In February 2022, air raid sirens rang out ominously in cities and towns all over Ukraine. 

As a fusillade of Russian bombs showered Ukraine, the world watched horrified as Russian tanks rolled across the Ukrainian border and onto Kyiv, the capital city. The Russian army hoped to quickly decapitate the Ukrainian government and basically take over the whole country. 

It didn’t happen. 

Kyiv was largely unscathed thanks to the well-seasoned Ukrainian Army’s nimble air-defense prowess. And Russia’s fantasy of a lightning-fast conquest, first of Kyiv and then of the rest of the country, never materialized. 

A protracted and painful war of attrition unfolded instead, a testament to Ukraine’s mettle and a stunning repudiation of Russian President Vladimir Putin and his military.

But dueling its mighty neighbor to a stalemate has come at a tremendous cost to Ukraine and her people. 

Since the Russian invasion of their country, many Ukrainians living with HIV are now hard-pressed to follow through with basics like lab work and trips to the pharmacy. With their health care system badly beleaguered by Russian bombs and missiles, many marginalized HIV-positive Ukrainians are suddenly on the ropes.

So how bad is it for the approximately 250,000 Ukrainians living with HIV?

In short: It largely depends on geography. 

Thanks to their resilience and ingenuity, most HIV-positive Ukrainians are doing pretty well managing their disease—for now. However, Ukrainians living under Russian occupation in Crimea, Donetsk, Kherson, Mykolayiv and Zaporizhzhya are in an uphill battle for their lives. 

Unsurprisingly, managing a disease closely associated with gay and bisexual men and drug users is not a priority under Russian occupation. 

In a speech ostensibly declaring war on Ukraine, Putin justified his illegal aggression as a bulwark against the erosion of “traditional values” in the United States and the European Union (EU): 

“They sought to destroy our traditional values and force on us their false values that would erode us, our people from within, the attitudes they have been aggressively imposing on their countries, attitudes that are directly leading to degradation and degeneration, because they are contrary to human nature. This is not going to happen.”

If in those words, you hear echoes of Fox News, you’re not alone. The Russian law banning LGBTQ portrayals in media and in schools makes Putin the spiritual godfather to similar “don’t say gay” laws in America. 

To Putin, homosexuality, intravenous drug use and prostitution are by-products of a decadent West and surely not indigenous to Russia. 

He’s wrong, of course. 

There have always been gay and bisexual people in Russia and all the territories of the former Soviet Union that Putin still seeks to dominate.

With the war now approaching two years, threats to Ukrainians living with HIV range from minor to existential. 

For starters, with millions of Ukrainians displaced and many thousands mobilized for war, medical personnel in the country are lacking. 

Before the Russian invasion, roughly 70% of HIV-positive Ukrainians were on a generic regimen (tenofovir disoproxil, lamivudine, dolutegravir) that’s not available in the EU, which is now home to roughly 4.8 million displaced Ukrainians. For traumatized and uninsured immigrants, this regulatory wrinkle is, at best, a major barrier to continuity of care. 

Other barriers loom even larger—for example, a lack of pre-exposure prophylaxis (PrEP) outside the big cities or the Russian destruction of hospitals and antiretroviral (ARV) clinics.

Stela Bivol, MD, MPH, leads the Joint Infectious Diseases Unit at the World Health Organization (WHO) Regional Office for Europe. 

“The needs of HIV-positive Ukrainians are the same as anyone living with HIV,” Bivol told POZ. “However, maintaining HIV-related services is a struggle for authorities and community groups in Ukraine itself [because] health facilities and infrastructure have been devastated by the war.”

Ukraine was once home to 390 ARV clinics throughout the country. Just 10 months after Russia’s full-scale invasion, 68 of them had been destroyed or heavily damaged. 

That was a year ago, and Russian attacks on Ukraine’s transportation and health care infrastructure persist to this day.

Not getting a timely refill because a hostile neighbor bombed your HIV clinic to rubble is not a threat that Americans living with HIV contend with. Americans don’t fret that a cruise missile might vaporize the neighborhood pharmacy.

HIV-positive Ukrainians live with these threats 24/7. 

Clinicians and activists on the ground in Ukraine report an uptick in drug use and HIV transmissions in the country. 

Tetiana Lebed leads the All-Ukrainian Association of Women Who Use Drugs. Some of her clients engage in survival sex. According to Lebed, who has been living with HIV for 18 years, increased drug use and HIV transmissions are tricky to quantify. 

“If we talk about the number of drug users while the war is going on, the statistics are not updated due to the impossibility of conducting a proper study,” Lebed told POZ. “But we and our partners are seeing an increase in the number of calls from people who use drugs, particularly among military personnel who have started using drugs for pain relief or to improve mental health. It should also be noted that people who used to use light drugs or used them sporadically began to use drugs by injection during the war due to prolonged stress.”

It’s a sentiment echoed by Dmytro Skirgiko, MD, a clinician at 100% LIFE, a Kyiv-based charity devoted to HIV treatment and prevention. 

“In connection with the war in Ukraine, there may be an increase in the use of alcohol and psychoactive substances,” Skirgiko told POZ. “This is due to the presence of mental health disorders. It is very important to take into account these features and plan activities that are aimed at prevention, including HIV.”

Skirgiko fretted that the mental health burdens for Ukrainian armed service members would only increase over time. 

“What about our supermen, our army guys?” Skirgiko wondered. “We know a new wave [of mental health challenges] will result from this war and occupation. What about those who use IV drugs and alcohol? I don’t know how many people in Ukraine will have problems with mental health as a result of this war, with depression and trouble sleeping. But it’s a big tide coming.”

Skirgiko described war and war trauma as a risk factor for HIV. For example, the destruction of clinics makes it harder for Ukranians living with HIV to comply with their regimens. Less compliance equals more contagion. 

Skirgiko described instances of patients receiving only two weeks of meds at a time, which is surely not conducive to optimal health care outcomes. 

And despite heroic efforts to protect Ukraine’s medical and transportation infrastructure from Russian missiles, logistical hurdles remain, resulting in fewer treatment and testing options for all chronic diseases, including HIV.  

And a dearth of treatment options may exacerbate drug resistance. 

“The Russian aggression has worsened the logistics of ARV and opioid substitution therapy delivery, especially in small towns,” Lebed told POZ. “Many hospitals were destroyed by Russian shelling or were damaged. Transport connections between cities have decreased, so patients need to spend more time getting their medicine. Hospitals are closed during emergencies to ensure safety. And if we talk about the frontline territories, the main reason is the disruption of logistics due to constant shelling, lack of personnel and damage to medical facilities.”

If Ukraine’s military service members are the heroic, sympathetic characters in the story, what about those still living on society’s margins, such as gay and bisexual men, sex workers and drug users? 

Petro Polyantsev is founder of ChemBrothers, a Kyiv-based support group for gay and bisexual men who use drugs.​ Some of those men engage in survival sex and many are HIV positive. 

According to Polyantsev, who has been living with HIV for 23 years, gay and bi men are heavily stigmatized and at risk to both acquire and transmit HIV. There’s no path to an AIDS-free generation in postwar Ukraine without addressing the needs of this population. 

“Due to limited access to health care and prevention services, transmission of sexually transmitted infections has increased,” Polyantsev said. “In particular, cases of transmission of HIV, syphilis and gonorrhea among gay and bisexual men (and other men who have sex with men [GBMSM]) have become more frequent. The first-level services, such as food and medical care, are the only way to help GBMSM survive during the war. Food, evacuation from the zone of active hostilities, medicines and first aid kits remain most in demand among representatives of the GBMSM community due to the war in Ukraine.”

According to a report issued by ChemBrothers in collaboration with HPLGBT, a Ukraine-based LGBTQ rights group, “more than 80% of the GBMSM community have lost their jobs and livelihoods, which significantly increases the burden on humanitarian projects. More than 70% of the GBMSM community became internally displaced persons and have been forced to leave their homes.”

And for HIV-positive women who use drugs, Ukraine’s patriarchal society is especially unforgiving, according to Lebed, even in cases of intimate partner violence. 

“A woman living with HIV who uses drugs is often refused a police report and medical services,” Lebed added. “Ukraine also has a small number of shelters for women who use drugs and suffer from domestic violence. And the war complicates the expansion of assistance to women who use drugs.”

Protecting Ukraine’s HIV-positive population and keeping them healthy won’t be easy. 

For her part, Lebed remains undaunted. 

“Russia has started an unjust war of occupation against Ukraine,” Lebed said. “However, we hold on and fight. We continue to provide HIV prevention and treatment services for people who use drugs. We continue to implement reforms, even under fire.”

Like Polyantsev, Lebed has made harm reduction recommendations to the government.

“We still do not have an approved drug policy strategy in the country,” Lebed said. “Therefore, it is difficult to talk about a detailed plan to combat injection drug use. This strategy is currently under development. We have provided our suggestions.”

According to the WHO’s Bivol, Ukraine does have some advantages. 

“Ukraine has one of the most progressive ARV programs in the region and one of the largest opioid agonist maintenance programs in the region,” Bivol told POZ. “Even during the war, civil society and the Ukraine Public Health Center have continued to provide not only essential services for people who inject drugs but also are in the process of introducing innovative approaches, such as a pilot [program] on using long-acting buprenorphine. On the ground, the WHO Country Office is supporting implementation, and at the regional level, we have also been engaged in connecting EU service sites to their counterparts in Ukraine.”

Moving past the current stalemate to hammer out a peace treaty won’t be easy. And Ukraine can’t—and mustn’t—bear the burden of Russian aggression alone. 

The best thing foreigners can do to support Ukrainians living with HIV is to lobby our own governments to arm Ukraine. The country is already receiving a lot of humanitarian and military assistance, but it needs more. If you feel strongly about protecting HIV-positive Ukrainians, then track down your Congress member and tell them so. 

Ukrainians living with HIV need health care and support, just like the rest of us. But they also need their army to repel Russia and reclaim their stolen territory. Hopefully, sooner rather than later, Ukraine can eventually resume its journey toward an HIV-free generation. 

Jay Lassiter is an award-winning freelance writer and podcaster based in Cherry Hill, New Jersey. When he’s not working to keep the government out of your bong, he’s often on X (formerly Twitter): @Jay_Lass.

Special thanks to Nataly Kravchuk, public relations manager for The All-Ukrainian Association of Women Who Use Drugs, for translation help.