Russia’s HIV epidemic, already severe before the invasion of Ukraine, has worsened dramatically under the pressures of war, with health authorities now facing what may become one of the country’s gravest long-term demographic crises – and Russia was already facing a sever demographic crisis thanks to the collapse of the Soviet Union in 1991.

“In the first year of the war,” Deutsche Welle correspondent Andrey Shashkov writes for Carnegie Endowment for International Peace, “the recorded incidence of HIV among military personnel soared by more than forty times,” citing Defence Ministry data. By early 2023, the rate of new cases among soldiers had jumped to nearly twenty times pre-war levels.

The implications are far-reaching. “The demographic and economic losses Russia will suffer as a result of this outbreak will have repercussions for decades,” warns Shashkov. “They may ultimately even exceed the damage it has sustained from its invasion of Ukraine.”

The scale of the epidemic is already stark. Russia passed the threshold of 1mn people living with HIV in 2016, or roughly 1.5-2% of working-age adults. Anything over 1% is considered to be a bridge density where the virus will transition from high-risk groups such as homosexuals and intravenous drug abusers into the general population.

Even at this late stage, the epidemic could still have been brought under control if there had been the political will, but the Kremlin is distracted by the war in Ukraine and all resources have been channelled into that effort, further undermined by the state’s propaganda. Instead of introduce proven methods of prevention the Kremlin’s message has relied on outdated and harmful ideas about family life and “moral staples” that is tied into the justification for Russia's aggression against Ukraine.

“The wartime wave of repression against civil society proved to be the final nail in the coffin of Russia’s already weak system of assistance for people living with HIV,” Shashkov says.

Less than half of those infected are now receiving antiretroviral therapy (ART) – the standard, lifelong treatment for the disease. Wartime austerity has exacerbated shortages of essential medicines, with regions increasingly unable to fund even domestic generic alternatives to Western drugs.

“The proportion of HIV patients receiving treatment has now fallen below 50% in Russia for the first time in many years,” Shashkov reports.

Meanwhile, the war has accelerated the collapse of civil society support. The Russian government has branded the Elton John AIDS Foundation – one of the largest global HIV NGOs – an “undesirable organisation”, and criminalised links with LGBT groups, deepening stigma and limiting outreach.

Military life has compounded the risks. In trench conditions, “the uninterrupted supply and administration of ART is hardly realistic,” Shashkov writes. Disruptions can lead to drug resistance, increasing the danger to both individuals and public health.

Field conditions exacerbate the likely hood of transmission thanks to the reuse of needles and less than sterile conditions in battlefield medial stations. Drug taking amongst soldiers and unprotected sex adds to the problem.

 “Unprotected sexual contact and sharing needles to inject drugs have not disappeared,” he notes. “On the contrary… both are thriving in a fighting army of men who live every day as if it were their last and are earning decent money.”

And the number of infections are exploding. The problem is so grave that it has been officially acknowledged even by Defence Ministry doctors. The number of new HIV cases detected in the armed forces grew fivefold from the first quarter of 2022 to the fall of the same year. By the end of 2022, it had grown thirteen times. And by the beginning of 2023, peak growth was recorded of more than fortyfold. By the end of that same year, the HIV detection rate among military personnel was about twenty times higher than before the war.

Russia’s rules officially bar HIV-positive individuals from military service. But on the front line, those rules are often ignored. “Commanders on the ground [are] refusing to let soldiers leave the front, no matter what condition they are in,” says Shashkov.

The virus’s spread is not confined to the armed forces. Pregnant women in fourteen regions now test positive at rates exceeding 1% – a sign, according to the World Health Organization, of a generalised epidemic.

According to UNAIDS, since 2022 Russia has been among the top five countries in terms of new HIV cases, accounting for 3.9% of the 1.5mn new infections worldwide. Only South Africa (14% of all new cases), Mozambique (6.5%), Nigeria (4.9%) and India (4.2%) have more new cases, and the latter two have significantly larger populations than Russia.

While most of the world has halved new HIV cases since the mid-1990s, Russia continues to record between 50,000 and 100,000 new cases annually. Globally, new tools such as long-acting injectable treatments and preventive vaccines are advancing. In contrast, Russia maintains bans on substitution therapy and sex education – policies Shashkov describes as “purely political.”

“There is no objective reason why HIV should be decreasing across the world – except in Russia,” he writes. “Those who have contracted HIV during Russia’s war against Ukraine will need expensive lifelong treatment… a burden on the Russian budget and healthcare system, and a blow to the labour market and demography throughout the second and third quarters of the twenty-first century – long after the war in Ukraine and Vladimir Putin’s rule come to an end.”