Disruptions to HIV Prevention During Armed Conflict in Ukraine and Other Settings

Abstract

Purpose of Review

This review evaluates recent literature to understand the ways in which war disrupts HIV prevention and creates conditions for HIV outbreaks, with a focus on Ukraine. We also examine potential responses that can be deployed to sustain HIV prevention services amid ongoing conflict.

Recent Findings

Recent studies and frameworks suggest that disruptions caused during war are comparable to other emergencies, like natural disasters. The most important disruptions included health system/infrastructure destabilization, displacement, and psychological and financial challenges for individuals in key populations. Wars in most settings, as exemplified by the recent war in Ukraine, demonstrate that these disruptions can be tempered through a coordinated, rapid response.

Summary

Lesson learned from Ukraine show that adequate preparation and a rapid, collaborative response by providers is needed to ensure HIV prevention during war. Future research should develop comprehensive frameworks outlining how to facilitate this response.

Introduction

Armed conflicts, including war, create complex emergencies that can affect civilian populations, resulting in interruptions to health system operations, psychological distress, financial insecurities, and population displacement [1]. Disruptions from war can facilitate HIV transmission through increased risky sexual behavior, substance use including drug injection with unsterile equipment, and interrupted access to HIV prevention and treatment services due to logistical challenges or reallocation of health-related funds to defense measures [2]. Displaced populations may further influence the HIV epidemic within Ukraine or in neighboring countries and beyond [3], especially as sexual and injection networks shift, thereby promulgating onward transmission.

Social instability characterized by poverty and desperation, which may facilitate HIV transmission, is heightened in complex emergencies. As HIV prevention and other resources are reallocated for defense and acute health needs stemming from conflict, prevention measures may be deprioritized for chronic conditions [4], including for HIV [5]. Observational data suggest that HIV prevention services decline substantially during conflict, especially for key-affected populations (KAPs) [6], as observed in Ethiopia [7], Cote d’Ivoire [8], Liberia [9], Syria [10, 11] and throughout Southeast Asia [12]. Elsewhere, as populations are displaced due to conflict, new strains of HIV are observed in these settings [13, 14]. In many other settings, heightened substance use, transactional sex, or financial insecurities may contribute to increased sexual- and injection-related HIV risk-taking [15, 16], which occur within the general population [17–19] or, in some cases, peripherally to the conflict due to increased risk activity (e.g., sex work) [20–22].

In addition to reviewing past influences of conflict or war on HIV risk, transmission, and allocation of prevention and treatment services, we comprehensively review recent data from Ukraine, a middle-income country with Europe’s worst HIV epidemic that is concentrated primarily in KAPs like people who inject drugs (PWID), men who have sex with men (MSM), and people who engage in sex work (PSW). Though Ukraine’s government has remained intact, recent studies suggest that the war has led to widespread disruption of HIV prevention services and behavioral changes in KAPs, with likely increases in HIV risk behaviors and transmission [23–25]. In this review, we examine recent frameworks for healthcare provision during war, analyze historic examples of conflict in countries with HIV epidemics, and apply our findings to the ongoing conflict in Ukraine.

How Violent Conflict or War Impacts HIV Risk, Prevention and Treatment Services, and HIV Transmission

Figure 1 provides a heuristic for understanding how conflict or war impacts HIV. The conflict itself results in psychological distress and financial insecurity, which can give rise to sexual- and injection-related HIV risk behaviors. HIV risk, however, can be attenuated through evidence-based HIV prevention and treatment services, but these services can be disrupted by bombings, staffing shortages, diversion of resources during war, and other factors. Even when services are available, KAPs may not feel comfortable accessing them due to local dangers like airstrikes. Utilization of prevention services can influence transmission of HIV and epidemic changes, like new infections from expanded transmission in settings where services were disrupted. Table 1 summarizes the benefits of critical services to the HIV prevention toolkit, namely pre-exposure prophylaxis (PrEP), HIV treatment as prevention (TasP), syringe services programs (SSPs), and opioid agonist therapies (OAT). Geographic displacement may also influence the capacity of KAPs to identify or access services, increase stress levels, and create financial insecurities, which in turn may result in survival sex and/or adaptive coping through substance use.

Fig. 1.

The Contribution of War to HIV Risk, Prevention Services, and HIV Transmission

Table 1.

Overview of HIV Prevention Strategies

	HIV Treatment as Prevention	Pre-Exposure Prophylaxis	Syringe Services Programs	Opioid Agonist Therapies
Key affected populations where efficacy documented	All populations	General population, MSM, TGW, PWID, PSW	PWID	PWID
Services provided	Prescription of ART. TasP reduces HIV transmission by supporting ART scale-up, as taking ART leads to lower viral loads, viral suppression, and is consequently associated with substantially lower rates of HIV transmission [103, 104]	Prescription of pre-exposure prophylaxis medication	Distribution of sterile injection paraphernalia, promotion of safe injection practices, HIV testing services, and condom/lubricant distribution	Maintenance on OAT using either methadone or buprenorphine is considered the gold-standard, evidence-based treatment for people with opioid use disorder [105]. Can be delivered at multiple touchpoints including in specialty addiction clinics, hospitals, emergency departments, pharmacies, primary care clinics, SSPs [106], and criminal justice settings [107].
Population-based efficacy	Sex: 96% from sex [108] Injection drug use: a 5% decrease was observed for every 1% increase in ART adherence [109]	Sex: 99% from Inection drug use: 74% [110] when used as intended; real-world, 50% [110]	66% [111]	59% [112]
Risks associated with sudden discontinuation, other than increased HIV transmission	Buildup of ART drug resistance, disease complications [113, 114], viral suppression, transmission of variants associated with resistance [97].	Incident infection with HIV [115]	Increased syringe sharing [116], late HIV diagnosis [117]	Intense withdrawal symptoms, recidivist injection of opioids, overdose, and suicide [85]. Reduced adherence to other HIV prevention and treatment services [30–32].

Existing frameworks on healthcare During conflict, though limited, can provide further guidance on common population health challenges and resolutions. The World Health Organization’s (WHO) Health Emergency and Disaster Risk Management (EDRM) Framework emphasizes that, in all emergencies including war, ensuring access to reliable care through community-centered risk reduction efforts is essential. This framework does not, however, offer concrete strategies for preparing health systems for the specific impacts of war [26, 27]. While this framework includes disruptions beyond war (e.g., natural disasters, disease outbreaks like COVID, etc.), this review will not cover them. Other than mere damage to health systems, an alternative framework by the International Peace Institute (IPI) proposes that non-permissive environments limit engagement with affected populations. According to the IPI framework, a coordinated and sufficiently-funded response that prioritizes chronic health conditions is critical to preventing public health crises amid violent conflict [28]. A different framework proposed by Zaryab Iqbal argues that wartime social and economic circumstances affect health system performance, and the main effects on health during war are direct casualties, damage to health infrastructure, economic decline, diversion of resources from health issues, and forced displacement. Still, few strategies for minimizing these effects are identified [29].

One recent framework [3] focuses specifically on HIV service provision and involves observations from the war in Ukraine. It suggests prioritizing care for the most vulnerable individuals receiving HIV treatment, yet secondary strategies may include HIV prevention services with OAT, SSPs and PrEP [3]. It is unclear whether treatment should be separated from prevention, as they are intertwined. For example, HIV TasP serves the dual role of controlling HIV and thereby onward transmission, but OAT and SSPs are both evidence-based primary and secondary prevention strategies that are highly effective and central to HIV epidemics concentrated with PWID. OAT also promotes better engagement in the entire HIV treatment cascade for people with HIV (PWH) [30–32]. To our knowledge, there are no other frameworks specific to conflict settings that address health, HIV services, or HIV prevention. This demonstrates a need for further theoretical research on this topic, particularly to identify methods for preparing a response by HIV prevention systems to the onset of conflict or other emergencies.

Historic Disruptions to HIV Prevention during War

Historically, war has substantially disrupted HIV prevention efforts and increased HIV risk, with the most important disruptions being direct damage to HIV prevention systems, forced migration (both internal and external, to other countries), and financial and psychological distress among KAPs. These disruptions may be further amplified by diversion of resources from HIV prevention and treatment services [29]. Table 2 outlines studies that demonstrate how the defined disruptions affect HIV prevention services, risk behavior among KAPs, and absolute transmission of HIV.

Table 2.

Historic conflict and its effect on HIV risk behaviors, HIV prevention services, or HIV transmission

Study	Setting (Years of war or violent conflict)	Type of disruption	Type of effect	Observed effect(s)
Vasylyeva et al. 2022 [13]	Georgia; 2008	Displacement	Risk behavior	92% of internally displaced PWID participating in a survey reported riskier drug behaviors after displacement
Daw et al. 2022 [14]	Libya; 2011–present	Displacement	HIV transmission	Internal displacement (1.5 million people) caused 48% of strains originating from Benghazi to appear in central and western parts of Libya
Agadjanian et al. 2008 [17]	Angola; 1975–2002	Displacement	Risk behavior	Conflict led to increased risk practices among displaced men (unprotected sex, risky partnerships, etc.)
Weledegebriel et al. 2023 [33]	Ethiopia; 2020–2022	System disruption	Prevention services	Damage to health infrastructure led to 95.5% reduction in lab services Number of patients receiving ART in January 2021 reduced by 83.6% relative to pre-war
Salama et al. 1999 [20]	Sierra Leone; 1991–2002	Other (soldier activity)	Risk behavior	Sexual contact with soldiers from areas of high seroprevalence
Wollants et al. 1995 [21]	El Salvador; 1979–1992	Other (soldier activity)	Risk behavior	Sex work centers emerged around military encampments
Hankins et al. 2002 [15]	Afghanistan; 2001–2021	Financial & psychological distress	Risk behavior	Increased prices for opium and psychological distress led to increased injection (heroin and buprenorphine)
Betsi et al. 2006 [34]	Cote d’Ivoire; 2002	System disruption	Prevention services	Condom distribution reduced, ART shortages were reported; 80% of HIV care facilities were abandoned; 75–88% reduction in availability of HIV care staff; 94% increase in the number of active prevention NGOs operating in the region Healthcare workers providing HIV services transitioned to perceived higher-priority health services
Westerhaus et al. 2008 [118]	Uganda; 1994–2008	Displacement	HIV transmission	Prevalence in a region with high rates of displacement was 11.9%, while nationally the rate was 4.7%
Westerhaus et al. 2007 [16]	Uganda; 1994–2008	Displacement	Risk behavior	Displacement created psychological and financial insecurities, likely increasing HIV risk behavior
Singh et al. 2005 [119]	Nepal; 1996–2000	System disruption Displacement	Prevention services Risk behavior	Access to HIV prevention supplies was reduced amid conflict Internal displacement led to increased risky sexual behavior
Buju et al. 2022 [120]	Democratic Republic of Congo; 2017-present	System disruption Financial & psychological distress	Prevention services	This conflict setting was associated with reduced access to HIV prevention services observed from higher rates of access to ART and loss to follow-up (29%)
Ahonsi 2010 [19]	Liberia; 1989–96, 1999–03 Sierra Leone; 1997–2002	Financial & psychological distress	Risk behavior	Increased rates of sexual violence against women continued after conflict had ended, though HIV prevalence rates remained relatively low
Pyne-Mercier et al. 2011 [18]	Kenya; 2007–2008	Financial & psychological distress	Reduced prevention services	Risk of ART interruption increased by 71% during conflict and was likelier among men
Culbert et al. 2007 [120]	Democratic Republic of Congo; 1994–2008	Financial & psychological distress System disruption	Reduced prevention services	A small number of patients experienced interruptions in ART treatment, though they eventually were able to re-start
Dupas et al. 2010 [22]	Kenya; 2007–2008	Financial & psychological distress	Risk behavior	Unprotected sex among sex workers was increased during and following periods of violent conflict
Goldenberg et al. 2016 [121]	Uganda; 1986–2006	Financial & psychological distress Displacement Other	Risk behavior HIV transmission	2/3 of surveyed sex workers lived in camps for internally displaced people, with 1/4 living there for more than 5 years, likely increasing risk behaviors 1/3 of surveyed sex workers had been infected with HIV after the start of conflict Abductions due to conflict led to increased HIV rates Higher rates of imprisonment were associated with higher rates of HIV

Damage to health systems has been shown to reduce prevention services coverage and potentially increase HIV transmission. In the Tigray region of Ethiopia, violent conflict damaged most healthcare infrastructure, reducing the proportion of PWH on antiretroviral therapy (ART) [33]. In Cote d’Ivoire, war led to reductions in personnel working in HIV prevention, limiting condom distribution and ART access [34].

Forced displacement from war has also caused major disruptions to HIV prevention as KAPs have become unlinked from prevention services, increasing risk of outbreaks. In Georgia, military conflict with Russia led to the displacement of over 190,000 people [35]. For PWID, who comprise 38% of Georgia’s PWH [36], displacement resulted in OAT disruptions, with 92% of displaced PWID reporting increased drug injection risk after migrating [37]. During Libya’s violent conflict starting in 2011, 1.5 million people were internally displaced, resulting in 48% of HIV strains from one region transitioning to other regions in the country [14].

War has historically also added financial and psychological strains that may alter patient priorities and disrupt prevention efforts. Exposure to human suffering and death, loss of family, and repeated air raid sirens and bombings can lead to depression, post-traumatic stress disorder, and anxiety [38]. These effects are reinforced and compounded by financial insecurity from loss of property, jobs, or family members [39]. In Afghanistan, financial insecurities and decreased opium access led many opium-dependent individuals to switch to injection of heroin or buprenorphine, increasing HIV risk [15]. In Georgia, displacement of distressed PWID increased injection risk [37]. Financial insecurities and psychological challenges in Uganda’s conflict led to increased sexual risk among KAPs [40].

Though there is sweeping evidence to show that conflict negatively affects HIV prevention efforts and increases HIV risk, there is mixed evidence on whether it has an influence on HIV prevalence. A review of war-affected countries in sub-Saharan Africa found evidence that prevalence actually stayed constant or even decreased [41]. Some logical explanations for this finding may be that HIV prevalence may decrease when those most at risk leave a country, services like HIV testing are disrupted, or excessive deaths occur. Regardless of impact on HIV prevalence, however, the risks of interruption to prevention services are clear-cut, and their absence in the short-term can lead to death. Moreover, in conflicts where HIV risk demographics are skewed toward PWID, as in Ukraine, conflict-associated transmission dynamics are likely different, as they may be more influenced by regular risk behavior (drug injection) and OAT access [42]. In these settings, future studies may find that HIV prevalence indeed increases during conflict.

The Russian Invasion of Ukraine

The war in Ukraine began in 2014 when Russia illegally annexed Crimea and staged sham referenda in eastern Ukraine. This invasion was dramatically amplified in February 2022, with a full-scale war that continues today. Ukraine provides a contemporaneous perspective of the impact of conflict on HIV prevention, which has been minimally discussed in prior reviews [41, 43–46].

Relative to the majority of the above-described countries with HIV epidemics affected by conflict (mostly in sub-Saharan Africa), Ukraine’s HIV epidemic is uniquely concentrated in PWID [47], a population where the HIV prevention toolkit involves SSPs and OAT alongside other interventions like PrEP and TasP.

As outlined in Table 1, temporary discontinuation of HIV prevention services can have profound physical and psychological effects, particularly with OAT [48]. Following Russia’s illegal annexation of Crimea in 2014, the abrupt discontinuation of OAT led to 10% of over 800 patients dying from suicide or overdose, alongside increased HIV transmission [49]. This is especially important given Russia’s incitement of conflict in other Eastern European/Central Asian countries like Georgia, Moldova, Azerbaijan, and Armenia, where HIV is also concentrated in PWID [47; if these countries were taken over by Russia, OAT would be banned, resulting in consequences for individual and public health [50].

The HIV Prevention Landscape in Ukraine

Before Russia invaded Ukraine, the country had the second-worst epidemic in Europe [51]. There were 260,000 PWH [52], and the HIV incidence was 15.52 per 100,000 in the population [53]. Only two-thirds of PWH knew their status and even fewer (57%) were prescribed ART [54], far below UNAIDS 95-95-95 targets. Finally, prior to the invasion, 83% of all PWH who were diagnosed with HIV were receiving ART in Ukraine; however, HIV detection rates were low, meaning that most PWH remained undetected and therefore untreated [53].

Both non-governmental organizations (NGOs) and Ukraine’s Ministry of Health had made considerable progress in addressing the epidemic through the implementation and scale-up of HIV prevention programs [55]. Before the war started, SSPs were made available by NGOs to an average of 90,396 unique clients per month (roughly 25.8% of all PWID), with these programs cost-effectively reducing HIV and HCV transmission [56]. Approximately 19,000 Ukrainians (~ 5.4% of all PWID) were receiving OAT in Ukraine’s 233 government- and privately-funded clinics [57, 58]; an additional 10,000 received it in private methadone clinics [59–61]. Of those enrolled on OAT, nearly 82% received take-home dosing of medication due to COVID-19 guidance [62], making OAT more accessible and improving retention without increasing mortality [63]. Absent the presence of NGOs providing these and similar services between 2016 and 2020, there would have been a 44% higher incidence of HIV in 2021 [64]. Finally, PrEP had been scaled up since 2017 to 8,700 people receiving free PrEP before the war [65], yet PWID were underrepresented [65].

The full-scale invasion of Ukraine starting on February 24, 2022, caused foundational disruptions. Two years in (February 2024), there had been 1,570 recorded attacks on healthcare facilities serving over 454,000 people [66]. Psychological distress from war has led to changes in demand for the drug supply, with a shift to synthetic stimulants [67], increased drug use, and other risky behaviors [24]. Over 11 million Ukrainians have been displaced to other parts of Ukraine or to nearby countries [68].

The war has impacted HIV prevention differently based on the proximity to armed conflict [69]. In early Russian-controlled areas, OAT was discontinued, as it is prohibited by Russian law [70]. Damage to health infrastructure has been substantial and transportation routes (for supplies, staff, and clients) were restricted, making access to HIV prevention challenging [23, 71]. Regions near the conflict also experienced damage to infrastructure, while those in regions farther to the west have experienced fewer direct attacks or combat but still have experienced HIV prevention system disruptions, as new needs to provide services for large numbers of internally displaced persons have emerged [23, 71].

Ukraine had learned substantially from prior disruptions to HIV prevention during the Russian annexation of Crimea (2014), the invasion of the Luhansk and Donetsk regions (2014), and the COVID-19 pandemic. In 2014, 1.5 million people were internally displaced [72, 73], with HIV outbreaks being documented through the emergence of new phylogenetic strains [74]. The 2022 invasion, which has caused far more damage and widespread displacement not only within Ukraine but also throughout Europe, may have resulted in far greater HIV transmission [74], though empiric data are limited. The resilience of HIV prevention programs within Ukraine and beyond is critical to preventing outbreaks. Below, we discuss existing data on the impact of the war on our HIV prevention services of focus (Table 1) and how these services have attempted to recover.

Syringe Services Programs During Conflict

SSPs, particularly in the early stages of war, experienced major disruptions. Financial resources have been diverted, likely due to prioritization of other health emergencies [23]. Early, pharmacies closed, were damaged, and/or experienced SIP shortages, increasing client reliance on SSPs [23, 75]. SSPs, however, also reduced SIP distribution as shipments became limited, cellular/Internet networks were disrupted, and curfews/roadblocks inhibited service deliveries.

SSP clients and staff were displaced across Ukraine and neighboring countries. In regions remote from direct conflict, demand for SSPs which were already limited increased with an influx of displaced PWID from Ukraine [23]. Displacement of SSP staff, meanwhile, reduced the capacity of SSPs to provide adequate services [23]. Outside Ukraine, refugees found it challenging to find SIP in pharmacies [76]. As SSPs became limited for PWID, needle sharing and other unsafe practices likely increased [23, 75] though most pharmacies have reopened.

In the first six months of the war, HIV testing services decreased by 50% [77], and the number of unique SSP clients declined by 13.3%, mostly in occupied regions [23]. NGOs overseeing SSPs, however, rapidly adapted by increasing mobile delivery services and transferring other services online [75].

Pre-Exposure Prophylaxis During Conflict

PrEP coverage was low in Ukraine before the war [65], but scale-up increased by 50% in 2022, suggesting that scaleup continues [78]. Still, adherence and persistence to PrEP was low [79, 80]. For refugees in Europe displaced due to conflict, PrEP was not always covered by public insurance (e.g., Poland), requiring refugees to pay out-of-pocket [76].

Opioid Agonist Therapies During Conflict

Interruptions to health systems providing OAT amid the war have been some of the most severe. When the war started, the two sites manufacturing OAT (Odesa and Kharkiv) halted production; the Odesa site resumed production in May 2022 [81]. The central OAT storage facility near Kyiv was attacked in 2022, leading to the westward transfer of medications and the disruption of distribution to clinics [81]. To address safety concerns and staff shortages, hours of operation were reduced [71]. Due to concerns about medication shortages, some OAT providers reduced doses for nearly a quarter of their patients [82]. Many private OAT clinics closed, as they relied on pharmacies to dispense, resulting in discontinuity of OAT and requiring many patients to seek care in governmental clinics, where their doses were substantially reduced [83]. In settings where Russia fully occupied new territories, OAT was abruptly stopped and for those unable to move to Ukraine-controlled areas, overdose, suicide, and HIV transmission likely occurred, similarly to what was reported in 2014 [49, 84].

Minimally, 10% of OAT patients were internally displaced while a large number became refugees in neighboring countries, like Germany and Poland, where they experienced considerable challenges [81, 85] including delayed continuity of treatment and months-long waitlists [70, 85]. As patients migrated to new sites, even as they carried take-home dosing to allow for travel, they were often treated as “new” patients, requiring daily observation and induction on low medication dosages, which precipitated withdrawal symptoms [82, 85]. For other displaced OAT patients, they were often forced to relocate to sites that were remote from urban OAT clinics, requiring extensive travel to receive OAT daily [85, 86]. For internally displaced OAT patients during and before the war, being on OAT resulted in loss of their driver’s licenses [87–89], making daily transit to clinics more challenging [86]. Finally, forced displacement of nurses and doctors led to staffing reductions within Ukraine [81].

War-related diversion of national resources and funding led the Ministry of Health to cut its budget for OAT programs, necessitating NGOs with support from international donors to fill a critical void [81, 90]. HIV prevention and treatment programs were fully funded by Ukraine’s Ministry of Health in 2021, but in 2022 and 2023, international donors (e.g., the Global Fund to Fight AIDS, Tuberculosis and Malaria [GFATM]) assumed partial funding responsibility to reduce the consequences of resource re-allocation [77].

Aligned with Fig. 1, widespread psychological distress and financial challenges were observed generally but also among PWID [69, 91], likely increasing drug injection rates [25]. Despite these challenges, OAT scale-up in Ukraine has continued. Between February 1, 2022 and April 1, 2024, the number of patients on OAT in all governmental clinics increased by 24.8% from 17,232 to 21,507 patients. Still, only the scale-up goals of one region have been met, indicating that progress has been dampened by war [92]. Sustained scale-up, however, involved a number of factors including active facilitation through the Network for the Improvement of Addiction Treatment (NIATx) [27, 60, 61, 69, 81, 82, 93], which has guided OAT scale-up and collaborative learning between providers since 2014; the COVID-19 pandemic, when services were also disrupted [62, 63]; war-time policy changes by the Ministry of Health, like expanded take-homes [71, 81]; and firm commitments by NGOs receiving support from international donors. Through NIATx, a bundle of implementation strategies and implementation tools, providers in weekly calls shared new experiences, learned from each other, received ideas from outside experts at Yale University, and implemented solutions rapidly to address challenges, including more rapid escalation of dosing during induction. These efforts led to same-day OAT initiation practices to meet the needs of large numbers of PWID seeking treatment, communication through crowdsourcing, and information sharing with patients and providers in real time [27].

HIV Treatment as Prevention During Conflict

Few studies have assessed challenges in ART delivery during war within Ukraine. One study from 2023 found that war-time stress led some patients to discontinue ART [24]. Overall, the number of PWH receiving ART from public AIDS centers reduced by 7% relative to 2021. Meanwhile, the proportion of late HIV diagnoses increased by 9% [77]. Among the 1,852 newly diagnosed patients since the war started, nearly 90% had started ART [94], a testament to a functioning HIV program, especially as pre-war planning by NGOs funded through international donors helped sustain the program [27]. These organizations also assisted internally displaced patients with continuing ART, provided daily amenities like food and housing [94], and facilitated shipment of over 200,000 90-day supplies of ART to Ukraine from Poland [95].

For externally displaced PWH (i.e., refugees) from Ukraine, access to ART became limited due to restrictions in where it could be accessed in many host countries, with many being difficult to reach. In one study from Poland, a large HIV clinic observed high rates of viral suppression in refugee PWH on treatment, and they also identified a large proportion of newly diagnosed PWH who presented with late-stage disease and variants associated with resistance to ART [96]. Many also had to navigate the transition from the generic ART regimen prescribed in Ukraine (tenofovir/lamivudine/dolutegravir [TLD]) to host country alternatives, as the WHO was forced to cease distribution of TLD in host countries due to dolutegravir’s patent-protected status in the European Union [76, 85].

Preventing HIV Amid War: Lessons Learned

The Ukraine war offers valuable lessons for preventing HIV transmission during violent conflict. Though provision of some prevention services (SSPs, TasP) was reduced in the country [23], these setbacks have been tempered by an operational government response and strong support from NGOs with international support. Impressively, other prevention services like OAT and PrEP have continued to scale up. These successes, amid a full-scale war that has brought intense challenges to service providers and clients alike, are likely attributable to the preparedness of providers to disruptor events as well as a rapid, collective responses led by local NGOs after the war started.

The two major disruptor events that Ukraine had experienced in the decade prior to the 2022 Russian invasion, the 2014 Russian invasion and the COVID-19 pandemic, allowed HIV prevention providers to learn how to adapt their services, as previously emphasized [27]. During COVID, providers adapted their services to include mobile clinics, remote consultations, and medication delivery [96–99]. These changes were replicated during the 2022 invasion, when many of these same services were re-initiated, particularly to provide access to hard-to-reach clientele [100]. OAT take-home dosing also increased during the pandemic, making providers and the Ministry of Health more open to reinitiating take-homes for even longer periods during the war [62]. During the 2014 invasion of Ukraine, the collaborative learning strategy, NIATx, was first introduced, giving OAT providers an integral toolset to solve problems as they arose through rapid-cycle change projects and collaborative learning. In the 8 years that NIATx operated before the 2022 invasion, OAT providers had implemented efficiencies in their services, preparing them to better respond to challenges amid a full-scale invasion [27]. Additionally, due to mass displacement in 2014 from Donetsk, Luhansk, and Crimea, NGOs developed critical skills in client evacuation and re-linkage to prevention services in host regions [75]. The 2014 invasion and COVID pandemic prompted many NGOs to create preparedness plans that they could initiate during future disruptor events [27]. Both disruptor events therefore represented opportunities (i.e., implementation gaps) that enabled greater preparedness during the current war.

Nevertheless, despite having taken steps toward preparedness, providers and NGOs could not have anticipated all the challenges arising from full-scale war. Providers in Russian-occupied and frontline regions faced major losses to health system operations, with physical barriers like widespread infrastructure damage, cellular network shutdowns, and roadblocks straining their capacity to reach clients [23]. Providers in other regions were overwhelmed by high levels of displacement, unable to attend to the needs of new clients [23, 71]. The Ministry of Health, in the face of other health challenges, lost the capacity to fund HIV prevention, but NGOs and providers worked to respond quickly [77]. The GFATM provided increased flexibility and additional support to NGOs to maintain HIV prevention and treatment scale-up needs beyond what was available through the Ministry of Health [77]. NGOs also advocated for public health-related wartime policy changes by the Ministry of Health, despite Ukraine having a historically rigid, reform-resistant health system [101]. Weekly meetings of the NIATx collaborative among OAT providers allowed providers to sustain and improve their response amid the war and even scale up services [27].

As Ukraine remains deeply entrenched in the war, the future is unclear as international donors turn their attention to other conflicts, worldwide political support diminishes, and war exacts untold tolls on patients and providers alike. Amid likely economic stagnation and social challenges during this period, Ukraine may face new challenges as international donors return funding to pre-war levels [3, 75].

As new wars emerge, as observed in Gaza and the West Bank, there are untold harms that are likely to emerge regarding HIV. Though the number of HIV cases in Palestine was low before the war, there was evidence of a growing HIV epidemic [102]. The strangling of humanitarian aid to Gaza, including essential medications, is likely to result in disruptions to HIV prevention and treatment services and unmeasured HIV transmission.

Conclusion

War creates profound barriers for sustaining HIV prevention. Studies from prior wars and the ongoing war in Ukraine corroborate this, with the main challenges being damage to health systems, displacement, and financial and psychological distress. Though studies examining the association between war and HIV prevalence have mixed results and require further investigation, it is known that prevention services are disrupted, creating conditions for potential HIV outbreaks. To adequately sustain access to prevention services amid war and other disruptor events, adequate preparation and the implementation of collaborative, rapid-response initiatives like NIATx among providers is critical. Frameworks that outline how to best prepare HIV prevention services for conflict and other disruptor events in order to achieve a coordinated response are limited and require further development.

Data Availability

No datasets were generated or analysed during the current study.