Kyiv is the capital of Ukraine and the country’s most populous city, with nearly 3 million inhabitants (this official figure may an underestimate. Internal migration from conflict and other causes may have doubled the city’s population). There are an estimated 19 800 people living with HIV in Kyiv, with HIV prevalence ranging from 0.3% to 0.6% across the city’s 10 districts1.
The HIV epidemic in Kyiv is largely concentrated among key populations. Kyiv city data from 2017 show that HIV prevalence is highest among people who use drugs (26%), gay men and other men who have sex with men (7%) and sex workers (7%)1.
In April 2016, Kyiv was the first city in the region to endorse the Paris Declaration. The ceremony was attended by diplomats and leaders of Ukrainian and international organizations engaged in the AIDS response. “We’ve joined the Fast-Track program to end AIDS,” said Mayor Vitaly Klitschko. “As chairman of the Ukrainians Cities Association [sic], I propose engaging other cities of our country in the program”2.
Since then, a concerted multipartner collaboration has worked tirelessly to reduce new infections and meet the 90–90–90 treatment targets in Kyiv. A detailed city profile has been completed, and a Fast-Track city strategic plan for 2017–2021 was developed that aims to have 82% of people living with HIV accessing antiretroviral therapy by 2020. In 2016, the city also mobilized considerable new resources to fund the plan, approving a budget of 238 million Hrv (approximately US$ 8.5 million) for prevention and treatment, including harm reduction for drug users (this amount includes donor funding, such as from the Global Fund to Fight AIDS, Tuberculosis and Malaria).
Central to the plan has been the redesign of HIV testing and treatment service delivery, shifting from a model of specialist services provided at the city’s AIDS Centre to a public health approach, where services are available at all health facilities. This has been accompanied by extensive training of health-care workers to reduce stigma and discrimination. Antiretroviral medicines, previously only available at the AIDS Centre, are now dispensed through other health facilities and a network of municipal pharmacies.
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1 Kyiv Fast-Track City Initiative 2018. Kyiv: Kyiv City State Administration; 2019.
2 Klitschko: Kyiv to become first city to curb AIDS epidemic by late 2017. In: UNIAN [Internet]. 8 June 2016. Kyiv: UNIAN; c2019 (https://www.unian.info/kiev/1369920-klitschko-kyiv-to-become-first-city-to-curb-aids-epidemic-by-late-2017.html, accessed 27 August 2019).
The Mayor of Kyiv has played an active part in the city’s Fast-Track agenda, and he personally attends local and international meetings along with civil society counterparts. For example, at the High-Level Meeting on Fast-Track Cities in New York City in 2016, he reaffirmed his commitment to the first 90: “The main thing today is to ensure treatment of 90% of HIV-positive people in the city. Mass screening and an awareness campaign will help more people learn their HIV status and start treatment on time”1.
The municipal authorities work closely with civil society organizations to plan and implement the city’s Fast-Track response. The coordinating body, the Municipal Council on HIV/TB, is co-chaired by the deputy head of the Kyiv City State Administration and the head of the Kyiv Network of People Living with HIV (100% LIFE), the largest patient-led organization in Ukraine. The Network and other civil society organizations are equal working partners in all meetings of the Kyiv Health Department. Civil society organizations also are implementing prevention, care and support programmes among key populations through funding from grants from the Global Fund to Fights AIDS, Tuberculosis and Malaria (the Global Fund). In 2018, they reached 43% of gay men and other men who have sex with men, 46% of sex workers and 63% of people who inject drugs2. In the fall of 2019, civil society organizations also received government funds to implement HIV services.
Partnerships with donors and the private sector also are strengthening service delivery. For example, the city administration provides free premises for a popular downtown HIV testing facility, the Youth Information Centre on HIV, which is supported by the Olena Pinchuk Foundation. In 2017, the Foundation donated US$ 250 000 towards the purchase of the antiretroviral medicine dolutegravir, enabling the city to improve its drug regimens.
In the three years since Kyiv signed the Paris Declaration, there has been remarkable progress in the city. For example, the availability of HIV testing services at all municipal health facilities has resulted in a 31% increase in the coverage of rapid testing. The number of sites providing antiretroviral therapy has expanded from three to 30, contributing to a tripling of people on treatment and a significant improvement in testing and treatment targets (from 55–66–73 in 2016 to 73–73–96 in 2018)2.
Key populations in particular have benefited: the number of sites providing opioid substitution therapy for people who inject drugs has increased from three in 2016 to 11 in 2018. PrEP, unavailable in 2016—and available to only 125 gay men and other men who have sex with men in 2018— will be expanded to more people at higher risk of HIV exposure in the near future. In addition to gay men and other men who have sex with men, PrEP also will be available to HIV-negative partners in serodiscordant couples.
Kyiv’s commitment has inspired other cities in eastern Europe to join the Fast-Track cities network. For instance, Odessa—which has a large population of people living with HIV—signed the Paris Declaration in 2017 and is committed to accelerating the city’s AIDS response.
Political will and leadership have been at the heart of this transformation. In his foreword to the 2018 Kyiv Fast-Track report, Mayor Klitschko summed it up: “For me, the life of each person is valuable, and no Kyiv residents will be left alone, without care and support”3.
1 Klitschko: Kyiv to become first city to curb AIDS epidemic by late 2017. In: UNIAN [Internet]. 8 June 2016. Kyiv: UNIAN; c2019 (https://www.unian.info/kiev/1369920-klitschko-kyiv-to-become-first-city-to-curb-aids-epidemic-by-late-2017.html, accessed 27 August 2019).
2 Personal communication from UNAIDS country office, Ukraine, August 2019.
3 Kyiv Fast-Track City Initiative 2018. Kyiv: Kyiv City State Administration; 2019
The HIV response in Kyiv is built on strong leadership and established and coordinated partnerships between the city authorities and communities. They work together to improve understanding of Kyiv’s epidemic – focused among people who use drugs, men who have sex with men, and sex workers – and identify the necessary solutions. They have also responded to emerging challenges, including COVID-19, to innovate and improve the response.
Flagship research to improve the response
Two recent research projects, undertaken with affected communities, demonstrate the strengths of Kyiv’s engagement with partners – and the importance of such initiatives to improve services and the lives of people living with HIV.
The People Living with HIV Stigma Index 2.0
Ukraine’s national network of people living with HIV, 100%LIFE, completed a study of stigma and discrimination in 2020 – the world’s first city-level People Living with HIV Stigma Index. The Kyiv People Living with HIV Stigma Index adapted the GNP+ Stigma Index methodology, protocol and questionnaire to Kyiv’s specific context and populations. Peer implementers from 100%Life collected data from people living with HIV and members of key populations. The survey generated a unique body of evidence relating to stigma and discrimination towards people living with HIV, as well as on treatment uptake and treatment-related behaviours. The Stigma Index survey report was widely disseminated, including on the UNAIDS and Kyiv City Public Health Centre (KCHPC) websites and through stakeholder meetings.
The Stigma Index data serve as a baseline for programming and for the monitoring of stigma and discrimination in the city. The data suggest that while encouraging progress has been made, worrying trends persist. In particular, there is an urgent need for additional programmes for people living with HIV. Over half (56%) reported high levels of self-stigma and nearly a third (32%) of those on antiretroviral treatment had interrupted treatment in the previous year – even before COVID-19 disrupted treatment access. The scale-up of HIV treatment in the city needs to be accompanied by community-level psychosocial services and support for adherence. Further efforts are also needed to eradicate stigma and discrimination in health care settings, particularly during the ongoing process of decentralizing HIV treatment.
Rapid assessment: Drug scene in Kyiv
KCHPC, the Institute for Social Research (ISR) and UNAIDS collaborated on a rapid assessment of the local drug scene to help strengthen Kyiv’s HIV prevention services for people who use drugs. The city’s partners need up-to-date information about changes in the drug scene; the particular risks run by people who use drugs of both contracting and transmitting HIV; and the services available to help mitigate these risks.
KCHPC and the ISR reviewed the available data and publications, developed questionnaires and implemented the survey. The rapid assessment report was completed in January 2021, and revealed a decrease in opiate users and increase in users of stimulants compared to 2015. This means that Kyiv’s current harm reduction strategies – including undersubscribed government methadone maintenance therapy clinics – are no longer as appropriate, as stimulant users require more clean needles and syringes and condoms than opiate users. It also creates challenges in service delivery, as stimulant users are more likely to use online dealers (for example through darknets), or to create products themselves using components available at pharmacies. They are therefore more “invisible” and less likely to be publicly accessible to service providers.
The report included recommendations in three main areas: harm reduction and drug use prevention; strategic information needs in drug use and prevention; and changes in legislation to remove legal barriers to harm reduction programmes. Specifically, the city needs to introduce demand-creation for opioid substitution therapy (OST) among people who inject drugs, as well as targeted HIV prevention services for non-injecting drug users. The key findings and recommendations were presented to city stakeholders in April 2021.
Using strategic information for HIV planning
Both the Stigma Index and the drug scene rapid assessment, as well as the 2019 Kyiv AIDS Spending Assessment, have been used to improve strategic planning for the city. The process of developing the 2022-2025 Municipal Public Health Programme and the 2022-2026 Municipal AIDS Response Programme benefited from the data, analysis and recommendations. As a result, the new Public Health Programme includes coverage for prevention of mother-to-child transmission of HIV; HPV vaccinations for adolescent girls, including those who are living with HIV; and the procurement of opioid substitution therapy (OST) drugs, HIV rapid tests and medicines to treat opportunistic infections.
The new AIDS Response Programme includes activities to overcome stigma and discrimination, improve treatment outcomes, and modernize HIV prevention among people who use drugs. Implementation with civil society and community organizations will help to counter stigma and discrimination and protect human rights, including the basic right to health.
Reacting to new and existing challenges
While the rapid assessment identified the new challenge of increased stimulant use, the COVID-19 pandemic created an entirely unexpected set of threats to the HIV response. These challenges add to and compound existing issues – but Kyiv’s systems have proved themselves to be robust and flexible enough to adapt successfully to these changes.
For example, UNAIDS and UNODC are piloting services for stimulant users in the city, while community service providers are adjusting delivery methods: peer workers provide needles and syringes, as well as linkages to testing and services, near the pharmacies at which people buy the components to ‘cook’ drugs.
Kyiv’s response to the COVID-19 pandemic has had yet greater impacts on the future of the HIV response. No single person interrupted treatment or was lost to follow-up during the city’s 2020 COVID-19 lockdown. This is due to the city’s thriving and empowered civil society organizations, including communities of people living with HIV and key populations, who work in strong partnership with the municipal government.
Anyone with a diagnosis of HIV in Kyiv is linked to care and starts treatment. Kyiv did not use HIV laboratories to run COVID-19 diagnostics and continued the decentralization of HIV-testing to primary-level health care facilities – meaning there was no deterioration in timely diagnosis, and services were maintained for newly diagnosed people and in emergencies.
However, municipal transport did not operate, and many people living with HIV could not visit their doctor to get their antiretroviral medicines. Kyiv’s 100%LIFE Kyiv social workers therefore packed and posted 50 to 70 parcels of medicines weekly to people who could not visit a doctor. 100%LIFE arranged a 20% discount with Ukraine’s two biggest postal operators (‘Ukrposhta’ and ‘Nova Poshta’), enabling it to reach more people. Individual consultations were maintained online. 100%LIFE provided a basic food supply and food coupons to the 156 people living with HIV for whom it provides palliative care.
In the absence of municipal transport, social workers organized transport for people testing positive from the testing centre to one-stop community clinics to receive follow-up services. This included confirmatory HIV testing, electronic registration, enrolment in health care, and prescriptions for treatment. Where necessary, clients received additional legal and medical consultations.
During the five months of the 2020 COVID-19 quarantine, 107 of the city’s 546 new HIV diagnoses were made by the NGO Convictus. Convictus also organized food supplies for members of key populations who lost their sources of income and supported particularly vulnerable people to access screening for HIV-related disease and to adhere to HIV treatment. Together with the Kyiv Municipal AIDS Centre, Convictus also promotes HIV self-testing and organizes the distribution of oral self-tests to those who are not able to visit outreach sites in person.
The community-run “Drop In Centre” provides a basic package of HIV prevention for people who inject drugs. During the lockdown, the outreach centre was relocated and new centres were opened to make them accessible on foot. Social workers received public transport passes to reach the centres if necessary, and clients of the most remote centres received mobile outreach. At the centres, information about COVID-19 precautions were added to information materials about HIV prevention. Thanks to funding from the Global Fund, staff and clients received face masks and hand sanitizer.
The NGO Teenergizer conducted regular online meetings and individual consultations to support school students studying at home during lockdown. Monthly broadcasts with celebrities discussed young people’s sexuality, reproductive health, STIs prevention and HIV. Teenergizer continued to offer personal online consultations on treatment adherence to adolescents living with HIV.
These adaptations and innovations can be used to maintain and increase access to services, particularly for key populations, in the future HIV response. Building cooperation with community-based and civil society organizations and contracting them to provide HIV services will be key to Kyiv’s continued success.
