Ukraine's battle to prevent a regional health crisis

When Russia invaded Ukraine on Feb. 24, it dropped a war onto a region already wavering in a battle against some of the world’s deadliest infectious diseases. On top of existing challenges, Russia layered the shelling of health facilities, health supply chain disruptions, and a refugee crisis.

“The war has been a devastating missile for people’s health in Ukraine,” Michel Kazatchkine, a special adviser to UNAIDS, told reporters at the International AIDS Conference in Montreal on Sunday.

With the war now dragging into a seventh month and showing no sign of ending, experts warn that rising poverty, the loss of basic services, and a fast-approaching winter are adding up to a looming regional health crisis.

Meanwhile, Ukraine’s health workers are putting their lives and mental health at risk to ensure patients receive lifesaving treatment for infectious diseases such as HIV and tuberculosis. They want the world to understand that conflict and poverty are key drivers of infectious disease — and that as Ukraine’s economy buckles under the weight of war, an entire region’s ability to keep people alive is at stake.

Their efforts have staved off an even worse disaster.

“Initially there was a fear of outbreaks in HIV and [tuberculosis], following the collapse of the health system. It didn't happen,” said Andriy Klepikov, the executive director of the Alliance for Public Health in Ukraine. “It's important to [say] that the worst forecasts [weren't realized] because of the very intensive work, both from the medical and governmental side as well as from civil society.”

He added: “Civil society and community proved to be the backbone of HIV response in this situation. When clinics were destroyed by rockets, by bombing, civil society organizations — through mobile clinics, through outreach — still managed ... to provide services [and maintain] access to people.”

Global health leaders have praised Ukraine’s health workers and emergency responders, and international donors have tried to support them with additional resources and flexibility.

“The way they've shifted from facility-based provision for relatively static populations to mobile-based for a population on the move has been enormously impressive,” said Peter Sands, the executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, in an interview.

“We can enable them with the money, but they've got to actually do it. The levels of commitment and professionalism and adaptability have just been quite remarkable,” Sands said.

But this has also taken a toll.

When the COVID-19 pandemic began, Klepikov said his organization, like many, adopted a work-from-home policy. When the war with Russia started this year, it shifted its approach to “living from office.” The office in Kyiv has also served as a shelter, a storage facility, and a hotline during the war.

Valeriia Rachynska, who leads the regional policy team at 100% Life, a network for people living with HIV in Ukraine, said she has two priorities in managing her team during wartime.

The first is to help them approach their jobs in a “psychologically safe” way, when their days often begin by calling colleagues to find out if they have survived the latest Russian airstrike.

The second: “Support our army,” she said. “Because if we lose our country, all this work, it will be for what?”

A regional crisis

For years, the Eastern Europe and Central Asia region has been the only one in the world where the main indicators of progress against HIV have moved sharply in the wrong direction.

Over the decade from 2010 to 2020, its number of new HIV infections increased 43%, AIDS-related mortality rose 30%, and countries struggled to make progress toward the United Nations’ 2030 goals on HIV, said Kazatchkine of UNAIDS.

With a 2030 deadline, UNAIDS calls on countries to diagnose 95% of all HIV-positive individuals, provide antiretroviral therapy for 95% of those diagnosed, and achieve viral suppression for 95% of those treated.

Kazatchkine said that in Eastern Europe and Central Asia, those numbers are hovering at 70%, 53%, and 50% respectively.

All of this bodes poorly for a region where many countries are already in — or on the brink of — economic crisis resulting from the war. The European Bank for Reconstruction and Development projects that Ukraine’s gross domestic product will fall 30% in 2022. And the United Nations Development Programme expects that 9 out of 10 Ukrainians will be facing poverty by early next year.

Countries whose economies are dependent on Russia are also under immense strain. Kyrgyzstan, for example, has seen the value of its currency fall 40% since February, and remittances sent from abroad have dropped 30% when they were expected to increase by 5%, Kazatchkine said.

“These countries will not be able to have a proper health budget and buy the medicines they need,” he said.

For people living with HIV or tuberculosis in and outside Ukraine, these economic shocks — which make basic needs like food, shelter, and energy harder to meet — also undermine the effectiveness of prevention and treatment for those infectious diseases.

“By the end of the year, we expect much worse consequences. We expect cold. And how do you think a person living with tuberculosis — even on ambulatory treatment, even with medications — if there's no food, if there's no shelter, no place to live, will it be good results of treatment or not?” Rachynska said.

Many expect the trauma of war will also drive further drug use and mental health problems in Ukraine and beyond.

“We should anticipate a major public health crisis across the region,” said Kazatchkine.

Russia’s hidden war

The toll inflicted by HIV in Eastern Europe and Central Asia is not evenly distributed. Rather, it is highly concentrated among so-called key populations — groups who tend to be marginalized or criminalized by stigma and law, are at greater risk of contracting HIV, and often have less access to prevention and treatment services.

Nine in 10 new HIV infections in the region occur among these key populations — and people who inject drugs, along with their sexual partners, account for 45%, Kazatchkine said. The Eastern Europe and Central Asia region is home to one-quarter of all people who inject drugs globally, and many governments in the region impose harsh criminalization with little appetite for “harm reduction” services that target those populations.

There is also significant variation between countries, and one stands out: While an estimated 1.6 million people are living with HIV in the region, roughly 70% live in Russia.

“The Russian Federation is by far the main driver of growth in the HIV epidemic in the region,” Kazatchkine said.

Instead of taking a science-based approach that includes harm reduction, public information campaigns, and sex education, the Russian government has often imposed policies that further marginalize vulnerable groups, restrict civil society, and suppress information about the epidemic.

When Russia annexed Crimea from Ukraine in 2014, it exported those hard-line policies to the peninsula, banning so-called opiate substitution treatments that can aid drug users’ recovery and even burning confiscated methadone in fires, Klepikov said.

“We have this hidden war in the health field between Russia and evidence-based science,” he said.

For Ukraine’s civil society health responders, that only raises the stakes of the war. International and Ukrainian health and humanitarian organizations are unable to access places like Mariupol, which Russia now occupies — and Russia has shown it is unable or unwilling to provide adequate services to even its own population living with HIV.

“They do not even plan to reach their own people … no way for us,” said Rachynska of 100% Life. “This is going to be a big problem.”

‘Just help us pay less’

Despite the enormous effort by Ukraine’s civil society organizations, the country still faces alarming gaps in prevention and treatment services.

Tuberculosis, particularly among vulnerable populations — and newly vulnerable populations like refugees — is one big area of concern.

Another is mental health.

“Everyone in Ukraine now, to a bigger or smaller extent, requires mental health support,” Klepikov said.

In terms of international aid, Ukraine’s health representatives say it’s not enough for donors just to focus on shipping medications to the country. They are also looking for policy and pricing changes that can help make things like long-acting preexposure prophylaxis, as well as long-acting antiretrovirals, accessible to people who most need them.

“These innovations are available already in Western countries, developed countries. … We should make these innovations available to Ukrainians because we need them even more with such mobility of the population, Klepikov said.

Civil society advocates also stress that while Russia’s approach to infectious disease is particularly harmful, Ukraine’s is far from perfect. Rachynska criticized the government’s criminalization of sex work at a time when many people are in desperate circumstances, and she called on the international community to push Ukraine’s health sector toward more progressive reform.

But the biggest need is immediate support to stem Ukraine’s descent into poverty during the war and shore up its ability to deliver health services.

“We will win this war, because justice always wins. … But what will be the price for us? How many lives? How many people will never see their kids? How many wives will lose their husbands? How many parents will live alone for the rest of their days? ​​We don’t know the price,” Rachynska said.

“Just help us pay less.”