Ukraine has the fastest growing HIV rate in Europe and probably has more people living with HIV/AIDS (PLWHAs) than any country in the European Union, although overall HIV prevalence is still low. One important challenge in the fight against AIDS in Ukraine is to prevent transmission of HIV from mother to child (MTCT). Taking up this challenge, Doctors Without Borders (MSF–Holland) in 2000 began an MTCT prevention pilot project in southern Ukraine, which has been successful in lowering MTCT rates.

The official number of registered HIV/AIDS cases in the Ukraine is 30,000 out of a population of nearly 50 million. However, it is common practice to multiply this by a factor of 10 to get a more realistic estimate. HIV infections are mostly concentrated in the southern part of the country. HIV prevalence among pregnant women is increasing and is disproportionately high in the Nikolayev region in southern Ukraine (0.63 per 100), indicating significant heterosexual transmission. Initially, health authorities believed HIV was confined to injecting drug users (IDUs), but MSF's work in southern Ukraine suggests it has already made major inroads into the heterosexual population.

Challenges to fighting AIDS

In Ukraine, as elsewhere in the world, PLWHAs are feared and poorly understood. A fundamental lack of knowledge regarding HIV/AIDS causes stigma and discrimination, and in the Newly Independent States (NIS) of the former Soviet Union it is not uncommon for people to lose housing, employment and even family support when they test HIV positive. The health system offers little pre- or post-test counselling and the testing is not truly anonymous.

The continued commitment of the NIS governments to free health-care for all has led to the budgetary collapse of the public health-care sector and a crumbling infrastructure. Federal funds for salaries, medical supplies and physical infrastructure are inadequate and antiquated centralised control has led to a critical lack of equipment and knowledge of recent advances in medicine.

Nowhere can this be seen better than in the special structures that have been put in place in the late 1980s to deal with HIV/AIDS. HIV/STI centres in communities throughout the NIS are often controlled from a central or federal department. Cities and surrounding communities themselves also set up HIV centres, often competing with each other and duplicating services. These HIV/STI clinics and hospitals are often unable to deal with the unexpectedly high number of HIV infections and operate with grossly inadequate resources. Due to their lack of resources and the fact that their names are often openly associated with HIV/AIDS, most clinics are poorly attended because people refuse to be seen there. In addition, Ukrainian physicians have little or no experience dealing with PLWHAs and the problem is compounded by the (post) Soviet medical system of specialists without primary care physicians. AIDS care in the region has often been delegated to infectious disease specialists, TB specialists and dermatologists.

Despite these challenges, Ukraine has now made the growing HIV epidemic a public health priority. The federal HIV/AIDS system is active in HIV education and has begun to develop national protocols for implementing HIV awareness, prevention and treatment programmes, including MTCT prevention. In spite of this political commitment, sex education in schools, condom promotion and needle exchange are still rare.

MTCT prevention pilot project

In the context of the difficulties described, MSF-Holland has been active in various HIV/AIDS prevention and care activities in Ukraine, in close collaboration with the Ministry of Health. One of these initiatives is an MTCT prevention pilot project, which started in 2000 and includes mothers who inject drugs.
Successful MTCT prevention requires cooperation and communication between antenatal clinics, maternity houses and outpatient HIV/AIDS centres. In Ukraine, these three evolved independently, with little or no communication among them. Ideally, women are offered voluntary counselling and (HIV) testing (VCT) during the antenatal period. In the IDU population MSF enrolled in the cohort, however, 30% were identified as HIV-positive only at the onset of labour in the maternity house, without having had any antenatal care or voluntary counselling and testing.

Given this situation, MSF selected and trained HIV-infected mothers to act as peer counsellors to provide pre- and post-test counselling. The peer counsellors also visit new mothers in the maternity houses to give them milk formula and assist in their transition as outpatients. Compliance with follow-up in this group rose dramatically following the introduction of peer counsellors.

In certain settings, elective caesarean section (C-section) is an additional method for MTCT prevention. However, the current fee-for-service structure in Ukraine means that HIV-positive women would be expected to pay up to US$ 300 for a C-section, a fee unaffordable for most women. In the pilot project, MSF persuaded obstetricians to view C-section as a medical necessity – and therefore free of charge – similar to other medical indications for C-section.

After delivery, all mother-child pairs were seen every two weeks as outpatients, and the infants were measured, weighed and examined for HIV status and overall health condition. The initial results from this ongoing project show decreased MTCT rates to levels similar to interventions in other parts of the world.

Conclusions

In Ukraine, stigma, discrimination and inadequate health services hinder the fight against AIDS. While these limitations equally apply to MTCT prevention, it has proven possible to achieve success in reducing MTCT without the availability of complex laboratory and testing facilities, and with limited access to most drugs. While several factors were involved in making this a success, the most critical one has been the involvement of peer counsellors, who have been able to establish contact with an otherwise hard-to-reach group, by creating an atmosphere of trust and confidentiality.