Organised by the Alliance for Public Health with the support of Ukraine, the Eurasian Harm Reduction Association, the Ukrainian Network of People who Use Drugs and the Precursor Foundation for Social Policy

Tuesday 15th March  8am-8.50am

Ganna Dovbakh, Eurasian Harm Reduction Association; Anna Shemet, Ministry of Health, Ukraine; Anton Basenko, European AIDS Treatment Group; Sergii Filippovych, #Sos 2.0, Alliance for Public Health; Magdalena Bartnik, Prekursor Foundation

Ganna Dovbakh (Eurasian Harm Reduction Association): Thank you very much for joining us in this early morning.  Usually, at this moment the alarm is finished, and all the missile attacks are finished, because they are attacking us in the night. So If I could speak, and I wanted to start today’s meeting. It’s right now only Ukraine is keeping a minute of silence for those who are killed in this in this brutal war.  So, I suggest for us to take the minute, to take the time to reflect on all the victims of this war. Thank you very much for providing your support, your countries, and your citizens for providing help to Ukraine and Ukrainian refugees.  Today we will speak about the Ministry of Health’s response to civil society and community, and we have a tremendous panel.  So, I am firstly presenting Anna Shemet who is representing the Ukrainian, Ministry of Health, over to you Anna.

Anna Shemet (Ministry of Health, Ukraine): The Russian war against Ukraine has lasted for more than 9 years and 2 months.  The war started on 20th February 2014 when Russia invaded and annexed Crimea.  The full-scale invasion began on 24th February 2022.  More than 22 000 000 people were forced to leave their homes including 8 000 000 refugees from Ukraine across Europe as of 27 February 2023. As of 17th June 2022. 739 healthcare facilities (HCF) were damaged 118 healthcare facilities were absolutely destroyed. The healthcare system has faced several problems including the occupation of certain regions and territories (12 regions have mostly been affected. The total front line is around 1300 km); difficulty in the logistics of drugs, medicine, and other supplies within regions; damaged or destroyed medical facilities; medical personnel draining and fleeing to other regions and countries; medical workers face an overwhelming amount of work; and finally, a shortage of drugs. The OST program was implemented in Ukraine in 2004. Since then the program has achieved significant results and is considered one of the largest programs in the Eastern Europe and Central Asia regions. It has achieved:  1. Implementing scientific-based standards of treatment; 2. Since 2017, OST drugs have been procured with the state budget funds, covering 100% of the needs of the regions; 3. Since 2020, there has been a medical guarantee program that provides free OST services; 4. Since 2020, OST has been implemented in detention facilities; 5. More than 95% of HIV-positive patients receive ART treatment; 6. Progressive policies regarding OST; 7. Ambitious targets are pursued for OST implementation; 8. Effective intersectoral cooperation on OST issues has been established (intersectoral working group on OST issues at the Ministry of Health of Ukraine); 9. The list of service providers has been expanding (treatment can be provided by any trained doctor); 10. А number of training courses has been rising (a system of online and offline training); 11.Large-scale prescription of OST drugs for self-administered intake. There have been a number of challenges  in implementing OST before the full-scale invasion including OST storage regulations (one-month supply in specially equipped premises); Issues that are connected to geographic access; Risks of OST drugs misuse; Ambitious goals regarding program expansion; low motivation of doctors to provide OST; transportation of drugs (military security).  The challenges and responses of providing OST at war include: 1. Difficulties with the logistics of OST medicine both from the warehouse and within the regions (destroyed roads, massive shelling, drivers refuse to deliver to regions where active military actions are taking place) 2. Risks associated with the lack of the OST drugs (national drug manufacturers stopped working, lack of funds from the state budget, impossibility of promptly obtaining raw materials) 3. Difficulties with the arrival of patients/medical workers to health centers (because of active military actions, problems with transport connections and public transportation) 4. National drug manufacturers stopped working 5. Occupation of territories and stopping of OST programs (implementation of the OST program in the occupied territories had serious risks for medical personnel, since OST is prohibited in russia) 6. Migration of OST patients within the country (as a result, some clinics face a significant overload for some period of time. Also patients try to receive OST treatment in several health care centers at the same time) 7. Private clinics were forced to stop working due to the inability to purchase OST drugs (as a result, a large number of patients turned to state hospitals for help) 8. Departure of OST patients abroad (problems connected to identifying OST patients. Issue to facilitate the continuity of OST treatment) 9. Uncertainty that the program will be able to work in the future – Regions where there has been a decline in number of OST patients 1.Luhansk oblast (-100%) 2.Cherson oblast (-81,4%) 3.Donetsk oblast (-64,1%) 4.Kharkiv oblast (-13,4%) 5.Zaporizhzhia oblast (-3,6%)  There have been a number of healthcare system responses to OST, since the start of the war, including:  1.Weekly meetings of key stakeholders to resolve arising issues 2.OST drugs purchase with additional GF funds 3.flexibility of financing to address urgent issues 4.Humanitarian aid (including new expensive OST drug)  In regards to the challenge of difficulties with the logistics of OST drug, the responses included:  Employees of the Public Health Center collected information about the availability of OST drugs every week instead of every month. Order of the Ministry of Health was issued which provides simplified and more efficient mechanism for ordering and supplying drugs.  The use of new logistics mechanisms, in particular the mobile clinic of a nongovernmental organization (Alliance of Public Health). Due to changes in regulations and a rise in the number of drugs permitted to be stored, there is a three-month drug reserve in every region now (instead of one-month reserve)    In regards the challenge of the risks associated with the cessation of OST drugs supplies, responses have included: Prompt procurement of drug residues from the national manufacturers; Negotiations with international agencies were held and it was agreed to purchase antiretroviral drugs with international projects funds; Manufacturers were involved to supply the drugs for Ukraine; Purchases of drugs for the country’s needs were made and stocks were formed.  In regards to the challenge of Difficulties associated with the provision of OST drugs every day or interruption of the OST treatment due to the inability to get to the health centres or because doctors leaving medical centres, there  was an implantation of the Order of the Ministry of Health of Ukraine that allowed to hand over OST drugs for up to 30 days ahead (the Order was promptly issued within a week of the beginning of the full-scale invasion)  In regards to the challenge of the intensive internal displacement of patients within the country and departure abroad, responses included: Additional supplies of drugs in the regions were delivered so that the health care facilities have opportunity to receive large number of patients without waiting for the next drug delivery; A mechanism has been created for an instant exchange of information between doctors to confirm the patient’s identity when moving within the country; Collected information about OST offices in different countries and provided support for patients travelling abroad to ensure continuity.  In response to the challenge of uncertainty among patients and medical professionals (particularly around miscommunication), the responses included: Weekly meetings for patients and doctors from the first weeks of the war to inform them of the current situation; Status reports on the status of the OST program every week/month; Weekly meetings of stakeholders on OST issues. Other responses regarding the provision of OST during the war in Ukraine have included: 1. A pilot project on video monitoring of the self-administration of OST drugs was launched 2. Research was started to investigate the impact of self-administration of OST medications on treatment retention and adherence 3. Doctors receive frequent training 4. Several studies were conducted which included: Assessment of changes in the drug scene; the Assessment of the level of knowledge of OST service providers; The prevalence of adverse reactions to OST drugs 5. The implementation of the medical information system – the register of OST patients – has been started 6. There have been steps taken to support the mental health of OST physicians and patients 7. A new OST drug was received as humanitarian aid – a prolonged form of buprenorphine (injection once a month) and a study of implementation was started 8. Implementation of pilot projects on HCV treatment based on OST sites. As of the 1st of February 2023, there have been 25886 OST patients, of which 19919 are in public HCFs and 8604 in private HCFs.  The number of OST patients in public HCF has increased in the last year from 17,403 on the 1st of January 2022, to 17510 on the 1st of April 2022, to 19919 on the 1st of January 2023.

Ganna Dovbakh (Eurasian Harm Reduction Association): Thank you very much Anna, and I must say that this is all unprecedented work, which, the Ministry of Public Health, nurses, doctors and civil society organisations have completed.  I need to say that from the very first minutes of this war, this commitment os support ppl who use drugs and the essential OST treatment, and the innovations to fulfil HR and support services, and innovate/change the system to make it more efficient, has been unprecedented. Civil society has developed a flexible system to implementing a wide array of services for PWUD.  I now present the representative of PWUD, from EATG, Anton Basenko,

Anton Basenko (European AIDS Treatment Group): Thanks Anna for saving my time, because she presented really well on the majority of issues that we as a community of people, OST patients, and the problems we have been faced with due to this war issue.  I will speak on behalf of two organisations.  The Ukrainian Network of People who use drugs.  This is a network of 1500 individual members, and 28 organisations.   Some  of the community achievements over the 2021-2023 period included social mobilization, building community linkage and coordination.  At the national level, the community is a member of the National HIV/TB Councils and Interdepartmental Group for the development of the State Policy Strategy on Drug Policy, 2030.  At the regional level, 24 representative offices have been created in all regions of Ukraine, which are part of the regional HIV/TB councils. We have been doing advocacy around legal changes to have really progressive, instead of regressive drug policy. There are 10 initiative groups of the PWUD community that received technical assistance, 5 new sites OST, and 5 IDU resource centres. There have been 6 national forums for PWUD held to improve laws, regulations and policies relating to HIV and HIV/TB.  Law 5715-1 was instated, on alternative deprivation of liberty of persons who committed offences while acutely intoxicated with narcotic or psychotropic substances. Proposals for decriminalization have been submitted to the 2030 State Drug Policy Strategy The community supported the law on combating HIV, which allows the use of modern prevention and treatment models. “We are united” is a good entry point to our largest key population in Ukraine. It is estimated that 350,000 people inject drugs in Ukraine, but nobody really tried to properly calculate this number of PWUD.  Of course for us, our life experience is the greatest motivation, the peer to peer support especially when  we are accustomed to live in a “war”mode, due to the war on drugs, when the real war comes into your country, we are prepared and you mobilise yourself more and more, and try to find some resources to build new networks of help, and that’s why I want to show you how this help looks like in critical times.  We were one of the first organisations to start actual support for people who use drugs during the war. PWUD community at the forefront, or the year that changed everything.  From those we were evacuated, 2198 PWUD and their family,  540 (182 children) were provided with travel and fuel, and 357(589) (49 families) were from “hot spots” (Kharkiv, Mariupol, Sieverodonetsk, Sumy, Kramatorsk, Sloviansk, Popasna) – GF 204 – Melitopol and Kakhovka within – International Network of People who Use Drugs (INPUD) and VONA. 500 – Kherson, Sieverodonetsk, Sloviansk, Dnipro and Mykolaiv – AIDSFonds 130 Crown Agents 235 ViiV.  The need of provisions of temporary shelter or rented apartments, more than 400 people received this.  The other basic need is food, we helped with provision of food for more than 7000 PWUD.  It’s not just about food and housing, but also other material aid and small funds for other needs.  Almost 2000 people received material aid.  1930 people were provided with funds for medicines, clothes, and food, including at three rehabilitation centres and three shelters (Ivano-Frankivsk, Poltava, Khmelnytskyi).  407 people provided housing in Poltava, Lviv, Ivano-Frankivsk, Khmelnytskyi, Zaporizhzhia, Dnipro, Chernivtsi and Kyiv.  We helped to assist in the delivery of ART and OST drugs, in order to avoid the interruptions of life saving drugs for people in the regions. It’s not only for people who use drugs, but also for those living with HIV.  We also assisted in the organising of harm reduction programs and access to overdose prevention, here you can see the delivery of harm reduction supplies to one of the regions of Ukraine.  Of course we should always say thanks to all the organisations who supported us, it would have been impossible without their resources and funding from these organisations.  We are grateful to our donors and partners for helping the PWID community.  The first part of my presentation was on people in Ukraine who are currently receiving treatment, but obviously this isn’t the only group that has been affected ..Now the other group I’m presenting on behalf of is, The European AIDS Treatment Group.  We are based in Brussels and have just celebrated 30 years. The European AIDS Treatment Group is a patient-led NGO that advocates for the rights and interests of people living with or affected by HIV/AIDS and related co-infections within the WHO Europe region.  Founded in 1992, the EATG is a network of more than 150 members from 45 countries in Europe.  Our members are PLHIV and representatives of different communities affected by HIV/AIDS and co-infections. EATG represents the diversity of more than 2.3 million people living with HIV in Europe as well as those affected by HIV/AIDS and co-infections. Once people started fleeing Ukraine it was our commitment to start helping them on this side, as refugees and migrants. The EATG focal point for Ukraine involved coordination with stakeholders and other members around case-management of access to ARV, TB, VH, OAT, MH treatments and services in EU countries for Ukrainian KP refugees.  The organisation contributed to the HelpNowUA initiative, as well as providing direct financial support for partner organisations in Ukraine and Poland.  The organisation also organised collecting donations and raising awareness with the media. In terms of policy and advocacy The European AIDS Treatment Group coordinated a civil society forum on HIV, VH, and TB (CSF) as a coordination platform in Ukraine.  Events were hosted to raise needs for Ukrainian KPs in emergency contexts.  Likewise there was a contribution towards The ECDC technical report on HIV care for Ukrainian refugees, as well as a global fund replenishment advocacy, where EC pledged 715 million Euros to the GF. I think that’s all from my side, thanks for letting me speak.  

Ganna Dovbakh (Eurasian Harm Reduction Association): Thank you Anton.  Actually that was important to note, how all the countries supported and how we were all very united in understanding the needs and to respond immediately.  And now I will give the floor to  Sergii Filippovych from Alliance for Public Health Ukraine, who will be presenting on one of the several biggest organisations working in Ukraine on behalf of civil society.

Sergii Filippovych (#Sos 2.0, Alliance for Public Health): On February 24, Russia launched a military invasion of Ukraine.  There have been attacks on several healthcare facilities such as the Severodonetsk Hospital and The Volnovakha Central District Hospital, which have been left in ruins. According to official UNCPR data, as of March 12th, 2022, there are 1.5 million refugees in Poland, 300,000 in other EU countries, and 100,000 in the republic of Moldova. As of March 2023 35% of Ukrainians have left their homes, and 1370+ healthcare facilities have been damaged or destroyed.  In terms of an overview of the situation with opioid substitution therapies (as of April 2022)  the APH jointly with public institutions, community-based organisations and patient organisations are working to ensure preserving patients’ access to OA.  Patients who moved to other regions of Ukraine receive prompt support and continue their OAT treatment.  Most patients (except those in occupied towns/sites and towns where heavy fighting goes on) stay at home and wait for their treatment to be delivered. Most sites still have some reserves thanks to previously issued 10,15, and 30-day supplies and small stocks.  Within SoS project 2.0 a new service – HelpNow – was launched to coordinate provision of medicines to OAT and ART patients in other countries, incl. Moldova, Poland, Germany, and Hungary.  In some areas additional interventions are launched: delivery of methadone is organised using medical vehicles of the sites/transportation of health personnel arranged to sites/social workers of NGOs and patients help medical workers in reaching the sites/patients, guard health personnel and sites.   47 countries globally have been covered with #HelpNow online coordination service for Ukrainian KPs refugees and IDP Emergency response program “HelpNow service” helps internally displaced and migrant KPs that had left their places of residence due to the russian-Ukrainian war to find access to services (HIV-ART, OST, mental health, social support and other relevant crucial issues) in their new place of residence / hosting country. It comprised several components that included: chat bot and online case management; and online medical consultations hubs in Poland and Germany with a wider range of support options online web-resource with relevant information.  Some of the key challenges faced (based on requests from people who have fled to European countries) included: congestion of sites, limited selection and location of sites (3 leaders – Germany, Czech Republic, Poland), especially in big cities. If a person asks for information in advance, we recommend going to smaller cities/regions. If when already settled – the service case managers look for ways to put a person on the program through established contacts (NGOs, volunteers); A complicated process of inclusion in the program, difference between the system in Ukraine and the accepting country (for example, the Netherlands: the route starts from a GP (family) and here it is already a problem to get to this GP (you have to wait a long time for an appointment, not all of them understand the special needs of people from the community + that it is always urgent); German social system is overloaded and it can take up to 2-3 months to obtain the necessary registration documents and health insurance); fear of disclosing HIV status and OST – patient status, especially in refugee camps to third persons (receiving people, employers, escort volunteers); issues of disclosure of confidential information by patients in crisis situations, as well as to relatives and children; high index of self-stigma;language barriers; people turning for help later then would be preferable (eg on the day when they have 1 pill left, etc).   Adherence to treatment (change of schemes, rhythm of life, type of employment, experience of stress and depressive states).  Ukrainian OST patients are considered primary patients in Germany and must visit the doctor in person for 3-6 months every day to receive the drug.   Changes in service delivery formats in Ukraine since the war: 12 months of the large-scale war caused the largest migration movement in Europe since the World War II — 15 million Ukrainians (35%) have left their homes and became internally displaced persons (IDPs) or refugees; Over 1,370 healthcare facilities in Ukraine have been destroyed or damaged by russian invaders, who are committing war crimes against the population denying civilians access to vital services and treatment, torturing and killing people. People living with HIV and TB, clients of programs supported by Alliance, social workers, and physicians are dying as a result of the war. New priorities for patients: Humanitarian needs (food, warmth, shelters) and only afterwards treatment. New formats: prolonged issuance and delivery OAT to the patient’s home (Kriviy Rih is already working + new regions).  According to official information, the Russian forces have attacked civilian objects 60 times more often than military ones. The most affected by these attacks is the infrastructure of near-front cities. Because of the Russian aggression, millions of Ukrainians have lost their homes. According to estimates used by the Ministry of Communities and Territories Development, more than 2.4 million Ukrainians were residing in ruined or significantly damaged homes as of the beginning of Q4 2022.  APH supported 33 shelters in 2022-2023 in Ukraine.  In January 2023 opened a new one in the hostel format – Safe Place.  In 2023, APH plans to open shelters in other cities of Ukraine on the example of the Safe Place.  As of 01 February 2023, 20,063 patients were receiving OST medications at 199 healthcare facilities in 23 regions of  Ukraine (except for the temporarily occupied territories), of which 17,679 patients were receiving methadone tablets and 2,384 patients were receiving buprenorphine.  97.1% of HIV+ OST patients taking ART (as of 01.02.2023) As of 01.02.2023, 90.6% of patients were under self-monitoring of drug use for up to 10 days.  Over the year, the number of patients increased by 2,853, including 2,633 since the beginning of the war. In conclusion, community-based services have proven their effectiveness to sustain HIV response during the war. The CSOs managed to provide immediate response to urgent needs and challenges, providing quick and life-saving services, being flexible and vital for those who needed support. The CSOs organised evacuation from the war zones, provided the first need services: shelters, food, medical support, support to kids, etc. In partnership with HCIs and CSOs have managed to save and expand the OAT program even under the war conditions. The official number of the patients in the state-run OAT program increased by 11,8% from 23.02.2022.(20,063 patients as of 01.02.2023).  It is an important lesson that the story with the discontinuation of the lifesaving services like it was in Crimea and occupied Donbas areas of Ukraine in 2014, repeated again.  The newly occupied territories saw an immediate termination of all harm reduction services and life-saving treatment for people who live with HIV and for people with drug dependency. Those who could not flee from these areas suffered from withdrawal syndromes and other negative health consequences.

Ganna Dovbakh (Eurasian Harm Reduction Association): Thank you, Sergei, and thank you to your team for this resilient effort, and for this support. What war is showing, is the true network, support, and community in their true meaning, it shows how in the first days all around Eastern Europe and Central Asia, all our community organisations have stood with Ukraine 24/7. We’re grateful to our Polish colleagues, Moldova, Estonia, Latvia, and everybody who mobilised. And for our partners, Poland became the first stop, the first location for millions of Ukrainians. Now I will give the floor to Magdalena Bartnik from Prekursor Foundation for Social policy, from Poland, to share the story of the support solidarity from this program.

Magdalena Bartnik (Prekursor Foundation): Good morning everyone, So after the invasion started in February in March, there were 2.4 million entries to Poland. And what we saw was the mass solidarity movement of family’s neighbours, local communities and non-governmental organisations and enormous grassroots spontaneous mobilisation not counting on state action and not waiting for it. Private and institutional activities also overlapped. Town mayors and community members were simultaneously transporting those fleeing the war, helping them materially and hosting them in their homes and cities, everyone helped. State involvement was criticized for being too late, insufficient, and interfering with much more effective spontaneous action. Act of March 12, 2022, on Assistance to Citizens of Ukraine was signed, giving access to social benefits assistance, public health care system on the same basis as Polish citizens, education for children and young people, to labour market on the same principles as Polish citizens, if they obtain a PESEL number. According to the European Union agency for the fundamental rights survey, published this year the important data we need to underline is that the health conditions of refugees residing in programmes are alarming at 20%, and as bad as 44% on average. The most common barriers to getting medical care are a lack of knowledge of the Polish language, and not understanding the functioning of the medical system. As of 6th March 2023, there were more than 1,564,711 people registered for temporary protection in Poland, 85% were women and children, and 15% were men. Estimated number of PWID from Ukraine in Poland (May 2022) PWID opioids 2000 – 8500 OAT 120 – 500. Before the war, the estimates show PWID opioids to be 15000 – 17000, 3000 on OAT, and 2500 (2019) receiving harm reduction, service clients. The current situation shows Ukrainian PWID OAT 120, and 380 harm reduction service clients. When we look at pre-existing conditions OAT, HR coverage is low at 15%, with OAT, HIV clinics in urban settings, and OAT showing a high threshold for sobriety regimes. There was low access to free HIV, HCV testing, poor access to social help, no access to safe housing/shelters, and lack of gender-sensitive programs. Support for people who use drugs coming to Poland from Ukraine, including outreach, online and in-person assistance in accessing and maintaining treatments, emotional support, and material aid. What have been the barriers to accessing treatment (OAT, ARV)? Language and communication, logistics, unmet needs such as childcare, social help, material aid, stigma/fear providing the information is not enough, people need to be assisted at every stage of the treatment entry process and ensuring the continuity of treatment, such as ensuring a sense of security and offering emotional support. Providing information is not enough people need to be assisted at every stage of the treatment and free process. There are different working hours for programmes for HIV treatment, for example, two hours in a week. So, it’s not just a lack of information about addresses and contact details. We needed to range and schedule meetings and find out all requirements needed, like medical records, sometimes translated medical records and so on. And when we realised the situation of people being hosted in small villages and towns, far away from urban settings and lack of ability to really communicate, whereas harm reduction services can navigate system really where this is really important to underline the assistance and being with someone at every step overstate there also, of course, unmet needs, childbirth and social health. We also provided material aid. Of course stigma and fear, So we tried to ensure a sense of security and offer emotional support once again the harm reduction service was the environment in which they could do this. There were people saying that we were the only ones with whom they could display or discuss their drug use and health status and that they were not able to talk about this with their host families or any other organisation and this is crucial when we think of reaching to people really getting the getting in touch with them and access and helping them to get the treatment. For two weeks and we’ll have patients come to the programme every day. Programme capacity is also an issue as we know that there are already waiting lists for patients who want to enter your treatment, as well as a lack of psychosocial support, safe housing, employment within the programmes, and lack of female-sensitive approaches. We also must take into account people moving and their ability to receive continuity of care. People on the move and continuity of care have been our main focus, including building relationships and community strengthening.
Ganna Dovbakh (Eurasian Harm Reduction Association): Thank you very much for this, you are heroes… and what I need to say is this war, and this disaster brings us to the real and true meaning of harm reduction, which is solidarity providing health support, employment, food, and place to shelter, mental health. Unfortunately, this is a systematic problem, and we’re facing it as a systematic problem which catalyses problems in harm reduction in European countries, hosting countries, in Central Asia. But I believe in solidarity we’re really succeeding to do better systems for Europeans and Ukrainians. Together we will win. Thank you very much.