Ukraine has the second largest population of people living with HIV in the Eastern Europe and Central Asia region. To strengthen HIV care, the country is prioritizing the delivery of a guaranteed package of services as part of ongoing health care reforms—which continue despite the full-scale Russian invasion and continuous attacks on medical and energy infrastructure.
This package of services, known as the Program of Medical Guarantees (PMG), will decentralize many health services, including those for HIV, to the primary health care (PHC) level. The potential of these reforms to improve HIV service delivery is huge: people living with or at risk of HIV will be able to access high-quality prevention and treatment services that are closer to home and integrated with other health services they already access.
However, are PHC facilities and providers—typically a person’s first point of contact with the health system—ready to provide HIV services? And if not, what do they need to get there?
The PATH-led, USAID-funded Re-envisioning Excellence and Accessibility in Clinic-based HIV Services (REACH 95) Activity is supporting the government of Ukraine to achieve HIV epidemic control 2030 goals. The activity aims to do this by improving equitable access to high-quality HIV service delivery at public health facilities through optimized case-finding, linkage to prevention and care, and support for decentralized treatment.
To kick off the project, PATH’s REACH 95 project team went on the road, visiting 62 health care facilities in 16 regions to conduct 11 in-person and five virtual baseline assessment visits between October 2023 and January 2024. During these visits, they evaluated facility and health care worker readiness to provide HIV services.
The current landscape
During assessment visits, the team met with the heads of regional health care administrations, staff at health care facilities, partnering NGOs, and other key stakeholders. These meetings provided an opportunity for stakeholders to share current practices, needs and gaps, and stories of health care delivery during the past two years of Russian-Ukrainian war.
The visits, combined with a concurrent online survey completed by 895 public health facilities, formed a comprehensive baseline assessment of current HIV service delivery among primary, secondary, and tertiary health care facilities in Ukraine.
Assessment findings painted a picture of what is working well and where gaps remained, which will help the REACH 95 project team to pinpoint opportunities to strengthen provider capacity, infrastructure, and processes. Only 26.9% of the facilities surveyed had signed an agreement with the government to deliver the HIV PMG, meaning three-quarters of facilities are not yet approved to do so.
REACH 95 is applying a phased approach, already underway, to support facilities to gain this approval over the five-year project lifespan.
"Based on the baseline assessment results and considering the regions' needs for decentralizing HIV services and the low availability of these services, the project team and the regions’ Departments of Health have identified 18 primary health care facilities in three regions—Chernihivska, Dnipropetrovska, and Mykolaivska oblasts—that require enhanced decentralization of HIV services,” said Svitlana Leontyeva, Chief of Party for the REACH 95 project.
“The selected PHC facilities will receive technical assistance during the first year of the project to sign a full package of HIV services with the National Health Service of Ukraine (NHSU) under the PMG.”
HIV service delivery and training
Over 68% of facilities indicated a need for HIV professional training for health care workers; this was even higher (71.3%) among PHC facilities.
During the assessment visits, many providers and administrators shared that while there is often a staff member formally assigned to various HIV service components, there is a disparity between policy and practice, with process and training gaps standing in the way of effective implementation.
For example, while 89% of health care facilities surveyed said they have a person responsible for HIV testing services, the visits revealed that in many facilities staff are assigned without corresponding training on HIV testing algorithms, standard operating procedures, and patient pathways.
While 95% of all facilities currently provide HIV testing services, only 85% of the total indicated that they both have and use rapid tests. Many facilities which did not have rapid tests cited challenges with accurately calculating need; providers highlighted the lack of clear guidance on when testing should be offered, who is responsible, and how to refer.
“The numbers from the baseline assessment speak for themselves—the need for training health care professionals is high. Our team has wasted no time in developing training plans for HIV services at all levels of care.”— Svitlana Leontyeva
REACH 95 provided HIV self-tests and informational material to a screening point in the Horodnianska hromada of Chernihivska oblast to launch the implementation of a HIV self-testing pilot. Photo: Svitlana Leontyeva.
Findings about preventive and treatment services were similar. Only 25% of surveyed facilities were currently providing pre-exposure prophylaxis (PrEP); among PHC facilities, this proportion was 8.3%. Similarly, 26% of all surveyed facilities provide antiretroviral therapy (ART), but only 3.2% of PHC facilities were currently providing ART. Provision of both PrEP and ART are both closely connected with the NHSU agreement to provide HIV services under the PMG.
HIV data and medical information systems
To understand how health care workers are currently entering HIV data electronically, the baseline assessment also included questions on medical information systems. Results showed that practices and systems vary widely across oblasts.
Overall, 62% of health care facilities reported that they enter data on HIV testing into local health information systems; however, this is not required by NHSU, and there are multiple local health information systems used (in fact, there are 40 such developers in Ukraine!). The main challenges identified included insufficient quality and completeness of data on HIV testing, lack of required disaggregation for PEPFAR reporting, and non-standardized data sets.
Unique needs of different regions
While the survey results provided a quantitative picture of the state of HIV service delivery, the in-person and virtual visits by the REACH 95 team across the country provided crucial information on the true complexity of the task at hand, and the need for customized, integrated strategies to address unique needs of regions and facilities.
In some oblasts, facilities had been damaged or destroyed during the war, resulting in disruptions to services. In Zakarpatska region, only two of the eight ART sites were functioning, and because of the rural and remote nature of the region, combined with war-related displacement, staff reported that very few people living with HIV know their viral load.
Different regions provided unique ideas on how and where to best integrate HIV services into other health services based on the health care landscape in that region: maternity hospitals, hospital entry departments, tuberculosis and sexually transmitted infections divisions, and private clinics were all cited as areas of opportunity for greater integration of HIV services.
Similarly, different stakeholders across regions cited different needs and preferences for testing types and delivery strategies, such as rapid tests, multi-tests, and HIV self-testing in ambulances.
Turning data into action
With the results of the baseline assessment compiled and analyzed, the REACH 95 project team is moving on to the next step: designing and implementing customized, integrated, and people-centered services that will help Ukraine’s PHC system meet its goals.
These will include differentiated service delivery options for HIV self-testing; multi-testing (testing for HIV combined with syphilis, Hepatitis B, and/or Hepatitis C); decentralization of PrEP provision; nationally certified education courses and training for health care providers; and stigma and discrimination awareness and education. Two initiatives highlight work that is already underway:
First, REACH 95’s HIV self-testing pilot project was recently launched in Horodnianska hromada, a de-occupied border community in Chernihivska oblast, near the Russian border, where the majority of residents lack access to health care facilities or have limited access to medical services, including HIV testing. The pilot will provide HIV self-testing, counseling, and support services to at least 1,000 people.
“For the residents of Horodnianska hromada in Chernihiv oblast, HIV self-testing services will now be available at non-communicable disease screening points alongside free screenings for hypertension, diabetes, and cancer.”— Svitlana Leontyeva
Second, REACH 95 has started to meet the needs for HIV professional training: a training of 20 trainers, who subsequently trained 260 mid-level health care workers from 13 regions; training for 20 regional project coordinators on monitoring and evaluation, who will further train staff on-site to work in a specialized monitoring information system; and, in collaboration with the Public Health Center of the Ministry of Health of Ukraine, week-long HIV training courses for 99 doctors of various specialties from project healthcare facilities in 16 regions.
A REACH 95 team of provider-initiated testing and counseling trainers conduct a practical session on HIV rapid testing skills during a training of trainers event in Lviv. Photo: Hennadiy Kyrylenko.
REACH 95’s goal is in its name: ensuring that 95% of people living with HIV know their HIV status, 95% of people who know their status are receiving HIV treatment, and 95% of people on treatment are virally suppressed by 2030. In Ukraine, reaching these targets is possible: the evolving landscape presents challenges and innovative opportunities for integrating person-centered services that meet the unique needs of all individuals.
