Over the last two decades, the number of people living with HIV in Russia has increased dramatically. While other parts of the world severely affected by HIV have been able to significantly reduce transmission rates over the last 10–15 years, primarily through effective prevention programs, Russian authorities have been unwilling to introduce such measures. As a result, the number of people testing positive for HIV in the country has now surpassed 1.2 million, and according to WHO criteria, Russia is facing a generalized HIV epidemic. The current epidemic did not appear unannounced. Over the last 20 years, medical researchers and the global health community have emphasized the severity of the situation in Russia. However, rather than building a viable domestic response to the challenge posed by HIV, the Russian regime has instead channeled its investments in HIV/AIDS programs toward global cooperation. This policy was pursued both during Putin’s two first presidential terms (2000–2004 and 2004–2008), and during Medvedev’s presidency (2008–2012). Putin’s re-election in 2012, however, marked a distinct shift in focus, priorities and rhetoric. While Medvedev had argued for institutional changes in order to modernize Russia and aimed at presenting Russia as a partner of the global community, Putin’s return was accompanied by major cuts in Russian donations to global HIV/AIDS aid, notable efforts to limit foreign interference in Russia, an increased use of anti-Western and pro-civilizational rhetoric, and, an overall stabilization of neo-patrimonialism. This thesis argues that Putin’s shift toward cultural conservatism in 2012 has affected the regime’s ability to reduce the spread of HIV in Russia negatively. The collected evidence supports that three developments in particular have contributed to this. The first is the introduction of legislation aiming to reduce foreign involvement in Russia, which has crippled civil society as main provider of prevention programs and services to key populations, and forced global agencies working on HIV/AIDS to leave the country. Secondly, Putin’s post 2012 cultural conception of the state has limited agency to anyone interested in pushing Russia out of the neo-patrimonial space. As neo-patrimonialism provides highly unfavorable conditions for successful implementation of reforms, which are likely needed to curb the epidemic, its stabilization has arguably assisted inaction. Lastly, Putin’s shift was accompanied by a value-based conservative rhetoric which has entailed increased access to state structures, policy crafting and governmental funding for actors opposing conventional HIV prevention.