Article Text
PDF
Abstract
Ukraine stands out among European countries concerning HIV epidemiological data. Since February 2022, the military conflict with Russian forces has posed unprecedented challenges to HIV prevention and care. AIDS Healthcare Foundation (AHF), a global non-profit organisation with operations in Ukraine since 2009, implemented a preparedness plan to protect staff members and support local facilities in the continuity of care throughout the war. In this manuscript, we describe the strategies adopted by AHF to anticipate the risk of military conflict, steps to implement a preparedness plan, main challenges faced by local staff members and managers, adaptations needed as the conflict evolved, and indicators of HIV care 1 year before and 1 year after the onset of the conflict. Our experience shows that safeguarding the organisation’s human resources has been a prerequisite to sustain services throughout the war.
- HIV
- control strategies
Data availability statement
The data that support the findings of this study are available on request from the corresponding author, VIAS.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
Summary box
Most studies discussing strategies to sustain health systems and HIV care throughout military conflicts were limited to describing services that need continuous attention, or the care needs of refugees seeking care across borders.
Scarce consideration has been devoted to preparedness tactics that allow services to maintain operations, and healthcare workers to remain safe, providing care.
In this study, we describe the strategies adopted by Aids Healthcare Foundation (AHF) to identify the risk of military conflict, steps to implement a preparedness plan, and main challenges faced by local staff members and managers.
We also present indicators of HIV care one year before and one year after the onset of the conflict, which reflect the successful continuation of AHF’s mission of caring for clients despite the significant challenges caused by the military conflict.
Introduction
The COVID-19 pandemic entailed broad and complex challenges to health services globally. But many Ukrainian providers describe that the pandemic was a mild training drill for the calamitous situation the country would be facing as of 24 February 2022, following the onset of full scale military conflict with Russia. In 18 months, the war resulted in the internal displacement of an estimated 5.1 million people, and more than 6 million sought refuge in other countries.1 According to the United Nations, up to 14 August 2023, the conflict caused 26 384 civilian casualties, of whom 9444 were fatal.2 The country’s health system has endured scarcity of basic and medical supplies, electricity, communication, transport and the reallocation of providers to war-related services. Moreover, attacks on healthcare facilities have severely threatened the safety of patients and healthcare workers.3
While several manuscripts published in medical journals have highlighted strategies to sustain overall medical systems and HIV care throughout the war, most were restricted to describing essential services that need continuous attention and the care needs of refugees seeking care across borders.4–6 Scarce consideration has been devoted to preparedness tactics that allow services to maintain operations, and healthcare workers to remain safe in the country, providing care.7
AIDS Healthcare Foundation (AHF) is a global non-profit organisation supporting HIV prevention and care since 1987, currently operating in 45 countries. AHF has been providing HIV services in Ukraine since 2009, establishing successful collaborations with governmental institutions and other stakeholders. Notably, people who inject drugs and other key populations are disproportionately affected by HIV in Ukraine, and the country faces significant challenges in HIV care, with alarming clinical indicators when compared with other European nations. The overall prevalence of HIV in Ukraine is 0.6%,6 three times higher than the estimated prevalence across the European Union.8 In 2021, Ukraine had the second highest rate of newly diagnosed HIV infections in the WHO European Region, with 37.1 cases per 100 000 population, following the Russian Federation with 40.2 cases per 100 000 population.9
Ukraine and Russia have sustained escalating conflicts since 2014. The previous year, after former Ukrainian President Viktor Yanukovych rejected a deal for greater economic integration with the European Union, protests in the Ukrainian capital Kyiv were contended with violent suppression by state forces. This episode uncovered clashing forces influencing Ukraine’s economic and political inclinations, with Western Europe and Russia occupying opposite sides. As uprisings intensified, President Yanukovych fled the country, and Russian troops took control of Crimea and easternmost parts of Ukraine, both of which are inhabited by a majority of Ethnic Russians, with contentious relations since Ukraine gained independence from former Soviet Union in 199110 11 (figure 1).
Regions with AHF services in Ukraine in September 2023. Image produced by the authors using ArcGIS (V.10.8, Esri, USA). AHF, AIDS Healthcare Foundation.
The full-scale invasion of Ukraine by Russian forces in February 2022 did not catch AHF providers off-guard. In December 2021, with the impending risk of war identified by AHF’s Global Department of Safety and Security (GDSS), facilities in Ukraine initiated a preparedness plan to maximise safety for staff and family members and to allow continuation of services. This strategy proved to be critical for AHF’s capacity to remain providing care throughout the conflict.
In this manuscript, we describe the strategies adopted by AHF to identify the risk of military conflict, steps to implement a preparedness plan, main challenges faced by local staff members and managers, adaptations needed as the conflict evolved, and indicators of HIV care 1 year before and 1 year after the onset of the conflict.
Identifying risks and implementing a preparedness plan: the role of security experts
Although tensions between Russia and Ukraine were palpable, particularly after the occupation of eastern territories and Crimea in 2014, most civilians did not believe a full-scale conflict would occur in early 2022. Yet, a few weeks earlier, in December 2021, AHF GDSS initiated an overarching preparedness programme across all facilities supported by AHF in Ukraine. Established since 2017 and crucially operational in recent conflicts in AHF-served territories, the GDSS is led by experienced specialists whose priority is to monitor risks that may endanger staff members and critical service operations. Moreover, the GDSS is responsible for implementing procedures to safeguard employees, clients and assets, allowing the continuity of services.
The collapsing relations between Russia and Ukraine had been closely monitored by AHF GDSS for several months before preparations for a potential Russian invasion were triggered in December 2021. Importantly, the effective implementation of a preparedness programme is a complex and costly undertaking, which is only possible when leading professionals have established credibility across the institution.
A fundamental step before planning and implementing the preparedness plan is to understand the nature of warfare and specific characteristics of the conflict zone. Warfare can vary from an ambiguous state (such as protests and civil disobedience) on one extreme, to a generalised warfare involving multiple countries on the other. A basic understanding of the spectrum of warfare is key to forecasting the nature and characteristics of potential attacks, including number of combatants, types of weaponry, expected level of destruction and speed of movement across the conflict zone. In Ukraine, early on AHF GDSS anticipated a highly mechanised conventional warfare. In addition, there was a general concern about potential cyberattacks, and projected challenges associated with scarcity of basic supplies, transport and mobility barriers, downfalls in banking and communication systems, and a severe winter.
Emergency response team and basic supplies
The preparedness plan started with the creation of the emergency response team, which consisted of AHF Headquarters, GDSS, AHF Europe Bureau and AHF Ukraine key staff. The emergency strategy in Ukraine initially focused on obtaining supplies and equipment that would allow staff members to sustain themselves for 7 days, with possible disruptions in electricity, gas, communication and water services (figure 2).
Examples of supplies purchased for AHF employees. Photo by Ralph C. Miles. AHF, AIDS Healthcare Foundation.
Since it is a well-documented fact that Ukraine can have particularly harsh winters, among the recommendations were supplies that would help prevent hypothermia: cold weather sleeping bags, small cooking ovens and camping stoves, thermos for soup, multilitre water containers, gas burners, etc. Next, we focused on water. In general, each person needs about 1 gallon of water per day. In Ukraine, the average family size is about 2.5 people, essentially meaning each family had to have two and a half gallons of water per day when sheltering. Under a prolonged air campaign there is also the possibility that power water will be cut-off. Our emergency plan ensured each employee had the ability to store the required amount of water for as long as possible and focused on making sure they kept it replenished as quickly as possible every time there was an opportunity.
Fuel presented another challenge. Several AHF employees in Ukraine owned vehicles. We strongly encouraged them to keep their vehicles’ tanks full as much as possible, and carry as much fuel as they could manage. Ideally, you would want to make sure you had enough fuel to be able to refuel at least one full tank. If a decision was made to evacuate, the emergency response team anticipated that available station stocks would be quickly sold out, which as it turned out was exactly what happened. Additionally, the typical distance one could achieve in a day’s drive dropped dramatically; staff reported the traffic jams leaving key urban areas were so large that sheltering in place became the best option. In one case, a trip that should have taken 1 day took three. The extra fuel made it possible for them to reach their destination.
Communication
One of the most critical security tools found in any organisation’s toolbox is the employee emergency communication system. Most organisations have employed some type of emergency communication system that allows them to quickly reach out to their employees, advise them of danger and get feedback. In many cases, these systems are siloed based on geography or business unit. An effective ability to reach out to all employees in an area where war is going to develop provides substantial advantage in preparedness and response capacity. Modern emergency communication systems are platform-agnostic, taking advantage of phone, data, short message service (SMS) text and internet communication channels. A well-developed system should also have all of the critical contact information for every employee kept up to date. We have been using this system to create a systematic check-in process for all employees. Once a day, typically at about 17:00 hours Ukraine time, the system automatically reaches out to the employees asking for their status. If an employee is in danger, they could request communication with the country programme manager, who will contact them and see if anything can be done to provide assistance. In one case, an employee found themselves trapped by heavy fighting in an urban area in the east of the country. The communication system, remarkably, was able to get through and allowed us to know their status. Over the course of 4 days, we maintained communication through various means until we were able to get them evacuated. Without the employee communication system, it is possible that we would have been unaware of their situation.
The employee emergency communication system was not the only tool for maintaining situational awareness of your employees. We also developed and implemented an old-fashioned strategy that relied on the use of latitude and longitude coordinates to identify nearby employees. We then grouped them based on the geolocation, allowing them to reach out and contact each other whenever necessary. This information was also put on a map, allowing the emergency response team to see graphically where employees were located, and facilitating the identification of safe routes for evacuation if needed.
Financial constraints
Financial constraints were also foreseen in the preparedness plan. The supplies in question, the extra fuel, water, all these things may cost above and beyond what an employee can afford. Experiences in other situations such as Myanmar and Ethiopia had proven to the leadership the importance of making financial resources available at the right time, and AHF’s senior leadership began discussing how to get the employees additional funds from the moment they realised that the situation could become much worse. Moreover, skyrocketing prices were expected once the conflict commenced, and the fluidity of bank transactions, typically relying on functioning internet-based systems, could be severely impaired in case of cyberattacks. In preparation, all staff members received an additional 30 days’ pay as a backup, giving them enough resources to purchase emergency supplies, and leaving additional funds to endure hardships and insecurities of the war. AHF also established an emergency budget which included purchase of goods needed in the winter and fast-tracked approval process for additional resources to support unexpected needs of staff members and clients.
Defence infrastructure
Referring back to the projected nature of warfare and the fact that this was predicted to be a largely conventional fight with combined arms operations, airstrikes were expected to be intense and thorough. This meant our employee population had to be prepared to go into civil defence shelters. Ukraine still had a number of shelters built in the Cold War days; however, many were severely damaged and had no functioning heating systems. Besides the personal heating equipment, generators were also purchased to provide power to facilities and shelters during electricity disruptions. In total, AHF Ukraine provided generators to 23 HIV care facilities in 2022, ensuring light, heating and working conditions for clinics regardless of power outages.
AHF also supported the renovation of Kyiv Hospital’s basement into a fully equipped 70-person bomb shelter. The hospital is located next to a military enclave that is a potential target for missile strikes. Indeed, the military enclave was attacked in early 2023, blowing out all the windows of the hospital.
Training and support for staff members
The GDSS conducted training sessions with staff members explaining the events that were anticipated, and the potential impact of the invasion on their routines. The sessions included discussions on the type of warfare and potential consequences of attacks, focusing on how to best shelter in place, prepare for evacuation and make provisions to keep all options open. Additionally, training incorporated strategies to ensure security of AHF’s property and assets, including patients’ data. Trust and credibility were built and reinforced as events predicted by the GDSS indeed happened but did not meet local staff unprepared. The last training session, which included practical safety and security training for personnel, took place 12 hours before the first bombing in Kyiv.
After the invasion, AHF emergency response team maintained periodic meetings with staff members using video conference platforms, with updates about the status of each employee and their families, location and impact of recent attacks, service operations and urgent needs. In March 2023, representatives of the emergency response team made a site visit to Ukrainian facilities. Providers in Ukraine were apprehensive that an in-person visit in the middle of war could mean something very serious—perhaps the announcement that the programme in Ukraine would be closed. But the main purpose of the visit was quite the opposite: to show support and underline the institution’s commitment with AHF Ukraine programme. There were clear remnants of destruction and shelling in the city, but also some signs of Spring coming up among the glass chards (figure 3). In 48 hours, the team shared testimonials, tears, laugh and few hours sheltering after an air raid siren announced imminent attack in Kyiev. Subsequently, they found out that there were 15 drones attacking Kyiv that night. The visiting team had a brief experience of what Ukrainians have been going through day in and day out—sometimes three times a day. There is only so much that can be communicated and absorbed and understood through emails, teleconference calls, reports and photos.
Signs of spring coming up among the glass chards in Kyiv. Photo by Terri Ford.
Support and supplies for clients
Before the war, AHF Ukraine had an operating telephone number available for direct communication with clients; after the invasion, this hot line proved to be essential for thousands of clients who were displaced or seeking refuge in other countries. Many patients called, desperately concerned about running out of their life-saving antiretroviral medications. Local providers were able to help fleeing Ukrainians obtain HIV treatment and overall assistance in the USA, Thailand, Europe and many other locations, taking advantage of AHF’s global operations.
Direct support with nutrition through the Food for Health programme for clients living with HIV and their families across Ukraine was launched in April 2023. It started with the distribution of food vouchers to the 500 clients most in need and continued with distribution of grow-your-greens packages and boosting gardening skills to support sustainability in basic food supplies. Additional initiatives have also been implemented to support communities beyond those directly assisted by AHF services. For instance, AHF provided rapid testing and counselling for HIV, hepatitis B and C, and syphilis to approximately 5000 servicemen from the Armed Forces of Ukraine.
Adaptations needed as the conflict evolved
The first days of the war required mapping the locations, identifying needs and providing urgent supplies for staff and contractors including safe routes for evacuation and replenishment of food reserves to allow sustenance for at least 7 days. Other actions included provision of crisis psychological counselling to country staff by qualified psychologists; the first sessions started in March 2022 in native language. Crucially, thanks to a rigorous preparedness plan combined with a flexible and continuous support programme, staff members were able to remain in the country, delivering services; once they could collect themselves, get their kids and parents safe, they wanted to ‘get back to work’.
Over the first months of conflict, Ukraine witnessed a huge internal migration of citizens from the east to the west, Lviv being the main city to host internally displaced people. In parallel, millions of Ukrainian citizens sought refuge outside the country borders, mainly to neighbouring countries including Poland, Czech Republic, Moldova and Slovakia. Together with AHF Europe, AHF Ukraine prepared information and publications about opportunities to receive HIV treatment in Europe and set up a support network across European countries to facilitate linkage to care of people who needed integration into health services in countries of transition and arrival. The hotline run by AHF Ukraine was instrumental to support these efforts. On average, there were between 90 and 100 clients using the hotline before the onset of the conflict; the first months of the war saw tripling of the clients with up to 300 monthly requests for support.
Mariupol AIDS centre closure and establishment of new partnerships
Mariupol, located in the southeast of Ukraine, is a historical centre for trade and manufacturing with approximately 100 000 inhabitants. The city has been occupied by Russian forces since May 2022. AHF-supported Mariupol AIDS centre was destroyed and became non-operational along with many other civil facilities in the city over the first months of conflict. Other clinics in eastern cities were also forced to temporary or complete closure due to attacks and shelling. Despite these downfalls, in April 2023, AHF Ukraine established three new partnerships with governmental institutions operating in western regions of the country to support people living with HIV who were migrating westward. AIDS centres in Khmelnytsky, Ivano-Frankivsk and Chernivtsi started implementing AHF testing and clinical care models to address the needs of a growing number of clients. The partnership included medical supplies, medications for opportunistic infections, support with diagnostic resources, and overall support with provision of people-centred approach.
Kherson and Kakhovskaya hydroelectric power plant
In mid 2023, despite the ongoing missile strikes that many cities in Ukraine were still enduring, numerous native Khersonians had returned home and started to rebuild their lives after the region was liberated from occupation, trusting that the worst was finally over. However, the events of 6 June 2023, unfolded like scenes from the darkest apocalypse movies: the Kakhovskaya hydroelectric power plant dam was blown up, leading to the flooding of 14 settlements. Regarded as one of the most significant man-made disasters in Europe in recent decades, the destruction of the Kakhovskaya hydroelectric power plant has left far-reaching consequences ranging from lost human and animal lives to environmental effects. AHF Ukraine team reacted promptly in support of local needs; our team has delivered 1000 menstrual hygiene products, 2000 water purification tablets and 1700 L of bottled water to the Kherson Tuberculosis Medical Center.
Odesa
Starting in October 2022, disruptions in electricity services ensued in Ukraine. Odesa oblast (province), one of the most populous and developed regions in Ukraine, has been heavily affected in this matter. From October 2022 to February 2023, electricity blackouts in the Odesa clinic lasted for 7–8 hours—almost the entire working day. Missile strikes left the city without water or heating. Despite all these difficulties, local providers refused to leave their vulnerable clients behind. The AHF Test & Treat clinic and partner clinics in Odessa were supplied in advance with autonomous electric generators and gas heating devices, which proved to be instrumental for continuity of care.
Indicators of HIV prevention and care before and after the conflict onset
A summary of initiatives adopted to support AHF services in Ukraine during the military conflict is shown in figure 4. As a result of the emergency plan, staff commitment, stable leadership, reliable communication and flexible/continuous support to clinics, staff members and clients, AHF’s programme in Ukraine experienced an increase in new enrolments in care and new antiretroviral therapy initiations (figure 5), reflecting continuity of testing, focus on linkage to care, and an efficient approach to open new facilities supporting both internally displaced clients and patients relocated from other services. Currently, AHF supports the treatment of approximately one in three people living with HIV in Ukraine, with programmes encompassing most of the country’s territory (figure 1). Online supplemental table 1 shows HIV prevention and care indicators in AHF Global Programme, Ukraine, and other lower-middle-income countries with AHF services, highlighting the relevance of AHF’s initiatives in 2022, along with comparison with 2021 data.
Supplemental material
AHF preparedness plan in Ukraine. Image produced by the authors using Canva Pro (V.3.0, Canva, Australia). AHF, AIDS Healthcare Foundation.
HIV prevention and care indicators before and after the conflict onset. Produced by the authors using Canva Pro (V.3.0, Canva, Australia). PLHIV, people living with HIV.
Conclusion
In this manuscript, we report the experiences of AHF emergency response team and local providers during the first 18 months of the military conflict in Ukraine. We describe the main features of the preparedness plan as well as adaptations adopted to safeguard staff members and support clients, which allowed the continuation of AHF’s mission of caring for clients despite significant challenges caused by the military conflict. Being prepared for a disruptive emergency situation is not a trivial task. Real-life testimonials of the preparedness process can inform and inspire other organisations that may in future events endure natural or man-made disasters.
Previous reports have anticipated numerous negative effects of the humanitarian crisis associated with the war in Ukraine on healthcare, including consequences to people living with HIV. Strategies to mitigate the detrimental impact of the military conflict on health services have been highlighted, but most have focused on strategies to accommodate the care needs of refugees in foreign countries,5 or on listing essential services that require continued provision,6 without diving into how continuation of services can be supported locally. Our manuscript brings concrete descriptions of initiatives implemented as part of AHF’s preparedness plan in Ukraine, as well as care indicators reflecting the encouraging results of this enterprise. Although significant improvements in HIV indicators have been reported in recent years, Ukraine still bears one of the most concerning scenarios in the European HIV epidemic.9 Our experience suggests that the implementation of a comprehensive and flexible preparedness programme with continuous support for staff members and patients can mitigate the detrimental impact of military conflicts on HIV care.
While strategies to reduce the impact of war on health services in states that are under military attack are needed, it is also important to notice that healthcare services in states undertaking offensive positions will also face challenges during wartimes. Regardless of its position in the igniting events of a conflict, a country engaged in war will unavoidably undergo disarrays in social organisation and cutbacks in healthcare-dedicated resources, often resulting in a deterioration of health indicators. International aid organisations may disregard the outstanding healthcare necessities in nations that have triggered a conflict based on the assumption that local resources are secure since the state ‘opted’ for engaging in it. However, the civil society in any nation experiencing military conflict will undeniably suffer from its catastrophic consequences, regardless of the country’s role in the conflict onset. Hence, mitigation strategies should also support providers and clients in countries located within offensive borders. Accordingly, AHF continues to provide HIV prevention and care services in the Russian territory throughout the conflict.
Our experience is not immediately applicable in other contexts. We present the strategies adopted by a single institution with global outreach, strongly supported by a dedicated security department that had been operating for several years before the onset of the military conflict in Ukraine. Most health institutions cannot commit specific funds to a security department, limiting their ability to implement multiple steps of the preparedness plan. However, both man-made and natural disasters may endanger the continuity of services, while prevailing healthcare demands do not cease to exist, and additional unexpected demands may emerge. Safeguarding the organisation’s human resources is a prerequisite to sustain services throughout an emergency situation.
Data availability statement
The data that support the findings of this study are available on request from the corresponding author, VIAS.
Ethics statements
Patient consent for publication
Acknowledgments
We thank all AHF Ukraine staff and their family members, as well as clients in AHF Ukraine programme, for joining us in this unprecedented challenge. We thank Thiago Avelino-Silva for helping in the development of figures 1, 4, and 5. Finally, we would like to express deepest appreciation to AHF and specially to Mr. Michael Weinstein for the leadership in supporting and providing the necessary resources for this lifesaving preparedness program.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Handling editor Seye Abimbola
Twitter @vi_avelinosilva
Contributors VIAS and AB conceptualised the manuscript. YL, AMZ, ZS, TF, FFF, WO, JvdH and RCM contributed with data reported in the manuscript. VIA-S, YL and RCM wrote the first draft of the manuscript. All authors revised and approved the final version of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Map disclaimer The inclusion of any map (including the depiction of any boundaries therein), or of any geographic or locational reference, does not imply the expression of any opinion whatsoever on the part of BMJ concerning the legal status of any country, territory, jurisdiction or area or of its authorities. Any such expression remains solely that of the relevant source and is not endorsed by BMJ. Maps are provided without any warranty of any kind, either express or implied.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.