Ukraine

"As noted in a systematic review by Horyniak and colleagues (2016), forced migrants have commonly witnessed and personally experienced pre- and post-migration stress and trauma, including loss of homes and livelihoods, violence, and family separation [8]. Among this population, the prevalence of mental health disorders, specifically depression and post-traumatic stress disorder, are particularly high due to this lived experience [9–11]. In past studies, comorbidity between mental health and substance use disorders has been well documented in the general population [12–14]. An emerging literature has begun on substance use as coping mechanism to document comorbidity among forced migrant populations [15–17].

"Also, forced migrants experience acculturation challenges, the process of cultural and psychological change that follows contact with a culture other than one’s own [18]. It has been hypothesized that migrants who are highly engaged in the host culture (‘assimilation’) may engage in substance use and addiction in order to adhere to mainstream norms and gain acceptance in their new communities [18–20]. Acculturation is an especially important factor for younger migrants, whose experiences are compounded by intergenerational conflict, and peer pressure as found in previous studies among Sudanese and Latino adolescents [19–23]. For example, in a study among ninth-grade adolescents, low levels of interest in maintaining their native culture alongside low levels of participation in their new culture, often due to discrimination and exclusion, has been associated with substance use [24] Additionally, forced migrants, commonly experience social and economic inequality, marginalization and discrimination [25–28]. These factors have been shown to be important determinants of health, and could contribute to feelings of stress and powerlessness, which may contribute to substance use [29–31]. In addition, forced migrants could be exposed to illicit drugs as well through their residence in disadvantaged neighborhoods where drugs may be readily available leading to increased morbidity and mortality [32,33]. As a contributing factor, the HIV outbreak in Ukraine has spread throughout the nation. According to Public Health Center of the Ministry of Health of Ukraine, Ukraine continues to have high rates of HIV infection in Eastern Europe and Central and Eastern Asia [34]."

"In Ukraine, naloxone is available without a prescription in pharmacies."

"The use of drugs or psychotropic substances (other than in public) is not treated as a criminal offence.

"Illegal production, purchasing, storage, transportation, shipment of drugs or psychotropic substances in small amounts not for selling purposes is an administrative offense and shall be punishable by a fine of 25 to 50 tax-free minimum incomes or community service for a period of 20 to 60 hours, or an administrative arrest for up to 15 days.

"Small, big and especially big amounts of drugs, psychotropic substances and precursors that are illegally trafficked are established by the MoH (MoH Order No. 188 of 01.08.2000 as amended).

"Any individual who voluntarily surrenders drugs or psychotropic substances that he or she has had in small quantities or which he or she has produced, manufactured,⁸ purchased, stored, transported or shipped without selling purposes shall be released from the administrative liability for such actions.

"In addition, the people aged between sixteen and eighteen years who have committed such administrative offences may be subject to other enforcement actions, such as warning or placing the minor offenders under the care of parents or guardians, or under the supervision of their teachers or labor collective upon their consent, as well as to other citizens at their request.

"Illegal manufacturing, purchasing, storage, transportation, shipment of drugs or psychotropic substances not for selling purposes in amounts exceeding the small ones stipulates the criminal liability. The maximum penalty for such criminal offences (if they are committed with the involvement of a minor and if the subject of such actions were drugs, psychotropic substances or their analogues in especially big amounts) is the imprisonment for a term of 5 to 8 years.

"The same actions, if repeated or committed by group of persons upon their prior conspiracy; or a person who has previously committed any similar offences; or if these actions involved drugs, psychotropic substances or their analogues in big amounts, shall be punishable by imprisonment for a term of up to 3 years.

"If the amount of drugs or psychotropic substances is less than big, but more than small, the offence shall be punishable by a fine of 1000 to 3000 tax-free minimum incomes, or correctional labor for a term up to 2 years, or arrest for a term up to 6 months, or restraint of liberty for a term up to 5 years (the liability was strengthened due to the amendments to the Criminal Code of Ukraine introduced by Law of Ukraine No. 2617-VIII of 22.11.2018, which entered into force on 1 July 2020). A person, who voluntarily applied to a treatment facility and began the treatment of drug addiction, shall be discharged from the criminal liability for such actions.

"At the same time, the illegal production, manufacture, purchasing, storage, transportation or shipment for selling purposes of drugs, psychotropic substances or their analogues shall be punishable by imprisonment for a term of 4 to 12 years."

"In Ukraine, the use of high-risk drugs is mainly associated with the injection of “home-made” opiates (the opium extract solution with the street name “shirka”) and stimulants of amphetamine family. Injecting drug use leads to a higher risk of HIV, Hepatitis B and C, and syphilis because of needle and syringe sharing.

"In 2020, a small decrease in cocaine users’ treatment demands was observed. Thus, as of the end of 2020, 274 cocaine consumers remained under surveillance, while at the end of 2019 there were 346 such people.

"There was also observed an increase in opioid users’ demands, i.e., 41,095 as of the end of 2020 persons compared to 40,324 people at the end of 2019.

"The number of consumers of cannabinoids and other stimulants who voluntarily applied for treatment remained barely unchangeable."

"Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Moldova, Romania, Russia, Tajikistan, Turkmenistan, Ukraine and Uzbekistan). Together, these 18 countries accounted for over 87% of TB mortality in the WHO Europe region with the highest in Turkmenistan (10.4 deaths per 100,000), followed by Azerbaijan (10.1) and Ukraine (8.4). In addition, an estimated 20% to 25% of TB cases in Eurasia go undetected.[19]

"The largest proportion of new and relapse cases (78,258, or 34.4%) come from Russia. The countries with the absolute highest number of TB cases over 10,000 are Russia (78,258), Ukraine (36,000), Uzbekistan (23,000), Romania (13,000) and Kazakhstan (12,000). There were an estimated 30,000 HIV-positive TB cases, with Russia (53%) and Ukraine (27%) contributing to the highest burden of coinfection. The TB notification rate exceeds 1,000 cases per 100,000 prison detainees in Azerbaijan, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine. The highest TBrelated risks in prison are calculated to be in Slovakia (40.7), followed by Czechia (24.9), Ukraine (23.8), Russia (23.5) and Azerbaijan (22.1). Russia accounted for almost half of the deaths in the WHO EU Region in absolute numbers. Although few countries report TB in people who inject drugs, higher rates of notification (new cases) among this group supports evidence that people who use drugs are at higher risk of TB.[20]"

"The epidemiological surveillance data on spreading of infectious diseases among the entire population of Ukraine are collected and summarized at all levels, from local to the national one.

"According to the official website of the Center for Public Health, as of January 1, 2021, Ukraine registered 15,659 (16,257 – in 2019) new HIV-infected people, 4,131 AIDS cases and 2,112 AIDS-induced deaths of Ukraine’s citizens, as well as 50 HIV-infected citizens of foreign countries.

"As for people who use drugs, considering the dynamics in 2013-2017, there was observed the following trend: the number of HIV-infected, individuals infected with tuberculosis and hepatitis B decreased, the number of individuals infected with hepatitis C remained barely unchanged, while the number of individuals with AIDS almost doubled.

"In 2018, the data collection form and method was changed, and Ukraine started collecting data on infectious diseases of ONLY people who inject drugs. This information is provided by the Regional State Administrations (the graph below).

"So, out of people who inject drugs, in 2020 HIV-infected were 12,687 individuals against 8,120 in 2019 (by 36% more), individuals with VHВ were 3,736 against 1,985 in 2019 (by 47% more), individuals with VHС were 13,200 against 8,520 in 2019 (by 35% more), individuals with tuberculosis were 6,007 against 4,582 in 2019 (by 24% more), individuals with HIV/VHB were 625 against 920 in 2019 (by 32% less), individuals with HIV/VHС were 2,348 against 1,932 in 2019 (by 18% more).

"In 2020, among people who inject drugs and psychotropic substances there were disclosed the following deceases for the first time: VHB – 552 individuals, VHC –1,375 individuals, tuberculosis – 471 individuals, HIV – 917 individuals, HIV/VHB – 42 individuals, HIV/VHС – 185 individuals."

"Overall, our findings confirm that significant gaps exist in the HIV treatment cascade among PWID in Ukraine. Only 58% of the estimated population of PWID living with HIV are aware of their status.

"Compared to reports from other countries, the proportion of PWID aware of their HIV status was comparable to Mexico [48], but lower than in Central Asia or other European countries [7, 49].

"We found a substantial 30% gap between HIV status awareness and ART initiation.

"There is a paucity of published data on ART coverage among PWID globally, and the figures vary considerably across countries. According to the European Center for Disease Prevention and Control (ECDC) [49], UNAIDS [7] reports, and published reviews [8, 48], there is a stark difference between higher- and lower/middle-income countries (LMIC) in reaching 90-90-90 target among PWID. Compared to other LMIC globally and within the Eastern Europe and Central Asia (EECA) region, the 70% ART coverage among PWID who were aware of their HIV- positive status that we have found in this study is higher than the average. This also indicates that the gap between the number of diagnosed PWID and the number of treated patients is relatively smaller in Ukraine.

"The final cascade indicator, viral load suppression (VLS), was achieved in approximately 74% of those PWID who reported being on ART. Additionally, 4.8% of HIV positive PWID with self-reported non-use of ART had been virally suppressed according to the lab results (4.5% among clients of harm reduction programs and 5.4% among non-clients). It might be attributed to the stage of the HIV-infection, interrupted ART uptake or misclassification of ART uptake due to the self-reported nature of data [50].

"From the available data sources, we may conclude that the level of viral load suppression in Ukrainian PWID is modestly higher than among their peers in other LMIC, but lags far behind higher income countries, (88% among those treated in Western Europe) [7, 48]."

"The estimated HIV treatment cascade outcomes among PWID in Ukraine are comparable to other lower- and middle-income countries, and reveals substantial gaps in progress towards the 90-90-90 goals in this key population. Improving the care cascade among PWID must be a priority for the national and international stakeholders in HIV response in Ukraine, especially at the stage of HIV status awareness. Intensive HIV testing strategies targeting hard-to-reach PWID subgroups that are not currently accessing any other health services are needed to address this gap. Scale up of OAT and community-level linkage to care and ART adherence interventions are essential to improve ART coverage and viral suppression among PWID."