March 2017, The Lancet HIV
Conflicts and resulting humanitarian crises in countries with high burdens of infectious disease present political, strategic, and logistic public health challenges for agencies charged with implementing health programmes. One need look no further than the ongoing conflict in eastern Ukraine, to illustrate this.
Access to treatments for HIV and drug-resistant tuberculosis in the separatist Donetsk and Luhansk territories has been an issue of concern from the early days of the conflict. Even before the conflict, these regions had some of the highest incidences and prevalences of HIV and drug-resistant tuberculosis in Ukraine and Europe. Donetsk has an estimated 30 000 cases of HIV and Luhansk 5000—above 1% of the population in both territories. 18 000 patients are enrolled in care in the territories and 8200 patients are on antiretroviral therapy. 2200 cases are newly diagnosed each year, and an estimated 12 500 patients will be in need of treatment at the end of 2017 (on the basis of a CD4 count eligibility threshold of 500 cells per μL).
As of March 1, 2016, there were 650 patients with drug-resistant tuberculosis on treatment in Donetsk and Luhansk. During the period of May 2016 to December 2017, an additional 900 patients with drug-resistant tuberculosis are expected to require treatment in the civil sector and the prison sector. The situation is of particular concern in the penitentiary sector because international programmes focusing on drug-resistant tuberculosis, including that of Médecins sans Frontières, were discontinued by the local authorities at the end of 2015. Medical needs associated with HIV and tuberculosis also include laboratory supplies for testing (including GeneXpert), CD4 cell counts, and plasma viral load measurement, as well as ensuring laboratory quality control.
Finances are needed to sustain the work of non-governmental organisations (NGOs) that support patients in care and prevention programmes, including the distribution of clean injecting materials for people who inject drugs—opioid substitution programmes were discontinued in both Donetsk and Luhansk in 2015. Before the conflict, most antiretroviral drugs were funded by the Ukrainian Ministry of Health. Medicines for drug-resistant tuberculosis were funded by the Global Fund To Fight AIDS, Tuberculosis, and Malaria and channelled to Donetsk and Luhansk through a Ukrainian NGO. However, the funding for medicines was discontinued in both the Donetsk and Luhansk territories by the Kiev authorities at the end of 2014, when these territories (and self-proclaimed Donetsk and Luhansk Peoples’ Republics) were declared by the Ukrainian Government as non-government-controlled areas (NGCAs).
In June 2015, I expressed concern about the pending risk of an abrupt interruption in the availability of antiretroviral drugs for thousands of patients with HIV in the Donbass (the region of which Donetsk and Luhansk are part). The clinics in Donetsk and Luhansk continued to treat patients until July 2015 when the interruption to supply became an urgent public health threat. What followed were intense health diplomacy efforts to alert and then to involve the de facto authorities in the NGCAs, the Ukrainian Government, the European Commission, bilateral donors, the UN and the Global Fund. The primary aim was to frame the critical situation to all stakeholders as a humanitarian emergency that required a special set of responses that were geared to ensuring stakeholder cooperation with the twin goals of securing funding for the essential medicines and providing access on the ground to the affected peoples in the conflict region.
Meetings with self-proclaimed officials in Luhansk in January 2016 and Donetsk in March 2016 resulted in roadmaps to seek temporary solutions to the risks of interruptions to supplies of drugs to treat HIV and drug-resistant tuberculosis until the end of 2017. Health diplomacy facilitated the search for possible funding sources to finance emergency support to the NGCAs, which ultimately brought together the Global Fund, UNICEF, WHO, UNAIDS, the Ukrainian Government, and non-governmental partners to set up the mechanism that enabled the drug supply needs to be met and soon came in the form of an emergency grant of US$3·6 million from the Global Fund to UNICEF, covering the supply needs of antiretroviral medicines and laboratory reagents in both territories for 1 year. The Global Fund is considering an extension to this grant. UNICEF successfully implemented a public health approach in which most treatment naive patients would start ART on an optimised single pill formulation of tenofovir disoproxil fumarate, emtricitabine (or lamivudine), and efavirenz and 60% of patients already on first-line therapy would switch to that regimen, resulting in significant financial savings.
Funding for drug-resistant tuberculosis medicines procurement was consolidated in the Global Fund grant to the Ukrainian NGO recipient until the end of 2017. All in all, a solution was found for over 10 000 HIV patients on antiretroviral treatment in the NGCAs and about 500 cases per year of people living with drug-resistant tuberculosis.
Of equal importance to funding guarantees, the Donetsk and Luhansk de facto authorities agreed on key logistic issues, including facilitating the delivery of antiretroviral drugs to the territories by UNICEF and that drugs to treat drug-resistance tuberculosis were still to be provided under the Global Fund grant and delivered safely and on expected schedule to Luhansk. The medical teams and authorities were also made accountable for delivering care and treatment and provide the needed epidemiological and treatment monitoring and evaluation data to WHO, according to international standards.
This diplomatic intervention was a success in terms of permitting the delivery of essential medicines; however, that is only a short-term solution while uncertainties around drug supply remain. The most realistic solution for the mid-term, beyond 2017, is to have the issue of the funding of HIV and drug-resistant tuberculosis treatments addressed within the frame of the Minsk negotiation process on the future status of the Donetsk and Luhansk separatist territories within Ukraine. Since mid-2016, discussions have been underway with the support of the Chair of the Humanitarian Working Group for the Minsk process, with the governments of France, Germany, the Russian Federation, and Ukraine and with the European Union, to attempt to place the issue of the funding of expensive tuberculosis and HIV medicines on the agenda of the negotiations.
The evolving geopolitics in Ukraine, Europe, the Russian Federation, and the USA brings fragility to the Minsk process. If no solution is found in the coming months, the region may again be at risk of treatment interruptions for HIV and drug-resistant tuberculosis that would lead to a regional public health crisis.