This is a completely new experience for me, and I am not sure what to expect. Many of the people I will be meeting are heroin users and most are HIV positive. I pile into the van with people from my group and with Marshall from PSI. We talk to the counselor, a really sweet woman who is so matter of fact in her description of this work, she puts us at ease. You can tell that she really loves what she does and is extremely dedicated.

We first meet with a 23-year-old woman who has come for clean needles—the needle exchange part is not funded by the United States, but by the Global Fund, and funding for this component is running out. The woman tells us she used to attend a PTU (I think about the kids I met today, some of the young mothers, and how any one of them could be this woman), but had to quit because she had to get a job to support herself. It's then she started using drugs. She has a boyfriend—he is in prison and she tells us she is waiting for him to get out. She has a hard edge to her and she seems visibly uncomfortable with our presence and our questions.

She tells us she's HIV positive and that she actually got her results in this van from the counselor some time back. She comes here regularly for support and for clean needles. She uses 2 grams a day, which costs about $66. The average monthly income in the region is $300 to $500 a month. When asked how she supports her habit, she doesn't answer. Many turn to sex work or petty crime or whatever they have to do to support their habit. It's really heartbreaking.

Next, Ivan comes in, a very thin, quiet, but confident man. He knows everyone who is gathered around the van and moves in and out of the van regularly. He is a peer educator. Ivan used intravenous drugs before prison. After being released, he started using intravenous drugs again. He knew of the program because he came to the van for clean needles and to get tested. He's also HIV positive.

He's clean now, and he helps other users get the help they need. He's really an inspiration. He's got a girlfriend—she is also HIV positive. They hope to marry and dream of a family someday.

The situation for those addicted to drugs is difficult here. There's no rehab mentality in Russia, and people have a hard time getting ARVs (AIDS drugs) until they are clean, so most people who are infected move quickly from HIV to AIDS because support services don't really exist for injecting drug users and it's nearly impossible for them to quit on their own. Methadone is not legal here.

I decide to get tested in the van. It's important and something everyone should do regularly. Here it's a pinprick to the finger and the counselor draws blood and the results come back in 20 minutes. She can test for HIV and hepatitis. The clients know they can be confidentially tested. If the results are positive, she works with them to provide case management. She also works at the clinic, and for those newly infected, she walks them through the process herself.

The last man who comes in is tall, very matter of fact and he smells of cigarettes. He says he will answer whatever we ask. Heroin has clearly had its affect on him, and there is a layer of pain and hopelessness between us. He tells us he uses with his wife. He is 29; she is 23 and has been using since she was 19. He doesn't see a reason for him or his wife to stop using unless she gets pregnant.

I ask if he is tested regularly, and he says they know their status. In Russia, it's still very difficult to talk about your HIV status due to fear of discrimination; I understand it.

We ask him if he has ever overdosed. He has not, but he tells us of two friends who recently did. One died, but the other was saved thanks to Naloxon. It's an overdose medication PSI provides at the mobile outreach. It costs less than $1 per shot and saves lives. The clients receive the drug for free.

After we leave the mobile outreach, I go back to my room and have to be by myself for a while and let this all sink in. The reality of it all is very intense and emotional.

Tomorrow I have another day ahead of me...


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