re really proud of how we managed to adapt to these circumstances. We distributed 347 harm reduction kits via courier delivery, 208 kits via mobile outreach, and delivered 133 [antiretroviral therapy regimens] just for the last month. Some people are asking for saliva tests so we’re trying to provide them, as well.”

    Russia continues to experience severe drug-related problems even in non-pandemic times. While there has been a decrease in opioid dependence in recent years, there has been a rapid increase in the use of new psychoactive substances (NPS). At the same time, in a hostile political environment, harm reduction options—including outreach to drug users and distribution of supplies—have decreased. 

    In 2010, there were 70 organized harm reduction programs in Russia, already too few for such a huge country. Today, activists estimate that there are only about 20.  

    The Russian government has instead introduced punitive measures to fight drug use, treating people with addiction as criminals. This puts huge pressure on the small number of remaining NGOs providing essential, life-saving harm reduction services.

    Most clients share “the condemnation and distrust of society.”

    Humanitarian Action has been working in St. Petersburg since 1997, and is the oldest harm reduction program in Russia. During all these years, people who use drugs, including injecting drug users and chemsex participants, have been and remain their priority. 

    “People who turn to us for help are men and women between the ages of 20 and 60 who, for various reasons, have begun to use drugs,” Aleksey Lakhov, the organization’s deputy director, told Filter. Most, he said, share “the low [valuation] of their own health, the lack of documents that entitle them to receive free medical and social assistance, the lack of trust in state healthcare institutions, and the condemnation and distrust of society.”

    Humanitarian Action’s work not only aims to prevent HIV and other infections and drug-related harms, but to help people solve their wider medical and social problems. It is conducted in part from two mobile units⁠—vehicles that are parked in the areas of the city where marginalized drug users live or gather. 

    One, known as the “Blue Bus” (pictured above), is a converted coach. The second is a converted Fiat minibus, affectionately called the “Little Bus.” People who attend these units receive a wide range of services—free of charge and anonymously. These include medical and psychological counseling, counseling around addiction and reintegration into communities, rapid blood testing for HIV, hepatitis B and C, and syphilis, and referrals to trusted doctors. Supplies offered include naloxone, sterile sryinges, alcohol wipes and water for injections, printed health information and condoms.

    Contents of Humanitarian Action’s harm reduction kits


    “It is important for us to help these people,” said Lakhov, “because even when they want and strive to change their lives, they do not always succeed because of the lack of necessary social skills and fears associated with going to various state institutions.”  

    Most of Humanitarian Action’s clients have tried unsuccessfully to stop using drugs, either on their own or in a medical setting. Many feel that they need to start life anew, restoring broken relationships with their loved ones, and again learning to trust people.


    Innovating to Meet New Drug-Use Patterns

    Humanitarian Action has expanded its range of services in recent years. In 2018, the drug scene in St. Petersburg, and in Russia as a whole, changed a lot. This was largely due to the explosive growth in popularity of Hydra, a darknet platform for buying drugs, and to the growing popularity of Telegram Messenger, where you can also buy drugs through various channels.

    As part of this, the nature of drug use in Russia has changed, harm reductionists say. While opioid users continue to be the main target group for Humanitarian Action and others, there has been a surge in young people using NPS, such as mephedrone and alpha-PVP.

    “Ensuring our presence where our new target groups gather. In this case, not in the streets but online, in darknet and instant messengers.”

    “We decided to adapt the harm reduction work, traditionally aimed at injecting opioid users, to the needs of other groups of drug users,” explained Lakhov. “So the technology of web outreach was developed—that is, ensuring our presence where our new target groups gather. In this case, not in the streets but online, in darknet and instant messengers.”

    At the end of 2018, Lakhov managed to contact the Hydra administrators and persuade them to use their platform to post information about his organization and HIV and hepatitis prevention. In March 2019, Humanitarian Action also launched an open Telegram channel where they share information about harm reduction and psychological aspects of addiction. A subscriber list of well over 2,000 continues to grow steadily. 

    They additionally launched two closed Telegram chats for their clients: one for opioid users and one for users of new psychoactive substances (NPS). The channels are separate because the two populations are culturally distinct, and have specific mental health issues—with panic attacks, psychosis and depression reportedly prevalent in the NPS group. Both channels are led and moderated by people who use drugs.

    Humanitarian Action’s work via darknet, instant messengers and mobile units—combined with efforts from the other NGOs in St. Petersburg—has produced some statistically impressive results.

    St. Petersburg is the first major Russian city to see a steady decline in new HIV infections. Ten years ago, it was among the top five most affected cities in the Russian Federation. Now it is only the 17th most affected. New data on the number of drug poisoning fatalities in St. Petersburg also show improvement. There were 580 such deaths in 2019, down from 611 in 2018—a decline of just over 5 percent.  


    Formidable Challenges

    Humanitarian Action survives thanks to international donors, which cover 70 percent of its budget, including big grants from the Elton John AIDS Foundation (EJAF), Sidaction and the Global Fund. Nevertheless, funding remains the biggest challenge—grants and subsidies from the Russian government cover only a tiny fraction of costs.

    “The only times when we could say we’re doing all we’d like to do were in the mid-2000s, when there was a lot of foreign money for this work,” said Lakhov. “Now, thanks to an EJAF Lighthouse program, we’re the only organization in the [Eastern Europe and Central Asia] region that received this grant in full. But this program ends in 2021 and we’re not sure whether we’ll be able to continue to help people at this level.”

    Besides providing very little money, the government is applying huge efforts to prevent essential support for drug users. In 2016, the Andrey Rylkov Foundation—the only NGO that provides sterile injecting equipment to people in Moscow—was declared a “foreign agent” by the Russian government. This means that the government regards it as a threat to national security because of its funding from international donors. 

    “We’re trying not to argue with the government … that has allowed us to continue growing and to seek mutual points of interest.”

    While this fate has not befallen Humanitarian Action, the future is uncertain. There are several more initiatives being adopted right now, on tightening control for the NGOs that receive funding from abroad and on “drug propaganda”—under which measures you could even go to jail for “promoting” drugs. Nobody knows for sure what promoting drugs is.

    “We’re trying not to argue with the government on the issues regarding drug policy and such,” said Lakhov. “That has allowed us to continue growing and to seek mutual points of interest with the government. But the situation is hard overall.”

    In recent months, Russian harm reduction programs have struggled with more challenges in the wake of COVID-19. Russia has been hit hard by the epidemic, which has slowed down the flow of illegal drugs, although Hydra and Telegram shops continue to operate. Humanitarian Action consequently had to shut down its buses along with some of their services, including blood tests and health check-ups. But they are still delivering essentials—with staff doing outreach in their own cars, and sending courier deliveries. 

    Humanitarian Action outreach workers preparing kits.


    Humanitarian Action is also striving to connect people to different social and medical services, and to answer questions via instant messengers and phone. Its case managers have provided over 400 consultations for the last month, up by 30 percent. It also saw an increase of over 100 new subscribers to its chats when it began making or sending deliveries. 

    But these solutions are imperfect. With in-person operations curtailed, the organization is currently only reaching about a third of its clients, some of whom don’t have smartphones or Telegram.

    There are yet more concerns. In 2018 and 2019, there were troubles with naloxone access all over Russia—a major plant in Moscow stopped producing it due to a lack of supply from abroad. Peer outreach coordinator Shagina fears this could happen again due to pandemic-related disruptions to international trade.  

    “Working with social distancing feels naked somehow.”

    “We can’t wait for the end of this shit to continue working in full, because it’s a fraction of what we’ve been doing normally,” she told Filter. “I miss my Blue Bus, where you can just talk to people, look them in the eye, support and encourage them for positive changes. Yeah, I really miss it!”

    Lakhov agreed. “Working with social distancing feels naked somehow. Like, when you’re opening the trunk of your car and giving out harm reduction kits and thinking about the cops. It brings unnecessary attention. But our clients are very grateful for what we are doing.”

    Humanitarian Action is a model program in a country where the odds are stacked against harm reduction. Whether it’s organizing trainings on overdose prevention with new psychoactive substances, or utilizing technology specifically designed for remote learning, Lakhov and his colleagues are always looking to improve. 

    Even though the government has been moving in the opposite direction, he remains positive and devoted to his work.

    “I’ve lost several friends to drug overdose, and I remember them every day,” he said. “To be really sustainable and to help as many people as you can, you need to keep moving. These challenges motivate you and drive you forward.”


    Photographs and video courtesy of Humanitarian Action.

    • Sam is a freelance journalist specializing in drugs and health. His work has appeared in Vice, ThoughtCatalog, TalkingDrugs and DrugReporter. He lives in Aberdeen, Scotland.

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