The war in Ukraine has resulted in the destruction and disruption of health services and logistical supply chains that hundreds of thousands of people living with, and affected by, HIV depend on for survival (UNAIDS, 2022a).
Although the Russian invasion of Ukraine in February 2022 did not come as a surprise, its ferocity, blatant disregard of human rights and denial of Ukrainian statehood still appals, even 3 months into the conflict.
The first waves of the COVID-19 pandemic in 2020 demonstrated the fragility of health services and facilities in even the most stable and wealthy countries. In the context of war, this fragility is multiplied, and for those fleeing to other countries accessing healthcare can be disruptive and traumatic. As of 16 May 2022, over 6 million people have left the country, many going to neighbouring nations such as Hungary, Moldova, Romania and Slovakia. Moldova has received the most refugees per capita, but Poland has taken the highest number in total, with over 3 million Ukrainian refugees arriving since February 2022 (UN High Commissioner for Refugees (UNHCR), 2022).
General impact on health
The war in Ukraine has inevitably led to the country's health system functioning at reduced capacity, and attacks near hospitals mean people cannot safely attend for diagnosis or treatment. Difficulties accessing maternity hospitals, for example, risk an increase in neonatal morbidity and mortality (World Health Organization (WHO), 2022a). Cancer care is also affected. Large numbers of cancer patients are moving westwards or out of the country altogether, and clinics in Poland, for example, face an influx of patients seeking oncological treatment and support (Anonymous, 2022).
Where services can continue, health workers are under constant threat, and supply lines can be cut at any stage. Civil society programmes, according to some sources, ‘have proven resilient’, and in some areas of the country have managed to sustain routine services (Simoneau and Khan, 2022). However, meeting the needs of a highly mobile population, on the move to escape the conflict, is putting additional strain on services, especially in the west of the country.
The health risks facing mobile populations are especially high. Martial law, in force since February 2022, prevents Ukrainian men aged 18 to 60 from leaving the country, so most refugees are women, children and elderly people (WHO, 2022b). For women, access to sexual and reproductive health care is vital, and there are reports of rape (Mannell, 2022) and trafficking attempts (Hoff and de Volder, 2022). For people with non-communicable diseases, treatment interruptions increase the risk of adverse outcomes if support is not continued (WHO, 2022b). The impact on the mental health of all people affected by the war will be significant, especially those who are displaced and facing exposure to traumatic events and ongoing daily stressors (Murphy et al, 2022).
Impact on HIV services
Ukraine has one of the highest rates of HIV in the European region, with about 250 000 people living with HIV, mainly concentrated in people who are drug users (UNAIDS, 2020). According to UNAIDS, the UN agency that helps co-ordinate the global HIV response, more than 40 health facilities that offered HIV services are now closed because of the war, with various levels of service disruption at other sites (UNAIDS, 2022a). Around 150 000 people in Ukraine require HIV treatment (Murphy et al, 2022), and one of the earliest priorities after the invasion was to ensure the supply of antiretroviral drugs to Ukraine. UNAIDS is working closely with in-country civil society to ensure drug supply and ongoing support (UNAIDS, 2022b). Linkage to care is a challenge, and according to UNAIDS the cumulative number of people living with HIV who started antiretroviral therapy in 2022 is 30% less than during the same period in 2021 (UNAIDS, 2022b).
Community responses
Civil society is proving vital in maintaining support to key populations, much the same as during the first waves of the COVID-19 pandemic. Anton Basenko is Programme Manager (Quality of Life) at the European AIDS Treatment Group (EATG) and has extensive experience in advocacy and activism around harm reduction and HIV prevention. He is a Ukrainian national, based in Brussels, but in close contact with colleagues and non-governmental organisations (NGOs) in Kyiv and elsewhere. Speaking in May 2022, he said there are:
‘Many parallels between civil society's responses to war, and to the COVID-19 pandemic.’
These include extended delivery of opioid substitution therapy and antiretrovirals, as well as seeking creative ways to ensure the supply of medication is maintained. The Alliance for Public Health, a large Ukrainian NGO, which usually uses mobile testing vehicles to deliver medication, clean needles and syringes, began using them for the delivery of food for key populations and humanitarian aid. Critically, the Ukrainian Ministry of Health authorised community outreach teams to disperse two key opioid substitution treatments, methadone and buprenorphine, even though both are controlled medications usually only available in more formal and secure settings.
A key issue is around funding. Many HIV prevention and support programmes in Ukraine are still supported by large international donors. Like during the early stages of the COVID-19 pandemic, the flexibility of donors—particularly the President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria—has allowed extensive reprogramming of community HIV services in Ukraine. For example, the Ukrainian drug users' network was able to evacuate more than 100 people from the Donetsk and Luhansk regions, providing accommodation, food and medication in a safer location.
It is also vital to provide up-to-date information for all key HIV populations during times of turbulence, especially about where treatment and support are available for people who were forced to relocate. This can save lives, and there are already tragic reports of drug users who were unable to access medication ending their own lives. Basenko said that a hotline run by a community-led organisation for drug users dealt with a threefold increase in calls, mostly from displaced people or those stuck in non-functioning clinics.
In countries receiving refugees, especially Poland, the priority is to ensure treatment continuity and to maintain support for people who may not have their medical files with them. Civil society—as during the COVID-19 pandemic—is taking much of the strain. Staff face a significantly increased workload, regularly updating and co-ordinating information on key services and access for Ukrainian refugees living with HIV, for example. It is vital to continue these additional services during what looks like an increasingly protracted period of conflict. Magdalena Ankiersztejn-Bartczak, President of the Foundation for Social Education (FES), a Polish NGO which, in addition to working in the HIV field, delivers education in sexual health and cancer prevention, shared in an email that:
‘Without long-term measures, these [extra] activities will come to an end, because many weeks of commitment mean that [eventually] people must go back to their everyday duties. We need [dedicated] support for Ukrainian refugees living with HIV.’
The future—what next?
Ukraine has made great gains in its fight against HIV, especially for injecting drug users. In recent years, the Ukrainian cities of Dnipro, Kyiv and Odessa all signed up to the Fast Track Cities initiative (https://www.fast-trackcities.org), a global programme that aims to unify political and community leaders to combat HIV. Harm reduction services have developed significantly in the Ukraine. Since 2010, new infections of HIV among people who use drugs has dropped by 21% (The Lancet HIV, 2022).
‘Ukraine has one of the highest rates of HIV in the European region, with about 250 000 people living with HIV, mainly concentrated in people who are drug users’
Taking a strong public health approach to HIV prevention and harm reduction marks Ukraine as distinct from its aggressive neighbour. Russian methods are traditionally much more punitive, and evidence of Russia's political pressure on other countries seeking a more public health approach to harm reduction is evident. In Kazakhstan, for example, Russian-supported anti-methadone propaganda was used to diminish the effectiveness of NGOs attempting to replicate Ukraine's model (Wheaton, 2021).
For Basenko, the war in Ukraine is much more than about tanks and guns. It's a ‘battle of ideologies’: the old world versus the new. It is a regressive pushback against Ukraine's efforts towards self-identity as a European nation, part of which is reflected in its civil society's efforts to promote a stronger emphasis on human rights and respect for the individual. For Basenko, if Russia succeeds in consolidating its hold on parts of Ukraine:
‘It will be a huge step back in public health [around] HIV to 20 years ago. That's what we see in areas occupied by Russia. We know the situation is getting worse. All the progress in the fight against HIV, gained since Ukraine was truly independent, is going backwards.’
It is important not to lose sight of anyone caught up in this conflict. For people affected by HIV, anything we do can make a difference. Basenko is passionate in his call to action:
‘We shouldn't just be observers! Wherever you are or whatever you are doing you can help! Some people accommodate Ukrainians, or provide a small donation, share food, or even stand in public squares with banners. But we should do something! This is a critical moment.’
For all healthcare workers, this is a direct appeal to seek ways to support colleagues and communities experiencing unconscionable trauma and disruption in this war. Think about it—what can we do to help?