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This, coupled with the tendency of men who inject drugs to have women who do not inject drugs as their primary sexual partner,25 and the fact that male-to-female sexual transmission of HIV is more efficient than female-to-male sexual transmission, has resulted in an increasing proportion of new HIV infections occurring among women.
New HIV infections among adult women have almost tripled in 12 years, from 1,814 in 2005 to 5,100 in 2017.26 As a result, 46% of adults living with HIV in Ukraine in 2017 were female, the vast majority of whom had become infected through sexual transmission.27 28 In 2016, there were an estimated 80,100 female sex workers in Ukraine, with an HIV prevalence of 5.2%.29 Prevalence differs greatly between areas, and in 2012 was estimated to be as high as 38.2% in Donetsk and 23.7% in Kyiv.30 In 2017, 58% of sex workers living with HIV were aware of their status and 29% were on ART.31 A study carried out in Ukraine in 2011 found HIV prevalence among female sex workers who inject drugs to be 43%, compared to 8.5% among female sex workers who did not inject drugs, which was the estimated prevalence of this population at the time.32 A basic package of services is available for female sex workers through a network of non-governmental organisations (NGOs) across all regions of Ukraine, which combines prevention of HIV with prevention of other sexually transmitted infections (STIs).33 In 2017, 48% of sex workers were estimated to have access to HIV prevention services.34 Despite this relatively low coverage in 2017, 93% of female sex workers reported using condoms with clients.35 36 Modelling estimates suggest that addressing the routine physical and sexual violence faced by sex workers at the hands of clients, police and other members of society in Ukraine would lead to a reduction of approximately 25% in HIV infections among this population.37 Recent estimates suggest that there are around 181,000 men who have sex with men (sometimes referred to as MSM) in Ukraine.38 39 Because of the way data are collected in Ukraine, transgender women are included in this population group.
When the epidemic first began in Ukraine, it mainly affected people – predominantly men – who inject drugs.
But since 2008, sexual transmission of HIV has been driving the epidemic, with sexual partners of people from key populations particularly at risk, who may then transmit to other sexual partners.7 It is now estimated that around 73% of new transmissions are the result of sexual transmission.8 Government and civil society have generally been proactive in responding to HIV and there has been some success in rolling out antiretroviral treatment (ART) and harm reduction programmes.
However, a study published in 2017 found that exchanging sex was having less of an impact on the HIV status of women who inject drugs than previously assumed, suggesting that risk and vulnerabilities associated with being a woman who injects drugs, rather than a woman who sells sex, tend to drive transmission among this group.19 In 2017, 65% of people who inject drugs were estimated to be able to access HIV prevention services.20 In the same year, 43% of people who inject drugs who were living with HIV were aware of their status and 38% were accessing ART.
Around 44% of people who inject drugs reported using condoms, while 97% engaged in safe injecting practices.21 22 Sexual partners of key populations, in particular the partners of people who inject drugs and the clients of female sex workers, are at elevated risk of HIV infection.
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Ukraine has the second-largest HIV epidemic in Eastern Europe and Central Asia, accounting for 9% of new infections in the region in 2016.1 In 2018, 240,000 people were living with HIV.
In 2016, 10,069 people became infected with HIV through heterosexual sex (52% were women and 48% were men), around 1,000 more than in 2015.
New heterosexual HIV infections were at their highest in 2013, at 11,472, and have been slowing since but this latest rise suggests new infections through this route may be increasing once more.23 24 The majority of people who inject drugs in Ukraine are men.
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However, the high level of stigma faced by men who have sex with men and other lesbian, gay, bisexual, transgender and intersex (LGBTI) people in Ukraine means that the majority keep their sexual orientation and gender identity hidden, suggesting the population estimate for this group is under reported.