Ukraine is home to the second biggest HIV epidemic in Eastern Europe and Central Asia, with an estimated 240,000 people living with HIV and, as of October 2017, 139,394 officially registered cases. The prevalence rate is underpinned by a large number of injection drug users, growing rates of sexual transmission, and the high concentration of at-risk and affected populations in the conflict-plagued Donbass, which threatens to undo recent progress in the rollout of lifesaving harm reduction programmes and antiretroviral therapy.
Operating against this background is AFEW-Ukraine, a non-governmental humanitarian public health organisation working to reduce the impact of HIV/AIDS and improve access to prevention, treatment and care for vulnerable populations.
Here, the charity’s executive director, Elena Voskresenskaya, shares her thoughts on the current HIV situation in Ukraine, the importance of primary care reform, and the hidden epidemics at the heart of the crisis.
What are the main drivers of the HIV epidemic in Ukraine?
The main driver of this epidemic has traditionally been drug use and in particular injection drug use. This is still a very important contributor, but lately the number of new cases of HIV infection among drug users as a percentage of parenteral transmission has gone down. In ten months of 2017, 63% of newly registered cases were due to sexual intercourse, and just 21% were caused by intravenous drug use.
While official information demonstrates that heterosexual transmission is prevailing over homosexual, we know thanks to evidence from our partners working directly with men who have sex with men (MSM) that the number of HIV cases among MSM and the LGBT community is constantly growing. Unfortunately, this is quite a hidden epidemic.
The HIV epidemic as a whole is not generalised and mostly affects the so-called ‘key populations’, including MSM, sex workers, and drug users. People in prison or detention facilities are also vulnerable because they often represent a combination of potential risk factors. Most of them inject drugs and practise unsafe sexual behaviours, especially MSM, and they live in confined conditions where the threat of infection is much higher.
Young people within each of the key populations are especially at risk – first because of their age, second because they practise unsafe behaviours and third because of the gaps in services and their access to services.
A big barrier here is legislation: adolescents are legally allowed to get tested for HIV without parental consent at the age of 14, but in reality, this doesn’t always work as well as it should.
If a young person does test positive for HIV, getting them onto treatment is another problem. In this instance, we would need to notify their parents, but this can be difficult because, in many cases young people with HIV belong to ‘unfavourable’ social groups: their parents are dead, in prison, drug users, or alcoholics. What do we do then?
We urgently need to address these issues among young people, because when young key populations grow up they become adult key populations, and they risk bringing in a new wave of the epidemic.
How is the conflict in Donbass complicating the HIV response?
The conflict in Donbass is making the situation much worse. The Donetsk region has traditionally had one of the highest HIV rates in the country; almost a quarter of all patients on antiretroviral therapy prior to the conflict were located in Donetsk and Luhansk. Once the conflict began it became difficult for that treatment to continue. Both NGOs and the Ukrainian government organised the supply of antiretrovirals to the Donetsk and Luhansk area, but security reasons made it impossible for the government to transport methadone over the border and into the (pro-)Russian separatist-controlled Donetsk territories.
As a result, drug users who were on methadone substitution therapy were lost to treatment or had to move to the government-controlled territories. We still don’t know what the consequences of that will be.
On top of that, the prevalence of HIV and other infectious diseases is growing within the military as a result of soldiers practising unsafe behaviours. This is another group that requires special attention from the government and health authorities. Because they’re living in confined conditions they are also at an increased risk of contracting tuberculosis, a common HIV co-infection.
Again, we don’t yet know what impact that will have down the line. If no measures are taken to prevent it, perhaps in a year or two we will see changes in the epidemiology of HIV when these soldiers return home and go back to their families.
How reliant is Ukraine on donor funding as part of the efforts against HIV?
The Global Fund to Fight AIDS, Tuberculosis and Malaria is our biggest donor, but the amount we receive from them is decreasing every year.
This is a normal thing because eventually, the government needs to start allocating its own funding. At the same time, we are in quite a complicated situation right now because the military conflict is still ongoing and the healthcare reforms have not yet been finalised.
The government has already taken control of a number of initiatives, including the purchase and provision of antiretroviral drugs, and, in an unprecedented move for Ukraine, they are also planning to purchase methadone with money from the state budget.
Unfortunately, this is not sufficient, because in order to be successful at treating and preventing HIV we will need much stronger mechanisms for social support and to promote adherence to treatment for people on both methadone and antiretrovirals.
It’s also unclear how HIV prevention will be funded in the future. HIV prevention programmes are mostly managed by non-governmental organisations (NGOs), who also do a lot of work with key populations. When the government takes over that work, we expect it will be very, very difficult for people who currently receive the NGO services to receive them at general practices.
The National Targeted Social Program to Fight HIV/AIDS in Ukraine for 2014-2018 also states that there should be an interagency-led information, education and communication strategy to prevent HIV in the general population, including large-scale information campaigns and special programmes for schools.
Who in the government will fund this? Most media campaigns have so far been carried out by international and non-governmental organisations using donor funding, but what will happen once that funding runs out? We don’t even know who in the government is in charge of prevention: the health ministry is the main body responsible for HIV, but they can’t cover everything.
We need an intersectoral approach to HIV prevention. Until we have a mechanism in place that unites the efforts of multiple ministries and administrations, I don’t think we will have any real success with prevention.
We also do not yet know what mechanisms will be put in place to maintain the results that have already been achieved by NGOs.
Frankly speaking, then, there is still a lot of uncertainty about what will happen once this transition from donor to domestic funding is complete, and while there is reason to be optimistic, we still have some serious thinking to do on it.
How do you expect the recently passed medical reforms – which aim to improve standards and reduce corruption within the healthcare system – to impact on the HIV epidemic?
We welcome the healthcare reforms, but unfortunately, we still don’t know in great detail how they will be implemented.
We expect to see testing increase under the reforms, as it will now be performed by primary care providers. Current HIV testing may be limited because it works on an opt-in basis whereby patients have to explicitly consent to be tested.
Ideally, we would like to see opt-out testing offered as a routine procedure within a general medical examination. That way, if someone doesn’t want to be tested, they can say so, but international experience shows that the more testing is offered the more people actually get tested.
Of course, it is also really important that all testing is confidential and can be anonymous (if the patient wishes). This would encourage a greater uptake.
Hopefully, we’ll see these changes start to happen, but unfortunately, the service providers are not yet prepared for them, so they won’t happen overnight. We need to see a lot more effort from the government and the medical schools to train primary care practitioners to deliver that service.
I am also worried about the levels of stigma within services. At the moment, all treatment and testing services are concentrated in specialised facilities and performed by service providers who have already been trained how to work with MSM or people who use drugs.
This is not so much a problem in large cities, but primary physicians in small villages may not be so welcoming. We know that stigma and a lack of friendly service providers result in late diagnoses, and many HIV-positive people are already reluctant to seek out treatment because drug use is criminalised.
Until the legislation changes, and until this stigma is effectively addressed, we will continue to have instances of people being afraid to disclose their status and look for services. We are working to address this, but there is a long way to go. Primary care reform, therefore, needs to be considered along with other policy changes.
What work is AFEW-Ukraine doing to prevent HIV transmission and support people living with HIV?
We have been based in the country since 2001 and since then have mostly focused on prevention programmes among the key populations.
We support communities to develop their advocacy capacity and ability to monitor services, and we facilitate informal associations of key populations as a platform for them to speak up and share their urgent needs.
In Kyiv, we are working alongside women with HIV to improve their adherence to treatment. Some of these women are survivors of violence or else married to men who use drugs, so we have established peer-support groups where they can share their problems and receive further help.
Some of our biggest projects deal with at-risk youth, including street children and young children who use drugs. We are trying to empower young people who use drugs to become advocates for the development of youth-friendly services. Evidence shows that early drug use often leads to injection drug use, which increases exposure to possible HIV infection, so we are currently working with adolescent drug users to discourage that.
This is important because nobody has really acknowledged that such a population exists; the national programme lists young people in general, but it doesn’t include any targeted prevention interventions for the most at-risk adolescents. National stakeholders are working to get that incorporated into the next programme, which is currently being planned.
This article will appear in issue 4 of Health Europa Quarterly, which will be published in February.