Ukraine has consistently had one of the highest burdens of HIV in the WHO European Region over the last few years (recorded second highest recent HIV/AIDS Surveillance Reports for Europe), but with the help of international partners and the WHO, Ukraine’s ability to detect and manage HIV cases has gradually improved.[1]^,[2] Advances in HIV testing and HIV treatment, supported in part by the training and onsite mentoring provided by WHO experts over the years, has led to a significant expansion in the number of individuals on antiretroviral therapy (ART) from 4777 in 2006 to 136105 in 2019. [3]^,[4] Moreover, there is now regular and systematic HIV data collection and the use of that data to plan HIV services for the population.

When COVID-19 was declared an emergency, health facilities in Ukraine became preoccupied with addressing the direct impact of the pandemic while trying to maintain existing health services. Facilities faced the challenge of continuing services, such as those for HIV, under new restrictions aimed at preventing transmission of the virus (e.g., on public transportation and the gathering of individuals).

These limitations had a profound negative impact on HIV testing rates and capacity. Since the first quarter of 2020, HIV testing rates and yield across 12 of the 14 highest HIV burden areas (where data was available) decreased by a median of 24% and 11% (respectively), with no substantial recovery by the end of the year. Moreover, the availability of laboratory testing for HIV viral load was also severely impacted, with many treatment facilities reporting no access to such testing or wait times of up to one month.

Treatment for HIV, on the other hand, rapidly responded and mitigated the effects of the pandemic. Within the first half of 2020, the number of individuals initiating antiretroviral (ARV) treatment had decreased by a median of 15% across all 14 high HIV burden areas (from the first to second quarter). By the third quarter of 2020, however, ARV initiation increased by a median of 6% across these areas since the second quarter. This recovery in treatment capacity was partly due to most areas being able to rapidly implement WHO’s recommendations for HIV treatment during the pandemic (including the use of telemedicine, provision of multimonth prescriptions for ART, and community dispensing of ART), which reduced the need for patients to attend the ART sites and better-protected people living with HIV (PLHIV) and service providers from COVID-19.

Three notable HIV-related health regulations allowed Ukraine to implement WHO’s recommendations:

• First, since infectious disease specialists are the only providers permitted to prescribe ART, regulations were relaxed to allow nurses at ART sites to arrange teleconferences with infectious disease specialists, who would then virtually authorize and initiate ART for individuals. Following initiation, ART site nurses, as well as staff from local medical and social services, would coordinate and assist individuals with follow-up care. This change greatly reduced the burden of HIV case management on infectious disease specialists, who are responsible for dealing with COVID-19. It was also crucial for rural ART sites, where there are often no infectious disease specialists available.
• Second, regulations were also relaxed to allow for more HIV rapid diagnostic testing at ART sites. This supported faster ART initiation since results from regular testing were delayed by weeks.
• Third, regulations were relaxed to allow for community dispensing (through mail, courier, and delivery) and multimonth prescriptions for ART. These measures eliminated or minimized the need to visit ART sites to acquire treatment for PLHIV during COVID-19.

The WHO Country Office (WCO) of Ukraine’s existing work with HIV service providers and scaling-up HIV care prior to the pandemic also played a major role in maintaining HIV treatment services. Experts had already been providing onsite guidance, strategic direction, and mentorship on scaling up HIV testing, treatment, identification, and linkage. When COVID-19 became a concern, the WHO internal incident management system established at country level started to address matters related to essential services from early on. The WCO worked quickly with the Ukrainian Ministry of Health’s Centre for Public Health and the U.S. Centers for Disease Control and Prevention to assess and intervene on COVID-19’s impact on HIV and WHO provided rapid COVID-19 support (i.e., providing training in infection prevention and control, supporting the strengthening of laboratories and surveillance, and assisting in the procurement of PPE and other equipment).

Within the realm of HIV care, COVID-19 exposed Ukraine’s deficient HIV testing capacity but provided a distinctive opportunity to transform HIV treatment practices. The pandemic’s urgency and limitations on in-person care led to a rapid recognition that HIV treatment was challenged by existing regulations (that limited ARV initiation, community dispensing, and multimonth prescribing), and swift efforts to relax such regulations followed. These changes prevented a dramatic deterioration in treatment for PLHIV, and to ensure barriers to HIV care are minimized moving forward, it is likely that these changes will be solidified in legislative reforms championed by WHO. The maintenance of these new treatment practices, in addition to continued efforts to improve testing capacity, is hoped to further the success of HIV management in Ukraine during and following the pandemic, and progress towards Universal Health Coverage.