Political changes in the Crimea region which took place from February 2014 – i.e., the annexation of Crimea by the Russian Federation – have significantly altered The Global Fund programs in the region.
The programs had been implemented by two principal recipients, the Alliance for Public Health (previously known as Alliance Ukraine) and the All-Ukrainian Network of People Living with HIV. The local implementing partners, six NGOs and the AIDS Centre moved under the Russian jurisdiction and the border with Ukraine was closed.
The closing of the border has stopped delivery of the prevention materials and medicines previously provided from Kiev and financed by the Fund. PRs were no longer officially allowed to provide money to their local partners in Crimea and to deliver materials and medicines. The change of the health system, different ARV treatment schemes, changed patients' registration rules for HIV-positive persons, changed procurement mechanisms, and a completely different policy environment – all of these things significantly affected beneficiaries of the Global Fund–supported HIV program.
According to Victor Isakov, Head of Grant Management for the Alliance for Public Health, the first half of 2015 was the hardest period for the local partner NGOs and the beneficiaries of the programs. However, then The Global Fund started to develop new flexible financing schemes that allowed the programs to be sustained in the annexed territory.
Developing the flexible systems required close and intensive cooperation among the PRs, the NGOs and The Global Fund. The Fund provides financing directly to the local NGOs. All materials and medicines are purchased locally. PRs are performing program monitoring and data collection and analysing; and are providing technical support, including planning, which is often ad-hoc and needs-based, as the current situation does not allow for long-term planning. NGOs are working closely with local medical institutions, including the AIDS centres (i.e. clinics).
According to Irina Potapova, Director of the NGO “Youth Center of Female Initiatives” in Sevastopol, Crimea, the most valuable outcome of the Global Fund’s approach is that continuous operations at local level are maintained.
Sub-contractors of the Alliance in Crimea are providing services to injection drug users, commercial sex workers, and men who have sex with men. The services being provided are mainly counseling and outreach work to reduce the risk of HIV/STI/TB transmission; distribution of HIV/STI prevention materials, condoms, and lubricants; rapid testing for HIV, STIs, hepatitis C, and hepatitis B; referral to health care and other facilities; and ensuring active TB case finding in risk groups. According to Alliance data, in 2015 three NGOs delivered prevention services to 11,104 IDUs, 2,689 CSW and 1,513 MSM.
“We try to stay away from the politics and to focus on the needs of our beneficiaries,” said Ms Potapova. “Therefore, our ultimate goal is to ensure proper case detection, diagnostics, provide prevention services, and follow up new patients until they are registered and linked with relevant medical institution for the treatment.”
In addition, up to 4,000 PLWH are receiving care and support services from the implementing partners of the All-Ukrainian Network of PLWH. According to Katerina Pandeli, the Grant Management Unit Officer for the Network, the biggest challenge for the HIV patients is the changed registration system in the Russian Federation, which requires that patients provide a completely different set of the documents compared to what the requirements were in Ukraine.
“The challenges with new requirements are significantly influencing adherence to the treatment, and so the number of default cases is increasing,” Ms Pandeli said. “Therefore, we do our best in supporting PLWH to collect the set of the required papers. Some patients prefer to receive treatment on Ukraine territory, which is allowed by Ukrainian government.”
All of these changes led to treatment disruptions. A survey conducted by the Network among 1,984 patients found that 52.2% of patients had their treatment interrupted for one reason or another.
“To save the lives of HIV-positive people in Crimea is our number one priority today,” Dmytro Sherembey, Head of the Coordination Council at the Network, told GFO. “The aim and, at the same time, the responsibility of our organization is to ensure high quality treatment for all beneficiaries. We continue running the program as it is only available support for PLWH in the region.”
Unfortunately, one program – opioid substitution therapy – had to be stopped in Crimea because the Russian Federation bans this form of the therapy. Since May 2014, the 806 patients receiving OST had to choose among four possible options: (a) stop using drugs; (b) enroll in Russian rehabilitation centres; (3) move to Ukraine and continue OST; or (d) start using “street drugs.”
According to unofficial information provided by the Alliance for Public Health, 50 people stopped taking drugs; 25 people went to Russia for rehabilitation; 60 people moved to Ukraine; and 80 people have died. (The numbers are approximate.) It is assumed that the rest of the 806 patients (about 590 people) started taking street drugs again.
This article was modified on 28 January to correct a number in the last paragraph. The Alliance for Public Health esitimates that 80 OST patients in Crimea have died (not 30 as originally reported).