Ukraine's HIV community including principal recipients of Global Fund grants have formally requested that grant signing for Phase 2 of a Round 10 HIV grant be expedited to mitigate the potential impact of the current political turmoil roiling the country. Ukraine and the Global Fund have successfully navigated turmoil before, but the current crisis that has left dozens dead and toppled the former president has thrown contingency planning into question and evoked fears of an epidemiological consequence for both HIV and TB incidence. In a letter sent in late February, four organizations -- International HIV/AIDS Alliance in Ukraine, the Center for Socially Dangerous Disease Control under the Ministry of Health, The All-Ukrainian Network of People Living with HIV and the State AIDS/TB Service -- urged the Fund to swiftly sign an agreement for Phase 2. “We know that the Board is meeting in the next few days and we are calling on you to take into account the latest information from Ukraine instead of allowing your decision-making to be based on false or outdated assumptions,” according to the letter, a copy of which was seen by Aidspan. Global Fund-supported programs have, since December 2013, been funded on a quarterly basis, which the letter's signatories say has created a feeling of insecurity and instability among sub-recipients. In the letter they say that "this grant agreement will serve as a guarantee for the stability of HIV and TB response in the country”. International HIV/AIDS Alliance in Ukraine – the country’s largest NGO -- has served as PR on HIV grants under the Global Fund since 2004, carrying out activities including the launch of anti-retroviral therapy, HIV prevention for key populations, harm reduction services, improving TB diagnostics in Ukraine and scaling up treatment for MDR-TB patients. The Alliance is also spearheading the transition to government ownership of all harm reduction, behavior change and service delivery programs in line with a national strategy (National Strategic HIV Plan for 2014-2018). The plan would see government begin to gradually assume financial responsibility for opioid-substitution treatment (OST) provision starting from 2015, and prevention activities from 2017. For the activists, however, the challenge is that although the former government notionally approved the plan, it is still awaiting formal approval, which could be indefinitely delayed due to the continued challenges in Ukraine. According to Andrei Klepikov of the Alliance, this could have serious consequences for the future of HIV programming in the country. “The financial crisis and the state budget deficit could put the budgetary component of the national plan at risk," he said, noting that already, the devaluation of the Ukrainian currency will make purchasing ART and other commodities more expensive. Infection rates have risen steadily in the last 15 years; in recent years the epidemic has stabilized and there has been a decrease of new HIV infections among drug users. The HIV prevalence is 0.66% among adults. The number of new TB cases reported in 2012 was 35,422, and co-infection of the two diseases is estimated at around 33% of people living with HIV. Escalating concerns about the future of the long-term relationship between the Global Fund, its in-country partners and the Ukrainian state were illustrated by a bill that made its way through parliament that required all NGOs receiving foreign assistant to register as international agents: a  bill that echoed a similar law in place in Russia since 2013. The effects of the law next-door have been chilling, forcing many NGOs working in social justice, transparency and public health to close their doors. While the bill ultimately did not become law in Ukraine, political pressure on NGOs, including the Alliance has decidedly increased, according to Klepikov, “Global Fund-supported activities in Ukraine were really on the radar screen of the security services, so despite the formal cancellation of the bill, there was real pressure on" he told Aidspan. Another hurdle that the political turmoil has placed in the way of Fund partners in Ukraine was anti-dumping restrictions that have prevented the release from customs of materials for a harm reduction program targeting injected drug users. Procured in September 2013, some seven million syringes worth an estimated $275,000 have remained in custody, awaiting resolution of a dispute over tariffs. The Alliance would distribute these syringes to drug users as part of a needle-exchange program designed to reduce the risk of transmission of HIV via dirty or shared needles. “Unfortunately, all our attempts to release the syringes with involvement of the former government re­mained unsuccessful until now," Klepikov. "At the moment, there is no official body to negotiate with, because the ministry has been restructured and we are waiting for new officials to be appointed." Also of immense concern to the Alliance are the mounting barriers to access in the Crimea region that has been invaded by Russian troops and sealed off from the rest of the country. Sevastopol, a major city in the region and host to the Russian Black Sea Fleet, is one of 300 cities where harm reduction and OST therapy activities are being carried out. Klepikov said that the Russian incursion has increased the risk that OST provision will be compromised, along with harm reduction programs -- which are banned in Russia. “We have serious concerns with regards to additional challenges for harm reduction programs in the area that is so heavily influenced by Russia, which has banned harm reduction at home," Klepikov said. "We consider that renewing a three-year contract with the Global Fund will help with policy advocacy in that regard as well."