The International HIV/AIDS Alliance in Ukraine

AIDSTAR-One's first case study in the Promising Approaches to Combination Prevention series examines the efforts of the Alliance-Ukraine to reach most-at-risk populations (MARPs) in Ukraine. Through its partner organizations, the Alliance-Ukraine provides the majority of HIV prevention services in the country, targeting the primary driver of Ukraine’s HIV epidemic: injecting drug use. Community engagement, advocacy for supportive policies, and linkages to government services complement evidence-based programming.

View the interactive case study below.

pdf Download the International HIV/AIDS Alliance in Ukraine Case Study (PDF, 642 KB).

Текст на русском языке (Russian Translation)

Visit our Case Study Series page to see other recent publications.

For additional information about the practice and related materials, visit the Promising Practices Database - HIV/AIDS Alliance Ukraine: Combination Approaches for Injecting Drug Users.

Photo of client receiving counseling.

Community centers supported by the International HIV/AIDS Alliance in Ukraine provide a variety of services related to HIV, including voluntary counseling and testing. (International HIV/AIDS Alliance in Ukraine)

The International HIV/AIDS Alliance in Ukraine

By Heather Bergmann and Sharon Stash

Promising Approaches to Combination HIV Prevention Programming in Concentrated Epidemics

In an old concrete building in Kiev—one of thousands like it left over from the Khruschev era—people fill the sitting room of an apartment that has become a drop-in center. The parquet floors are worn, as are the couches, where several sit absorbed in a televised soccer match. Everyone in the room is freshly showered, enjoying a moment's peace, while a washing machine runs in the background. On a shelf in a hallway sit booklets on drug use and HIV beneath posters offering messages of inspiration and determination. At a nearby table, two case workers sip tea as they open boxes of rapid HIV tests. The people in this room—clients and workers from local community-based organizations—share a common goal. Injecting drug use has brought them to this drop-in center where, day by day, they work together to fight addiction and HIV.

Injecting drug use is the major driver of HIV transmission in Ukraine, which has one of the fastest growing epidemics in the world. The virus spreads rapidly within populations of injecting drug users (IDUs) who share needles and syringes. Stigmatized and marginalized for their drug use by health care workers and other members of the community, many refrain from seeking out the clinical and support services they desperately need. Their isolation deepens when, usually to maintain their addiction, they engage in other behaviors, such as sex work, that further increase their chances of acquiring HIV.

Fortunately, many IDUs in Ukraine have found their way to services such as the Kiev drop-in center. The International HIV/AIDS Alliance in Ukraine (Alliance-Ukraine)—a member of a global partnership of nationally based organizations called the International HIV/AIDS Alliance—is the leader of HIV prevention efforts in the country. The largest HIV/AIDS-focused organization in Ukraine, the Alliance-Ukraine manages a combination HIV prevention program, continually tailoring its approaches to the changing needs of most-at-risk populations (MARPs), primarily IDUs, sex workers, men who have sex with men (MSM), and prisoners.

Since 2004, the Alliance-Ukraine has scaled up its services to MARPs by engaging civil society as well as community-based organizations (CBOs) and nongovernmental organizations (NGOs) in the response to HIV by forging strong linkages to the national health system and by supporting national goals for universal access to care, support, and treatment.

Disclaimer: The author's views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

Combination HIV Prevention

The work of the Alliance-Ukraine exemplifies key aspects of combination HIV prevention programming in concentrated epidemics. By managing HIV programs and providing technical support and financial resources to local partners, the Alliance-Ukraine simultaneously:

  • Implements program and policy efforts that are evidence-driven and supports systems of program monitoring, evaluation, and operations research designed to help the program adapt to new challenges and reach newly identified MARPs.
  • Employs a combination of behavioral, biomedical, social normative, and structural strategies and risk reduction approaches that target different audiences.
  • Ensures that affected communities play a central role in the response to the epidemic and meaningfully involves people living with HIV and vulnerable people—sex workers, IDUs, and MSM—in all aspects of the response to the epidemic.
  • Maintains effective linkages to government services, ensuring access to basic health care services and treatment.
  • Conducts flexible, responsive advocacy for supportive policies and an improved regulatory environment.

The need for comprehensive and integrated HIV prevention programming could not be greater for Ukraine. An estimated 1.6 percent of Ukrainians between the ages of 15 and 49 years are living with HIV (UNAIDS/WHO 2008). Most infections occur among MARPs, including IDUs (17.3 to 70 percent prevalence), sex workers (8 to 30 percent prevalence), MSM (4 to 23 percent prevalence), and prisoners (3.5 to 12 percent prevalence) (Kruglov et al. 2008).

The Alliance-Ukraine program is currently implementing two major HIV initiatives and supports more than 150 NGOs and CBOs working in HIV prevention and care. Since 2004, the Alliance- Ukraine, along with partners PATH and the All- Ukrainian Network of People Living with HIV/AIDS, has implemented the Scaling Up the National Response to HIV/AIDS through Information and Services (SUNRISE) Project. Funded by the U.S. Agency for International Development, the SUNRISE Project targets the regions of Ukraine most affected by HIV, expanding access to information and services for MARPs. In 2004, the Alliance- Ukraine began receiving funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) through the International HIV/AIDS Alliance secretariat.

The Alliance-Ukraine and the All-Ukrainian Network of People Living with HIV/AIDS now serve as co-principal recipients for a major GFATM grant. This grant focuses on providing integrated services, particularly treatment and prevention, to IDUs, who are key to the dynamics of the epidemic. The goal of the program is to strengthen and expand prevention services, particularly among groups at the center of the epidemic. At the same time, the program seeks to scale-up access to and improve the quality of antiretroviral treatment, develop better care and support services for affected people and communities, and improve the monitoring and evaluation of the epidemic’s spread and the response to it.

The Alliance-Ukraine sets a global example for combination prevention programs by using a data- driven process to select prevention activities that address the key drivers of HIV transmission in Ukraine. The Alliance-Ukraine not only closely monitors national surveillance but also collects program data and conducts an ongoing program of operations research. The Alliance-Ukraine uses operations and programmatic research to understand its primary target groups of IDUs, sex workers, and MSM. Because epidemics are dynamic and the characteristics of at-risk populations change, the Alliance-Ukraine also employs operations research to understand newly emerging risk groups and behaviors and to modify its program activities based on findings.

The Alliance-Ukraine implements behavioral HIV prevention through targeted risk-reduction strategies for IDUs, sex workers, MSM, and incarcerated individuals. Peer support, provided on a one-to-one basis or through group sessions, occurs at drop-in centers that cater to the needs and preferences of each of the different groups. Outreach workers and mobile clinics also bring behavior change messages and essential services to MARPs at known gathering points. The Alliance-Ukraine continually seeks to identify new locations from which to broaden the reach of its program activities. The Alliance-Ukraine also implements biomedical prevention activities to respond directly to injecting drug use, the main cause of HIV transmission in Ukraine. Through its local implementing partners, the Alliance-Ukraine provides buprenorphine and methadone, medications for the treatment of heroin addiction, and clean needles and syringes. The Alliance-Ukraine partners also provide condoms and a variety of HIV prevention and care services, including counseling and testing, sexually transmitted infection (STI) diagnosis and treatment, and psychosocial support. The Alliance-Ukraine also maintains effective linkages to government services, including those provided through national AIDS centers, such as counseling and testing, prevention of mother-to-child HIV transmission, antiretroviral treatment, and psychosocial services.

The Alliance-Ukraine sets a global example for combination prevention programs by using a data-driven process to select prevention activities that address the key drivers of HIV transmission in Ukraine.

The Alliance-Ukraine also implements activities to address structural factors limiting effective public health responses to the drivers of the HIV epidemic in Ukraine. Recently, the organization successfully championed the registration of methadone for substitution therapy and the introduction of rapid HIV test kits through local NGOs. Advocacy has focused on expanding access to harm reduction, lowering the purchase price for antiretrovirals to conform to international standards, and increasing funding for HIV-and AIDS-related activities. Alliance-supported programs also work with law enforcement and state social services to ensure an enabling environment for prevention by raising awareness of HIV prevention and substitution therapy and by pushing for decriminalization of minor drug offenses.

In addition to working at the national and regional levels, the Alliance-Ukraine works at the community level to ensure an engaged, active civil society. The Alliance-Ukraine supports the advocacy efforts of CBOs, building grassroots support for structural changes, and works to ensure that civil society organizations have the necessary financial and technical resources to meet local needs.

Reaching Most-at-Risk Populations

The Alliance-Ukraine implements several simultaneous approaches to increase people's access to information and services. Services for MARPs have been expanded through drop-in centers and linkages with complementary services such as government clinics, mobile services, and public and private sector pharmacies. Recently, the Alliance- Ukraine has adapted an innovative approach, peer- driven interventions (PDIs), to expand the reach of its program activities to the growing number of IDUs not reached by existing program activities.

Drop-in centers: Drop-in centers address the needs of their clients in a holistic manner, particularly addressing issues affecting MARPs. Typically staffed by people from most-at-risk communities, such as MSM and former IDUs, drop-in center staff and volunteers can both relate to their clients and serve as positive role models while providing strong advocacy on each client's behalf. Drop-in centers often cater to specific target populations but also offer a broad range of services because clients may engage in multiple HIV risk behaviors. Outreach workers bring information about the centers to clients in the community, seeking to reach members of MARP groups. The drop-in centers become more accessible for MARPs when staff engages local law enforcement to learn about the services the center provides and reduce harassment of prospective clients. In addition to HIV prevention information, drop-in centers offer such basic non-health services as showers, laundry facilities, and kitchens that help clients with daily needs and provide extra incentive for people to come. Drop-in centers also offer opportunities for social interaction, over a game of ping-pong or a soccer match on TV. These activities help build trust between clients and staff that facilitates dialogue about such difficult issues as drug use, sexual behavior, and HIV.

Having government medical staff provide services at drop-in centers gives clients a personal connection to the government AIDS center, making it easier for them to seek additional services.

Linkages with other services: Drop-in centers run by the Alliance-Ukraine's implementing partners are often located within or nearby other centers that offer such complementary services as counseling and testing. The Alliance-Ukraine works to maintain a high level of coordination with government HIV services. In some instances, government AIDS centers have invited local NGOs supported by the Alliance-Ukraine to share their office space. Patients receiving counseling and testing services provided by government physicians in one room are referred down the hall to other rooms occupied by local NGOs that provide support services. Drop-in centers run by local NGOs invite government workers to provide counseling and testing on a mobilebasis, bringing these essential services closer to clients in environments where they feel welcome and comfortable. Having government medical staff provide services at drop-in centers gives clients a personal connection to the government AIDS center, making it easier for them to seek additional services.

Image of International HIV Alliance/Ukraine staff


Staff at alliance-supported NGOs like Faith, Hope & Love in Odessa provide HIV services to most-at-risk populations throughout Ukraine. (H. Bergmann, JSI)

New testing and referral strategies: Recognizing the challenges, stigma, and discrimination that MARPs face while trying to access services, the Alliance-Ukraine has played a major role in championing the provision of rapid HIV testing by NGOs. Although national standards require the use of enzyme-linked immunosorbent assay tests in government AIDS centers, some of the Alliance-Ukraine's implementing partners have begun to offer rapid tests in their drop-in centers and mobile clinics (see subsequent discussion). Clients who test positive are referred for confirmatory testing to the government AIDS centers. Volunteers or NGO staff often accompany clients to the center to make sure they are able to navigate the health system and are able to receive the confirmatory test, counseling, and support. Testing for other STIs, including gonorrhea, chlamydia, and syphilis, is available in NGO-run drop-in centers and mobile clinics. NGO staff may also refer clients to government facilities for treatment; if necessary, they will dispense medications provided by the Alliance to augment those available at government clinics. By providing services that complement what government clinics offer, Alliance-Ukraine partners increase access to essential services for MARPs; referring and accompanying clients to official clinics also improves access by supporting populations that may be reluctant to approach facilities run by the authorities.

Medication-assisted treatment: The Alliance-Ukraine initiated and rolled out medication-assisted treatment (MAT) for opiate-dependent clients, offering substitution therapy with buprenorphine and methadone. Clinics involved in the program provide MAT free of charge, a great help to clients who cannot afford the treatment. Psychosocial support is often available on a one-on-one basis and through group sessions with psychologists and peers. Counseling prepares clients to initiate MAT and adhere to treatment regimens. Linkages to groups providing rehabilitation for various chemical dependencies other than opiates, including alcohol, allow the centers to serve clients with different risk behaviors.

Mobile clinics: Because not all members of MARPs will come to a drop-in center, the Alliance-Ukraine's partners operate mobile clinics that bring services to clients. Routes are influenced by the target population: mobile clinics targeting IDUs stop near "shooting galleries," while mobile clinics targeting sex workers travel along highways at night. Outreach workers distribute mobile clinic schedules in the community along with other HIV information. The mobile clinics are staffed by social workers or counselors and a nurse or other medical staff. They typically offer voluntary counseling and testing, STI diagnosis, condoms and needles/syringes, informational materials, and referral services. The specific mix of services and supplies offered by the mobile clinics reflects the needs of the target populations; for example, mobile clinics targeting sex workers also provide gynecological exams and feminine hygiene products. Mobile clinics serving clients who test positive are referred to government AIDS centers and STI clinics for confirmatory tests.

Image of mobile unit


Medical staff in mobile ambulances provide a variety of services, including testing for HIV and other sexually transmitted infections. (H. Bergmann, JSI)

Photo of mobile clinic


Mobile ambulances, like this one in Cherkassy, travel throughout communities to reach more people. (H. Bergmann, JSI)

Pharmacies: To expand its reach to MARPs, the Alliance-Ukraine is now working with public and private sector pharmacies throughout the country that play vital roles in the national response to HIV. Pharmacies are numerous, widespread in communities, and are easily accessible to clients. At pharmacies, MARPs can more easily blend in with other clients. After presenting a card at participating pharmacies, clients receive a basic package of clean syringes and needles, condoms, and informational materials. Some pharmacies also serve as exchange points for used syringes and needles. Pharmacists receive sensitivity training to reduce the stigma felt by their clients, thus creating a friendlier environment to access services.

Peer-driven interventions: Adapted from the techniques developed to reach IDUs in the United States in the 1990s, PDIs are a cost-effective way to give programs access to hard-to-reach populations, expanding services beyond the usual clients and preventing program stagnation (Broadhead et al. 1998). Injecting drug use in Ukraine is changing; among younger people, opiates are losing popularity to stimulants that are prepared—"cooked"—by people using locally available ingredients. The Alliance-Ukraine noticed that the clients coming to the community centers and mobile clinics were predominantly older male opiate users. To reach beyond this clientele and draw in new groups of young stimulant users, the Alliance-Ukraine began to pilot a PDI that was adapted to the local environment.

PDIs use social networks and peer influence to access networks of people engaged in hidden behaviors (Broadhead et al. 1998), such as injecting drug use or informal sex work. The Alliance-Ukraine's partner organizations begin by carefully selecting clients ("seeds"), often active users, who understand drug-using populations and are strongly motivated to serve others like themselves. Seeds receive counseling and education at the community center and learn how PDI works. They then distribute three coupons to members of their drug-using community along with HIV education, relaying specific pieces of information that the coupon recipients will be asked to repeat later. For each coupon that is returned to the community center by a newly recruited IDU seeking services, the seed receives a small amount of money; additional money is awarded to the seed for each question these first-wave clients get correct on a quiz testing their knowledge of HIV. These first-wave clients then receive additional basic HIV education and referrals to counseling and testing services; they also receive their own three coupons and the cycle repeats itself. The program can choose to award a slightly larger incentive for recruiting clients with certain characteristics. For example, if the program wishes to reach younger, stimulant-using female clients, they can increase the amount of money paid to people who successfully recruit these types of clients.

Alliance-Ukraine's Technical Approach

Image of new needles and syringes provided by a pharmacy.


Pharmacies distribute packages with harm reduction commodities—including clean needles/syringes, alcohol swabs, condoms, and information on HIV services. (H. Bergmann, JSI)

Strengthening the civil society response to HIV and AIDS at a regional level: Since 2008, the Alliance-Ukraine awards grants annually to dozens of NGOs and CBOs to implement HIV and AIDS prevention and care activities. After mapping MARPs and examining local information on the epidemic, the Alliance-Ukraine issues a call for proposals that identify target populations and locations for prevention programming on a regional basis. By including examples of "typical" projects in the call for proposals, the Alliance-Ukraine provides applicants with models of known efficacy that they can adopt and modify to their particular setting. External consultants review proposals from each region, recommending some projects as proposed for funding and others on the condition that they agree to make recommended changes.

Unfortunately, there are few NGOs both willing and able to work with MARPs. The Alliance-Ukraine has developed a strategy to engage more community organizations in HIV and AIDS activities and build their capacity. It recruits candidate CBOs, called initiative groups, that have a demonstrated ability and desire to work with MARPs but little or no experience in implementing HIV-related activities. The Alliance-Ukraine helps the CBO develop those skills, providing financial and technical support. As in other areas of the Ukraine-Alliance's work, one goal is to encourage the meaningful involvement of vulnerable people, including those living with HIV and AIDS, in the design and implementation of program activities. After developing their skills in service provision or advocacy, these initiative groups go on to register as local NGOs.

Ongoing operations and programmatic research: The Alliance-Ukraine is adept at using different sources of data on HIV and AIDS, including data from surveillance surveys, special studies, and program monitoring. Analysis of these data allows the Alliance-Ukraine to adjust the mix of services to meet client needs. Increasing data utilization at all levels of program planning and implementation remains an ongoing challenge, as does increasing the flow of data both to and from implementing partners. Operations research, a relatively new component of the Alliance-Ukraine technical assistance portfolio, is initiated by technical support managers and program staff. Operations research provides feedback on which programmatic approaches are working—and which ones are not—while identifying which additional services or facilities target populations may need.

Injecting drug use in Ukraine is changing; among younger people, opiates are losing popularity to stimulants that are prepared—"cooked"—by people using locally available ingredients.

To identify characteristics of stimulant users in Ukraine, Alliance-Ukraine partners conducted a series of focus groups with stimulant users in June 2008 and February 2009 (Shulga 2008b; Shulga and Smyrnov 2009). Results from these focus groups helped in the development of a 2009 research protocol to study stimulant users in Ukraine which identified the most popular drugs, methods of consumption and other injection behaviors, reasons for use, and characteristics of users.

To improve harm reduction service delivery to stimulant users, the Alliance-Ukraine collaborated with the Foundation Open Society Institute to develop the "Group Level Intervention for Stimulant Users," which consists of 12 weekly educational sessions. The intervention was piloted at three pilot sites in 2009 and appeared to be highly effective; staff at an additional 10 project sites were trained for implementation in 2009 and 2010.

STIMULANT USERS: AN EMERGING IDU POPULATION

In 2006 and 2007, Alliance-Ukraine partner NGOs noted the growth of stimulant users in their quarterly program reports, a trend confirmed by the data of the All Ukrainian AIDS Centre (Yeshenko 2009) and behavioral monitoring of IDUs (Alliance- Ukraine 2005, 2008). Analysis revealed that the proportion of stimulant users increased from 20 percent in 2005 to 34.5 per-cent in 2008, while opiate use decreased from 91 percent to 82.2 percent. A further literature review showed that stimulants were more commonly used by people younger than 25 years old (Chintalova-Dallas et al. 2009). There was also some evidence that stimulant users were at higher risk of HIV transmission than were opiate users because of riskier injection behavior (Booth et al. 2008). Implementing partners accustomed to working with opiate users reported difficulties working with an emerging population of stimulant users: it was not clear which stimulants they were using and there was no consensus on how to address their addiction (Shulga 2008a).

Adapting to ongoing changes in the dynamics of the HIV epidemic among MARPs: The Alliance-Ukraine conducts operations and programmatic research to understand newly emerging MARPs, and to explore the behaviors that place them at increased risk for HIV. For example, recent research aims to understand the context of stimulant use among people, elucidating the mechanisms through which use of these non-opiate drugs create routes for HIV transmission. These high-risk behaviors include frequent injections and increased needle sharing among young people who gather in apartments to "cook" and consume drugs.

In addition to their other program management and technical support activities, technical support managers lead research efforts at the Alliance-Ukraine; this dual role helps the organization maintain a vital connection between program design and program implementation experience at the field level. These staff provide technical support to implementing partners while helping to develop and test new approaches to working with vulnerable groups. Where merited, technical support managers manage pilot interventions, monitor results, and evaluate approaches for potential adaptation and wider implementation. They are also involved in the development of educational models on emerging technical topics.

Flexible, responsive advocacy for supportive policies and an improved regulatory environment: Vulnerability to HIV is exacerbated by poverty, the abuse of people's rights, and social inequalities based on gender, class, and sexual orientation. As such, HIV programs for MARPs are compelled to address the underlying environmental, legal, and regulatory factors that increase vulnerability. The Alliance-Ukraine advocates for policies that create an enabling environment and that limit stigma and discrimination.

Image of International HIV Alliance/Ukraine staff working on a computer,


Monitoring data and putting the information to use at the local level helps the Alliance-Ukraine maintain a flexible approach to HIV services. (H. Bergmann, JSI)

At the national level, the Alliance-Ukraine successful advocated for the registration and delivery of methadone to Ukraine, for provision of rapid HIV tests, and for monitoring and moderating the purchasing prices for antiretroviral drugs.

The Alliance-Ukraine seeks to involve partners in policy and advocacy work and build local capacity to engage communities in the response to HIV. Since 2004, the Alliance-Ukraine has conducted national training for people living with HIV and AIDS on policy and advocacy for human rights, and does similar rights-based training with other vulnerable groups (IDUs, sex workers, MSM), NGOs, and health care workers. More intensive "summer schools" on policy and advocacy take place every year.

Other local advocacy activities include raising awareness with law enforcement about HIV and drug use. Community centers provide their clients with cards containing legal information about drug possession and their rights if stopped by the police. Likewise, police receive informational materials on laws relating to HIV and drugs. Law enforcement personnel learn about safer injection practices, antiretroviral treatment, and the importance of adherence, as well as locations of community centers. Knowing police are not waiting outside the centers to harass and arrest them for possession of antiretrovirals, clean syringes, or other harm reduction materials helps clients feel more confident about using services.

Program Results

Data that suggest the HIV epidemic is stabilizing among Ukrainian IDUs after years of growth provide evidence of the impact of harm reduction programs. HIV incidence among IDUs decreased slightly in 2007 and 2008 for the first time in a decade, and among recent IDUs (individuals who have injected for two years or less), HIV prevalence is decreasing. IDUs are reporting less risky behavior: reported use of sterile equipment at last injection has risen since 2006.

By the end of 2008, 194,440 IDUs had been reached with harm reduction services. This number implies coverage of 60 percent of IDUs in Ukraine, estimated to be 325,000 people. The program reaches an estimated 33 percent of IDUs with harm reduction services; over the years, 66 percent of IDUs have had some level of contact with program activities. The harm reduction programs are reaching more individuals each year, providing crucial information and services to this MARP.

The Alliance-Ukraine provides the vast majority of prevention services in the country. In 2008 alone, more than 300,000 people accessed HIV prevention services through the Alliance-Ukraine’s programs. As of January 1, 2009, the Alliance-Ukraine had reached 194,440 IDUs, 32,740 sex workers, 18,671 MSM, and 57,553 incarcerated individuals.

In addition to its success in service delivery, the policy and advocacy accomplishments of the Alliance-Ukraine demonstrate their leadership in HIV prevention. The Alliance-Ukraine advocated for implementation of MAT with methadone, coordinated efforts to register the medicines, and obtained government decrees on its use from the president and Ministry of Health. The Ministry of Health implemented an HIV monitoring system based on the Alliance-Ukraine model. The Alliance-Ukraine successfully handed over 6,070 clients on antiretroviral therapy to government and state budgets in December 2008.

What Has Worked Well

Placing communities at the center of the response: Throughout its work with MARPs, the Alliance-Ukraine maintains its core commitment to meaningful involvement of vulnerable people, including those living with HIV and AIDS, and to ensuring that their communities at large play a central role in the response to the epidemic. IDUs, sex workers, and MSM are involved in program planning, as are NGO staff, who are often former or current members of these groups. By employing members of affected populations, implementing partners enjoy close ties with affected communities and can more easily gather current information on risk groups and behaviors. By addressing the needs of MARPs in a holistic manner, and by recognizing people’s right to social interaction, basic human amenities, and respect, the Alliance-Ukraine’s partner organizations further the goals of harm reduction and HIV prevention. Through close collaboration with implementing partners, the Alliance-Ukraine receives current information at the local level, allowing the organization to adapt to changes in the epidemic, risk groups, and risk behaviors.

By addressing the needs of MARPs in a holistic manner, and by recognizing people's right to social interaction, basic human amenities, and respect, the Alliance-Ukraine's partner organizations further the goals of harm reduction and HIV prevention.

Continuous learning and innovation: The Alliance-Ukraine demonstrates a unique capacity for institutional learning and innovation. Ongoing generation and utilization of data on the epidemic and on program activities guide the selection of activities and implementing partners at the regional level. Operations and programmatic research is used to identify additional risk behaviors and sub-populations within MARPs and what their needs are. Operations research enables the program to explore newly identified risk groups and behaviors and to modify its programmatic approaches to reach vulnerable populations and prevent program stagnation.

Continuous learning has resulted in important innovations. For example, PDI expands the reach of the program to new members of MARPs and new groups. Initiative groups deepen civil society’s engagement and allow services to be delivered in places and to communities that might otherwise be missed. Operations and programmatic research helps the Alliance-Ukraine understand the needs and HIV-related risk behaviors of younger groups of stimulant users.

Challenges

Countering structural barriers: Because vulnerability to HIV is increased by poverty, the abuse of people’s rights, and social inequalities, HIV programs for MARPs must address the underlying environmental, legal, and regulatory factors that increase vulnerability. To adapt to a continually changing context, the Alliance-Ukraine finds it necessary to maintain a dynamic understanding of its clients’ lives and the various contextual factors that increased their vulnerability to HIV. The Alliance-Ukraine has had to persist, innovate, and continually change what it does to get decisionmakers on board at the national, regional, local, and client level.

At the national level, the Alliance-Ukraine advocates for improved implementation of HIV and AIDS activities through the National Council on HIV/AIDS under the administration of the Government and President of Ukraine. Working at a national level, the Alliance-Ukraine has been able to champion structural changes that have permitted its clients to access MAT and rapid tests, as well as the registration of medicines, implementation of import quotas and monitoring systems, and more. Working with local law enforcement and social services to raise awareness about the cross-cutting issues of HIV and injecting drug use, as well as dependence and rehabilitation, has helped foster a less punitive environment for IDUs and has improved relations between these groups.

Other challenges remain. For example, within Ukraine’s medicalized health care system, MARPs face the continuing challenges of stigma and discrimination, sometimes at the hands of health system personnel. The government AIDS centers, narcotics clinics, and STI clinics are working together with Alliance-Ukraine partners to address these issues, for example, by coordinating aspects of their service delivery with local NGOs whose outreach workers are drawn from affected populations. Additionally, some clients now also find it easier to access needle exchange commodities, educational materials, and condoms in numerous public and private sector pharmacies, where they blend in more easily with the typical flow of pharmacy clientele and where they are more readily received by pharmacy staff, many of whom have dealt with drug use and HIV in their home communities.

Coordinating the activities of numerous implementing partners and managing demand for technical support: The Alliance-Ukraine provides a large and increasing number of local implementing partners with technical support and resources, while allowing communities to make decisions and take action. Some organizations receive one-on-one technical support; the Alliance-Ukraine also organizes seminars and provides technical and management resource materials. As national prevention programs are scaled up, the Alliance-Ukraine faces the challenges of providing these resources to an even larger number of organizations in a multitude of settings. The Alliance-Ukraine is attempting to meet these challenges through the development of standard approaches and regional NGO proposals, as well as the development and dissemination of technical and managerial aids. The Alliance makes use of regularly scheduled monitoring visits to provide technical assistance to organizations, and conducts supervision and technical support site visits on a more targeted basis, as needs arise. Technical assistance covers a range of technical design and program management issues (e.g., human resource management, financial management, data and reporting issues). Participation in and coordination of regional planning exercises help ensure that efforts are complementary. The Alliance-Ukraine aims to expand available opportunities for institutional learning through its establishment of Regional Informational Resource Centers that provide technical support at the request of local implementing organizations. The Alliance-Ukraine and several of its implementing partners participate in regional and local HIV/AIDS coordinating councils, as part of an ongoing effort to strengthen integration with the national program.

Recommendations for Implementers

Consider evidence-based combination programming: Combination programming has served this organization well, increasing the reach of the Alliance-Ukraine to many members of MARPs that might otherwise remain without access to services. In addition to behavioral interventions, IDUs benefit from biomedical interventions that reduce the harmful practices that increase HIV transmission. Structural interventions that advocate for helpful policies and regulations help curb stigma and discrimination as they promote new and needed changes in services (for example, the addition of methadone and rapid tests).

Base program decisions on an evolving understanding of MARPs and the context of risk: Knowledge of MARPs enables the Alliance-Ukraine to understand the evolving context of risk and to carefully select program elements that, in combination, counter a wide array of factors that increase people’s vulnerability to HIV. This knowledge is active, not passive: to stay on top of changes in the environment and in risk factors, the Alliance-Ukraine has developed instruments to assist implementers routinely and systematically assess and understand the context of programs working with IDUs, including changes in drug use behaviors and the broader social and policy environment. To maintain a positive impact on prevention for MARPs, the Alliance-Ukraine has to remain flexible. Routine monitoring of program implementation allows implementing partners to analyze any changes in drug use and adapt services accordingly. Knowing the local context and being willing to change, even when met by resistance from communities or parts of the health care and legal systems, are key lessons from the Alliance-Ukraine experience.

Intensify and expand efforts to reach MARPs: While building on its successes in reducing the spread of HIV among IDUs, the Alliance-Ukraine plans to scale-up and intensify its outreach to MSM, street-based sex workers, sex workers who inject drugs, prisoners, and street children between 10 and 18 years old. The Alliance-Ukraine plans to consistently employ novel approaches, such as PDI, to focus on hard-to-reach populations, providing incentives for increased uptake of new groups of younger stimulant users, women, MSM, and informal sex worker populations. Establishing a range of services that meet clients’ needs will continue to help expand the reach of programs.

Expanding HIV prevention and care throughout Eastern Europe and Central Asia: Building on its experiences in Ukraine and expanding on its innovative program efforts, the Alliance-Ukraine aims to become a technical hub for Central Asia and Eastern Europe. Staff members are providing technical assistance to programs in the region that seek to expand or improve services, supplementing programmatic resources already available. In particular, the Alliance-Ukraine is supporting continued scale-up of substitution therapy programming in these regions. In addition to sharing descriptive information on programs, the Alliance-Ukraine can provide specialized training and support the adaptation of programmatic approaches or development of typical projects based on their successful models.

References

PDF AidsAlliance.org. n.d. Mission and Values of the International HIV/AIDS Alliance in Ukraine (Alliance-Ukraine) Outside link (PDF, 24 KB) (accessed July 8, 2011).

Alliance-Ukraine. 2005. Analytical Report Based on the Research Results "Evaluation of the Size of Most-at-Risk Populations Vulnerable to HIV Infection in Ukraine." Kiev: Alliance-Ukraine.

Alliance-Ukraine. 2008. Analytical Report Based on the Research Results "Evaluation of the Size of Most-at-Risk Populations Vulnerable to HIV Infection in Ukraine." Kiev: Alliance-Ukraine.

Booth, R. E., W. E. Lehman, C. F. Kwiatkowski, J. T. Brewster, L. Sinitsyna, and S. Dvorak. 2008. Stimulant Injectors in Ukraine: The Next Wave of the Epidemic? AIDS and Behavior 12(4):652–61.

Broadhead, R. S., et al. 1998. Harnessing Peer Networks as an Instrument for AIDS Prevention: Results from a Peer-Driven Intervention. Public Health Report 113(Supplement 1):42–57.

Chintalova-Dallas, R., P. Case, N. Kitsenko, and Z. Lazzarini. 2009. Boltushka: A Homemade Amphetamine-type Stimulant and HIV Risk in Odessa, Ukraine. International Journal of Drug Policy 20(4):347–51.

Kruglov, Y. V., Y. V. Kobyshcha, T. Salyuk, O. Varetska, A. Shakarishvili, and V. P. Saldanha. 2008. The Most Severe HIV Epidemic in Europe: Ukraine's National HIV Prevalence Estimates for 2007. Sexually Transmitted Infections (Supplement 1):i37–i41.

Shulga, L. (for the Expert Group on HIV Prevention among Stimulant Users). 2008a. Analysis of 27 projects that reported conducting HIV prevention among stimulant users in 2008. Unpublished report.

Shulga, L. 2008b. Peer-Driven Interventions Trip Report (to five projects in Poltava, Kirovograd, Cherkassy, Vinnitsa, and Khmelnitsky), Alliance-Ukraine: December 12–19. Unpublished report.

Shulga, L., and P. Smyrnov. 2009. Increased Stimulant Use in Ukraine: Focus-Groups Results. Poster presented at the IHRA 20th International Conference, Bangkok, April 20–23. Abstract 698.

UNAIDS/WHO. 2008. Epidemiological Fact Sheets on HIV and AIDS, 2008 Update. Outside link (accessed July 8, 2011).

PDF Yeshenko, G. 2009. HIV Infection in Ukraine. Information Bulletin No. 31. Kiev: Ministry of Health. Outside link (PDF, 774 KB) (accessed July 8, 2011).

Resources

Publications of the International HIV/AIDS Alliance in Ukraine are available here Outside link.

International HIV/AIDS Alliance Outside link

Acknowledgements

AIDSTAR-One would like to thank the entire International HIV/AIDS Alliance in Ukraine staff and their implementing partners for their enthusiasm for and dedication to the completion of this case study. The project also expresses gratitude to the Alliance-Ukraine program clients who were willing to share their experiences and provide a personal richness to the information gathered. Thanks also to the All-Ukrainian Network of people living with HIV/AIDS, the Coalition of HIV/AIDS Service NGOs, and Constella/Futures for sharing their time and experiences. Special thanks also to Ukraine's National AIDS Center, UNAIDS, and USAID in Ukraine and Washington, DC, for their assistance, advice, and helpful feedback. AIDSTAR-One also thanks the Together for Health project for its support in making the case study possible.

Recommended Citation

Bergmann, Heather, and Sharon Stash. 2010. Case Study: The Alliance-Ukraine: Promising Approaches to Combination HIV Prevention Programming in Concentrated Epidemics. Case Study Series. Arlington, VA: USAID AIDS Support and Technical Assistance Resources, AIDSTAR-One Task Order 1.