Yearly Archives: 2015

An AIDS Crisis in Ukraine

More than 6,500 deaths have been reported in the Donbass region, where Ukrainian forces have battled Russian-supported separatist fighters for control since April 2014. The political violence has led to a humanitarian crisis. More than 8,000 patients being treated for H.I.V. or drug dependence have had life-saving medicines cut off, or will soon be without them, unless action is taken right now to allow a humanitarian convoy through.

Health care was an early casualty of the conflict in the Donbass. The Ukrainian government, saying it wished to ensure that national resources did not fall into the hands of armed groups, cut off funding in November to all facilities in the region, including hospitals, and told patients who remained in the conflict zone that they could travel to government-controlled territory to receive medicines. Unsurprisingly, this has proved impractical for many people who are sick, poor or simply frightened. Mechanisms to monitor and respond to disease outbreaks are no longer functional in the territory; immunization coverage is low, and health experts now fear possible outbreaks of polio and for the safety of blood supplies.

People at risk for, or living with, H.I.V. are already suffering. Ukraine has one of the highest rates of H.I.V. infection in Europe; the majority of patients were infected with the virus through contaminated drug injections. Before the conflict, Ukrainian programs helped control H.I.V. infections in the Donbass by providing sterile needles and syringes and methadone, a medicine the World Health Organization recommends to reduce use of and craving for heroin. Ukraine successfully reduced H.I.V. infections, particularly among young people who inject drugs, for whom infection rates decreased more than fivefold between 2007 and 2013.

Unfortunately, the Donbass conflict now jeopardizes that progress. According to the International H.I.V./AIDS Alliance in Ukraine, a nongovernmental organization based in Kiev, more than 1,000 patients in the Donbass have either had their methadone stopped or reduced to substandard doses, forcing men and women to undergo painful withdrawal or return to street drugs. Requests to the Ukrainian government to replenish methadone supplies, accompanied by an offer by Doctors Without Borders to oversee distribution, were met with the response that the medicine — distributed routinely to hundreds of thousands of patients across Western Europe — could be transported, under Ukrainian law, only by armed convoys. In June, a number of patients sent a video appeal to government officials, saying they feared for their lives because their treatment had been interrupted. It is not known how many people have succumbed to overdose or suicides after methadone treatments were ended, though the video reported nine deaths.

People living with H.I.V. in the Donbass now face a similar interruption in life-saving antiretroviral treatment. The W.H.O. estimates that supplies of H.I.V. medicines will last only until mid-August in some parts of the Donbass. The Global Fund to Fight AIDS, Tuberculosis and Malaria has offered to pay for more antiretroviral treatments, and Unicef is willing to procure them. However, no humanitarian convoy has delivered medicines into the territory since February. Thousands of men and women, many of whom overcame discrimination and financial barriers to secure access to H.I.V. medicines, are now watching their antiretroviral pill supplies vanish, and with them, their hopes for survival. The W.H.O. reports that medicines for multidrug-resistant tuberculosis, diagnosed at high levels in the region, are also running low.

For their part, those in control of the self-proclaimed Luhansk and Donetsk People’s Republics in the Donbass have shown little interest in protecting the lives of people with H.I.V. A number of reports have documented violence against people who use drugs and other marginalized groups. The People’s Republic of Luhansk has indicated that it does not want to continue opioid-replacement therapy (consistent with Russian policy), and has announced that United Nations agencies must register with them prior to provision of any humanitarian aid. The Ukrainian Parliament has exempted itself from culpability for the Donbass, passing a resolution in May that the rights of those remaining are the responsibility of the “occupier.” At the same time, the authorities in Luhansk or Donetsk have not moved to fill the H.I.V. treatment gap, leaving patients in a desperate limbo.

No one should be forced to choose between fleeing their home and stopping life-saving treatment.

This is a humanitarian crisis that can be easily solved. The Ukrainian government, even if reluctant to commit resources in the “temporarily occupied” region, should permit passage of a United Nations convoy with medicines funded by international donors. Those controlling the Donbass could also give the green light for the convoy. The government of Ukraine should work on an interim procedure to provide assistance to the population in these territories and facilitate the passage of humanitarian aid.

The Minsk Group, which is led by France, Russia and the United States and tasked with finding a peaceful resolution to the conflict, should urge immediate action to restore the medicine supply in the Donbass.

Silence and inaction will only bring more suffering. Nothing is gained by making patients hostage to geopolitical disputes. Both the Ukrainian government and the leaders of the separatist Donbass region should ensure that, as a matter of medical ethics and human decency, innocent and vulnerable medical patients do not join the list of casualties in this conflict.

Is Armenia close to ending AIDS?

As it is the case throughout the East European and Central Asian region, unsafe drug injection has been a driver of the HIV epidemic in Armenia over the last 15 years, though far less today than, say, a decade ago. 40 percent of people who inject drugs are estimated to be infected with HIV in Armenia, and close to 100 percent are infected with the hepatitis C virus. Heterosexual intercourse has been the main route of HIV transmission reported in the last three years among men and increasing numbers of women.

I was in Armenia very recently to learn about the country’s response to its epidemic and came away undoubtedly pleased with progress on a number of fronts but concerned on others.

For people who have been diagnosed with HIV, treatment is now accessible to all those eligible for it, with most people on therapy having viral loads below the threshold of detection. By any measure, that certainly stands as a remarkable success story in the region.

Armenia is also one of the few countries in the Eastern Europe and central Asian region proactively implementing Opioid Substitution Therapy (OST). The Program has the clear support of the Government.

I visited one such program at the Armenian Republican Drug Centre located in a typically Soviet-era austere social service building on the outskirts of Erevan, 30 minutes by bus from the centre of town.


(Centre staff member preparing the rose garden for Spring)

Dr Petros Semerjian’s office runs off an unlit corridor in the Narcological Centre, which is supervised by uniformed guards. Semerjian has directed the since Centre since its creation and opened the first OST clinic in Erevan with the support of the Open Society Foundation more than 10 years ago. OST, he says, is “one of the treatment options” for opiate-dependent people, half way somehow between the Russian and the Western European positions.

Patients in Armenia may access substitutive treatment following approval by an internal advisory committee, usually, after two failed attempts of medically-assisted weaning. 260 patients currently receive methadone on a daily or three times a week basis, assisted by several nurses and doctors. NGOs claim that the program is not attractive to users because the committee that decides on admissions in the program includes a representative from the police. Dr Semerjian argues that associating police with the work of the clinic, as he has done since the early days of the Centre, prevents law enforcement from being confrontational with the Centre and from harassing the clients.

However, with the big picture in mind, what is worth considering here is the fact that Armenia, a country that is almost entirely economically and politically dependent on its partnership with Russia, has a Government that strongly backs its OST and AIDS programs.

The scale of the OST remains however at a very small scale, thus much below that at which it could demonstrate a public health impact on HIV prevention. This is common across the region, providing ammunition for the regional anti-methadone proponents to claim that it is not effective. Dr Semerjian, with much experience in dealing with the system, together with his own strong convictions, stands strong on his assertion that these numbers reflect the right proportion of clients that should access substitutive treatment but my sense is that small numbers of patients are enrolled in the program for reasons that seem to me reflect more the doctor’s personal views than a real assessment of what the program should achieve from a public health perspective.

Of concern to me too are the current dynamics of HIV infection in Armenia.

Most of the men diagnosed with HIV have a history of migration and have worked for some time in the Russian Federation. Together with their female partners in Armenia, they represent 73 percent of all reported cases diagnosed in the last three years. Additionally, an estimated 60 percent of the estimated number of HIV-infected people in the country do not know their status.

While migration is also a risk factor for Central Asian countries and Russia itself, the magnitude of the epidemic which reflects the absolute need for Armenians to migrate to find work, make it a unique phenomenon in the region.

The future of the epidemic in Armenia remains uncertain, despite its small size: some 2,000 infections diagnosed would reach around 90 percent of all infections diagnosed. On the one hand one might be tempted to think that Armenia may be close to ending its epidemic, yet the uncertainty remains on who the undiagnosed are and how to reach them (is it about migrants as some experts believe, or also about vulnerable populations who are largely marginalised from national AIDS programs?). Exacerbating the issue is the decrease in international funding — something which is similarly occurring in other countries in the region — at a time when the country cannot afford (and is not politically ready to afford) to assume the funding gap left from the progressive departure of the Global Fund to Fight AIDS, Tuberculosis and Malaria.

On paper though, it’s certainly something well worth contemplating: if the political will, more expertise and the funding were all there, Armenia could well be the first country in the EECA region to end AIDS.