MONTREAL — Russia’s war against Ukraine includes a “hidden war against evidence-based medicine” that poses a number of threats on the “health battlefield,” said Andriy Klepikov, executive director of the Alliance for Public Health, one of the largest HIV- and TB-focused nongovermental organizations in Ukraine and nearby areas. More so than for HIV or TB treatments, opioid-agonist treatments are most likely to be affected by war-related interruptions, which may have a cascade of consequences for patients with HIV and TB.
“Unfortunately, we’re facing the situation in Russia where ideology, prejudice has taken over science, particularly in the area of harm reduction, which is prohibited,” he said at a press conference during the International AIDS Society (IAS) Conference 2022 here. “Methadone, buprenorphine, opioid agonist treatment is prohibited in Russia…, which is nonsense because the WHO [World Health Organization] put these medicines on the list of essential drugs, so actually, with such attitudes of Russia, it’s a war against science.”
The crisis presents “a significant threat” to Ukraine’s recent “hard-won gains” against HIV, confirmed Michel Kazatchkine, MD, special advisor to the WHO’s regional office for Europe and a member of the Eastern and Central European and Central Asian Commission on Drug Policy (ECECACD), at the press conference. ECECACD advocates for better drug policies across the region.
Between 2010 and 2020, Eastern Europe and Central Asia experienced a 43% increase in new HIV infections and a 30% increase in AIDS mortality. Ukraine, by contrast, managed to stabilize and contain its epidemic. The rate of new infections in the region was only 10%, said Kazatchkine. Nevertheless, it was estimated that at the time the conflict began, 260,000 people in Ukraine were living with HIV, including 152,000 who were receiving antiretroviral therapy. The Russian Federation remains the main driver of the region’s growth in HIV, fueled largely by people who inject drugs and the absence of opioid agonist therapy, he said.
“The Russians say they are against the notion of someone substituting one drug with another, which they say puts their government in a position to provide drugs to people, therefore going against the international conventions,” he said. He is urging the WHO to move away from framing the use of methadone as “harm reduction” and rather present it as “the best standard of treatment” for opioid dependence.
There are fears that Russia’s HIV problems will become Ukraine’s, with war-related sexual violence on the rise, said Valeriia Rachynska at the press conference. She is head of the Regional Policy Team for 100% Life, the largest network of people living with HIV in Ukraine. “This is a new vulnerable group that we didn’t have before…with a lot of unofficial cases because people don’t want to share,” she told the press conference. “They hide this information, and therefore we cannot provide them with the medical services they need.”
The provision of such services has become a high-risk undertaking in parts of Ukraine, where civil society groups have stepped up as “the backbone,” said Klepikov.
“In such high pressure, having air raid sirens, having all our towns attacked by rockets, we managed to sustain [an] HIV/AIDS program,” he said. “Civil societies delivered medications…. When we faced a shortage of fuel…we did it by bicycle, [and] if there were no bicycles, we walked.”
Deliveries were made not only to territories controlled by Ukraine but also “to really hard-to-reach points…occupied by Russians,” added Rachynska. “Since their local authorities refused to receive this medication…it was delivered directly to patients… [with] door-to-door delivery. Through all the checkpoints, all our deliveries were successful. But the biggest challenge still for occupied territories is that no international organizations have the mandate to work there.”
Such is the case in Mariupol, where the WHO has no access, confirmed Kazatchkine. “As we speak, in Mariupol, there are 900 people on HIV treatment who are running out.”
For the parts of Ukraine where services have been maintained or reestablished, Klepikov is already declaring victory in the war. “I think actually we are doing pretty well. The initial fear of outbreaks of HIV and TB didn’t happen…. So the figures are comparable with the pre-war situation.”
Indeed, “from a very macro perspective,” roughly 70% of Ukraine’s health systems are functional, agreed Kazatchkine. However, the overall picture in Ukraine is a mixed one, with “hot areas of despair…. The war has been a devastating missile for people’s health,” he said. “It has caused and continues to cause civilian deaths. It’s been a major shock to health systems, including destruction of infrastructures and from primary care clinics to larger hospitals with, in a number of cases, intentional shelling of healthcare facilities, limited availability and challenges to deliver medical supplies, and shortages in healthcare personnel, [who were either] killed, injured, or had to flee their homes and their regions.”
Within this fragile health system, the region also has the world’s highest incidence of hepatitis C infection and the highest burden for multidrug-resistant tuberculosis. “It accounts for 99% of multidrug-resistant TB in the entire European region, and Ukraine is not exempt of that,” said Kazatchkine. “The TB incidence in Ukraine is 73 per 100,000, whereas it is less than 10 per 100,000 in Western Europe, and at least one third of new TB cases in Ukraine 2 years ago were multidrug-resistant cases.”
Kazatchkine says one opportunity that Ukraine can seize in this period is the chance to accelerate much-needed reforms in the country, which was struggling to modernize its healthcare system even before the war. “Of course, Ukraine should not reconstruct a 400-bed TB hospital ― it needs to move to ambulatory ways of treating tuberculosis,” he said.
Rachynska agrees. “We still have criminalization of HIV transmission in Ukraine. Each time, for a person having sex, it’s a risk to go to jail ― 5 years just for having sex. Even though we have all the science in front of us that if it’s undetectable it’s not transmittable,” she said. “We still have criminalization of sex workers…. It wasn’t okay before, but now, when we’re facing poverty, if girl will decide to do something for a piece of bread for her kid, she can be arrested…for 15 days in prison. It’s a shame and it’s a sin to punish people just for their wish to survive…. It’s a crime against humanity.”
She says human papillomavirus vaccination is still not included in routine immunizations because it is too expensive, and she says medical cannabis is urgently needed for a country straining under the weight of posttraumatic stress disorder.
In a war that he predicts will be long and worsening, the former president of Poland and current chair of the ECECACD, Aleksander Kwasniewski, agreed at the press conference that “the problem which will be huge in the coming months is mental.” And with up to 15 million Ukrainians displaced, there are broad ramifications.
“Beyond Ukraine, we should anticipate a major public health crisis across the region,” agreed Kazatchkine. “I see a high risk of increasing drug use and actually drug trafficking because of both the chaos in the region and the mental state of the population in the next very short years, so this will be the challenge for our commission.”
Rachynska urged people to think beyond medical parameters to the basic needs of her country. “We expect cold. And how do you think a person living with tuberculosis, even on ambulatory treatment, even with medications, if it’s no food? If it’s no shelter? No place to live? Will there be good results of treatment? You cannot put everything on medicalization. One million people are without any shelter because their homes were bombed…. One million people are homeless, without food, without dress, without meds, without hope. This is just the start of the war, not the middle. It’s a long, long way. It’s a big marathon.”
International AIDS Society (IAS) Conference 2022.
Kate Johnson is a Montreal-based freelance medical journalist who has been writing for more than 30 years about all areas of medicine.