The HIV epidemic in Russia, which began in the late 1990’s, has been largely concentrated among people who inject drugs
[1–3]. Through 2009, 567,558 cases of HIV have been identified, with more than 10% added in 2009 alone
. Estimates suggest that more than 1.2 million Russians are infected with HIV, with 82% reporting injection drug use (IDU)
St. Petersburg, the second largest city in Russia with a population of 5 million registered inhabitants, experienced an expanding heroin market in the late 1990’s and a subsequent epidemic of HIV. Presently, among the city’s estimated 83,000 IDUs
, about 82% of IDUs inject heroin as their primary drug, and about 18% inject ephedrine-based stimulants
. As of 2009, more than 38,000 individuals had been diagnosed with HIV with 76.4% of cases attributed to injection drug use
. HIV prevalence among St. Petersburg IDUs is alarmingly high, increasing from <5% prior to 2000 to 30% in 2003 and to 44% in 2007
[9–11]. In longitudinal cohorts of IDUs, HIV incidence was 4.5 per 100 person-years in 2003 and 7.2 per 100 person-years in 2009
HIV transmission among IDUs results primarily from unsafe injection practices such as the sharing of used syringes due to the lack of access to sufficient supply of sterile syringes
[14, 15]. This is often considered a structural issue related to law and public policies. This has been especially true in the U.S., where laws have restricted access
[16–18]. Outside of the U.S. where access is not legally restricted, the extent to which local pharmacies are willing to sell syringes to IDUs is an important factor shaping epidemic control efforts. In Edinburgh, Scotland, for example, an outbreak of HIV among IDUs in the mid-1980’s has been attributed to a decision reached by pharmacists and the police to halt sales of syringes to customers who appeared to be IDUs by subjective judgment
. Studies on expanding access have been conducted in several locations, most notably in the U.S.
[20, 21], in the wake of changing laws that allowed purchase and possession of syringes without prescription
[22, 23]. Large-scale expansion of targeted sales of syringes to IDUs from pharmacies has been shown to contribute to maintaining low prevalence of HIV-1 among Australian and British IDUs and lowering HIV incidence in New York City
[24–26]. However, most studies on syringe access, even those undertaken most recently
[27, 28], have focused on locations in which syringe sales had been legally restricted in some way. The situation is very different in St. Petersburg, Russia.
According to Russian federal laws and regulations, syringes can be sold in all pharmacies without legal limitations. However, there are often gaps between the formal laws and their street-level implementation
[16, 29, 30]. Syringes and condoms are not included in the required pharmacy formulary as stated in the governing decree, “On minimal assortment of medicinal agents” and approved by the Ministry of Healthcare and Social Development
. Accordingly, availability of syringes in a pharmacy is not regulated by any legal act but varies with commercial polices of the specific pharmacies. Thus, declining to sell syringes is not a violation. It is important to note that since there are very few syringe exchange programs in St. Petersburg, pharmacies are the primary source of syringes for IDUs
The “International Feasibility Study of Pharmacy-Based HIV Prevention” is a multi-site, cross-sectional, multi-phase, multi-methods research project – three sites are located in the U. S. and the other three – in China, Russia and Vietnam. The aim of the collaborative project is to evaluate the feasibility of implementing pharmacy-based interventions to reduce HIV transmission among IDUs. In this manuscript, we examine syringe access at the pharmacies of St. Petersburg including stocking and sales practices as one of the multi-site study objectives. Specifically, we explored the role of syringe access ecologically and, focusing on two of the city’s 18 districts, examined how pharmacies’ business models and their stocking and sales practices may influence access. First, we tested the hypothesis that since syringe access was not legally restricted, those districts with a higher pharmacy density would have lower rates of HIV infection. Second, we sought to understand differences between policy and practice by attempting to purchase syringes at each pharmacy in the two districts.