Will the Russian war in Ukraine unleash larger epidemics of HIV, TB and associated conditions and diseases in Ukraine?

Human-Centered Design of an mHealth Tool for Optimizing HIV Index Testing in Wartime Ukraine: Formative Research Case Study

BACKGROUND

Assisted partner services (APSs; sometimes called index testing) are now being brought to scale as a high-yield HIV testing strategy in many nations. However, the success of APSs is often hampered by low levels of partner elicitation. The Computer-Assisted Self-Interview (CASI)-Plus study sought to develop and test a mobile health (mHealth) tool to increase the elicitation of sexual and needle-sharing partners among persons with newly diagnosed HIV. CASI-Plus provides client-facing information on APS methods and uses a standardized, self-guided questionnaire with nonjudgmental language for clients to list partners who would benefit from HIV testing. The tool also enables health care workers (HCWs) to see summarized data to facilitate partner tracking.

OBJECTIVE

The formative research phase of the CASI-Plus study aimed to gather client and HCW input on the design of the CASI-Plus tool to ensure its acceptability, feasibility, and usability.

METHODS

This study gathered input to prioritize features and tested the usability of CASI-Plus with HCWs and clients receiving HIV services in public health clinics in wartime Ukraine. The CASI-Plus study's formative phase, carried out from May 2023 to July 2024, adapted human-centered design (HCD) methods grounded in principles of empathy, iteration, and creative ideation. The study involved 3 steps: formative HCD, including in-depth individual interviews with clients, such as men who have sex with men and people who inject drugs, and internet-based design workshops with HCWs from rural and urban HIV clinics in Chernihiv and Dnipro; software platform assessment and heuristic evaluation, including assessment of open-source mHealth platforms against CASI-Plus requirements, prototype development, and testing of the REDCap (Research Electronic Data Capture) prototype based on usability heuristics; and usability walk-throughs, including simulated cases with HCWs and clients.

RESULTS

The formative phase of the CASI-Plus study included in-depth individual interviews with 10 clients and 3 workshops with 22 HCWs. This study demonstrated how simplified HCD methods, adapted to the wartime context, gathered rich input on prioritized features and tool design. The CASI-Plus design reflected features that are both culturally sensitive and in alignment with the constraints of Ukraine's wartime setting. Prioritized features included information about the benefits of HIV index testing; a nonjudgmental, self-guided questionnaire to report partners; client stories; and bright images to accompany the text. Two-way SMS text messaging between clients and HCWs was deemed impractical based on risks of privacy breaches, national patient privacy regulations, and HCW workload.

CONCLUSIONS

It was feasible to conduct HCD research in Ukraine in a wartime setting. The CASI-Plus mHealth tool was acceptable to both HCWs and clients. The next step for this research is a randomized clinical trial of the effect of the REDCap-based CASI-Plus tool on the number of partners named and the rate of partners completing HIV testing.

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

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. 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.

A Scoping Review of Factors Associated with HIV Acquisition in the Context of Humanitarian Crises

Humanitarian crises-natural or human-made events that can threaten communities' health, safety, security, and well-being-may affect the HIV epidemic dynamics. Common aspects of humanitarian crises such as poverty, powerlessness, disruptions to the health systems, and social instability can contribute to a person's vulnerability to HIV infection through increased risk behaviors and limited access to health services. Guided by the Joanna Briggs Institute methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) reporting guidelines, we conducted a scoping review of literature published in English between January 1990 and March 2022 to characterize the global evidence of modifiable and non-modifiable factors for HIV acquisition in the context of humanitarian crises. We systematically searched, screened, and synthesized literature from MEDLINE, Embase, Global Health (all accessed via Ovid), and Scopus, and also grey literature through websites of humanitarian agencies and relevant non-government organizations, the International AIDS Society's abstract databases, and Google Scholar. We considered studies presenting empirical data on HIV prevalence, incidence, or risk factors in humanitarian crises-affected populations, including refugees, asylum seekers, and internally displaced persons. Forty-nine studies met the inclusion criteria. The majority of studies were quantitative (n = 43, 87.8%) and cross-sectional (n = 37, 75.5%) in design. Most were single-country studies (n = 43, 87.8%) and conducted in Sub-Saharan Africa (n = 31, 63.3%). We identified 5 non-modifiable factors for HIV acquisition (i.e., age, gender, location, place of birth or origin, and ethnicity) and 60 modifiable factors that we further classified into five categories, namely 18 policy and structural, 9 sociocultural, 11 health and mental health, 16 sexual practice, and 6 humanitarian crisis-related traumatic event factors. Within the modifiable categories, factors that were most often investigated were education level, marital status, sexually transmitted infection diagnosis, condom use, and experience of rape or sexual trauma, respectively. Informed by the findings, we applied the social-ecological model to map the identified multidimensional factors associated with HIV acquisition at the levels of individual, social and sexual networks, community, public policy, and the context of humanitarian crises. The current review provides a comprehensive, global analysis of the available evidence on HIV prevalence, incidence, and risk factors in humanitarian crises and implications for potential programs and research. Future research is warranted to further understand the directionality of the non-modifiable and modifiable factors affecting HIV acquisition, and the multilevel barriers and facilitators to the uptake of HIV prevention strategies in the context of humanitarian crises. Such research can generate actionable evidence to inform the development of ethical, trauma-informed, and culturally appropriate HIV prevention interventions in humanitarian settings.

Design and implementation of a Type-2 hybrid, prospective randomized trial of opioid agonist therapies integration into primary care clinics in Ukraine

INTRODUCTION

Ukraine has high HIV prevalence, concentrated among people who inject drugs (PWID), mostly of opioids. Maintenance on opioid agonist therapies (OAT) is the most effective evidence-based treatment for opioid use disorder. As PWID experience high morbidity and mortality from preventable and treatable non-communicable diseases, international agencies recommend integrating OAT into primary care centers (PCC).

METHODS

A randomized, type-2 hybrid implementation trial was carried out to compare outcomes of OAT integration in PCC to OAT delivery at specialty treatment centers (STC) - standard-of-care. Tele-education supporting PCC providers in managing OAT, HIV, tuberculosis and non-communicable diseases along with pay-for-performance incentives were used to facilitate implementation. Consenting patients underwent 1:2 randomization to either STC or PCC. Quality health indicators (QHIs), a composite percentage of recommended primary and specialty services accessed by patients (blood/urine tests, cancer screenings, etc.), were defined as efficacy outcomes and were assessed by participant self-report at baseline and every 6 months over 24 months and electronic chart reviews after the completion of the follow-up. The primary outcome is defined as the difference in composite QHI scores at 24 months, in which a repeated measures likelihood-based mixed model with missing at random assumptions will be used. Providers at PCC completed surveys at baseline, 12 and 24 months to assess implementation outcomes including changes in stigma and attitudes towards OAT and PWID.

PRELIMINARY RESULTS

Among the 1459 participants allocated to STC (N = 509) or PCC (N = 950), there were no differences in clinical and demographic characteristics. Self-reported prevalences were available for HIV (42 %), HCV (57 %), and prior tuberculosis (17 %). Study retention at 6, 12, 18, and 24 months was as 91 %, 85 %, 80 %, and 74 %, respectively.

CONCLUSION

PWID have a high prevalence of medical comorbidities and integrating OAT into primary care settings has the potential to improve the health of PWID. Findings from this study can help guide implementation of integrated care in Ukraine and throughout similar low-resource, high-burden countries in the Eastern European and Central Asian region.

Demographic, epidemiological and clinical characteristics of Ukrainian war refugees with HIV infection in the Slovak Republic

BACKGROUND

The Slovak Republic, an Eastern European country, borders Ukraine, which has one of the highest rates of HIV/AIDS in Europe. This study aims to inform readers about the demographic characteristics of Ukrainian war refugees with HIV/AIDS seeking temporary protection status in Slovakia due to the Russian invasion of February 24, 2022. It focuses on their epidemiology, immunological profiles, co-infections, and treatment.

DESIGN

Multicenter, retrospective study between March 1, 2022, and March 31, 2023.

METHODS

Data were collected from all Ukrainian patients with refugee status living with HIV or newly diagnosed, who presented to any of the five HIV/AIDS centers in Slovakia. Information was obtained through medical interviews, physical examinations, laboratory tests and medical reports from the Ukrainian Ministry of Health.

RESULTS

From March 1, 2022, to March 31, 2023, 141 Ukrainian refugees were included, mostly women (56.7 %, n = 80), with a median age of 41 years. The median CD4+ count was 680 cells/mL; 69.2 % (n = 97) had a viral load below 40 copies/mL. On arrival, 87.8 % (n = 123) were on ART, 90.2 % (n = 111) on dolutegravir. Coinfections included hepatitis C (31 %, n = 41), hepatitis B (12.5 %, n = 17), and tuberculosis (11.3 %, n = 16). Three died from AIDS complications.

CONCLUSION

The study provides a detailed overview of the epidemiological, demographic, immunological, co-infection, and treatment characteristics of Ukrainian PLWHA displaced by the war to the Slovak republic. With the conflict ongoing, it is necessary to be prepared for more refugees in the coming months.

Joint HIV and hepatitis C virus phylogenetic analyses signal network overlap among women engaged in sex work and men who purchase sex

BackgroundTransmission of HIV and hepatitis C virus (HCV) are heavily influenced by complex interactions within sexual or injecting networks where risk behaviors occur. In Ukraine, women engaged in sex work (WSW) and men who purchase sex (MWPS) are disproportionately affected by both viruses. The aim of our study was to the investigate the influence of underlying networks on transmission of HIV and HCV.MethodsA cross-sectional integrated bio-behavioural survey was implemented among 560 WSW and 370 MWPS representative of sex work hotspots in Dnipro, Ukraine (December 2017 to March 2018). A portion of the HIV reverse transcriptase gene (n = 13; 62% WSW, 38% MWPS) and HCV NS5B gene (n = 46; 70% WSW, 30% MWPS) were sequenced from dried blood spot specimens. Tip-to-tip distances on phylogenetic trees were used to infer phylogenetic clusters for identifying potential transmission clusters.ResultsPhylogenetic analyses identified two HIV clusters containing four sequences (50% WSW; 50% MWPS) and 11 HCV clusters containing 31 sequences - the majority comprising infections in WSW (83.9%). Nearly half (45.4%) of HCV clusters contained at least one WSW with a history of injecting drugs.ConclusionsJoint analyses of HIV and HCV signal overlap in sex work and injecting networks in Ukraine, suggesting implications for the comprehensive coverage of prevention programs for WSW including harm reduction services. Conducting phylogenetic analyses with HCV may provide a more complete appraisal of underlying transmission networks than HIV alone, particularly in the context of high HIV treatment coverage yielding viral suppression.

"…because the social work never ends": a qualitative study exploring how NGOs responded to emerging needs while upholding responsibility to HIV prevention and treatment during the war in Ukraine

INTRODUCTION

Since the onset of the Russian invasion on 24 February 2022, the health system in Ukraine has been placed under tremendous pressure, with damage to critical infrastructure, large losses of human resources, restricted mobility and significant supply chain interruptions. Based on a longstanding partnership between the Ukrainian Institute for Social Research after Oleksandr Yaremenko (UISR after O. Yaremenko) and the Institute for Global Public Health at the University of Manitoba, we explore the impact of the full-scale war on non-governmental organizations (NGOs, including charitable organizations) providing services for key population groups in Ukraine.

METHODS

We conducted in-depth qualitative interviews with key representatives from NGOs working with key population groups (i.e., people living with HIV, sex workers, men who have sex with men, people who inject drugs and transgender people) throughout Ukraine. Members of the UISR after O. Yaremenko research team recruited participants from organizations working at national, regional and local levels. The research team members conducted 26 interviews (22 with women and four with men) between 15 May and 7 June 2023. Interviews were conducted virtually in Ukrainian and interpretively analysed to draw out key themes.

RESULTS

Applying Roels et al.'s notion of "first responders", our findings explore how the full-scale war personally and organizationally impacted workers at Ukrainian NGOs. Despite the impacts to participants' physical and mental health, frontline workers continued to support HIV prevention and treatment while also responding to the need for humanitarian aid among their clients and the wider community. Furthermore, despite inadequate pay and compensation for their work, frontline workers assumed additional responsibilities, thereby exceeding their normal workload during the extraordinary conditions of war.

CONCLUSIONS

NGOs play a vital role as responders, adapting their services to meet the emergent needs of communities during structural shocks, such as war. There is an urgent need to support NGOs with adequate resources for key population service delivery and to increase support for their important role in humanitarian aid.

An implementation evaluation of the Breaking Down human rights barriers to HIV services initiative in Ukraine

INTRODUCTION

Globally, stark inequities exist in access to HIV treatment and prevention. The eastern European and central Asian region is experiencing the sharpest rise in new HIV acquisition and deaths in the world, with low rates of treatment and prevention services, especially for key and vulnerable populations who face a range of human rights-related barriers to HIV prevention and treatment.

METHODS

An implementation learning evaluation approach was used to examine the implementation of the Breaking Down Barriers initiative targeting key and vulnerable populations in Ukraine. Between September 2022 and April 2023, researchers conducted 23 key informant interviews with individuals from the Ukrainian government, implementing organizations and human rights experts. Using a concurrent triangulation design, researchers and key informants, in a process of co-creation, sought to describe programme accomplishments, challenges and innovations in implementation, between 2021 and 2023, including periods before and after Russia's February 2022 full-scale invasion.

RESULTS

Eight rights-based interventions related to HIV were identified in Global Fund programme documents and key informant interviews as making up the core of the Breaking Down Barriers initiative in Ukraine. These included programmes seeking to: eliminate stigma and discrimination; ensure the non-discriminatory provision of medical care; promote rights-based law enforcement practices; expand legal literacy ("know your rights"); increase access to justice; improve laws, regulations and policies; reduce gender discrimination, harmful gender norms and violence against women and girls; and mobilize communities for advocacy. These programmes received US$5.9 million in funding. Key informants reported that significant progress had been made addressing human rights barriers and scaling up interventions, both before and after Russia's invasion. Programme implementors adopted innovative approaches, including using paralegals, hotlines and other community-led interventions, to ensure that key and vulnerable populations, including displaced individuals, were able to access prevention and care.

CONCLUSIONS

An implementation learning evaluation approach examining programmes addressing human rights barriers to HIV services, designed as a process of co-creation between researchers, programme implementors, government officials and human rights experts, can provide a robust assessment of programme outputs, outcomes and evidence of impact, despite a challenging operational environment.

Communicable diseases in Ukraine during the period of 2018-2023: Impact of the COVID-19 pandemic and war

BACKGROUND

By examining 2018-2023 data, this study explored the intricate impact of the Russian invasion, ongoing COVID-19 pandemic, and environmental disruptions on communicable diseases in Ukraine. This conflict exacerbates challenges in disease surveillance and healthcare, compounding stress among the population.

METHODS

Leveraging the Centers for Disease Prevention Control's surveillance system, the study employs active and passive surveillance, utilizing medical records and laboratory reports. Notification rates gauge the incidence of communicable diseases, offering insights into trends during the study period.

RESULTS

While salmonellosis, shigellosis, and rotavirus incidence are decreasing overall, there is a surge in viral hepatitis A, chronic hepatitis B, and C. This conflict hampers hepatitis C management, as evidenced by decreased numbers of treatment centers and patient enrollment. The prevalence of cough cases will increase in 2023, emphasizing the importance of sustained vaccination. The incidence of tuberculosis will increase in 2023 despite a general decrease.

CONCLUSION

This study underscores the urgent need for sustained efforts and adequate resources, infrastructure, and international support to mitigate public health challenges in conflict-ridden Ukraine. Prioritizing vaccination programmes and enhancing healthcare accessibility in affected regions are crucial.

Impact of war-associated factors on spread of sexually transmitted infections: a systemic review

Introduction

Statistical data indicate a link between war and the spread of sexually transmitted infections (STIs), then it is necessary to carefully analyze the factors that directly affect the identified pattern in order to overcome this problem. Therefore, the purpose of the study was to systematically analyze the factors that influence the spread of STIs during war.

Methods

The study included all original research articles and meta-analyses on the impact of war on the spread of sexually transmitted infections that met the following eligibility criteria: (1) articles published exclusively in English; (2) articles published in the period 2013-2023; (3) studies with quantitative, qualitative or mixed design. The search for relevant literature was conducted using four databases: PubMed, Embase, Web of Science, and Ebsco.

Results

The articles selected for our systematic review had different research designs and were mainly published as original studies (n = 8) and literature reviews (n = 6). As a result of the evaluation of the selected articles for the systematic review, the authors identified migration, a decrease in access to health care, difficult access to contraception, sexual violence as the most frequent factors directly affecting the spread of STIs during the war.

Conclusion

This systematic review systematizes data on the impact of hostilities on the spread of STIs and outlines the main factors that contribute to the dissemination of pathogens far beyond the territory at the epicenter of the conflict.Systematic review registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023479808, CRD42023479808.

Contextualizing Public Health Interventions in Eliminating Endemic Diseases: New Lessons From a Review of Sri Lanka's Success in Eliminating Malaria

Malaria remains a major global public health issue, demanding significant resources from governments, health organizations, and international organizations toward its elimination as an endemic disease. In 2016, Sri Lanka achieved the remarkable feat of being declared "malaria free" by the World Health Organisation (WHO), after over a century of indigenous disease. To identify significant lessons of global importance in eliminating endemic malaria by reviewing literature on Sri Lanka's successful elimination campaign. The history of malaria in Sri Lanka highlights the nation's journey from widespread malaria prevalence to achieving malaria-free status in 2016. Key interventions, such as the establishment of the Anti-Malaria Campaign in 1911, the introduction of Dichloro-Diphenyl-Trichloroethane (DDT) in 1946, and the launch of a malaria eradication program in 1958, played crucial roles in controlling the disease. However, challenges such as insecticide resistance, environmental changes, and civil war periodically caused resurgences. The 21st century saw intensified efforts in surveillance, vector control, and community engagement, culminating in the elimination of indigenous malaria cases in 2012. Despite this success, the risk of reintroduction from imported cases remains, necessitating ongoing vigilance and preventive measures. The case study of Sri Lanka is remarkable, and can provide valuable insight for stakeholders involved in eradicating malaria, with the caveat that this case is further evidence of the differential nature of malaria transmission worldwide.

The Effects of COVID-19 Pandemic on HIV Service Provision in Ukraine

Ukraine faced significant fluctuations in COVID-19 morbidity and mortality, alongside an escalating HIV epidemic. This mixed-methods study, conducted between February and August 2022, employed a sequential explanatory design combining a quantitative analysis of national data and qualitative interviews to investigate the pandemic's effects on HIV services in Ukraine. The observed trends confirmed that the pandemic significantly disrupted facility-based HIV testing due to logistical challenges, an increased burden on healthcare workers, and supply shortages. Meanwhile, community-based testing showed resilience, largely attributed to programmatic adjustments rather than the pandemic itself. The initiation of antiretroviral therapy declined, especially during initial lockdowns, reflecting diminished treatment capacities. Despite these challenges, telemedicine and home medication delivery innovations supported antiretroviral therapy adherence. Furthermore, improvements in viral load testing and suppression rates showed healthcare resilience. The study highlights the critical need for adaptable, sustainable healthcare strategies in crises, emphasized during the war with Russia.

HIV diagnoses among people born in Ukraine reported by EU/EEA countries in 2022: impact on regional HIV trends and implications for healthcare planning

Following Russia's invasion in 2022, over 4.1 million Ukrainians sought refuge in the EU/EEA. We assessed how this impacted HIV case reporting by EU/EEA countries. Ukrainian refugees constituted 10.2% (n = 2,338) of all 2022 HIV diagnoses, a 10-fold increase from 2021. Of these, 9.3% (n = 217) were new diagnoses, 58.5% (n = 1,368) were previously identified; 32.2% had unknown status. Displacement of Ukrainians has partly contributed to increasing HIV diagnoses in EU/EEA countries in 2022, highlighting the importance of prevention, testing and care.