War-Torn Ukraine Is Also an HIV and Tuberculosis Hot Spot

Ukraine, in addition to a war with Russia, also faces an HIV epidemic. As of 2021, an estimated 240,000 Ukrainians are HIV-positive, 100,000 of them living in regions now impacted by fighting. The country also has one of the world’s highest rates of tuberculosis (TB), a respiratory infection that, prior to COVID-19, killed more people worldwide than any other infectious disease. TB and HIV share comorbidities, and TB is one of the most likely causes of death for a person living with HIV. Things are so bad that before Russia’s invasion in February, Ukraine had the highest per capita burden of both HIV and TB in Europe.

Daily medication can treat and prevent the transmission of both diseases, but hundreds of thousands of people around the world continue to die of them each year in large part due to a lack of access to money or medical care. Russia’s war in Ukraine—which recently marked six months—has upended daily life across the country and risked impeding patients’ access to HIV and TB medication.

Since late February, demand for HIV preventative medication has surged as much as 300 percent in some parts of western Ukraine, and demand for TB drugs has followed a similar pattern as millions of civilians flee conflict zones in the east and redistribute demand for health care services across the country. Neighboring Poland and Moldova are also facing strains as their health care systems work to provide care to Ukrainian refugees.

But so far, a cadre of Ukrainian and international organizations have been able to maintain HIV and TB care across Ukraine using all tools at their disposal—the internet, mobile clinics, and even van convoys—to bring medical care to patients in need. Of course, these services are just one part of the broader package of physical and mental health services Ukrainians require. But the resilience of HIV and TB care is a meaningful victory, providing lessons to those looking to defend health in times of crisis elsewhere.

Sometimes, this is dangerous work. The New York Times has reported on the efforts of one Ukrainian nongovernmental organization, the Alliance for Public Health, to get humanitarian aid convoys into conflict-affected areas while in danger of being targeted by Russian troops. The group’s fleet of 15 vehicles has carried more than 340 tons of cargo since the start of the war, including HIV and TB medications. The risks of doing so are real: The Ukrainian Ministry of Health said there have been 869 attacks on health care facilities as of July 24, with 123 facilities completely destroyed, 18 medical workers killed, and more than 50 people injured. Despite the grim toll, the Ministry of Health and groups like the Alliance for Public Health are pushing forward to ensure access to care continues.

A key supporter of this work has been the Global Fund to Fight AIDS, Tuberculosis, and Malaria, an international organization that funds nongovernmental organizations around the world—such as Ukraine’s Alliance for Public Health—and helps them provide testing, treatment, prevention, and support services for people affected by these diseases. Global Fund programs are designed and managed by in-country committees composed of people living with HIV and TB, local nongovernmental organizations, international donors, and (in this case) the Ukrainian government. These stakeholders jointly vote on proposals and implement grants. (I work for Friends of the Global Fight, an independent organization that aims to educate, engage, and mobilize U.S. decision-makers to support the Global Fund and U.S. bilateral global health programs.)

This multistakeholder governance model is both equitable and effective. Ukrainians living with HIV and TB have a direct understanding of treatment shortages and barriers to care in their local contexts, meaning they can monitor these challenges and decide how Global Fund programs respond at every level. This is as true in war as it is in peacetime. Community monitoring and the responsive allocation of funds have meant that no HIV medication shortages have been reported in Ukraine half a year into the Russian invasion.

Community-led programs have also been critical to addressing Ukrainians’ physical and mental health needs. The psychological toll of the war has been immense, especially for women who have experienced rape and gender-based violence. Community-led organizations—such as Positive Women, an organization serving Ukrainian women living with HIV—provide psychological counseling and support services to survivors of sexual violence and other community members. Neighboring countries have also stepped up, with doctors and nongovernmental organizations offering psychological support services as well as treatment to pregnant women with HIV, ensuring they do not pass on the virus to their babies.

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The remarkable resilience of HIV and TB care provision in Ukraine even amid a brutal war offers three key lessons for international donors about how health care and foreign aid should be managed in times of crises around the world.

First, a community-driven approach to health care is indispensable, as people living with and treating a disease know their needs and challenges better than anyone else. This is especially true in an emergency, when new and unpredictable obstacles to care are guaranteed to arise. Civil society and community groups should hold decision-making power in all global health programs, and trust and relationships with local communities should be considered a key component of pandemic preparedness for those seeking to build and support resilient and sustainable health systems.

Second, long-term investments in community-led health care build the capacities crucial to addressing health needs in times of crises. The Global Fund provided $15 million to local groups in Ukraine when the war broke out, building on the more than $850 million the organization has invested in the country to strengthen its health system over the last 20 years. It also builds on the $15 billion the Global Fund has invested in conflict zones and other so-called challenging operating environments since its founding in 2002, accounting for about 30 percent of its investments over the past 20 years. The organization is funded by more than 100 government donors, the private sector, and public and private foundations.

In times of crisis, there is too little time to build a public health response from scratch. Instead, both international and local responders must lean on the institutions, networks, and technologies built up over the previous years and decades—whether that’s to track COVID-19 variant data, develop a COVID-19 vaccine, or manage deadly infectious diseases during a war.

Finally, standing relationships among health care providers and the populations they serve—as well as local, disease-specific expertise—are critical to an effective rapid crisis response, which requires moving money and people around quickly and accountably. In a crisis, bureaucratic delays can be deadly. The Global Fund, for its part, used its existing relationships with the Ukrainian government, civil society organizations, and health care providers in Ukraine to move money quickly during Russia’s invasion in February—advancing from planning to approval of funding to adapt HIV and TB care within five days.

Going forward, governments and donors must continue to strategize how to prepare for health emergencies, whether they are respiratory pandemics or interstate conflicts. As the response to HIV and TB during the ongoing war in Ukraine shows, there is no concrete line dividing the responses to health challenges in crisis and conflict situations. During conflicts, a commitment to community-driven programming, long-term investments, and adaptability will be key to ensuring crisis preparedness and defending health—both for today and tomorrow, in Ukraine and beyond.