Research partners from Boston, Ukraine, Russia fear war will hurt HIV and substance use efforts

Russia has a higher percentage of people with HIV than any other country in Europe and Central Asia, according to researchers and official government data. The second highest rate of HIV in the region is in Ukraine.

The crisis has been fueled in part by something that's carried over from the days of the Soviet Union: the mistreatment of people with HIV and substance use disorder, said Dr. Karsten Lunze, an assistant professor at Boston University School of Medicine and Boston Medical Center's section of general internal medicine.

"The stigmatization of these people is pervasive, and it's a real concrete problem," Lunze said. "It means that people who carry these stigma have a very difficult access to the health care sector."

The epidemic was first driven by injection drug use, though heterosexual sex now accounts for a higher percentage of HIV transmission in Russia. In Ukraine, data from a United Nations program show the same trend, though public health researchers have found unsafe drug injection still leads to the highest percentage of new HIV infections.

Lunze has collaborated for years with scientists from Ukraine and Russia to try to curb HIV rates and increase access to treatment for people who inject drugs. Now that there's a war between Ukraine and Russia, Lunze and his colleagues in both countries are afraid their efforts could be in jeopardy.

"Our primary worry and fear now is for the lives and the livelihoods of our colleagues and friends in Ukraine who are under constant bombardment and attacks," Lunze said. "And then ... we are, of course, very worried about all of our work."

He and his colleagues acknowledge the Russian invasion has created a difficult emotional dynamic for the team.

"If you consider that you now have partners in the room from Russia, from Ukraine, from the U.S., in a constellation where one country attacks the other ... What are we going to say?" Lunze said. "It's not our Russian colleagues' fault that one country went at war against the other."

One of Lunze's collaborators is Tetiana Kiriazova, a senior researcher at the Ukranian Institute on Public Health Policy. Their work together has helped increase access in Ukraine to medications to treat substance use disorder, including methadone and buprenorphine.

Kiriazova says Russian military attacks are happening in areas where the medications are made and people seek help.

"We just see the [intentional] shooting of public health facilities in many regions in Ukraine — specifically in Mariupol, in Kharkiv, in Kyiv," Kiriazova said.

She added that the two manufacturers of methadone and buprenorphine in the country are in Kharkiv and Odesa, both active war zones, and a large stockpile of the medications is in Kyiv.

"So of course, for those people who have substance use disorder, it's a real disaster because people cannot get access to the treatment," Kiriazova said.

"It's not our Russian colleagues' fault that one country went at war against the other."

Karsten Lunze

She fled the war in Ukraine and is now in Berlin. Lunze is also currently in Berlin, staying with family; he's helping provide support to Ukranian refugees.

Dr. Marina Vetrova is one of their research partners. She's an addiction psychiatrist at First Pavlov State Medical University in St. Petersburg.

According to Vetrova, Russia focuses on abstinence from drug use, as opposed to harm reduction. Patients don't have a choice of treatment medications for opioid use disorder; Russia only authorizes naltrexone. Research shows that's the least effective of the drugs used to manage an addiction and prevent an overdose death.

And if people want the free care government-run clinics offer, they're put on a list.

"When they go and actually seek treatment, they need to be registered as person with substance use disorder, and [it leads] to very negative consequences for their social life," Veterova said. "This is exactly why most of the people with even severe substance use disorders, they don't want to go to clinics."

The registration requirement can affect people's rights in areas including parenting, employment and obtaining driver's licenses, according to the researchers. Private clinics, where such registration doesn't take place, offer more limited care, Vetrova said.

"So of course, for those people who have substance use disorder, it's a real disaster because people cannot get access to the treatment."

Tetiana Kiriazova

The public health scientists have had success studying a behavioral intervention — a group therapy that encourages people to address their negative feelings about themselves and their struggles. The scientists said that's led to more people seeking whatever help is available.

Some of the group's research is continuing, at least for now. Lunze said that includes data collection and field interviews with people who are vulnerable.

For example, researchers continue to enroll and follow up with study participants in Odesa, a strategically important city in the war that has been hard hit. It has carried a large burden of HIV in Ukraine and is one of the group's main study sites.

"And that's very astonishing — due to the dedication of our colleagues in Ukraine," Lunze said.

Though he has fears about the war and the "severing" of the health care system and research, he said he is "inspired" by the resilience his research partners in Ukraine have shown.

They are under incredible stress "from sirens, from having to resort to a bomb shelter several times a day, spending the night in a basement or in an underground car garage," Lunze said. "In that environment, they have kept the spirit of collaboration and of dialogue, and they have kept their service towards the most disadvantaged in our society."

In Ukraine, that's people at risk from addiction and HIV — and now a war.

In Russia, people who confront the same diseases and now face the unknown effect of international sanctions on their treatment options.

For Vetrova in St. Petersburg, the situation is painful to watch.

"We are also human here, so we just feel, like ... very sorry and fear and everything," she said.

As her team prepares for a project coming up, she is uncertain if they will be able to continue or if they'll be shut down.

"And while we [are] waiting, we just feel our emotions and [are] trying to deal with them," she said.