People living with HIV in occupied Ukrainian territories face the imminent prospect of being unable to access treatment as authorities increasingly tie its provision to accepting Russian citizenship.
An estimated 15 000 people currently receive HIV treatment in occupied parts of the Donetsk and Luhansk regions, commonly known together as the Donbas, in east Ukraine. Much of the region has been occupied since 2014 when Kremlin-backed separatists declared independence from Ukraine. Until then, treatment for HIV and tuberculosis, as well as diagnostic tools and reagents, was funded through a grant from the Global Fund to fight AIDS, Tuberculosis, and Malaria.
But after 2014, an agreement was reached under which Ukraine would procure the drugs using a dedicated grant from the Global Fund and drugs would be delivered to the territories by UNICEF and partner non-governmental organisations (NGOs). That system became unworkable in spring 2022. In summer 2023, after stocks of antiretrovirals had run out, doctors turned to providing out-of-date drugs. Russian federal authorities then took over funding for most HIV treatment in the Donbas.
Local sources (who cannot be named for safety reasons) involved in health care in the region have told The Lancet HIV that this treatment is being tied exclusively to holding a Russian passport—under Russian law free HIV care is given only to Russian citizens. But they also say that as much as 50% of people with HIV in the region do not want to take Russian citizenship, meaning they will soon have to choose between losing access to life-saving treatment or being forced to take on a nationality they do not want.
Sources point out that although people without Russian passports can currently access limited HIV treatment provided through regional-level authorities, funding for those programmes is low and will not last beyond a few months of this year.
“Today there is no shortage of drugs for continued treatment or new prescriptions. But the regional budget will definitely not be sufficient to treat all people without Russian passports…people who have HIV and continue to stay here will have to get a passport, otherwise they will not have access to treatment”, one source said.
Groups both in Russia and Ukrainian controlled parts of eastern Ukraine, which work with people with HIV say that conditioning the provision of services, including health care, on Russian citizenship—a practice known as passportisation—is widespread in occupied territories.
“This is a trend that we have seen from the Russian Federation going back to 2014 in Crimea. They condition the provision of humanitarian, medical, all services, on taking a Russian passport. And in the areas occupied since 2022, Russia has been very aggressive in making people get Russian passports”, Dmytro Sherembey, head of the Ukrainian NGO 100% Life, told The Lancet HIV. “If you are Ukrainian in these newly occupied Donbas areas, and you have HIV but no Russian passport, you will not be able to get treatment and you will be left to die. The occupiers don’t care about that, they’re happy to accept these people dying”, he added.
Leaving the Donbas for Ukrainian-controlled areas is not an option for many, with the only way out either through a dangerous, semilegal route across active fighting zones, or through Russia, Belarus, and then Poland (for which a Russian passport is needed).
Information in occupied territories is strictly controlled and authorities will not talk to foreign media. But several organisations have documented evidence of locals being coerced into accepting Russian citizenship by the withholding of services, especially health care. Testimony from those who have escaped to Ukrainian-controlled areas also confirms health care is systematically denied to people without Russian passports. In the Donbas, the practice has the potential to make a dire situation even worse—Ukraine has the second largest HIV epidemic in eastern Europe and central Asia, behind Russia.
If people do not get the treatment they need, the effects on them, and the regional HIV epidemic, could be disastrous, especially in the context of the ongoing war and its effects on the course of the epidemic”, Michel Kazatchkine, former UN Secretary General’s Special Envoy on HIV/AIDS, told The Lancet HIV.
The Lancet HIV spoke to several international, Ukrainian, and Russian experts and HIV activists about a possible resolution to the situation. Few were willing to speak on the record, but they all said people with HIV who have yet to take a Russian passport appear set to face a difficult choice very soon, especially because earlier in 2023 Russia’s parliament passed legislation decreeing all people in occupied areas must have Russian passports by July 2024 or face deportation or detention. The source in the Donbas health-care sector said they will eventually have to take a Russian passport or give up on any treatment there.
Sherembey said many are likely to take the latter option, despite the risks. “People with HIV in these areas can be conscripted into the army immediately after they get Russian passports, regardless of whether they have HIV or not. For some time, Russian soldiers openly HIV positive have been serving in the armed forces.”