Working hours are short. And the job involves no more than sitting at a desk, answering the telephone. But manning one of Moscow's HIV/AIDS hot lines is so taxing that seven out of 10 workers leave the job in the first year.
"Sometimes people call when they are on the brink of suicide, and our specialists have to overcome that," says Andrei Romanov, the head psychologist of a team of 11 that work the "AIDS Info- share" hotline. "A person in a critical situation is afraid of everything. He's still alive, but he feels dead."
The hot line takes 30 calls daily. It's one of the few places in Russia - where the problem remains stigmatized by its association with drug users and prostitutes - that provides encouragement and support to the surging ranks of HIV-positive people and those who develop AIDS.
About 1 million Russians are estimated to be HIV positive - a number that experts say puts the country on the threshold of an epidemic.
Russia faces one of the world's fastest-growing rates of infection - the number of HIV cases mushroomed in five years to levels the US took two decades to reach. The World Bank projects that by 2020, the number of HIV cases in Russia could range anywhere between 5.4 million and 14.5 million.
But official response has been virtually nonexistent. Just three federal-level staff oversee a meager budget of $4 million - just 3 cents per Russian. Brazil, with fewer HIV-infected people than Russia - though more than triple the death toll from its longstanding epidemic - spends 100 times as much as Russia fighting AIDS, and has 200 staff working on the issue. Brazil's measures are credited with cutting projected HIV/AIDS cases by half in recent years.
In Russia, two changes are key. The disease is moving into the mainstream population, and as those diagnosed HIV positive in the late 1990s develop AIDS, the demand for costly services could overwhelm Russia's feeble health-care system.
"Ultimately, Russia must ask itself: How many Russians have to die before the Russian government begins to take this seriously?" says Vinay Saldanha, head of the Canada AIDS Russia Project, who has worked on the issue here for a decade. "Russia is the only member of the G-8 that does not provide comprehensive prevention, care, and support for people with HIV and AIDS."
Russia has officially registered just under 282,000 HIV cases as of June - one-quarter of the estimated actual cases. Only 4,000 Russians so far have died of AIDS - a factor that has helped mask the crisis. But Mr. Saldanha estimates that in the next three years alone, barring more resources, Russia's annual death toll could surge to between 6,000 and 15,000 lives "on the back of a health system that is ill-equipped to handle the challenges of HIV and AIDS."
Some 1,800 Russians now receive AIDS treatment that costs the state between $7,000 to $12,000 annually per patient. Officials plan to start treating 7,000 more people next year with new cash from Western donors. The World Health Organization estimates that 71,000 Russians will need antiretroviral treatment by 2005.
Those numbers may drive a change in official response. "One reason Russia has been able to ignore it is because people are not dying in the streets yet," says Shombi Sharp, head of the HIV/AIDS unit for the UN Development Program in Russia. "By sheer math, the number of people coming down with AIDS is now forcing a shift from prevention to treatment.... Now health consequences are changing. They will start seeing a large number of people dying."
In response to the growing crisis, extra cash is coming from a $240 million, five-year award from the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The US and other Western donors are also funneling cash toward Russia. And one-third of a new $150 million loan from the World Bank is aimed at preventing HIV/AIDS. But Russia needs $150 million this year alone.
"We've been dealing with all these faceless statistics in this epidemic that have been diagnosed with HIV, but they haven't actually needed anything until now," says Saldanha. "Now all those diagnosed ... are progressing toward AIDS. Russia can no longer afford to neglect these hundreds of thousands of people who urgently need treatment."
Still, the issue has remained off the radar screen in Russia. Politicians are reluctant to associate themselves with the disease. President Vladimir Putin has touched on the issue in broad policy speeches, but done nothing more. In fact, the stigma and misperceptions about risk run so deep that poll results published last May by Komsomolskaya Pravda newspaper found that while 1 in 5 Russians knows someone with HIV, 46 percent think those infected should be isolated from the rest of society.
Such results are no surprise for some at the Ministry of Health, which experts give good marks for effort. "No one will recognize an invisible problem," says Vadim Pokrovsky, head of the Federal AIDS Center in Moscow. He compares Russia's 4,000 AIDS deaths with the 35,000 Russians who die in road accidents each year. "I hope it is enough to recognize the reality, and that it is not necessary to wait for hundreds of thousands of deaths to increase the budget."
Politicians argue that the flow of donor funding means there is no need to increase the federal budget for HIV/AIDS. Total public spending on HIV/AIDS by federal and regional bodies, and in hospitals, amounts to less than $20 million. But relief groups are pressing for more visible support. "We need pictures of President Putin visiting an AIDS ward," says Saldanha. "If Tony Blair could have lunch with HIV/AIDS people at No. 10 Downing Street, why can't Putin do it?"
One way to gain influence may be through the Russian Orthodox Church, which began working with AIDS Infoshare three years ago on HIV test counseling and prayer services.
"The church itself wants us to do it, because many of the people who have to deal with AIDS - parents of the infected, spouses, and family - often turn to the church with their problems," says Igor Ptcheline, director of AIDS Infoshare. Senior church officials have "considerable influence on our authorities," he says. That is a welcome change in a usually hostile environment where Ptcheline has overheard officials say: "Let them all die - it will be easier for us."
Coping with such reactions is the Moscow hot line's work. Callers are calmed with advice about family and marital issues, living with HIV, even reassurance - for believers - that the church does not believe that HIV/AIDS is punishment from God.
"She had the idea that even God would not listen to her, and this call [to the hot line] was the way out," says Romanov of a recent call from a woman. "I told her: 'God is love and He loves everybody.' "
• First of two parts. Tuesday: A visit to a town at the center of the epidemic.