Ahead of the International Day Against Homophobia, Biphobia, Interphobia and Transphobia (IDAHoBiT) held annually on 17 May, UNAIDS talks to Evelyne Paradis, Executive Director of ILGA-Europe, the Europe-based Lesbian, Gay, Bisexual, Trans and Intersex Association about protecting the rights of LGBTI people in humanitarian crises. 

How do humanitarian crises particularly affect LGBTI people?  

Humanitarian crises affect everybody, however, some communities sometimes need a targeted response because of pre-existing vulnerabilities. These particular vulnerabilities make people feel unsafe when dealing with humanitarian organisations providing safe shelter, basic necessities food and medical aid. Not knowing if they will be treated without discrimination, simply welcomed and be taken care of, is a barrier for people in accessing humanitarian support.

ILGA-Europe is heavily involved in the Ukraine crisis.  What are the main challenges facing LGBTI people affected by the war? 

In the Ukraine crisis, what we are seeing is that LGBTI people are not de facto integrated in first aid supply chains. Transition-related and intersex-specific medication, such as hormone replacement therapy, and to a certain extent medicines for people living with HIV, are not ensured in humanitarian packages at the moment. On top of this, a significant portion of the LGBTI community cannot meet their basic needs, due to pre-existing socioeconomic inequalities.

Trans women with a male gender marker on their documents can be obliged to join the army or cannot leave the country along with other women, which puts them in a potentially very harmful situation.

Having access to safe shelter is also an issue. In Ukraine, many LGBTI people don’t feel safe to be ‘out’ in regular shelter, while some who are displaced in the country are reporting facing discrimination when trying to rent an apartment. As a result many of the LGBTI groups have set up shelters to support their communities. Some of those who are staying and are visible have been physically attacked, as LGBTIphobia was already an issue in Ukraine before the war.

This is all happening while LGBTI people face the same struggles everyone else is facing; money, food, caring for loved ones, and so much more.

What are organizations like ILGA-Europe doing to help? 

We are sending direct financial support to groups who are staying in Ukraine and are providing direct support to their communities, as well as to LGBTI groups in hosting countries. We’re also actively working to mobilise resources for all the LGBTI groups working in support of LGBTI people in Ukraine and abroad. We’re working with large humanitarian groups and organisations like UNAIDS and connecting them to the needs on the ground, while advocating with European institutions and governments to take action both in support of LGBTI communities in Ukraine and for LGBTI people who have left the country.

What can be done to better address the unique needs of LGBTIQ+ people in humanitarian crises?  

What we are seeing is that an LGBTI perspective is really not integrated into humanitarian work and the development of protection measures, such as protection from gender-based violence or access to medicines. In many ways we have had to start from zero, including having to establish contacts with actors in the humanitarian sector.

While it is still early in this particular crisis to have specific recommendations, there will be no doubt be a lot of learning to be done from the work currently happening, so that we make sure that in future LGBTI perspectives and needs are integrated in the way humanitarian actors respond from the start.

Many civil society and community organizations are supporting LGBTI people affected by the war in Ukraine.  What challenges do they face in carrying out this important work?  

Most LGBTI organisations are not set up to be doing humanitarian work, and yet they are supporting basic needs in addition to the work they continue to do for their communities. But they cannot do it all. If they become the first point of support and assistance, there’s a lot of other work, like advocating for rights, that will not be done. This is true in Ukraine as well as in hosting countries.

Inequalities, stigma, discrimination and human rights violations against are continuing to prevent LGBTI people from being able to access the HIV and health services they need. How can we achieve positive political, legal and social change?  

The work that has started with the humanitarian sector shows there’s a need, but it’s also an opportunity. If the humanitarian sector incorporates an LGBTI perspective and LGBTI people in their work from the start, this can mean a positive change for these communities, especially in times of crisis.

Evelyne Paradis will be one of the speakers at an IDAHOBIT event held on the 17 May focusing on how to better protect the rights of LGBTIQ+ people, particularly in the context of the war in Ukraine, and how to ensure equal rights for all. More information

The start of the Ukrainian war fifty days ago surprised many people including Berliner Aids-Hilfe’s migration consultant. Sergiu Grimalschi, along with his colleagues, has been thrust at the forefront of helping thousands of Ukrainian refugees coming to Germany, primarily those living with HIV.

Mr Grimalschi, a professional interpreter, came to Berlin from Romania in the early 1990s. For the past twenty-five years, he has been working on the HIV response primarily with migrants and is currently employed by Germany’s oldest HIV organization. From 2006 to 2012 he helped countries in Eastern Europe and Central Asia (EECA) develop HIV health services and worked in Ukraine, Belarus, Russia, and Poland.

UNAIDS spoke with Mr Grimalschi about the challenges Ukrainian refugees living with HIV face in Berlin.

Question: Sergiu, many refugees living with HIV in Germany are now coming to you directly. Were you able to prepare for this ahead of time?

Answer: No. No one was prepared and, to be honest, the war was a complete surprise for us, and for me personally. Eastern Europe has been a priority for my organization since 2010. We all speak eastern European languages and have stayed informed about the situation in the region. So, when the war started, I did a simple thing that turned out to be decisive. I wrote one mass email to an EECA group saying that anyone living with HIV fleeing from the war to Germany could contact me or my colleague by phone. First, I got called by colleagues from Moldova, with whom I worked closely during the COVID-19 pandemic when we provided medicines to people stuck in Europe. Then various Ukrainian organizations started contacting me. They continued to share my email and within a week the Berliner Aids-Hilfe numbers were on all social networks and on all Telegram channels.

Question: Many refugees living with HIV fled to Europe, in particular Germany, because they believed that everyone here has access to HIV treatment and services. True or false?

Answer: Yes, everyone has access except migrants without health insurance. That has changed only recently.

In Berlin, for example, every person, including undocumented and uninsured migrants could access treatment but only since the end of 2018.

All this was due to the fact that people without health insurance in Germany cannot be treated, and the law does not take into account people without insurance. And, as you know, if you cannot be treated, you die. Since 2000, we focused on all possible ways to provide all people living with HIV without insurance with access to medicines and qualified medical treatment.

Addressing this issue was the most difficult and the most important task for us in many years, but we managed to solve it. And that is thanks to many years of advocacy work that we did.

Question: So tell us how you deal with influx of refugees in Germany?

Answer: It is still not so simple. Firstly, the situation is very different in different states (landers) of Germany.

Secondly, when the first refugees began to arrive, there were no really organized structures, so we had to improvise with colleagues across the country. One bad thing was for example that Ukrainian people fleeing their homes were advised to leave medicines for those who stayed in Ukraine. In the first days of the war, medicines were collected throughout Germany in order to send them to Ukraine or Poland. But after one week, a lot of people living with HIV from Ukraine were in Berlin. A few women came to me saying, ‘I have only 2 or 3 pills because I gave everything to my husband.’

We had to find an urgent solution.

We went to doctors in Berlin and found stockpiles of HIV treatment but then we ran out. Doctors wrote out prescriptions, but it was not clear how they would be covered or paid for. Only Dolutegravir, for example, which is a part of the treatment that a majority of Ukrainians living with HIV take, costs more than 700 euros here. But everyone made extra efforts– doctors, social workers, other people living with HIV – they said, 'There is a war going on.’ And eventually the German health authorities began gradually to cover treatment costs.

Many people who arrive from Ukraine still do not understand how one gets treatment in Germany. There are no big specialized centers that dispense medicine here. I explain to people: ‘we help you to get an HIV-specialized doctor in your region who gives you a prescription and then you can go to the pharmacy and get your medicine.’

In recent weeks, onlly some of the 16 German regions have been treating people without insurance, without registration, based only on the person’s passport. For the past two weeks in Berlin, doctors have been authorized to treat Ukrainian refugees just by providing photocopies of their passport and sending it to the social services to get reimbursed. A real show of human solidarity.

Question: How many people are currently receiving antiretroviral therapy in Berlin?

Answer: At the moment, about 600 Ukrainians living with HIV are in contact with me throughout Germany and 150 in Berlin. Overall, I would say about 2,000 people total but not everyone has asked for help yet because they have enough medicine.

Question: Sergiu, tell us how the war started for you?

Answer: When my mother called me from Romania on the morning of February 24 and said, ‘the war has begun,’ I asked her, ‘Mom, did you sleep badly? Stop!’ I thought she had a bad dream. I never thought that Russia would go ahead with the invasion of Ukraine.

Personally, I am very connected to Eastern Europe. My grandmother left Russia in 1918, my grandfather was from Chernivtsi, which means that theoretically, he could have been Ukrainian if he had not left in 1940. I have a lot of very good friends, relatives, and colleagues with whom I worked there so this is terribly painful for me.

Question: Sergiu, as I understand it, you not only help refugees with treatment but also help out with housing and other things?

Answer: Yes, of course, we help with the refugee registration and access to social aid services, health insurance, psychological support in their language and everything that they need. We also advise people against going to the countryside. It is better for people living with HIV or who need substitution therapy to stay in Berlin or other big cities, because there are better health facilities.

I and my colleagues and friends try to help people with accommodation and clothing. I have a friend, a Romanian doctor, whose house was empty. I asked her if she wanted to help. Now six Ukrainian families live in her house. Another German friend gave 2,500 euros to women from Ukraine for urgent needs. Of course, I am accountable for all this money, but this is a personal, private initiative. One of my friends, a lawyer, bought iPads for many refugee children. He says children need to study so now they can go online.

Question: Amazing work Sergiu... What keeps you going?

Answer: I am impressed by all this human solidarity and I hope that all this horror will end shortly...This is a big test for all of us.

COVID-19 is having a devastating impact on the Jamaican economy. In 2020, the economy declined by more than 5%. According to the World Bank, the poverty rate increased from 19% in 2018 and 2019 to about 23% in 2020. Working women have been among the most affected by the crisis, accounting for approximately 78% of health-care and humanitarian employees and 55% of staff in industries that are highly susceptible to COVID-19, including commerce and tourism. Jamaica’s tourism industry, for example, which reached 4.2 million visitors in 2019, plummeted in 2020 and 2021 as a result of the global travel restrictions related to the pandemic.

In response, the Jamaican Government has implemented a series of recovery strategies, including a reduction in taxes. It also launched the COVID-19 Allocation of Resources for Employees (CARE) programme, aimed at assisting workers and businesses during these difficult times.

People living with and affected by HIV have also felt the impact. The strains caused by COVID-19 on health-care workers and facilities, compounded by loss of income and movement restrictions, have generated disruptions in access to HIV and other health-related services.

In response, Jamaica’s National Family Planning Board and UNAIDS, in partnership with key stakeholders in the design and implementation of the country’s social protection strategy, including the Ministry of Labour and Social Security, the Planning Institute of Jamaica, the Ministry of Local Government and Rural Development and civil society organizations, collaborated to produce an assessment of national social protection and HIV. The assessment provided a mapping of social protection services in the country, identified gaps in outreach and opportunities to respond to the specific needs of people living with and affected by HIV, such as increasing awareness on the existence of and application requirements to benefit from these programmes, and provided recommendations for the improvement of social protection.

Of the more than 100 people questioned, a considerable number were not aware of the existence of social protection programmes, despite several programmes being offered in the country. There was also an apparent lack of clarity on who is eligible to participate in the programmes. In general, people living with HIV, specifically mothers less than 25 years old who are living with HIV, are among the populations facing the most barriers in accessing HIV and social protection programmes in Jamaica, particularly the Programme of Advancement Through Health and Education (PATH). For example, to apply for PATH, a family score is assessed, which includes all members of the family. Where the family is deemed not poor, it would not qualify for PATH, including the young mother.

“Social protection schemes are critical for ending the AIDS epidemic because they address socioeconomic inequalities, which fuel HIV risk and vulnerability, including stigma and discrimination and other human rights abuses, by breaking down barriers to accessing HIV services,” said Richard Amenyah, the UNAIDS Country Director for Jamaica.

Among its recommendations, the assessment stressed the importance of raising awareness of existing social protection programmes, revising the selection criteria for social assistance, digitalizing enrolment and transfer payments, enhancing local coordination and consolidating labour market programmes.

“Social protection programmes play an important role in cushioning society’s most vulnerable from the harsh social and economic realities brought about by circumstance such as the COVID-19 pandemic. As such, the recommendations of this assessment can only enhance existing social protection programmes and strengthen multisectoral collaboration in this area for the benefit of those most affected, including persons living with HIV,” said Lovette Byfield, the Principal Director of the National Family Planning Board.

Andrii Chernyshev heads the advocacy work of the Ukrainian national lesbian, gay, bisexual, transgender and intersex (LGBTI) organization ALLIANCE.GLOBAL, which is one of the largest among about 30 LGBTI community organizations across the country. After the start of the war in Ukraine, he moved from Kyiv to the central part of Ukraine, a safer place to continue his work. His Facebook page has been full of announcements about where LGBTI people fleeing hostilities can find shelter and help, both inside and outside the country.

Before the war, the primary focus of ALLIANCE.GLOBAL was public health, HIV prevention, monitoring of violations of human rights and national LGBTI advocacy. But the war has brought about new urgent tasks.  

“The main challenge for all people during the war, including LGBTI people, is just to survive. Many have lost their homes and relatives. Just recently, we welcomed several people from Mariupol, which is now completely destroyed. Although they managed to leave the city, they are in a very bad psychological state,” said Mr Chernyshev.

According to the Office of the United Nations High Commissioner for Refugees, there are now 7.7 million internally displaced people in Ukraine. This number includes members of key populations, including LGBTI people, and others who are especially vulnerable.

Sviatoslav Sheremet, the coordinator of policy and legislation work of the National MSM Consortium, said that there are several factors that make LGBTI people especially vulnerable. “Many LGBTI people are fleeing the areas occupied by Russian forces. People are afraid, and this fear has pushed them to actively move out to safer zones in Ukraine and outside the country.”

He noted that LGBTI people often cannot reveal their sexual orientation or gender identity, fearing violence, rejection and discrimination if they do. He underlined that all cases of homophobia are still being recorded and submitted to state bodies. “The proceedings on such cases are postponed until there is peace,” he added.

Both ALLIANCE.GLOBAL and the National MSM Consortium have significantly changed their work. Several additional shelters for LGBTI people have opened in Dnipro and Chernivtsi. Men and women, including transgender people, can stay there one night and move on, or stay longer, and can bring their relatives and friends. People also receive financial support to leave the war zones and reach shelter.

“The shelter in Chernivtsi, for example, was in a non-residential building,” said Mr Chernyshev. With a small grant from the UNAIDS Emergency Fund and other donors, we installed a shower and bought heaters. People have food, the Internet, a first aid kit, access to HIV counselling and antiretroviral therapy.”

LGBTI organizations outside the country have also provided support to people in need.

Stas Mishchenko, an LGBTI activist from Ukraine, now lives in Munich, Germany. At the beginning of the war, he joined the Contact Group of Munich Kyiv Queer, which is part of the Alliance for Assistance to Queer People of Ukraine, a group of more than 50 LGBTI organizations in Germany whose members volunteer to help people who have fled to Germany and those who remain in Ukraine.

“Sometimes there is homophobia and transphobia in refugee camps. And even if these are not systemic, there is always the human factor, combined with stress, fear and violence. That is why we accompany people on their way to us, provide psychological assistance, try to resettle them in private homes, help with humanitarian aid,” said Mr Mishchenko.

“The war exacerbated both good and bad in our society,” said Marina Novachuk, UNAIDS Community Adviser at the UNAIDS Country Office for Ukraine. It is essential for the state and all stakeholders engaged in protecting forcibly displaced people to recognize and respond to the unique needs of LGBTI and gender-diverse people.”

Over the past 20 years, Ukraine has made a real breakthrough in ensuring the rights of LGBTI people and in protecting their security. LGBTI rights are an integral part of the National Human Rights Strategy. Leaders of the LGBTI community sit on the National Council of HIV and TB, as well as on regional councils. The number of participants of the annual equality marches has risen from just a dozen to thousands of people. Ukraine plans to develop legislation on the registration of civil partnerships.

“Achieving civil equality has been the goal of my work for many years—I have seen huge improvements. The attitude towards LGBTI communities is a litmus test of civilization,” Mr Sheremet said.

In April 2022, Ukraine received a questionnaire from the European Commission on its readiness for candidate status for membership of the European Union. On 18 April, Ukraine completed and submitted the first part of the questionnaire, which includes several questions on the situation with regard to LGBTI people and legislation, specifically about the legislative and policy instruments in place to prevent and respond to discrimination and how hate crimes are addressed in the criminal code. ALLIANCE.GLOBAL and the National MSM Consortium team will follow the process closely.

“We have been working on changes in the legislation on LGBTI rights for many years now and we hope that now it will take not years but months to change. But first the war should end,” added Mr Chernyshev.

A new publication by UNAIDS and the World Health Organization (WHO) emphasizes the importance of integrating HIV and mental health services and other interventions, including linkages to social protection services, for people living with HIV and other vulnerable populations.

Mental health conditions increase the risk of HIV infection, and people living with HIV have an increased risk of mental health conditions, which are associated with lower retention in HIV care, increased risk behaviours and lower engagement with HIV prevention.

Furthermore, despite an increasing body of evidence showing that effective methods of prevention, screening and diagnosis of, and treatments for, common mental health conditions, including depression and anxiety, exist and can be implemented in low- and middle-income countries, services for mental health, neurological and substance use conditions are often not integrated into packages of essential services and care, including for HIV.

“We know that integration of screening, diagnosis, treatment and care for mental health conditions and psychosocial support with HIV services does not need to be expensive,” said Eamonn Murphy, UNAIDS Deputy Executive Director, a.i., Programme. “The integrated approaches that are people-centred and local context-specific ensure better HIV and overall health outcomes, well-being and quality of life.”

The publication is primarily intended for national and local policy-makers, global, regional, country and local programme implementers, organizations working in and providers of health, HIV, mental health and other relevant services, civil society and community-based and community-led organizations and advocates.

Although focus is on the integration of mental health with HIV services and other interventions, the considerations in the publication may be relevant to other services, including for HIV comorbidities such as tuberculosis, viral hepatitis and sexually transmitted infections.

“Our publication successfully brings together tools, best practices, case studies and guidelines that can help countries and facilitate the integration of interventions and services to address the interlinked public health challenges of mental health and HIV, all while improving access to care for persons who are the most vulnerable, such as adolescents and key populations,” said Meg Doherty, Director, Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO.

“With this joint UNAIDS/WHO publication, we hope we can collectively support countries, service providers and other practitioners, policy-makers, programme implementers and communities in their efforts to address HIV, mental health, neurological and substance use conditions for affected individuals in an integrated and impactful way,”  said Devora Kestel, Director, Mental Health and Substance Use, WHO.

Integration of mental health and psychosocial support with HIV services and interventions, including those led by communities, is one of the key priority actions included in the Global AIDS Strategy 2021–2026: End Inequalities, End AIDS and the 2021 United Nations Political Declaration on HIV and AIDS: Ending Inequalities and Getting on Track to End AIDS by 2030. Both documents call for addressing the interlinked issues of HIV and mental health through integrated services by investing in robust, resilient, equitable and publicly funded systems for health and social protection, by reversing health and social inequalities and by ending stigma and discrimination.

The new publication stresses that the AIDS epidemic cannot end without addressing the mental health of people living with, at risk of or affected by HIV, ensuring equitable access to HIV services for people with mental health issues and conditions and achieving universal health coverage.

The economic impact of the COVID-19 pandemic on lesbian, gay, bisexual, transgender and intersex (LGBTI) people has been huge. A 2020 survey of more than 20 000 LGBTI people from 138 countries showed that many had lost their jobs because of the pandemic. In addition, members of the community experienced increased discrimination, hate crimes and arrests. Criminalization combined with stigma and discrimination of LGBTI people in some countries has hindered their ability to seek essential economic and health-care support.

Several of the 23 UNAIDS Solidarity Fund grantees across Brazil, Ghana, India, Madagascar and Uganda are supporting LGBTI organizations in building economic capacities and driving social impact for their respective communities through diverse social entrepreneurship projects.

Uganda is home to more than 1.5 million refugees. Same-sex sexual relations are illegal in the country, and being a refugee brings a host of other challenges, including social exclusion. Adding to this, the COVID-19 pandemic has destroyed the livelihoods of many of Uganda’s refugees who are members of key populations. Through a Solidarity Fund grant, the Simma Africa Creative Arts Foundation set up the Rainbow Drip Craft Shop Project, which markets creative and cultural goods, including fine beaded and brass jewellery, handmade leather-craft shoes and Ankara fusion clothing made by LGBTI people and adolescent girls and young women from refugee camps and host communities. “The shop has become a safe space and a creative outlet for the community to channel their skills and talents towards building self-sustaining livelihoods,” said Natasha Simma from Simma Africa.

Also working with the Ugandan LGBTI and sex worker communities, Vijana Na Children’s Foundation (VINACEF Uganda) has set up a community-run salon offering diverse beauty treatment services. About 80 community members have been connected to social services and trained in social enterprise and financial management. “The social entrepreneurship project has enhanced community involvement and strengthened the capacity of LGBTI and sex worker communities while allowing them to gain and practice new skills to earn a sustainable income,” said Benard Ssembatya, the Executive Director of VINACEF Uganda. Inspired by this initiative, VINACEF Uganda is forming a network of salons to improve access to information on HIV, sexual and reproductive rights, tuberculosis, cancer and noncommunicable diseases for community members.

Similarly in Brazil, tapping into the talents of members from the LGBTI and sex worker communities in beauty treatment, Associação Social Anglicana de Solidariedade do Cerrado (Casa A+) implemented the Empodera Mais Project. “We motivated members from vulnerable backgrounds to participate in the social entrepreneurship project through the provision of the Empodera Mais Kit, with basic equipment and supplies for entering the hairdressing and beauty treatment profession,” said Anglican Bishop Maurício Andrade, the founder of Casa A+. The technical skills provided and encouraged members to start businesses in beauty treatment and survive the hardships of the COVID-19 pandemic. Technical partnerships with professionals, a beauty studio and institutions such as Palmas’ Municipal Department of Human Development provided the participants with on-site experience before launching their own businesses and generated a professional network to exchange experiences and get new business.

In Ghana, the Hope Alliance Foundation and the OHF Initiative launched the Community Economic Empowerment Program to set up social enterprises led by people living with HIV and LGBTI people to support them economically to confront complex political and COVID-19-related challenges. The initiative provided vocational skills training for the production of food and hygiene products to 30 young people, supported the creation of social enterprises in fashion design and supported the refurbishment and revamping of 10 selected small-scale businesses adversely impacted by COVID-19.

In India, Nachbaja.com’s online artist platform was set up to overcome the challenges of discrimination, unfair remuneration and the safety of artists from the LGBTI community. Meanwhile, Gaurav Trust opened its doors for members to be a part of a community-led salon, La Beauté and Style, and mobilized additional funding for sustainability and scalability.

Stories of growth continue with Let’s Walk Uganda, whose Jump Start project was established to host small-scale enterprises in fashion, design and the production of liquid soap led by gay men and other men who have sex with men. Community members have proven their ingenuity to grow, scale up and diversify their enterprises by successfully reinvesting the revenue from the first batch of products in new entrepreneurial ventures. This led to the development and launch of the UNAIDS-supported Stall App, an online social marketing app that could help to boost the sale of products developed by several key population-led enterprises, including other Solidarity Fund grantees.

“We must recognize that while the rest of the world recovers from the economic impact of the COVID-19 pandemic, its effects will last longer for marginalized communities. Hence, it is of the utmost importance to continue to support innovative community-led social enterprises designed to support livelihoods and overcome special challenges,” said Pradeep Kakkattil, the UNAIDS Director of Innovation.

Restoring the self-reliance and dignity of LGBTI communities must be grounded in initiatives led by themselves, with a focus on addressing inequalities. A common thread that connects these diverse enterprises is the ingenuity of LGBTI people in the face of hardship. The grantees demonstrated the potential of empowerment through art, creativity and professional skills supported by the Solidarity Fund seed funding.  Acknowledging and embracing diversity in sexual orientation and gender identity in all areas is crucial to making the community visible, protecting them from stigma, discrimination and violence, and engaging them in the response to pandemics.

Odesa is a major Black Sea port, with a substantial drug use. In the 1990s, Odesa saw the outbreak of HIV infection in Ukraine. But more recently it has successfully developed one of the world’s most effective systems of harm reduction services for people who use drugs. The system is funded by the state and local budgets and implemented jointly with non-governmental and community organizations. Odesa was one of the first cities in Eastern Europe and Central Asia that signed the Paris Declaration. Last year, it reported a reduction of new HIV cases among people who use drugs.

Natalia Kitsenko is head of the public health department of the Road to Home Foundation, one of Odesa’s oldest organizations providing services to people who use drugs. UNAIDS spoke with her about how her organization has been managing to continue to help people in need, even during this war. 

Question: Did many people flee Odesa?

Answer: Yes, many left, mostly women and children. The people in our organisation are an exception. Of 60 employees, 4 people left because they have small children. The rest stayed and we are actively continuing our usual work and also providing emergency assistance to women with children and elderly people fleeing from other cities—Mykolaiv, Kherson, Mariupol and Kharkiv. We mostly provide transportation to the Moldova border and connect them with volunteers who then help them in the country or in another destination depending on their needs.

We also prepare food such as pies and dumplings for people in need. This whole situation has united us; I have seen a lot of mutual support around.

Question: How many people from your harm reduction program have left the city?

Answer: Our coverage in Odesa and surrounding region includes about 20,000 people per year. As far as we know only 7 clients have fled abroad. Some clients have gone into the local territorial defense groups. Others have taken part in building protective structures, which involves collecting bags of sand and transporting them to protect streets and monuments. Others reside with us for the services they need. We had an influx of people who use drugs from other regions of Ukraine where conditions are far worse.

Question: What services does your organization offer to people who use drugs?

Answer: First of all the basic harm reduction package which we provide under the state budget includes consultations, HIV prevention (syringes, condoms, wipes, lubricants, etc.); HIV testing, and TB screening. Among clients who have used these services for a long time, the detection rate of HIV infection is 0.02%. Among new clients who have just joined the programme, it reaches up to 7%. We set up a client recruitment model with the Alliance for Public Health coordination using the Global Fund Grant and ECDC support. We encourage people who use drugs to bring their close friends to our community centres for testing. This is an important aspect because new clients, especially young people, those who recently started using drugs, can be a very difficult group to reach. Many hide their use and try to stay invisible. This recruitment system allows us to attract them to our harm reduction services, and first of all to testing. Management of new cases, support for diagnosis and receiving antiretroviral therapy, screening, and follow-up for tuberculosis is also provided through donor funding, in particular the PEPFAR project.

Question: Have you gotten additional funds?

Answer: Yes. We just received additional funding from the UNAIDS Emergency Fund to purchase medicines, dressings and hygiene products for our clients. This is a very timely and essential help because many medical products like Fluconazole (antibiotic) are not affordable to our clients and they are not widely available anymore.

Question: Natalia, you have been working in the HIV field for more than 20 years, have public attitudes changed regarding people living with HIV and drug users?

Answer: We have seen a welcome dramatic reduction in the level of stigma and discrimination and the overall attitude towards our clients in medical settings. However, we still experience problems with prejudices. Many people say that they do not want to have our syringe exchange points and community centers near their homes, and that they don't want to see people who use drugs near them as they fear that they might threaten their comfort, well-being and safety. We understand these fears, and we try to explain to concerned people why we are here, how these syringe exchange points and community centers work. We organise outings and sessions to explain to people the reality that people who use drugs face. We work to continually demonstrate our contribution and show how we help keep the epidemics of HIV, TB and hepatitis under control.

Since the war started we have also provided shelter to people who live by our centres. As our syringe exchange points are usually in basements, when the sirens sound the neighbors come to us; and that means for some their first time being in close contact with people living with HIV or people who use drugs.

Question: What are the most pressing issues for you now?

Answer: At the moment we are experiencing difficulties in providing our customers with Naloxone, which can prevent drug overdoses. Although we are constantly working on counseling and informing people about signs of overdosing, with the war going on, overdoses have increased. And because Naloxone is manufactured in the heavily bombed city of Kharkiv we have no more. We need it in any form, preferably ready-made, intranasal or injectable, as this would save many lives. And we need to sustain HIV services for people who use drugs together with providing them with urgent humanitarian aid.

On 10 April, Tetyana Pryadko (not her real name) was phoned by her doctor, who told her that her antiretroviral therapy to treat HIV had arrived. For Tetyana, who has been on treatment for 10 years, it was an important call. Her treatment hadn’t been interrupted once in 10 years, but now she had only a five-day supply left. She lives in Chernihiv, which was on the war’s front line, cut off from the old supply chains that kept her supply of HIV treatment uninterrupted.

Before the outbreak of the war, antiretroviral therapy was widely available in Ukraine. Larisa Getman, the Head of the HIV Management and Response Department of the Public Health Centre, Ministry of Health of Ukraine, explained that, “The majority of antiretroviral therapy was procured by the state through the National Procurement Agency.” 100% LIFE is the largest organization of people living with HIV in Ukraine, that implements the procurement of medical goods under the Global Fund projects and operates humanitarian aid under PEPFAR programs, including emergency supplies of antiretroviral drugs.

Valeria Rachinskaya, the Director of Human Rights, Gender and Community Development at 100% LIFE, who herself has been on antiretroviral therapy for many years, explained that the COVID-19 pandemic had actually improved treatment adherence, since it has become the norm to have a multiple-month supply of medicine at home, which was mailed to those who couldn’t access a clinic. Remote counselling and the widespread use of mobile applications have also become routine.

“People weren’t without medicines at the start of the war. The worst was for people in the cities that were the most heavily bombed, where not only medical facilities were destroyed but also logistic chains were interrupted,” she said.

“Before the war, the whole procurement and delivery process in Ukraine was quite easy,” said Evgenia Rudenka, Head of 100% Life’s Procurement Department. “Cargo was delivered to the airport, we cleared it at our warehouse and transported it. But the war happened, and it was urgently needed to figure out how to deliver those medicines to the country, and, most importantly, how to deliver them to patients. And we worked out these mechanisms from the very first days of the war with our partners.”

At the request of the Ukrainian Public Health Centre, under support of USAID and CDC, the United States President’s Emergency Plan for AIDS Relief (PEPFAR) agreed to help with the urgent supply of antiretroviral therapy. Chemonics, a purchasing agency of PEPFAR, searched around the world for spare stock and secured vital supplies.

Through the support of the European Union who immediately developed the special humanitarian aid transit procedures for Ukraine, deliveries have begun to take place through neighbouring countries, primarily Poland and Romania. “Through the support of the Railway Service, we have organized the pickup of the cargo at a separate station away from the main delivery point of most Humanitarian Aid that comes to Ukraine. It was done with the purpose to manage the immediate distribution to regions. (As a huge number of humanitarian supplies from different countries goes through the State Agency for Strategic Reserves of Poland, it is quite hard to take the goods immediately from there.) So we have brought in a logistics company that can deliver goods to Ukraine under the humanitarian transit procedure, to a warehouse in Lviv, from where we are able to make the immediate distribution” said Ms Rudenka.

The most difficult and the most important part of the process is delivery throughout Ukraine, including the front-line zones.

According to Evgenia, many logistics companies have stopped operations during the war, and those that remain have increased the cost of their services by two- or threefold.

Commercial organizations are not willing to go to cities such as to Kharkiv, Kherson or Mykolaiv, but volunteer drivers, working in coordination with local authorities, drive there, evacuating people and delivering medicines and other goods.

“Where there is fighting, the volunteer drivers will unload at, for example, the regional administration headquarters, and then we communicate with the medical institutions that are the final recipients, we tell them where to pick up the goods,” she said.

Even so, several volunteers have come under attack, and four have been killed.

“The situation for people living with HIV in Ukraine is desperate. We are trying to deliver medicines, food, and other emergency assistance to people in need, but the work is dangerous and volunteer drivers are putting their lives at risk. If we don’t get more help, I am not sure how much longer we can continue, especially reaching people in the front-line zones,” said Dmytro Sherembey, the Head of the 100% LIFE Coordination Council.

Men and boys are less likely to test for HIV, to initiate antiretroviral therapy and to remain engaged in care, and are therefore dying of AIDS-related illnesses and many other diseases at disproportionately higher rates than their female counterparts. This has become increasingly clear over the past decade.

Globally, antiretroviral therapy coverage of men lags that of women. In many countries in eastern and southern Africa, the region with the highest HIV burden, more than half of men aged 24–35 years living with HIV are unaware of their status and therefore not on treatment. This imperils their own health and increases the risk of HIV transmission. The diagnosis of undiagnosed men is essential for promoting men’s health and breaking the cycle of HIV transmission.

Primary health-care services in eastern and southern Africa place a great deal of focus on women of reproductive age, and reproductive, maternal and child health services offer ideal entry points for HIV services—similar entry points for men are not commonplace.

The architecture of health service delivery needs to be reviewed. Are health institutions organized in ways that promote access to services for men and boys?  Do HIV-related health systems, policies and strategies include men, especially men at higher risk of HIV? However, health-system barriers go beyond the service delivery level, and a broader supportive enabling environment needs to be created, including laws, policies and health strategies.

UNAIDS has recognized the gaps and the importance of male engagement in the HIV response—therefore, in collaboration with Sonke Gender Justice, the World Health Organization, UN Women and other partners, Male engagement in HIV testing, treatment and prevention in eastern and southern Africa: a framework for action was developed. The framework provides a foundation for country-led action to achieve the globally agreed HIV goals in the Global AIDS Strategy 2021–2026: End Inequalities, End AIDS and work towards achieving gender equality. It categorizes existing research and best practice and elaborates strategies on how to increase HIV prevention services coverage, and HIV testing and treatment among men and boys, within a broader gender equality agenda.

In line with the Global AIDS Strategy 2021–2026 and an emphasis on societal enablers, the framework provides direction and strategies on addressing structural barriers. The focus is on transforming social, economic, legal and policy structures, addressing supply- and demand-side factors and transforming gender norms.

“On our part, I confirm the United Nations family’s continued commitment and support to governments and civil society in eastern and southern Africa to engage men, for fewer new HIV infections, better treatment and fewer AIDS-related deaths. The road ahead is clear. The urgent and hard work of implementation with the close engagement of men needs to begin now,” said Anne Githuku-Shongwe, the Director of the UNAIDS Regional Support Team for Eastern and Southern Africa.