Objectives: to examine attitudes of Russian policy-makers and HIV stakeholders towards harm reduction (HR) scale up, focusing on the factors constraining the scale-up process.
Methods: Semi-structured interviews with representatives of 58 government and non-governmental organisations involved in HIV policies and programmes in Volgograd Region, Russian Federation.
Results: We found a considerable diversity of opinion on HR scale-up and suggest that Russia is experiencing the situation of power parity between HR supporters and opponents with many stakeholders being indecisive or cautious to express their views. We identified six main factors which constrain policy decisions in favour of HR scale-up: insufficient financial resources; lack of information on HR effectiveness; perception of HR as being culturally unacceptable; reluctance of IDUs to use the services; opposition from law enforcement agencies and the Russian Church; and unclear legal regulations. We demonstrate a complex interplay between these factors, policy-makers' attitudes and their choices on HR scale-up.
Conclusions: A number of actions are needed to achieve a successful scale-up of HR programmes in Russia and similar political contexts: (i) a strategic approach to HR advocacy, targeting neutral and indecisive stakeholders; (ii) more systematic evidence on HR effectiveness and cost-effectiveness in the local context; (iii) HR advocacy targeting law enforcement agencies and the Russian Church; and (iv) aligning best international HR practices with the objectives of local policy-makers, practitioners and service-users.