A View from the Frontlines in Slavyansk, Ukraine: HIV Prevention, Drug Treatment, and Help for People Who Use Drugs in a Conflict Zone

Slavyansk (pop. approx. 130,000) was occupied by pro-Russian forces of the “Donetsk People’s Republic” (DPR) from April 12 – July 5, 2014, when the Ukrainian army regained control. Slavyansk, along with the still-occupied cities of Donetsk and Luhansk, is in the Donbas, which has the country’s highest rates of HIV infection and drug use. To learn how the ongoing conflict has impacted HIV prevention and drug treatment in the conflict zone, we interviewed staff of Slavyansk’s main HIV-service agency, Nasha Dopomoga (“Our Help”).

Displacement and Instability

Even at the height of the shelling, the staff of Nasha Dopomoga tried to provide services to their clients, conducting outreach work such as needle and syringe exchange. News reports estimate that by June 2014, up to 40 percent of the city’s population had fled (Ukraine News One, 2014).¹ Among those who left Slavyansk were 47 clients of opioid substitution therapy programs (OST). Thanks to strong collaborative relationships between HIV service personnel and dispensaries, most displaced OST patients were able to continue to receive substitution therapy. When Slavyansk returned to Ukrainian control, about 90 percent of those who fled during the fighting returned to the city, including most of Nasha Dopomoga’s clients (Report, 2014). However, fewer services are now available to them. Christian groups that provided necessary and complementary services to the HIV and drug treatment organizations, such as psychosocial services and daily living assistance, have left the region.

A New HIV Risk Environment

Part of the DPR’s agenda was to target and stamp out drug use by banishing dealers from Slavyansk and meting out violent punishments to users. These efforts to eliminate drug use in the city were unsuccessful; rather, new drugs entered the market: homemade “ice” or “honey” prepared from the white liquid from poppy straw and additional chemicals (sold in powdered form, mixed with water, and injected) and homemade opium cooked from store-bought poppy seeds. Prior to the conflict, dealers cooked and sold ephedrine- and poppy-based (“shirka”) drugs, in preloaded syringes, with tacit approval from the police (Booth, 2003). With the decimation of the police force and no similar “understanding” with the Ukrainian National Guard that now controls the city, these drug manufacturing and distribution systems no longer exist. Shirka has become more expensive and people have begun to produce their own homemade drugs from poppy seeds. Increased repression of drug use—first by the DPR and now by the National Guard—has created a much more closed drug culture: people prepare and use drugs in smaller, more secretive networks. Moreover, hidden networks may be more difficult to access in outreach efforts. How these changes will affect HIV risk is yet unknown, given that drug use network characteristics are linked to HIV risk behaviors such as norms related to equipment sharing, the ability to procure clean equipment, and perceived risk (De et al, 2007; Latkin et al, 2010).

Although Slavyansk has been “liberated,” supply chains have been disrupted and basic first aid supplies are either unavailable or difficult and dangerous to get. Donetsk, which had served as the regional distribution center, remains under the control of the armed DNR, and new supply lines from cities such as Kyiv have yet to be fully established. In addition, the regional AIDS center in Donetsk had previously conducted confirmatory tests on HIV express tests. During the conflict, Nasha Dopomoga’s outreach workers continued to use rapid tests to screen people for HIV and hepatitis, but without electricity blood samples could not be frozen and sent to Donetsk for confirmatory testing. As a result, people with positive express tests results were not registered at AIDS centers and therefore not linked to essential HIV care and treatment services. There are an estimated 10–12 such persons in Slavyansk alone. Similarly, an additional 50 people living with HIV who came to Slavyansk as refugees have been denied registration in Slavyansk—and therefore access to antiretroviral therapy and other services—because they are “non-locals.” Slavyansk remains cut off from Donetsk and confirmatory tests are still not being performed.

An Erosion of Trust

Perhaps the most devastating effect of the conflict on HIV prevention work is the erosion of trust. Establishing trust with clients was critical to successfully working with the drug-using population, which in Ukraine has been the target of violence and repression for years (Booth, 2013; Mimiaga et al, 2010). New clients in Slavyansk often suspected outreach workers to be “spies” from the police. Through consistent efforts, the staff at this agency managed to build a high level of trust and engagement with clients. Outreach rounds were built around small communities of clients in this small city, where a sense that “everyone knows everyone else” contributed to the formation of an extremely closed and hidden drug use population. The conflict has exacerbated the closed nature of the agency’s client base, and both clients and outreach workers have become more cautious.

Trust between Nasha Dopomoga and the government has also eroded. Prior to the conflict, the agency had established agreements with local authorities for conducting outreach. Today, in the context of an ongoing lustration process, the constantly changing government administration has little interest in focusing on controversial issues of HIV prevention and drug misuse. Justifiably, outreach workers fear that the National Guard and new police force will not honor previous approvals from the municipality to conduct their work. Moreover, prior to the conflict, outreach workers made home visits to clients’ apartments. In the current context of suspicion and targeting of drug users, home visits are rarer, and outreach takes place in less private, less trust-engendering environments. New client recruitment has also gotten more difficult, given the general atmosphere of fear and mistrust that stems from anti-drug user policies.

Lasting Effects?

The staff at this and other agencies has shown tremendous commitment to their clients and courage to continuing working with them despite these challenges. Prior to the conflict, they consciously cultivated a flexible approach to their clients in order to respond to shifting funding priorities and changing HIV risk environments. While these skills will help them weather the current crisis, they are unlikely to succeed without the support and commitment of the Ukrainian government and international organizations. Slavyansk became the destination for thousands of refugees from territories that are still being contested. With the lack of service organizations and limited supplies, meeting the needs of these new arrivals will be a challenge.

HIV and drug use remain significant public health problems in Ukraine. The current situation in Slavyansk sheds light on some of the long-term impacts political instability and armed conflict may have on HIV prevention efforts with people who use drugs—disruption and decimation of services, new drug and HIV risk environments, and erosion of trust, among others. It is uncertain how committed to fighting HIV and supporting HIV prevention organizations and drug treatment programs the Ukrainian government and international community will be as the conflict continues, particularly given the country’s dire economic outlook. Ukraine has made significant gains in providing access to ARVs, OST, and harm reduction programs (Bojko et al, 2013). It remains to be seen whether these gains will be sustained.