February will mark the two-year anniversary of the invasion of Ukraine, a conflict that not only impacts the daily lives of its residents but particularly affects those grappling with diseases and facing the brunt of bombings. Individuals with HIV or tuberculosis find themselves in a particularly vulnerable position. In this interview, Olga Gvozdetska, the Deputy General Director of the Public Health Center, provides insight into the current state of the country.
“In times of war, we have prioritized the supply chain, and through the collaborative efforts of donors, volunteers, and partners, we have successfully restored it. We have even been able to deliver medicines to patients in temporarily occupied areas, thanks to the invaluable support of organizations such as the Red Cross, Médecins Sans Frontières, CO ‘100% Life,’ and the Alliance for Public Health”. Furthermore, the country has received an emergency fund exceeding $25 million from the Global Fund to Fight AIDS, Tuberculosis, and Malaria, addressing the most urgent needs in this field.
Today, over 90% of individuals diagnosed with HIV in Ukraine and aware of their status are undergoing medical supervision. Almost an equivalent proportion of those recently diagnosed are actively receiving care. It is important to note, however, that current data is solely accessible from government-controlled regions, with information from occupied territories being unavailable.
In the face of these challenging circumstances, the Public Health Center of the Ukrainian Ministry of Health (PHC) has effectively managed the HIV response system. This involved addressing various challenges presented by the ongoing conflict, as highlighted by Gvozdetska. Patients who had to relocate due to the conflict have been able to access antiretroviral therapy in their new locations, necessitating adjustments to their follow-up routines.
The western part of the country has experienced an increased workload in prevention services due to the influx of individuals from the eastern and southern regions. To ensure that no one is overlooked, resources have been strategically reallocated. Furthermore, efforts have been made to guarantee the uninterrupted provision of treatment and to prevent shortages of essential drugs by establishing reserves.
According to the Global Fund report, HIV programs registered a solid recovery from the impact of COVID-19 in 2022, but can the same be said about Ukraine? What is the situation there?
This was a long journey for us, and we are proud of our achievements. All of us together have become a united front in the combat to overcome the HIV epidemic in Ukraine. This front has withstood the blow of 2022. This front remains strong today. The impact of the war is far more dramatic. Nevertheless, we are holding the line. They won’t rob us of our achievements. We will come back and restore everything.
In what context are HIV and TB patients getting treatment in the midst of active hostilities and temporary occupation, can you ensure the continuity of treatment and provision of medicines? Are treatment services reaching the most vulnerable populations, such as people in need of tuberculosis (TB) treatment or human immunodeficiency virus (HIV) treatment?
In early 2022, there were an estimated 245,000 people living with HIV in Ukraine, with 130,239 on antiretroviral therapy (ART). However, with the onset of the full-scale invasion in 2022, treatment was compromised for a portion of them. The full-scale invasion posed threats to the effective HIV/AIDS response, making the provision of the full range of prevention and treatment services more challenging. Patients, especially those in the south-eastern regions of Ukraine, suffered the most.
Patients were not always able to easily receive services on-site due to active hostilities and occupation. They were unable to safely reach healthcare facilities for medical check-ups or to replenish their medicines, and healthcare workers could not safely organize the delivery of blood samples from ART sites to regional diagnostic laboratories due to shelling.
Healthcare professionals, including doctors and nurses, had to make unconventional decisions on their own, driven by a sense of responsibility for the lives of their patients. Despite personal fear, they devised solutions that their previous lives had not prepared them for.
How many people are at risk of not receiving treatment or medical follow-up?
More than 11,000 individuals on antiretroviral treatment are still receiving it. The healthcare facilities located in the government-controlled areas are provided with sufficient stocks of ARVs to both dispense medicines to patients who continue treatment and initiate ART for new patients. Currently, there are no issues with the logistics of medicines to hospitals. Treatment is provided to patients free of charge. Unfortunately, the current situation and whereabouts of patients from the occupied areas in Donetsk, Luhansk, and Kherson regions are still unknown.
What is the impact of migration on displaced patients?
The population migration both inside and outside Ukraine amounted to millions of persons. The usual patient pathways have changed, communication with doctors and healthcare facilities was interrupted, and the need to find new “entry points” to receive services has emerged.
We responded promptly and in highly professional way. I should mention that historically, the western regions of Ukraine have had lower epidemic rates as compared to the east and south, thus, the overload to the system, healthcare facilities and healthcare professionals was unexpected and significant. Nevertheless, the healthcare professionals managed to cope with this challenge.
In Ukraine, all patients diagnosed with HIV are registered in a secure medical information system for monitoring of socially significant diseases. When the patient changes his/her place of residence and seeks care at a new healthcare facility, the doctor can see the patient’s previous records and ART regimens. This system allows us to automatically track the patient’s missed scheduled visits to the doctor, generating a list of such patients containing the necessary information. After a patient misses a scheduled visit to a doctor, a patient is actively tracked and contacted, including via phone and messengers, with a subsequent invitation of the patient to the clinic. Moreover, in 2022, guidelines were developed for healthcare facilities on simplified registration of internally displaced persons.
According to WHO estimates, the number of adults living with HIV who will relocate abroad may reach over 30,000 persons, with over 4,000 currently undergoing treatment. To ensure continuous care for those requiring ongoing treatment, a clinical management protocol has been established to facilitate the exchange of data between Ukrainian and foreign healthcare professionals.
What is the current status of healthcare professionals, and in what ways are they affected by evacuations?
Residential buildings, educational institutions, and power supply facilities are repeatedly targeted by missile attacks,also hospitals. Since the beginning of the invasion, over 100 Ukrainian healthcare workers have been killed, one third of them at their workplace. The war has taken the lives of dozens of patients. Since the beginning of the full-scale invasion of Ukraine over 1000 healthcare facilities have been damaged by shelling, including over 50 hospitals that provided services to people living with HIV. Nearly 30 centers providing antiretroviral treatment are presently non-operational, having been completely destroyed, while almost 40 remain occupied.
Speaking about the structural units of hospitals where patients received treatment, some of those that continued operations functioned with specific restrictions due to the forced evacuation of personnel. In certain regions, personnel in charge of reporting on HIV epidemic monitoring were compelled to relocate. Several facilities operated solely for dispensing medicines, while others were either completely closed or destroyed. Laboratories in Donetsk and Luhansk oblasts temporarily suspended their operations.
However, despite the war, life goes on. People are being born, getting sick, and can die without proper medical care. Maintaining a network of facilities and making medical care accessible to people is an important objective for the government. With the support of partners from across the entire civilized world, Ukraine is gradually improving its air defense, thus, reconstruction and major repairs are ongoing wherever possible. We are grateful to all international partners of Ukraine for their emergency response programs, humanitarian aid, and recovery funds.
How have the specialists at the Public Health Center responded to the ongoing crisis, and what measures or strategies have they implemented to address the challenges?
Specialists of the program departments of the Public Health Center withstood the crisis and responded to it in a professional manner, acting innovatively and “outside the box”. All this allowed us to minimize damage to the sector. The Public Health Center operated as an emergency response center for humanitarian needs. It primarily involved managerial decisions, adaptation to logistical issues, collecting up-to-date information on the needs of healthcare facilities and patients and addressing them, establishing contacts with foreign clinics and partners to provide support to patients who had moved outside the country.
As multiple crises hider us from ending these diseases by 2030, what do you expect the situation in Ukraine to be like in the coming years?
Our aim has not changed: to end HIV, to achieve the 95-95-95 targets. The current situation, both Ukraine and globally, makes its own adjustments to our plans, prompting us to be adaptive and respond to new challenges every day. We hope that the fire of war will not spread across the planet, affecting vulnerable countries, claiming the lives of civilians, patients, doctors, creating barriers to the effective combat the epidemic that humanity has been dealing with across the globe for over 30 years. I believe that everything we are doing in Ukraine is our contribution to preventing this scenario.
Is it possible to fight stigma and discrimination of patients, conduct an awareness-raising campaign or carry out studies in wartime?
As for the stigma and discrimination, I believe people become more tolerant of many things in times of war, tolerance and social cohesion provide the basis for survival in a crisis. When people are hiding in basements, when they share the last bit of food with each other, there is no room for discrimination. I believe our society has become more open to diversity. In wartime, the issues of legal governance of civil relations for the LGBT community made progress, in 2022 Ukraine finally ratified the Istanbul Convention, actively advocated by HIV-positive women.
Awareness-raising campaigns are also vital, as people need to be reminded that simple things can save lives, condoms protect against sexual transmission of HIV, treatment is available and free, and doctors are ready to help. COVID-19 made us ready to conduct awareness-raising campaigns in the modalities feasible in wartime by transferring all communications to digital format. Nowadays, people get information staying at home, as the Internet is almost ubiquitous. Hospitals and doctors also got used to communicating with patients online.
Last but not least, may we state that it is worth continuing to invest in the conflict zones?
Currently, Ukraine has managed to hold its ground in the fight against HIV, and continues to expand prevention programs to contain HIV. However, Ukraine would not have been able to hold this frontline without the financial support of donors, partners, EU countries, and the United States. As you are well aware, epidemics know no borders. If our country’s healthcare system doesn’t receive funds today, tomorrow the epidemic will be at the door of other countries.
Investments in reconstruction and recovery are important and relevant today. Investments in people and their capacities will pay off through economic recovery and further progressive growth. Investments in democracy will pay off in the further development of civil society and democracy. Investments in human rights will ensure harmonization with European standards and values. The war is not the end; it is a huge challenge that has marked the start of rapid changes and development. Tomorrow, this country will become a member of the European Union. What kind of country would you like to see joining the EU?