Russia’s invasion of Ukraine could spark an upsurge in HIV and tuberculosis and undo a decade of gains in public health, experts warn.
Ukraine has long wrestled with high rates of both diseases. Public health reforms spearheaded by government and civil society groups have made inroads, but the war has disrupted supplies of antiretroviral drugs against HIV and TB medication. This, combined with the poor conditions for displaced people fleeing the frontlines, has created an ideal environment for the spread of disease and left patients worried about a very uncertain future.
“I can’t interrupt this treatment, I have to take it every day,” said Svetlana, a resident of Dnipro, a city 450 kilometers southeast of Kyiv. She has been on antiretroviral drugs since she was diagnosed with HIV in 2010. “We’re ill people and these tablets are life-saving. I get in a panic.”
Svetlana has a sick mother to take care of, and herself suffers from hepatitis. The basic medicines they both need are no longer available in pharmacies. She now has a stock of HIV medicine at home for the next month, as doctors have begun distributing bigger batches to keep patients supplied in case they are forced to flee or are unable to reach AIDS treatment centers.
Health under siege
Around 250,000 people, or 1 percent of the population between the ages of 15 and 49, live with HIV in Ukraine — the second-highest number after Russia in the Eastern Europe and Central Asia region. Ukraine is also on the World Health Organization’s watchlist for TB, recording 17,533 new cases in 2020. Multidrug-resistant TB, which can’t be treated with normal medication, is a serious problem, accounting for an estimated 29 percent of new cases in 2018, according to the WHO.
Despite those challenges, Ukraine has embraced a health reform agenda, said Michel Kazatchkine, an academic and special adviser to WHO Europe. In the past two years, the country hosted successful clinical trials for oral treatments against drug-resistant TB. It has also been proactive in negotiating for antiretroviral drugs, as well as implementing harm-reduction programs for injectable drug users, who make up around half of all new HIV cases.
The hard-won gains made in recent years risk being swept away in days, said Andriy Klepikov, executive director of the Alliance for Public Health (APH).
He leads the biggest health-focused nongovernmental organization operating in Ukraine. APH rolled out the country’s first opioid replacement program, key to getting drug users off street drugs and no longer sharing needles — a major avenue of HIV spread — and into health and social services systems.
The most immediate problem facing officials and activists working in public health is making sure that patients living with disease are able to get ahold of medicines they need.
In Dnipro, the local AIDS treatment center has enough antiretroviral medicine for about seven months, according to Iryna Bozhko, acting director of NGO Synerhiya Dush, which provides psychosocial support to HIV and opioid replacement therapy patients. But the center’s doctors are now coping with a flood of up to 20 new clients per doctor daily, as displaced people flee heavy fighting in Kharkiv and other cities.
Patients with TB face similar problems.
The country has enough medicine to last a year, said Lucica Ditiu, executive director of the public health group Stop TB Partnership. But there’s no assurance that warehouses storing the medicine won’t be bombed. And if patients, in the chaos of war, interrupt their treatment, they risk falling sick again and even developing difficult-to-cure drug-resistant TB.
Sheltering for extended periods of time in closed spaces like basements or bomb shelters also hastens the spread of the disease.
“The problem is that people will become sicker and they will transmit it to the people around them. And now, in the current situation — with so much stress, fear and the lack of food — it’s very easy to get infected with TB,” said Ditiu.
If much of the disruption to health infrastructure is collateral damage caused by indiscriminate bombing, some of it could become deliberate policy, fuelled by Russian antipathy to public health approaches it sees as politically suspect and tied to the West.
Ukraine’s harm-reduction program — which covers needle exchanges for drug users, rapid HIV testing, and opioid replacement therapy — could be a target.
The program has been able to reduce HIV among young drug users, a particularly vulnerable population, by a factor of 10, said Anton Basenko, program manager for the European AIDS Treatment Group.
Basenko, who was born in Ukraine and now lives in Belgium, was one of the first to enter opioid replacement therapy. Addicted to heroin at 16, he was able to access opioid replacement therapy when he was 24 — among the first in the country to get the treatment. He credits the program, together with antiretroviral drugs, with saving his life.
Basenko said that Russia — the only country in the region where HIV infections are still growing — strongly opposes the program, which it sees as going against traditional Russian values and an avenue of influence for Western-backed NGOs.
When Russia invaded east Ukraine and annexed the Crimean peninsula in 2014, officials banned local opioid replacement therapy programs, even staging public burnings of the medicines, a decision that the U.N. says resulted in 100 deaths from suicide, overdoses or complications related to HIV and tuberculosis over the next year.
For now, public health campaigners in Ukraine have to make do.
One of two main domestic factories producing opioid replacement drug methadone in Kharkiv is no longer working. When the APH tried to organize the distribution of stocks from warehouses and the other factory in Odesa, on the Black Sea coast, the Ministry of Health said it was impossible as they could not arrange the armed guard required by law for transporting narcotics.
“Most regions are already under fire and out of treatment medications, or with limited supply already,” said Pavlo Skala, an associate director at APH who is coordinating operations from the organization’s office in Kyiv.
However, the organization has found a new use for special armored vehicles intended for transporting methadone in an innovative project offering substitution therapy to clients in hard-to-reach areas. The U.S.-backed project never had time to get up and running, but with volunteer drivers the vans are evacuating besieged civilians trapped in towns near Kyiv, like Irpen, Bucha and Pushcha-Vodytsia, that are bearing the brunt of the Russian attack on the capital.
“They are going to dangerous places and evacuating people from there,” said Skala.
Mobile clinics that used to travel fixed routes offering HIV and TB testing, counseling and prevention services have also been repurposed for a war footing. A fleet of 16 buses purchased with funds from the Global Fund to Fight AIDS, Tuberculosis and Malaria that was awaiting commissioning for new routes in the Kyiv region are now bringing in aid from the Polish border.
“It’s the first time within the Global Fund history in Europe we’re dealing with these challenges and stress and humanitarian crisis and shortage of supplies,” said Skala. “We are making history here.”
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