Ukraine and HIV: Health on the frontlines

Eastern Europe and Central Asia is the region of the world where HIV acquisitions are increasing the fastest. In Ukraine, an estimated 260,000 people are living with HIV. Many thousands more are vulnerable to acquiring HIV and rely on access to HIV prevention services. 

In this episode of HIV unmuted, the IAS podcast, we hear how the Russian invasion of Ukraine could mean a resurgence of Ukraine’s AIDS epidemic. And in a region with an already rapidly growing HIV epidemic, this could be a public health disaster. 

Our guests are:

• Valeriia Rachinska from 100% Life, the largest organization of people living with HIV in Ukraine, experienced a Russian invasion when Russia annexed Crimea in 2014. After that, she’s not afraid to fight, but she’s afraid to live under Russian occupation. Despite this fear, she stays to help where she is desperately needed.

• Andriy Klepikov never thought he would be an internally displaced person. Crammed into an office with seven other people and two pets, he tells us how he continues to lead the Alliance for Public Health, delivering critical HIV services.

• Michel Kazatchkine is an Advisor to the World Health Organization in the region and the former UN Secretary-General Special Envoy on HIV in Eastern Europe and Central Asia. He helps us understand why the HIV epidemic in the region continues to grow and why this war is both a catastrophe for public health and an extraordinary mobilization of solidarity.

If you want to help those in need in Ukraine, click on the links below to donate:  

ALLIANCE FOR PUBLIC HEALTH AND 100% LIFE 

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. 

Transcript

FEMI OKE, Host
 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, Host 

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 health care. One in every 100 Ukrainians are 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. Valeria 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. 

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

VALERIA RACHINSKA, 100% LIFE 

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

I'm trying to be, you know, strong now, but you know, today news for us are really heartbreaking yesterday 

Our humanitarian convoy from our volunteers of 100% life was bombed by Russians. Seven of our volunteers were killed. Seven, our people and people that was like extremely good people. It's my, some of them, were my friends, some of them I never saw in my life, but I communicated with them on phone every time and people just came to help. So simply it was, it wasn't like a military target. 

And Russians killed them for purpose because they are humanitarians. So... I’m sorry. 

FEMI OKE, Host 

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

VALERIA RACHINSKA, 100% Life 

And we were going to meet each other, you know, after war and, you know, (?), and maybe on everything that we faced here, and it's doesn't happen. It wlll not happen in the future. And it will not happen these meetings for thousands of Ukrainian citizens. Wives will never see their husbands. Husbands will never see their wives, children who lose their parents, parents who lose their kids. 

FEMI OKE, Host 

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, Alliance For Public Health 

Over the next days, next week, these supplies will be running out. So it's critical to renew, to renew the supply. 

For opioid substitution therapy situation, even more dramatic because we had two production sites. And one factory in Kharkiv was bombed and destroyed. A site in Odessa was also attacked. 

But now we got finally approval of the global fund and our brave drivers just deliver medicines in the area like sumi so close to the to the fighting borderline constantly bomb bombarded by Russian. 

FEMI OKE, Host 

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 home in a rush and didn’t take their HIV medication with them. 

ANDRIY KLEPIKOV, Alliance For Public Health 

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

FEMI OKE, Host 

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

VALERIA RACHINSKA, 100% Life 

Our results were really great. When we showed, all our country showed that, this consolidation of all the partners together with government, together with civil society organization and pensions organization, we can reach the greatest results. 

So we are almost reach here - I think we, we would reach the next year, the next year's targets of UNAIDS 90-90-90. Because almost like, all the people we are on treatment here. And the treatment was like an innovative TLD. So, one drug, one time a day. So... and for everyone. And efficacy of treatment was really great, and everything measurable, and everything in positive direction. But right now people stop to take medication. 

FEMI OKE, Host 

Life has changed dramatically. It's no longer business as usual. Andriy is now living in his office with seven others and 2 pets since fleeing his home in Kiev . 

ANDRIY KLEPIKOV, Alliance For Public Health 

Day before the war was quite regular, maybe didn't differentiate much from any other ngos all over the world with some planned routine activities, scheduled meetings, certain time for do some, work on, on our computers, email exchange, but now everything has changed. The main change is unpredictability. We don't know what will happen during the next moment. 

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

FEMI OKE, Host 

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 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, Alliance For Public Health 

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

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

So, nothing good can happen in these territories under control of Russians. VALERIA RACHINSKA, 100% Life 

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

People are very concerned about the long-term public health impacts of Russian occupation. ANDRIY KLEPIKOV, Alliance For Public Health 

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 a number of people who had risk of treatment interruption of arv and tb treatment, this is pick up the highest number in the world . 

FEMI OKE, Host 

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 tb in malaria and the former un secretary general special envoy on HIV in Eastern Europe and Central Asia, 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, what it normally looks like and how that has changed because of the Ukraine conflict? 

DR 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 epidemic continues, 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, and we'll discuss Ukraine I suppose in more detail in a minute, has seen actually a decrease in the number of new cases in between 2010 and 2018. 

FEMI OKE, Host 

Can you be more specific? What is it about the Russian federation, which means that there are an increase in numbers of HIV cases. What is, what is going on before the conflict? 

DR MICHEL KAZATCHKINE 

It is what we call a concentrated epidemic. That is an epidemic that is occurring almost exclusively 90, over 95% in high-risk groups, including people who use drugs or people who have been injecting drugs. And then men having sex with men, sex workers, people incarcerated, transgender, other vulnerable group. 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 - well, they're discriminated all over the world - but they're criminalized. So, 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 - and I said that's 50% of the new infections - there is no harm reduction. 

FEMI OKE, Host 

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

DR 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 the 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 black market, and they're protected from the harms of injection. 

FEMI OKE, Host 

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

DR MICHEL KAZATCHKINE 

I was very much involved in sort of securing continuity of care at that time. I was the un secretary general special envoy for HIV for the region. And what happened is first in Crimea, Crimea became Russian territory, yes? Or called Russian territory by the Russian federation, although not recognized by the international community as, as Russian territory therefore from one day to next antiretroviral therapy for example, instead of being supplied by Ukraine has been supplied by Russia. However, prevention services also followed the Russian pattern. And the key thing is that within a week or 10 days after annexation, Crimea and the Russian minister of foreign affairs Lavrov said, within six weeks, I want all of the harm reduction activities - opioid substantive therapy - to be discontinued. That was unfortunately followed by at least hundreds, the Alliance for Public Health say over a thousand, deaths by suicide and overdose. Very sad. 

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

DR MICHEL KAZATCHKINE 

The other countries that are independent, of course, are independent, but they still economically dependent on the Russian federation because most of their workforce migrates to Russia, where there are six or seven millions labor migrants, you know, from Central Asia, from the caucuses... and these countries are very dependent. Their currencies are annexed on the Ruble. The Ruble has dropped 50%. So, the capacity for these countries to buy their medicines, and their capacities to adapt their systems also to an influx of, of refugees. You know, there's somewhere 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, to, to support these refugees. I think will be very limited. 

FEMI OKE, Host 

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? 

DR MICHEL KAZATCHKINE 

In the areas where there's ongoing fighting, you know, the hot areas you see on tv - Kharkiv, Mariupol, whatever, it's, it's war it's destruction, it's collapse of health systems... So, medicines and access to medicines is not anymore, the priority to anyone. The priority is to survive and, and to fight. But in most of Ukrainian territory, despite the threat, despite the, 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, Host 

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

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

FEMI OKE, Host 

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

DR 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, you know, to deal with the emergency. Then, the second lesson is the extraordinary resilience of the healthcare system that we're witnessing and of healthcare workers. And the next lesson is the speed at which the international system and the international solidarity has 

organized itself. I'm in touch, in close touch, with the regional office of the world health organization with neighboring countries, Moldova, Poland, the Czech Republic, Slovakia, and the Romania and so on. And it's amazing, not only are they putting together shelters, families are offering lodging, but for example, there are already schools in, in Ukrainian language that opened in many of these, of these countries within two weeks of the beginning of the conflict. And the health system community, the health care community sorry , is very much mobilized. And who is currently organizing stocks of needed medicines - antiretroviral drugs, anti-tuberculosis drugs i- n sort of hubs across the region so that continuity of treatment is ensured. So, the IAS which is the sort of incarnation of the movement I think can be proud of having brought all of these people from the public sector, from the private sector, from the communities, the 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, Host 

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, Valeria and Andriy and their organizations are defining their work differently in the face of expanding needs. 

ANDRIY KLEPIKOV, Alliance For Public Health 

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 those goes beyond usual scope sometimes it's humanitarians and sometimes it’s personal support. So it goes much wider that our initial mandate, but we manage to address and be responsive to all the emerging needs. 

FEMI OKE, Host 

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

VALERIA RACHINSKA, 100% Life 

I don’t know, I cannot explain this feeling, but I know that my place here and I need to feed people. I need to make logistic. I need to make emigration, I need to protect. So maybe I wouldn't be a good soldier, but I’m good protector and I good humanitarian. So, I’m trying to be a on my place. 

FEMI OKE, Host
 But their dedication, their resilience and their strength strikes at the heart of fundamental human rights. ANDRIY KLEPIKOV, Alliance For Public Health 

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

FEMI OKE, Host 

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.