Fate of people with HIV in jeopardy in Ukraine

As the war in Ukraine escalates, the humanitarian crisis continues to grow. Since Russia invaded the country on Feb 24, the devastating effects on the population have become ever more acute. Indiscriminate attacks on civilians and civilian infrastructure are increasing, with little or no recognition of humanitarian corridors, and mounting loss of life. To date, an estimated 200 health-care facilities are situated in the conflict zones, and several hospitals have been destroyed by military operations. The implications for people needing access to the country’s health systems are catastrophic.

Continued provision of, and safe access to, HIV treatment and prevention services in Ukraine for those living with and affected by HIV are at great risk. Early in the war, concerns had been expressed about the availability of HIV services during the conflict, with UNAIDS stating that supplies of antiretrovirals for the country’s over 150 000 people on HIV treatment were limited to a few weeks. Although initial aid deliveries have concentrated on essential medicines and emergency materials, according to WHO, supplies of antiretrovirals will be met through funding and cooperation with international aid agencies, Ukraine Ministry of Health, and local non-governmental organisations.

Before the invasion, Ukraine’s response to HIV had been mixed, hampered by poor socioeconomic conditions, reduced external funding, and unrest in the eastern separatist provinces. However, in recent years the country had made substantial progress in tackling the epidemic, which is mainly concentrated among people who inject drugs. The estimated population of people who inject drugs is over 350 000 with an HIV prevalence of 21%. In particular, there was a big scale-up in harm reduction services, including needle exchange programmes and the largest opioid agonist therapy programme in eastern Europe and central Asia. The country has seen a 21% reduction in new infections since 2010. The besieged cities of Dnipro, Kyiv, and Odessa had recently signed up to the Fast Track Cities initiative. The conflict threatens to undo years of progress.

There are antiretrovirals in the country, but access to supplies are already limited in the areas worst affected by the conflict, as highlighted in a Feature in this issue. In-country storage, delivery, and distribution of supplies may be disrupted as the intensity of the conflict spreads. Mitigations for interrupted and limited supplies of antiretrovirals are expected to include trying to anticipate stockouts, multimonth prescribing, and identifying areas expected to have an influx of internally displaced people with HIV. Potential difficulties also exist for the supply and distribution of methadone for opioid agonist therapy. It is shocking that, so far, respect for humanitarian corridors from Russian military has been scant—the existence of these corridors is not only essential for the safe escape of civilians but also to ensure medical supplies reach those most in need. Some organisations have already had to scale back or stop their HIV programmes.

As covered by The Lancet HIV in 2018, the ongoing conflict and occupation by Russian forces in the breakaway eastern separatist provinces of Luhansk and Donetsk decimated HIV services in the area, and serves as a warning for the health and welfare of people with HIV should a Russian-supported regime succeed in Ukraine. The separatist authorities and the Russian administration in annexed Crimea stopped opioid agonist therapy, reflecting the situation in the Russian Federation where the therapy is illegal.

The conflict could have serious implications for the HIV response in adjacent countries too. As of March 11, according to the UN migration agency, 2·5 million refugees had crossed the western Ukraine border to neighbouring friendly countries and estimates suggest that this will soon reach 4 million. Continuity of HIV services for those refugees who do make it to adjacent countries is a concern. It is imperative that health systems in these countries are supported, particularly Moldova, one of the poorest countries in Europe. The sanctions too are likely to take a toll on the already limited funding to HIV services in the Russian Federation, which has the largest HIV epidemic in eastern Europe and central Asia.

SEE ALSO:

• The Lancet HIV: Russia’s invasion of Ukraine threatens HIV response