Ukraine has the second-largest HIV epidemic in Eastern Europe and Central Asia.1 In 2015, 220,000 people were living with HIV – 100,000 more than in 2010.2 AIDS-related deaths have almost halved over the same period, from 14,000 in 2010 to 7,900 in 2015.3
Annual new HIV infections in the country have risen from 9,500 in 2010 to 16,000 in 20154, although the infection rate slowed in 2014 and 20155, suggesting recent prevention measures are having some effect.
Government and civil society have generally been proactive in responding to HIV and there have been some successes in rolling out antiretroviral treatment (ART) and harm reduction programmes. However, recent gains are being threatened by conflict, which broke out in 2013 and has seen the regions of Donetsk and Luhansk come under the control of pro-Russian separatists and the Crimea – now under de facto Russian control.
The Ukrainian Centre for Socially Dangerous Disease Control (UCDC) estimates that 24% of all new HIV infections in 2014 happened in conflict-affected areas and that 21% of people receiving ART live in disputed territories.6 The high concentration of vulnerable populations in conflict-affected areas, coupled with the worsening socio-economic situation unfolding in Ukraine as a result of the war, are of great concern for the country’s HIV response.
Key affected populations and HIV in Ukraine
Ukraine’s HIV epidemic has been closely associated with injecting drug use, which increased in the mid-1990s during the socio-economic crisis that followed the break-up of the Soviet Union. However, between 2005 and 2014, the proportion of people who became HIV positive through sexual transmission increased from 19% to 42% among men and from 53% to 86% among women.7 As a result, in 2008 the sexual transmission of HIV took over injecting drug use as the main driver of HIV in the country.8
People who inject drugs (PWID) and HIV in Ukraine
It is estimated that between 0.8-1.2% of Ukraine’s adult population inject drugs9. This equates to approximately 310,000 people, of whom 75% are men (232,500) and 25% are women (77,500).10
In 2014, injecting drug use accounted for 24.3% of all new HIV infections in Ukraine.11 A total of 3,449 people were infected with HIV by sharing needles and other injecting equipment in 2015, although encouragingly this figure has halved from 2010, when 6,934 people were infected with HIV through this route.12
In Ukraine, HIV prevalence among people who inject drugs was estimated at around 20% in 2015.13 In 2012 - the most recent data available - HIV prevalence was higher among women who inject drugs (23.6%) than men who inject drugs (20.8%).14
Based on 2011 survey data, only 35.7% of people who inject drugs had tested for HIV in the previous 12 months and 48% had used a condom the last time they had sex.15
The sexual partners of key affected populations and HIV in Ukraine
Sexual partners of key populations, in particular the partners of people who inject drugs and the clients of female sex workers, are at elevated risk of HIV infection in Ukraine.
In 2015, 9,043 people became infected with HIV through heterosexual sex – roughly the same number as in 2010, when 9,122 people were infected. New heterosexual HIV infections peaked at 11,472 in 2013, suggesting that infections through this route are starting to slow.1617
The majority of people who inject drugs in Ukraine are men. This, coupled with the tendency of men who inject drugs to have women who do not inject drugs as their primary sexual partner18, and the fact that male-to-female sexual transmission of HIV is more efficient than female-to-male sexual transmission, has resulted in an increasing proportion of new HIV infections occurring among women.
For example, in 1995 37.2% of new HIV infections in Ukraine were among women; in 2008 this had risen to 44.5%.19 New HIV infections among women (aged 25 and older) more than doubled in seven years, from 1,814 in 2005 to 5,057 in 2012.20 As a result, 44.2% of people living with HIV in Ukraine in 2014 were female, the vast majority of whom had been infected through sexual transmission.21
Sex workers and HIV in Ukraine
In 2014, there were an estimated 80,000 female sex workers in Ukraine, with an HIV prevalence of 7.3%.22 Prevalence differs greatly between areas, and in 2012 was estimated to be as high as 38.2% in Donetsk and 23.7% in Kyiv.23
A study carried out in Ukraine in 2011 found HIV prevalence among female sex workers who also inject drugs to be 43%, compared to 8.5% among female sex workers who did not inject drugs, which was the estimated prevalence of this population at the time.24
In 2011, 58.5% of female sex workers had tested for HIV and knew their results.25
Modelling estimates show that addressing the routine physical and sexual violence faced by sex workers at the hands of clients, police and other members of society in Ukraine would lead to a reduction of approximately 25% in HIV infections among this population..26
Men who have sex with men and HIV in Ukraine
Recent estimates suggest there are around 176,000 men who have sex with men (sometimes referred to as MSM) in Ukraine.27 The high level of stigma faced by men who have sex with men and other lesbian, gay, bisexual, transgender and intersex (LGBTI) people means the majority keep their sexual orientation and gender identity hidden. Studies from other countries suggest the total number is between 1.6% and 6% of the population, which in Ukraine equates to between 734,400 and 2.7 million people.28
According to data cited by the East Europe and Central Asia Union of People Living With HIV (ECUO) in 2016, HIV prevalence among men who have sex with men is estimated at 16.9% in Ukraine.29 Despite this, in 2015 less than 60% of men who have sex with men who live in Ukraine reported taking an HIV test and receiving the results within the previous 12 months.30
Prisoners and HIV in Ukraine
Prisoners are another group at particular risk of HIV in Ukraine. Harsh criminalisation of drug use has resulted in extraordinarily high levels of incarceration in the country. Before conflict broke out in 2013, 324 people out of every 100,000 were incarcerated – well in excess of the world average of 146 out of 100,000. In 2014, though, large numbers of prisoners were rapidly released into the community, dropping the rate to 195/100,000.31
HIV prevalence in prisons is estimated at 19.4% in Ukraine, although almost half are unaware of their status.32 Fewer than 4% of Ukrainian prisoners living with HIV receive ART.33
A wide-ranging 2016 study of HIV in prison populations across Eastern Europe and Central Asia presented data from Ukraine suggesting that people who inject drugs who have been to prison have a significantly higher HIV prevalence than people who inject drugs but have not been to prison (28% vs 13%). Additionally, previously-incarcerated people who inject drugs reported 3.9 more injections per month and had a 1.5 times greater chance of sharing syringes than injecting drugs users who had not been in prison.34 The study concluded that incarceration, and specifically heightened injecting risks after incarceration, could contribute between 28% and 55% of new HIV infections among people who inject drugs in Ukraine over the next 15 years.35
There is also a high prevalence of HIV co-infections in Ukrainian prisons. Incarceration contributes to tuberculosis (TB) transmission in Ukraine36, and although Ukraine’s prison population consists of 0·5% of the adult population, 6·2% of all new TB cases across the country are a direct result of incarceration. This association is even starker for people who inject drugs who are also HIV positive, with incarceration linked to 75% of TB infections for this population.37
Hepatitis C prevalence in prisons is also substantially high: estimated at 60.2%.38
HIV prevention in Ukraine
In spite of the difficult socio-economic situation facing the country, Ukraine approved a new four-year HIV strategy in 2014 (the National HIV/AIDS Programme 2014-2018).39 The strategy takes a patient-oriented approach and includes access to prevention programmes for key affected populations.40
Opioid substitution therapy (OST)
Ukraine has been providing OST since 2004. In early 2013, 7,353 people were receiving OST across 148 sites. Four times as many men were enrolled in the programme as women. About 89% received methadone, with the remainder receiving buprenorphine. All individuals receiving OST also received other counselling and support, provided by a network of NGOs.
Since its inception, OST programming in Ukraine has been largely funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria.41 With Ukraine’s Global Fund grant halved in 2017, the Ukraine government has committed to fully finance OST provision in 2017.
Dmytro Sherembey, the Chair of the All-Ukrainian Network of People Living with HIV, described this as “a titanic achievement”.42 But this match funding will still only result in OST coverage of 3.5%.43 despite Ukraine’s 2014-2018 HIV strategy committing to increasing OST and rehabilitation programmes for at least 35% of people who inject drugs by 2018.44
Ukraine has been scaling up its NSP provision since 2012. Ukraine’s national policy stipulates that NSP services should be free of charge and ‘low-threshold’, meaning that people are not required to meet specific criteria in order to receive injecting equipment.45
In early 2012, there were at least 1,667 NSP sites in Ukraine across 27 regions.46 The programmes distributed an average of 75 needles and syringes per person in 2012, below the World Health Organization/UNAIDS recommendation of 200.47
A 2011 bio-behavioural survey (IBBS) of people who inject drugs in Ukraine found 95.5% of respondents used sterile injecting equipment at last use. As 57% had not witnessed the filling of the syringe, 8% had shared syringes/needles over the past 30 days and 59% had shared drug injection utensils, the survey estimated that 81.5% of people who inject drugs still engaged in some form of risky injecting behaviour.
The proportion of women sharing a syringe was much higher than the proportion of men (60% and 30% respectively). 48
How conflict is affecting harm reduction in Ukraine
Around a fifth of people living with HIV who inject drugs (45,000) in Ukraine live in Donetsk and Luhansk, two of the regions worse affected by conflict.49 It is estimated that 40% of people living with HIV who have been receiving HIV-related harm reduction services now live in territory controlled by Russia or pro-Russian separatists.50
As Russia does not permit the use of OST, many OST services in these annexed territories have been closed down. OST provision ceased in Donetsk in June 2016.51
Other HIV prevention programmes in Ukraine
A basic package of services is available for female sex workers through a network of non-governmental organisations (NGOs) across all regions of Ukraine, which combines prevention of HIV with prevention of other sexually transmitted infections (STIs).54 In 2011, HIV programme coverage for female sex workers stood at 61%, and 92% of female sex workers reported using condoms with clients.55
Around 53% of men who have sex with men were estimated to have been reached through HIV prevention programming in 2011. Fewer NGOs were working on prevention programmes for men who have sex with men, compared to those working on prevention programmes for sex workers.56
HIV prevention programmes for the general population
In September 2016, Ukraine launched an HIV prevention campaign, ‘Believe it or Not’. The national campaign encourages men and women to know the facts about HIV and to protect themselves.
An online platform with key facts about HIV, HIV testing sites, an epidemiological review and other elements on HIV awareness is also available as part of the campaign.57 Posters, city lights and billboards will promote campaign messages across the country.58
In one of the first campaigns of its kind, the Alliance for Public Health held a youth oriented, music festival-style awareness initiative in five cities for World Aids Day 2016.
A flash mob, Put Red Ribbon On, spread large red ribbons in the cities where the Harm Reduction for Adolescents who use Drugs in Ukraine project was taking place. Almost 1,500 rapid test kits were distributed, as well as 32,000 condoms and counselling and testing for 353 people in mobile clinics. 59
HIV testing and counselling (HTC) in Ukraine
In 2013, 2.9 million people, or 6.5% of Ukraine’s population, received HIV testing and counselling (HTC). However, more than 60% of those tested were pregnant women and blood donors. The remaining number of people tested for HIV amounts to only 2.5% of Ukraine’s population, of whom less than a quarter are from key affected population groups.60 As a result, it is estimated that in 2012 around half of those living with HIV in Ukraine did not know their status.61
Even where testing is available, people are often diagnosed at a late stage of infection. For example, in the first six months of 2012 the Kiev AIDS Centre reported 89% of people who were diagnosed with HIV had advanced HIV (a CD4 count of less than 350). Only 28.5% of these people were initiated on ART.63
Antiretroviral treatment (ART) and HIV in Ukraine
In 2015, 27% of people living with HIV (58,338) in Ukraine were on ART.64 This equates to 29% of women and 25% of men living with HIV in Ukraine on ART.65
Although access to ART has expanded significantly in recent years, new HIV infections continue to outpace enrolment onto ART in the country.66 As a result, coverage of ART remains significantly lower than the global average with key populations most likely to miss out.67 For example, only 8.3% of people in Ukraine who are on ART are people who inject drugs, despite this population representing the majority of people living with HIV in the country.68
Despite late diagnosis and low HTC coverage, viral suppression is arguably one of Ukraine’s more successful stories. In 2015, 77.7% of people in Ukraine on ART had a suppressed viral load, making them far less likely to pass HIV on to someone else. This is the second highest viral suppression rate in the region, next to Russia (85%). However, only 27% of people living with HIV are on treatment, meaning the effect this will have on the rate of new HIV infections in the country will be minimal.69
HIV co-infections in Ukraine
Tuberculosis (TB) and HIV
The situation with HIV/TB co-infection in Ukraine remains grave. UNAIDS reports that TB is the most significant AIDS-related disease and cause of death in Ukraine.70
The 2013 WHO Global TB Report indicated that 75% of people living with TB in Ukraine were also living with HIV.71 Multi drug resistant TB (MDR-TB) is also of great concern, with the 2016 WHO Global TB Report finding Ukraine to be one of the 30 countries worst affected by MDR-TB in the world.72
Hepatitis C and HIV
Chronic hepatitis C virus (HCV) is the fifth leading cause of death of people living with HIV in Europe.73 A survey carried out in 2015 in Ukraine found HCV prevalence to be 55.8% among people who inject drugs, 15% among sex workers and 4% among men who have sex with men.74 In 2014, HCV/HIV co-infection was registered in 38.4% of all new HIV diagnoses in the country.75
Barriers to the HIV response in Ukraine
Ukraine funds the majority of its HIV response domestically and has been increasing its investment significantly, year-on-year. In 2010, international funding for Ukraine’s HIV response stood at US $33.8 million, compared to domestic funding of US $38 million. In 2013, international funding rose by around US $7.7 million to US $41.5 million, while domestic funding rose by US $33.7 million to US $71.7 million.76
However, conflict has changed Ukraine’s political and economic priorities. Gross Domestic Product (GDP) in Ukraine has dropped by 8% since 2013, when the conflict began, while inflation has increased to 24.9%, the highest rate experienced by the country for 14 years.77 Furthermore, Ukraine’s national currency has been devalued by 200%, leading to financing cuts in many sectors including health.78
In the same year that conflict broke out, the World Bank reclassified Ukraine as a lower-middle-income country. As a result, international support for HIV programmes is decreasing, raising concerns about whether increasingly squeezed domestic spending will be able to adequately fund an effective HIV response, with key affected populations most likely to miss out.
Punitive and repressive laws faced by key affected populations in Ukraine continue to prevent people from these groups accessing HIV prevention and treatment services.
ILGA-Europe, the European section of the International LGBTI Association, rated Ukraine 44 out of 49 European countries for LGBTI equality in 2016.79 Ukraine has laws that criminalise sex acts between consenting adults of the same gender, sodomy, and cross-dressing or ‘gender impersonation’.80
In January 2015, the Ukrainian parliament dropped an ‘anti-propaganda’-style Bill, similar to the 2013 Russian ban on “propaganda of non-traditional sexual relations among minors,” which has been used by Russian authorities to block support for HIV information and support services for men who have sex with men.81. In May 2014, Crimea passed this legislation, which effectively prohibits any public displays of LGBTI activities, resulting in the banning of Crimea Pride in August 2015.82
Equal Rights Trust research indicates that, since November 2013, the situation facing men who have sex with men who live in Crimea and parts of Donetsk and Luhansk has grown even more dangerous, with the authorities expressing virulently homophobic views and increasing levels of violence against men who have sex with men.83 There have been reports that the ‘Luhansk People’s Republic’ has sought to criminalise same-sex sexual activity with imprisonment of between two and five years. Many men who have sex with men are thought to have fled the region.84
Punitive drug laws also inhibit access to HIV testing and treatment for people who inject drugs. Criminalisation of drug use and discriminatory practices restrict access to NSPs. Police have been reported to arrest people who access harm reduction services and extract bribes for the possession of syringes or needles.85 86
Administrative barriers relating to harm reduction also exist. In Ukraine, official name-based registration of people who inject drugs is required to receive OST. However, registration often results in restrictions in employment, loss of privileges (eg, driver’s licence) and targeting by police.87
HIV-related stigma and discrimination plays a large role in preventing people living with and most affected by HIV from accessing the services they need.
A 2013 survey by the People Living with HIV Stigma Index in Ukraine found HIV-related stigma had reduced since the survey was last conducted in 2011 (from 51% experiencing some form of stigma or discrimination in 2010 to 40% in 2013). However, it was still a significant issue with people from key affected populations experiencing stigma more often than people living with HIV not identified as being from these groups. About a quarter (26%) of respondents in 2014 had been gossiped about due to their HIV status and 18% had experienced verbal assaults, harassment or threats.88
Civil society’s role in Ukraine’s HIV response
In January 2014 the Ukrainian government amended the existing legal framework on NGOs, forcing all groups receiving foreign funding and engaging in ‘political activities’ to register as ‘foreign agents’, mirroring a law first introduced by Russia in 2013. The law was then repealed after President Yanukovych fled the country.89 As of 2016, this legislation remains inactive.
Despite this reprieve, NGOs and activists, particularly those working with key affected populations, are finding it increasingly difficult to work in the occupied territories of Crimea and Southern Donbas.90 For example, in May 2015 the Nash Mir Centre reported that many LGBTI NGOs in Crimea had shut down with many activists fleeing to Kyiv or leaving Ukraine altogether.91
The future of Ukraine’s HIV response
Ukraine’s HIV response faces an uncertain future. On the one hand, effective prevention and treatment work targeting key affected populations carried out in the past decade is beginning to show gains, with the rate of new infections, both through sexual transmission and injecting drug use, starting to slow.
The country’s 2014-2018 HIV strategy continues to target key affected populations at a total cost of US$776 million. But as Ukraine continues to face conflict, and the country’s socio-economic context remains unstable as a result, the availability of funding for this strategy remains a concern. The human cost of this could be huge. In 2013, USAID estimated that at least 17,500 more people will become infected with HIV and 39,445 people will die due to AIDS-related causes by 2018 unless the strategy is fully implemented.92
The situation faced in conflict areas is also a concern. Increasingly conservative legislation has caused OST services to shut and engendered an increasingly hostile atmosphere towards people who inject drugs, men who have sex with men and others from key affected populations. If HIV prevention and treatment services falter in these regions, the small gains against Ukraine’s HIV epidemic that have been made in recent years could soon be reversed.