In March, we reported that Ukrainians displaced by the conflict were struggling to access HIV and drug dependency treatment. It has now been four months since Russia invaded Ukraine, and people living with HIV who have been displaced by the conflict continue to face serious risks to their health.
The situation in Ukraine
Antiretroviral therapy (ART) is still available in Ukraine but less accessible in areas with active conflict. Unfortunately, areas most affected by HIV, such as the Donbas, are also those most affected by the conflict. Even where clinics have remained open, supply of treatment is patchy and staff have very limited capacity. The risk of disruption to HIV treatment access has been further exacerbated by attacks on healthcare facilities, resulting in 101 healthcare facilities being destroyed and 600 damaged, according to the Alliance for Public Health.
There can be serious health consequences when people living with HIV are unable to access treatment. These include a much greater risk of developing drug resistance, immune suppression and other health conditions, as well as passing HIV on to others. These issues arose following the war in eastern Ukraine in 2014 and are likely to worsen now that the conflict has increased considerably in scale.
International funding bodies such as PEPFAR (the US President’s Emergency Plan for AIDS Relief) and the Global Fund to Fight AIDS, Tuberculosis and Malaria have committed emergency funds to ensure that supplies of HIV treatment are available within the country. This has been achieved by shipping ART in from neighbouring countries, but getting these vital medicines to people living with HIV has proven more challenging, especially in areas on the front-line.
Ukrainian HIV clinicians have formed mobile teams which can be rapidly deployed to support local healthcare providers with HIV-specific services for internally displaced people in remote areas. Civil society organisations are also working with the Ukrainian Ministry of Health’s Public Health Center to maintain HIV services, often at considerable risk to their own lives. Several volunteer drivers have been killed while trying to deliver desperately needed medication.
Sites providing drug dependency treatment (Opioid Agonist Therapy (OAT), also known as Opioid Substitution Therapy) are still functioning in the country and have sufficient supplies for at least a month, with the exception of cities under siege such as Mariupol and Okhtyrka. However, the two factories that produced OAT within Ukraine have closed due to shelling which risks longer-term supply. The Ukrainian government has responded by initiating the process of procuring OAT from abroad and calling for donations, as well as adjusting rules to allow people to take OAT home (rather than daily dispensing) and rationing OAT to cover basic needs only. There are concerns that OAT clinics will be closed in Russian-occupied areas, since the Russian government is known for its hostility to OAT and supplies were cut off in Crimea when it was annexed in 2014. However, it is not yet clear if this has now occurred in areas occupied since the war’s escalation in 2022.
The situation for Ukrainian refugees
Approximately five million refugees have escaped the war since February. UNAIDS and WHO estimated in March that around 28,000 of these refugees would be living with HIV, yet considerably lower numbers have actually registered for care in their host countries. There may be a number of reasons for this, including people being unaware of what HIV services are available and how to access them, concerns about stigma and confidentiality, or they may simply be prioritising basic needs over health for the time being, such as finding accommodation.
A month ago, Dr Justyna Kowalska reported at a webinar on HIV care in Ukraine that HIV clinics in Poland are starting to see more patients living with HIV from Ukraine, with around 1400 people registered overall. She has put this down to greater understanding among Ukrainian refugees that ART is provided free-of-charge, as well as people running out of the personal supplies of ART that they brought with them from Ukraine.
For some patients considering a return to Ukraine, the issue they now face is establishing whether their former clinic is still functioning and how they can access ART. If providing these patients with a longer supply of their treatment regimen is not feasible (as is the case in Poland due to limited supplies of dolutegravir), the best option may be to switch treatment regimens so more can be provided. Dr Kowalska suggested that bictegravir could be a good option due to its similarity to dolutegravir.
In addition, she highlighted that the major issue faced by her Ukrainian patients is emotional trauma. Psychological support as soon as possible is absolutely vital – especially for people living with HIV since poor mental health can also impact on treatment outcomes. Dr Oleksandr Bilchenko, a leading cardiologist in Ukraine, also highlighted in a recent WAVE webinar on care for women living with HIV that the stress of war can also increase the risk of cardiovascular disease, and clinicians should take this into account when monitoring patients.
There are no data so far on numbers of Ukrainian refugees accessing OAT, but since availability varies considerably between countries it is likely that some refugees will be experiencing challenges in accessing it. However, the majority (over 80%) of people registered for OAT in Ukraine are male, so it is feasible that many OAT patients will have remained in Ukraine due to conscription laws.
The response
There have been a number of initiatives launched to support Ukrainians living with HIV to access the healthcare they need either in Ukraine or in their host countries.
Medical data-sharing algorithm: In April 2022, the Ukrainian Public Health Centre (part of Ukraine’s Ministry of Health), the World Health Organization and a number of European partners published a standard procedure for the sharing of medical data between Ukraine and countries receiving Ukrainian refugees. This should help overcome barriers to appropriate care due to patients missing documents when they arrive in their host countries.
Information on HIV treatment and healthcare for Ukrainian refugees and internally displaced people: A number of information sources have been compiled to provide Ukrainian refugees, and those supporting them, with information on where they can access HIV treatment and other healthcare in their host countries. HelpNow was established by Ukrainian non-governmental organisations, the Ukrainian Ministry of Health and international bodies to support Ukrainian people’s access to HIV, TB and hepatitis treatment both in Ukraine and around the world. More information is available here (in Ukrainian). NAM has published a page in English, Ukrainian, and Russian which lists other sources of information as well as where people can seek HIV treatment in 41 countries across Europe and Central Asia. The European Union has supported the development of the Treatment4Ukraine website, which provides information in English and Ukrainian on access to healthcare services in 45 countries.
Telemedicine: HelpNow have recently launched an ‘Online Doctor’ as part of their service, whereby Ukrainians living with HIV can access online advice and counselling from Ukrainian HIV clincians. Similarly, the Help24 website established by the Alliance for Public Health is providing free online consultations for people living with HIV in Ukrainian and Russian on HIV, mental health, drug dependency, and other health issues.
Clinician networks: Young Investigators from the European AIDS Clinical Society have established an initiative called Dare To Share Care, which enables clinicians to donate ART and other medical supplies, as well as financial contributions, to organisations working on the ground in Ukraine. Clinicians from the same group have devised a unified European support framework for delivering HIV care to Ukrainian refugees, giving guidance to clinicians caring for a new group of patients on which services should be prioritised.