There is a famous quote by Antoine de Saint-Exupéry that “war is not an adventure; it is a disease”. Wars not only kill and maim people — they also disrupt and dislocate entire ways of life.

Already in Ukraine, there are reports of hospitals and clinics damaged or destroyed and medical personnel becoming casualties themselves. Supply chains collapse, threatening the availability of basic necessities; and services such as the provision of clean water, sewerage and electricity generation are not spared. Those who live through war are subject to serious trauma and health vulnerabilities that can linger for years, if not decades. Women and children suffer the most from the destruction and displacement, women in particular in their role as carers and protectors of families, with little or no resources.

This is what Ukraine faces in March 2022. A brutal and indiscriminate invasion has generated more than two million refugees and countless displaced women, men and children — and the destruction continues apace.

At this moment of vast human suffering, it is difficult even to look forward, let alone create a list of priorities for an emergency response that is only beginning to take shape. But make no mistake; Ukraine’s plight is already a public health crisis, with many urgencies piled atop long-standing health issues. Among these is HIV.

Ukraine has the second-largest HIV epidemic in Eastern Europe and Central Asia, with more than 250,000 people living with HIV in the country, or around 1% of the population. For many years, Ukraine’s HIV epidemic was concentrated among people who use drugs, a group already facing significant challenges across the region.

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The hard-won introduction of effective harm reduction services — led by civil society organisations like our partner in Ukraine, Alliance for Public Health (APH) — has dramatically reduced the proportion of infections acquired through sharing needles and other injecting equipment.

Indeed, thanks to APH and the community partners it worked alongside, Ukraine had been a driving force for harm reduction compared with its neighbours in the region. But these types of services, vital though they are, are likely to be among the first jettisoned as the humanitarian crisis deepens.

In the event of an occupation by Russia, where harm-reduction essentials like methadone are illegal and needle exchange is highly restricted, they could face total obliteration, with dire consequences for the people whose health depends on them, and for Ukraine’s HIV response. Russia does not provide accurate, up-to-date statistics on its HIV epidemic to UNAids, but the World Health Organisation has estimated that new HIV infections in the country have been rising by 10-15% each year.

The conflict in Ukraine is already disrupting access to HIV treatment in the here and now. People living with HIV may have only a few weeks remaining of the medication they need to stay healthy during this period of intense turmoil and danger. It is vital that the humanitarian clusters that are beginning to operate within the country, and in the neighbouring states, take steps now to ensure an adequate supply of antiretroviral treatment remains available, with the support of international donors and agencies like the Global Fund for Aids, TB and malaria.

With the public health system under attack, they will need to work more closely than ever with civil society and community organisations to ensure that treatment reaches the people who need it. But they must also acknowledge that treatment alone will not be enough. While antiretrovirals have transformed HIV from a life-threatening illness to a manageable condition, they are not sufficient on their own to avoid a dangerous resurgence of HIV — and certainly not in a country like Ukraine where only about half of people living with HIV were receiving treatment before the Russian assault began.

Extensive, targeted HIV prevention and harm reduction efforts must be part of the humanitarian response, both inside Ukraine and in the neighbouring countries. It cannot be either treatment or harm reduction — it has to be both.

We have launched an urgent appeal for our partner APH to sustain its essential work with people living with and affected by HIV in Ukraine. Throughout this crisis, APH continues to provide services, from HIV prevention and testing for the people and communities most at risk to rapid emergency support for people living with HIV who have been displaced by the conflict.

In some cities, APH offices have been repurposed as shelters for marginalised groups, while the organisation’s mobile HIV testing units are being deployed to deliver food and medicines, and in some cases to evacuate its clients and their families to safety. As the humanitarian crisis in Ukraine grows, APH is providing a lifeline to thousands of people, including many of those who may struggle to access humanitarian support.

Right now, HIV is one danger among many for the people of Ukraine, but we must not let it slip from sight. The legacies of this war will be painful and enduring, but we can at least not add to them through neglect. DM

Professor Nana Poku is Chair of Frontline Aids and Vice-Chancellor and Principal of the University of KwaZulu-Natal.