HIV services in Ukraine resilient but starting to feel the strain

Although there is continuity in the provision of HIV prevention, treatment and care in Ukraine, the country is starting to falter in its provision of some services and has become totally reliant on external funding, Olga Gvozdetska, the acting Deputy Director General of the Public Health Center of Ukraine’s Ministry of Health, told the 19th European AIDS Conference (EACS 2023) in Warsaw last week.

Ukraine is having to provide a national health service in a situation where 414 hospitals have been damaged or destroyed, including 29 providing services to people with HIV, and 254 healthcare workers have been killed or seriously injured. The state of HIV services in the occupied parts of Luhansk, Donetsk and Mikolaiv oblasts (provinces) is unknown but it is known that central laboratories in Luhansk and Donetsk have closed.

In some ways HIV treatment and care have held up well. For instance, up to last year, Ukraine had been drawing nearer to the UNAIDS 90-90-90 target for HIV treatment. In 2019 52% of Ukrainians with HIV were diagnosed, on treatment and virally suppressed; in 2022 the proportion was 58%. This falls far short of the European Union average of 75%, but is higher than many countries in eastern Europe.

Although we do not yet know the figure for 2023, the proportion of the Ukrainian population that was tested each year for HIV fell from a pre-COVID peak of 6.6% in 2019, to 5% in 2020, 3.1% in 2022 and is set to be 2.5% in 2023. Given that the UNHCR estimates that 14% of the country’s population has left since the start of the war, this represents a greater fall numerically.

The number of people in government-controlled areas on antiretroviral therapy (ART) has fallen from just over 130,000 in 2021 to just over 121,000 now – a fall of 7%. New diagnoses fell from 16,658 in 2021 to 12,292 in 2022 and the proportion of late diagnoses, defined as people with initial CD4 counts below 350, has risen from 56% to 65%. While the proportion of people with HIV knowing their status and the proportion of those on treatment who are virally suppressed has held up, the proportion of people with HIV on ART has fallen from 83% last year to 77% this year.

Ukraine has also experienced a complete reversal in the security of its health funding, Gvozdetska added. In 2021, for the first time ever, the entirety of Ukraine’s HIV prevention, treatment and care services were provided by its government. This went into immediate reverse in 2022 with 85% of the HIV budget having to be provided by The Global Fund and PEPFAR, and in 2023 no HIV funding has come from the government.

Dr Tetiana Koval is from the Medical University in Poltava, the oblast with the second-highest HIV prevalence after Odessa. COVID had already impacted upon testing and diagnosis services there, with 351 new diagnoses of HIV in 2018, falling to 240 in 2020, and only recovering to 295 in 2022. These were not primarily people who had recently acquired HIV. They were people who had been unable to test or who had put it off, as evidenced by the fact that their average CD4 count at diagnosis fell from 293 in 2019 to 202 in 2022, and the proportion diagnosed with a CD4 count under 350 (and therefore classed as late presenters) rose from 52% in 2020 to 65% in 2022.

While many Ukrainian citizens who are now living abroad return home to clinics to access HIV therapy, the number accessing care abroad has increased in the last year. In Poland, the number of Ukrainians accessing HIV care has increased from 2500 this time last year to 3396 now. Although Poland initially received by far the largest number of refugees from Ukraine, many have now moved on and it is estimated that Poland’s 1.6 million Ukrainian refugees accounts for only 27% of the European total. But the 3396 still only represents about half the number of HIV-positive Ukrainians one would expect.

That is still putting a strain in Poland’s health system, though. In 2021 1046 people born in Poland were newly diagnosed with HIV and started treatment, so the arrival within 18 months of 3396 people needing care represents a considerable challenge to a country with only about 20,000 people with HIV already on treatment.

These are in the main people who were already diagnosed in Ukraine and virally suppressed; the average CD4 count in Ukrainians previously diagnosed with HIV and accessing HIV care in Poland was 561.

A greater clinical challenge is the increasing number of people now being diagnosed for the first time in Poland. Professor Miłosz Parczewski, president of the Polish Scientific AIDS Society, told the conference that 216 Ukrainian refugees for whom there are full clinical records have now been diagnosed with HIV for the first time in Poland, though this is almost certainly an underestimate. Their average CD4 count on diagnosis was only 189, and nearly 70% were classed as late-diagnosed.

Of them 40%, or 28% of all those diagnosed, had an AIDS-defining illness, of which by far the most common was tuberculosis, representing 40% of AIDS-defining diagnoses. Eleven per cent of these had multi-drug resistant TB. As with those already diagnosed, about two-thirds of them are women and 65% acquired HIV through heterosexual sex, as opposed to 20% of people with HIV born in Poland. Another 35% are people who acquired HIV through drug injection, compared to only 5% of people with HIV born in Poland.

Within six months of starting treatment, 91% of the Ukrainians were virally suppressed and their average CD4 count, though still low at 271, had at least increased by 85 on average. However, viral suppression rates were lower in people with active TB (at 80%). In the 18% of people with chronic hepatitis C, only 75% were virally suppressed.

The predominant HIV subtype in Ukrainians is A6, the type also seen in Russia and a few other countries such as Iran. Fully 88% of newly diagnosed Ukrainian refugees had A6, with only 8% having subtype B, the type largely spread between gay and bisexual men in western countries.

One aspect of A6 that gives rise to concern is the ease with which it develops resistance to the NNRTI drug rilpivirine. While no diagnosed Ukrainians had virus with pre-treatment resistance to protease or integrase inhibitors, and only 2.6% had NRTI resistance, 14.5% had pre-existing resistance to the NNRTI class that includes rilpivirine.

People with A6 given the injectable ART combination of cabotegravir and rilpivirine have a 15-fold greater relative risk of developing virological failure than on other regimens, so although injectable ART is not a consideration in Poland right now, it will not be suitable for people with subtype A6 in the future, and people will have to be screened for it.

Back in Ukraine, Olga Gvozdetska reminded the conference, internal migration and displacement has also affected where services are needed, with about five million people moving from the eastern frontlines to the relative safety of the west and as many again have moved abroad. Forty per cent of the country’s infectious disease physicians who still remain have moved to the western provinces.

As for the people in the occupied territories, no one knows if they are receiving HIV care. But this is also the case in some of the hardest-hit areas still in Ukrainian hands, such as Kharkiv, where power cuts as well as shells have decimated medical records.

This means that, although we have no evidence yet, we do not know directly whether the war in Ukraine will lead to an increase in HIV incidence – all we are seeing so far are delays in diagnosis. But even if the war stopped tomorrow, Gvozdetska said, it would take at least $10 billion dollars to restore Ukraine’s healthcare system. “War has changed everything since 24 February 2021,” she told the conference.