ST. PETERSBURG, Russia — Quietly, the number of Russians who have received a positive H.I.V. diagnosis passed the one million mark this year. There is, however, little indication that the government will commit adequate resources to stem the acceleration of the virus from high-risk groups into the general population.
About 850,000 Russians carry H.I.V. and an additional 220,000 have died since the late 1980s, said Vadim Pokrovsky, the longtime head of the Moscow-based Federal AIDS Center, who estimated that at least another 500,000 cases of H.I.V. have gone undiagnosed.
Although the label “epidemic” prompts denials from some senior officials, experts on the front lines like Mr. Pokrovsky are calling it just that. The overall estimate of victims constitutes about 1 percent of Russia’s population of 143 million, enough to be considered an epidemic, they argued. Beyond that, they said that heterosexual sex would soon top intravenous drug use as the main means of infection.
“This can already be considered a threat to the entire nation,” Mr. Pokrovsky said, noting that the caseload is increasing by about 10 percent a year. In 2016, 100,000 new infections are anticipated, about 275 daily. It is the largest H.I.V. epidemic in Europe and among the highest rates of infection globally.
Despite the grim milestone, experts do not expect much change in Russia, where victims still face the kind of stigma prevalent in the 1980s in the West and where continuing trench warfare between the Kremlin and independent nongovernmental organizations saps collective efforts. In addition, some prominent voices push “family values” as the ideal prevention program.
In many ways, Russia’s fight against H.I.V. is a case study in the constant tension between civil society and a Kremlin under President Vladimir V. Putin; public activity outside government control is considered inherently suspect. Tensions heightened this year after the Justice Ministry blackballed a number of bantam N.G.O.s involved in combating H.I.V./AIDS as “foreign agents” because they received grants from abroad.
Anton Krasovsky, a prominent talk show host fired in January 2013 after coming out as gay on air, says he has spent his personal savings building an N.G.O. that tries to bridge that divide.
“Since we are not talking about fighting Putin, but fighting a virus, people have to understand that they can fight this virus only if they are on the same side as Putin,” Mr. Krasovsky said. “It is impossible to change the situation without coming to some kind of an agreement.”
The president has remained largely silent on H.I.V. Over all, activists said, the combination of indifference toward victims, government financial austerity, hostility toward foreign funds and a powerful camp of AIDS deniers all amounts to the lack of a coherent national effort.
Experts criticized a new, rather vague Russian government strategy on fighting H.I.V. that was released in October for lacking a plan of execution or any new money.
Despite that, both sides in the H.I.V. battle agree that Russia has made some progress. The fact that a national strategy exists — as well as an advertising program promoting H.I.V. tests backed by Svetlana Medvedeva, the wife of the prime minister — at least implies some high-level interest.
In St. Petersburg, one married couple, Dr. Tatiana N. Vinogradova and Andrei Skvortsov, straddles the government-N.G.O. divide on the issue.
Dr. Vinogradova, slim beneath her white coat, with bobbed brown hair and beige stilettos, is a third-generation H.I.V. warrior. Her grandmother, an infectious-diseases specialist, treated one of the first patients in St. Petersburg in the late 1980s and pushed the city to establish an AIDS Center. Dr. Vinogradova’s mother ran it, and she herself is now its deputy head of scientific research.
Mr. Skvortsov, wiry, scrappy and H.I.V. positive — a reformed drug addict and ex-convict — runs a small N.G.O. called Patients in Control. It was founded in 2010 to try to cajole, pressure and embarrass both federal and local governments into providing government-guaranteed treatment.
At the St. Petersburg AIDS Center, Dr. Vinogradova, 41, has seen the prevalence among drug addicts shrink while cases among heterosexual couples soar.
“Calling it an epidemic would be akin to admitting that the government let the problem get out of control over the past 30 years,” she said, explaining why the government avoids the term. But she uses the national strategy and any official statements she can find to try to wring more money out of politicians. “This is Russia, so everything has to be top down to get anything done.”
The couple has tried to use their marriage to help break the stigma that the disease is an untreatable plague limited to drug addicts, homosexuals or others likely to die anyway.
“I watch people jump back a meter when he says he is living with H.I.V.,” Dr. Vinogradova said, with older medical professionals particularly still fearful despite the raft of evidence that anyone taking antiviral drugs is not infectious. “Now whenever I hear about H.I.V. discrimination, I take it as a personal offense.”
When her husband needed an operation last year to repair with a metal implant a collarbone broken in a motorcycle accident, the surgeon refused after discovering his H.I.V. status. Mr. Skvortsov, 37, recently appeared on a talk show with Evgeniya Prokhoda, an H.I.V. activist in the southern city of Krasnodar, and one of the first Russians to speak about carrying the virus on national television without hiding her face.
She detailed the gantlet of fear and discrimination she had faced, including when authorities put her son in an orphanage for about a year after her own mother sued to have him removed from home. The day after she appeared on television, Mrs. Prokhoda was fired.
Activists and experts always come back to the lack of government support as the root problem.
Under World Health Organization guidelines, to reduce the spread of the disease, at least 90 percent of H.I.V.-positive patients should receive antiviral drugs.
In Russia, a little more than 37 percent receive such treatment, according to government statistics. “The prevention programs are not working, the coverage is not sufficient to break the curve,” said Vinay P. Saldanha, the Unaids regional director for Eastern Europe and Central Asia.
Russia is among five countries that account for almost half the new infections globally; the others are South Africa, Nigeria, India and Uganda, according to Unaids figures, although in some of them, a much higher percentage of the overall population is infected.
Most of the $338 million annual Russian federal H.I.V. budget is spent on medicine, and almost nothing goes to preventive education. Veronika Skvortsova, the health minister, has repeatedly called expanding treatment programs a government priority. (The minister is not related to Andrei Skvortsov.) After a deep recession, however, little new money has materialized.
At the same time, the Russian Orthodox Church and some politicians promote “conservative values” as the best way to combat H.I.V.
Patriarch Kirill called for “moral education,” stressing that the “establishment of family values, ideals of chastity and marital fidelity” should be at the forefront of curbing the virus.
Both the government and the church staunchly oppose sex education for children. One senior government official stated that classical literature was the best teacher.
The state also adamantly opposes methadone for drug addicts, sometimes denigrated as a “narcoliberal” scheme. In other countries, methadone programs are used both to treat and to monitor patients infected by intravenous needles.
The emphasis on traditional values dismays those fighting the disease. “Traditional values just means leaving everything as it is,” Mr. Pokrovsky said. “If we have traditional values and do nothing, the epidemic will keep spreading.”
Compounding the problems, the federal government has tried to silence organizations that challenged its policies, labeling them “foreign agents” for receiving grants from abroad, forcing some to close.
The Andrey Rylkov Foundation for Health and Social Justice, which hands out free needles and condoms in southern Moscow, now has to staple a small label to its plastic bags saying “Foreign Agent” as required by law. Recipients said they could not care less, but it means that the foundation cannot work with government organizations.
“H.I.V. is not a personal problem, it is a social problem, and it should be solved as a social problem,” Elena Plotnikova, who works for the foundation, said as she handed out supplies. “The basic attitude of the government is: You made a bad decision and we are not going to help you.”
N.G.O.s are considered crucial to reaching populations that avoid government contact, including drug addicts, prostitutes and gay men. Help varies widely from city to city. St. Petersburg is perhaps the most enlightened, treating all comers to its clinic and sponsoring an advertising campaign.
Dr. Vinogradova and Mr. Skvortsov appear together on one poster encouraging people to get tested. The couple is startlingly open about their sex life, stressing that his being on antiviral drugs means that she remains H.I.V. negative even though they do not use condoms.
In the poster, wearing navy blue shirts, they stare into each other’s eyes. “I know that there are no barriers to my love,” reads the text. “H.I.V. is not an obstacle to creating a family; it’s possible to live a long life with H.I.V.”