#06: Ukraine and HIV: Health on the frontlines

Femi Oke:

Welcome to HIV unmuted, the IAS, International AIDS Society’s podcast. I’m your host, Femi Oke.

From our first episode, we’ve followed the emergence of this mysterious disease in the 1980s from a likely death sentence to a manageable condition if you have access to medication.

Today, many people living with HIV continue to face challenges in accessing HIV services. In Eastern Europe and Central Asia, criminalization, stigma and discrimination are the main barriers to an effective HIV response.

And these barriers are particularly prohibitive in Russia.

Unknown:

Only the oligarchs have it easy here in Russia. Everyone else – gays, teachers, journalists, people with HIV – have it tough.

Femi Oke:

Eastern Europe and Central Asia is the region in the world where new HIV infections are increasing the fastest.

In Ukraine, an estimated 260,000 people are living with HIV. Just over half take HIV medication. Many thousands more are at greater risk of acquiring HIV and rely on access to HIV prevention services.

The Russian invasion of Ukraine brings into sharp focus the fragility of access to medication and prevention. Humanitarian emergencies and conflict disrupt health services, making people living with and affected by HIV more vulnerable. Conflict also often involves mass displacement impacting access to healthcare. One in every 100 Ukrainians is living with HIV. A lack of access to HIV medication and prevention services could mean a wave of deaths and risks a resurgence of Ukraine’s AIDS pandemic.

And in a region with an already rapidly growing HIV epidemic, this could be a public health disaster.

With me today are two leading voices from Ukrainian AIDS service organizations. Valeriia Rachinska is a director at 100% Life, the largest organization of people living with HIV in Ukraine. She is also openly living with HIV.

Andriy Klepikov is an IAS Governing Council member and the Executive Director of the Alliance for Public Health.

Both are displaced in Ukraine, working to ensure that critical HIV services are not disrupted.

Valeriia told us about the challenges that they are facing in maintaining continuity of HIV services during the conflict in Ukraine.

Valeriia Rachinska:

Right now, interruptions of treatment have started because we don’t have stocks of medications. We don’t have anything to give to people.

I’m trying to be strong now. But today, news was really heart-breaking. Yesterday, a humanitarian convoy of our volunteers from 100% Life was bombed by Russians. Seven of our volunteers were killed – seven of our people, extremely good people. Some of them were my friends; some of them, I had never seen, but I communicated with them on the phone … and people just came to help. It wasn’t like a military target.

The Russians killed them on purpose because they are humanitarians.

So … I’m sorry.

Femi Oke:

The personal toll the war is taking on civilians cannot be underestimated. Valeriia had plans to meet her colleagues once the war was over.

Valeriia Rachinska:

And we were going to meet each other after the war and, you know, laugh, and maybe talk about everything that we faced here. And it will not happen. And these meetings will not happen for thousands of Ukrainian citizens. Wives will never see their husbands. Husbands will never see their wives. It will not happen for children who lose their parents, for parents who lose their kids.

Femi Oke:

More than 100 confirmed attacks on health facilities in Ukraine have thrown supply routes in the country into disarray, making it even more difficult to continue providing HIV services.

Andriy’s organization, Alliance for Public Health, is also battling the impacts of the war and struggling to make frontline deliveries of HIV prevention and treatment.

Andriy Klepikov:

Over the next days, next week, these supplies will be running out. It’s critical to renew the supply.

For the opioid substitution therapy situation, it’s even more dramatic because we had two production sites: one factory in Kharkiv was bombed and destroyed; a site in Odessa was also attacked.

But now, we finally got approval from the Global Fund, and our brave drivers just delivered medicines in areas like Sumy, which is so close to the fighting borderline and constantly bombarded by the Russians.

Femi Oke:

Even in the areas that aren’t in direct conflict, there are many obstacles in providing HIV services for thousands of people who fled their homes in a rush and didn’t take their HIV medication with them.

Andriy Klepikov:

Sometimes, they left medicines at home because they left their homes under such huge stress that treatment was no longer a priority. Saving lives was the main and sometimes the only priority: their own lives and the lives of loved ones, of families.

Femi Oke:

Before the invasion though, Ukraine was making progress in the HIV response and was on the road toward reaching treatment and prevention targets.

Valeriia Rachinska:

Our results were really great. Our country showed that with this consolidation of all partners – together with government, civil society organizations and pension organizations – we can reach the greatest results.

We almost reached the targets. I think that we would have reached next year’s UNAIDS 90-90-90 targets because almost all the people are on treatment here. And the treatment was … one drug, one time a day, for everyone … And efficacy of treatment was really great, everything was measurable, and everything was moving in a positive direction. But right now, people stop taking medication.

Femi Oke:

Life has changed dramatically. It’s no longer business as usual. Andriy is now living in his office with seven others and two pets since fleeing his home in Kyiv.

Andriy Klepikov:

The day before the war was quite regular, and it maybe didn’t differentiate much from any other NGOs all over the world. There were some planned routine activities, scheduled meetings, certain times for doing work on our computers, email exchanges. But now, everything has changed. The main change is unpredictability. We don’t know what will happen in the next moment.

But in terms of the office work, it’s definitely not boring because the office functions as a hotline, as storage, as a shelter.

Femi Oke:

Even as we are speaking to our first two guests, we hear the air raid sirens – a reminder of the immediate threat to life.

But this is not the first time Russia has invaded Ukraine. And our guests have witnessed the impact on HIV services before: when Russia annexed Crimea in 2014.

Andriy Klepikov:

Unfortunately, the experience of annexation of Crimea doesn’t give any optimism in the current situation. I clearly remember, following annexation, when Russian police forces came to medical facilities and confiscated all methadone, the medicine used for opioid substitution therapy treatment, for over 800 patients. They just burned the medicines, like books were burned in the Middle Ages.

Some had very severe health consequences following cancellation of the treatment and cutting off of the treatment. Some committed suicide.

Nothing good can happen in these territories under Russian control.

Valeriia Rachinska:

We are not afraid to fight with Russians, but we are afraid to live with them.

Femi Oke:

People are very worried about the long-term public health impacts of Russian occupation.

Andriy Klepikov:

I’m concerned about further escalation of the conflict because, even now, the war and Russian aggression caused enormous damage to Ukraine, to Ukrainian people and to the most vulnerable. If we think about the number of people at risk of interruption of ARVs and TB treatment, this is the highest number in the world.

Femi Oke:

To better understand the conflict in terms of the broader context of the HIV response in the region where Ukraine is located, I spoke to Dr Michel Kazatchkine, the former Executive Director of the Global Fund to Fight AIDS, TB and Malaria and the former UN Secretary-General’s Special Envoy on HIV in Eastern Europe and Central Asia, and currently an advisor to the World Health Organization in the region.

It’s so great to talk to you. Can you tell me about the region that you are responsible for … what it normally looks like and how that has changed because of the Ukraine conflict?

Michel Kazatchkine:

Well, the so-called Eastern Europe and Central Asian region is a region of 13 countries. And it is basically the only region of the world where the HIV epidemic continues to grow. Between 2010 and now, the number of new incident cases has increased by 30%. This is by far because of the Russian Federation. Ukraine … has actually seen a decrease in the number of new cases between 2010 and 2018.

Femi Oke:

Can you be more specific? What is it about the Russian Federation that means that there is an increase in numbers of HIV cases? What was going on before the conflict?

Michel Kazatchkine:

It is what we call a concentrated epidemic. That is an epidemic that is occurring almost exclusively – over 95% – in high-risk groups, including people who use drugs or people who have been injecting drugs, men having sex with men, sex workers, people incarcerated, transgender, other vulnerable groups. What distinguishes Russia from Ukraine, let’s say, and from other countries, is that those people are not basically served in the Russian Federation. They’re discriminated against – well, they’re discriminated against all over the world – but they’re criminalized. It is very difficult for these vulnerable populations to get access to care. It is also very difficult to get access to prevention. And there is very, very little prevention. There is no PrEP, basically, in the Russian Federation and for people who use drugs – that’s 50% of new infections – and there is no harm reduction.

Femi Oke:

Michel, you talked about harm reduction. What does that mean? Why is that so essential and how has that even become political?

Michel Kazatchkine:

Well, harm reduction is a set of interventions that we offer to people who use drugs to reduce the harms of drugs while they continue to use and inject drugs. There are two main interventions. One is the supply of clean needles so that people don’t share needles. The other is what’s called opioid substitution therapy – that is, providing people with a medicine called methadone, which basically gives them the same positive feelings as heroin, but they do not have to use heroin. They do not have to buy it and they do not have to inject it. So, they’re protected from the harms of uncertainty of the black market, and they’re protected from the harms of injecting.

Femi Oke:

I am wondering what difference it makes when there is a conflict in a region. And we’ve had a little sense of a dress rehearsal with Ukraine because the war with and the conflict with Russia started back in 2014. There were certain areas that had been annexed, certain areas where they do not come under Ukraine’s current government. What has happened to the HIV communities in those regions?

Michel Kazatchkine:

I was very much involved in securing continuity of care at that time. I was the UN Secretary-General’s Special Envoy for HIV for the region. And what happened is that, first, Crimea became a Russian territory … or it was called a Russian territory by the Russian Federation, although it was not recognized by the international community as a Russian territory. From one day to the next, antiretroviral therapy, for example, instead of being supplied by Ukraine, was supplied by Russia. However, prevention services also followed the Russian pattern. And the key thing is that within a week or 10 days of annexation of Crimea, the Russian Minister of Foreign Affairs, Lavrov, said, within six weeks, I want all of the harm reduction activities, the opioid substitution therapy, to be discontinued. That was unfortunately followed by at least hundreds – the Alliance for Public Health says over a thousand – deaths by suicide and overdose. Very sad.

Femi Oke:

Michel, what impact will this conflict have on the region in terms of public health?

Michel Kazatchkine:

The other countries that are independent [are] still economically dependent on the Russian Federation because most of their workforce migrates to Russia where there are six or seven million labour migrants from Central Asia, from the Caucasus. And these countries are very dependent. Their currencies are annexed toon the ruble. The ruble has dropped by 50%. So, [that affects] the capacity of these countries to buy their medicines and their capacity to adapt their systems to an influx of refugees. Something like 300,000 people are estimated to have fled to the east and south, not only to Russia, but to Kazakhstan, to Kyrgyzstan, to Georgia, to Armenia: the capacity of those countries to support these refugees, I think, will be very limited.

Femi Oke:

What information are you able to gather at this stage about the HIV epidemic in the whole of Ukraine now that the whole of Ukraine is at war with Russia?

Michel Kazatchkine:

In the areas where there’s ongoing fighting – the hot areas you see on TV, like Kharkiv and Mariupol – it’s war, it’s destruction, it’s a collapse of health systems … Medicines and access to medicines is not anymore the priority to anyone. The priority is to survive and to fight. But in most Ukrainian territory, despite the threat, despite the challenges – with roads that are blocked, with people fleeing, with sometimes bridges destroyed and so on – despite all of the logistic challenges, somehow the system continues to work.

Femi Oke:

Michel, that really is extraordinary in the middle of a conflict. The systems that have been put in place up until the Russian invasion are still functioning.

Michel Kazatchkine:

Yes, they are. It is remarkable. And of course, everyone is very much mobilized.

Femi Oke:

What does this tell us, Michel, about how to manage the HIV epidemic during a humanitarian crisis? What lessons are we learning from Ukraine?

Michel Kazatchkine:

Well, the first lesson, I think, is that a war is a catastrophe for health – of course, in the emergency period that we are in now. But I’m very concerned personally about the next few months and coming two, three years. I really expect a big health crisis across the region. We need a ceasefire. We need humanitarian corridors to deal with the emergency.

Then, the second lesson is the extraordinary resilience of the healthcare system and of healthcare workers that we’re witnessing. And the next lesson is the speed at which the international system and international solidarity has organized itself.

I’m in close touch with the regional office of the World Health Organization in neighbouring countries, Moldova, Poland, the Czech Republic, Slovakia, Romania and so on. And it’s amazing: not only are they putting together shelters and families are offering lodging, but there are already schools in the Ukrainian language that opened in many of these countries within two weeks of the beginning of the conflict.

And the healthcare community is very much mobilized. WHO is currently organizing stocks of needed medicines – antiretroviral drugs, anti-tuberculosis drugs – in hubs across the region so that continuity of treatment is ensured.

The IAS, which is the incarnation of the movement, I think, can be proud of having brought all of these people from the public sector, the private sector, the communities and civil society together in this fight. And now it is paying off in difficult times. War is horrible. It is death and suffering. It is also an extraordinary mobilization of solidarity.

Femi Oke:

Because Ukraine’s HIV response has been pioneered through public and community partnerships, it has continued to provide for people even through the horrors of war.

We don’t know what the long-term effects of this conflict will be on Ukraine’s progress in the HIV response. In the meantime, Valeriia, Andriy and their organizations are defining their work differently in the face of expanding needs.

Andriy Klepikov:

We are acting strongly and very openly to all emergent needs. Now I am proud that we didn’t say no to any request and that goes beyond the usual scope – sometimes, it’s humanitarian and sometimes it’s personal support. So, it goes much wider than our initial mandate, but we manage to address and be responsive to all the emerging needs.

Femi Oke:

Why do people like Valeriia and Andriy stay? Why do they continue to provide these much-needed services at great risk to themselves?

Valeriia Rachinska:

I don’t know, I cannot explain this feeling. But I know that my place is here and I need to feed people. I need to do logistics. I need to help with evacuation. I need to protect. Maybe I wouldn’t be a good soldier, but I’m a good protector and a good humanitarian.

Femi Oke:

But their dedication, their resilience and their strength strike at the heart of fundamental human rights.

Andriy Klepikov:

It’s always important to remember that those who needed our help and were in a desperate situation in normal conditions require much more in the given situation of the war conflict. And they need more support. And we, as an organization supporting these people, would also appreciate your support. Together, we will win.

Femi Oke:

We are witnessing the worst humanity has to offer in the atrocities committed in Ukraine. These events continue to make people living with and affected by HIV even more vulnerable. But among the sadness and despair, there are stories of resilience from people who illustrate the best of society. People who risk their own lives, whose colleagues have given their lives to bring help and hope.

If you want to help those in need in Ukraine, please click on the show notes for more links and information.

If you are listening to this episode before 29 July 2022 and want to learn more about how conflict impacts people living with HIV and the latest scientific breakthroughs in the HIV response, attend the 24th International AIDS Conference, AIDS 2022, virtually or in person in Montreal.

Until next time, I am Femi Oke with HIV unmuted, the IAS, International AIDS Society’s podcast. It’s true, you can’t keep us quiet.