This story appears in the UK's December issue of VICE magazine.
Anatoly sits on his bed watching television. He arrived in Krasnoarmiis'k only two days ago. He crossed the border separating the Ukraine from the People's Republic of Donbass on foot. A border region at war, despite an apparent ceasefire. A war that is devastating the people, spreading death and destruction.
Anatoly. All photos by Tomaso Clavarino
Anatoly is a drug addict. He escaped from Makiivka, a city in Donbass, harassed by mortars and grenades, because people like him are not wanted there now that the city is under the control of pro-Russian separatists. Anatoly has been using drugs for thirty years now, since he tried first as a young boy, taking psychotropic substances to kill the boredom of his life among the city's dull, Soviet-made buildings. "I was reborn five years ago. I had reached the edge, and I almost died," he tells me. "Then I started to attend the rehabilitation clinic in my city, for methadone treatment, and I slowly began to come back to life, to have a social life." That clinic has now been shut down, and Anatoly had to come all the way to Krasnoarmiis'k, to keep on trying to live that new life. What happened in Makiivka also happened in Horlivka, and in most of the other cities of the People's Republic of Donbass, many rehabilitation services have been shut down without warning, according to those I spoke to. "In September, I was queuing, like any other morning, and then a nurse arrived and told us that the center was shutting down, for good," says Anatoly. This was, according to activists, patients, NGOs, and doctors, the decision of the pro-Russian Separatist government of Donetsk: part of a plan to transition to a "Russian way" of dealing with drug addiction, which can amount to no services and no help. The are reports of drug addicts in rebel areas becoming victims of intimidation, and being forced to work, for example digging trenches.
Two drug addicts inside an apartment on the outskirts of Kiev. Intravenous drugs have for years been the primary route of HIV transmission in the country.
The methadone distribution center in Donetsk is the only one left in rebel territory. But it won't last long. Supplies are running short and new supplies are blocked. "This is a terrible situation. I can't see any other way to define it," explains Irina Klueva, manager of the opioid substitution therapy (OST) department of the Hospital of Donetsk. "Out of the 240 patients that we had before the war, only 90 are left, because we do not have enough methadone. And those few left will soon have to leave because we are running out of supplies. In recent months, we have registered around ten deaths, here in Donetsk. They were all people forced to drop out of rehabilitation. They either committed suicide or died from overdoses." Thousands of people have gone back to living on the streets, using (mostly illegal ) drugs again, and swapping syringes, which are often infected, according to Klueva. Not even the services for reducing the damage—like needle exchanges—have been left intact in this area of Ukraine.
A view of the Troeschina district, in Kiev, where is easy to find any sort of illegal drug.
"The war and the situation in the east of the country is now having a devastating effect on the whole of the Ukraine, and it will become even worse," Natalia says. She has no doubt. Natalia works for the Svitanok Association in Kramatorsk, a territory under the control of Kiev, which offers assistance and help to HIV positive people who have escaped from the People's Republic of Donbass, as well as those still living in rebel-controlled areas. "They're mostly junkies and prostitutes, they no longer have the right to access antiretroviral treatments because supplies have been blocked by the government of Kiev in retaliation against the separatists." So Natalia and her colleagues set off once or twice a month, their cars loaded with medicines, spending hours in lines at checkpoints, bribing soldiers at the borders, to take antiretroviral medicines to Donetsk and Luhansk.
Ilya fled from Crimea a couple of months ago, after Russia decided to shut down all the substitution therapy services for drug users. He is now trying to rebuild his life in Kiev.
War does not only lead to immediate death, destruction, and injury; it's wounds may be so deep that their effects last long after today. And this is likely to be the case in Ukraine, a country with 260,000-340,000 people living with HIV at last count, and a prevalence rate of 1.3 percent in 15- to 49-year-olds, according to UNAIDS. The country boasts one of the highest rates of HIV infection in Europe, yet thanks to the commitment of several NGOs, Ukraine had managed, over the years before the outbreak of the war in Donbass, to reduce the rate of HIV infection. "Though there is no official data coming out of Donbass, the situation has deteriorated," Natalia explains. "The number of infections is rising. This is due in part to the restrictive policies carried out in DPR, and also to the situation at the front, where soldiers are forced to stay away from their homes and families for months, and have sexual intercourse with HIV positive prostitutes, often without protection."
According to data from the Elena Pinchuk ANTIAIDS Foundation, between January and November 2015, more than 13,000 cases of infection have been recorded in Ukraine. An uptick connected to the failure of the Health System, the destruction of medical buildings, and the shutting down of assistance programs for HIV positive people. On top of those factors, the deterioration of the economic situation in the country and the 300 percent devaluation of the Ukrainian currency, a fall of 25 percent has been registered in the purchase and distribution of condoms in 2014. Making unprotected sex the primary cause of transmission of the virus in Ukraine's general population, according to Olga Rudneva, executive manager at Elena Pinchuk ANTIAIDS Foundation.
A drug user in his house in Troeschina district shows his swastika tattoo. According to pre-war data, 21.7 percent of those injecting drugs, over 25 years old, are HIV positive in Ukraine.
The HIV epidemic grows along with the continuing extension of a war that seems frozen, yet never stops, night or day. A war forcing people to leave their homes, their lives, and to go and look for shelter on the other side of the border. There is no official data on how many of Ukrainian's 1.4 million (according to IDMC) internally displaced people are HIV positive. And there is no official data about where these people are, or how many drug addicts are among them. There is no control from the Central Government, not even in territory still under Ukrainian control. The displaced arrive from Donbass, from Crimea, and most of them leave to go to the big cities, to try and rebuild a life there.
A man sitting on his bed in Kiev's Hospital N2 where many patients are both HIV and TB positive. Often TB and HIV go hand in hand; they are often referred to as the "terrible twins" by doctors and researchers
One of the few patients still on substitution therapy in Donetsk. Behind him, a ward of the hospital destroyed by some heavy shelling in the past months
This is not easy for any, but is especially challenging for those living with HIV, who have lost everything and live in a country where HIV-positive people are stigmatized. "I left Simferopol, in Crimea, after they shut down the replacement therapy (OST) program," says Andrei, an HIV positive drug addict. "I got to Kiev hoping to start a new life, but it's hard, really hard. When people find out you are HIV positive, they stare at you, and finding a job is practically impossible for people like me. We escaped from Crimea because there was no future there for us. If I had stayed there, I'm not sure I'd have survived without treatment. I don't think I would've made it."
Ruslan, 33 years old, in his apartment drug laboratory. In Ukraine homemade drugs such as Krokodil are common as they are cheap and highly addictive.
"This is my life, it's worth nothing and I'm not afraid of losing it."
The most recent data available, dating back to the period before war broke out, demonstrates that 21.7 percent of those injecting drugs, over 25 years old, are HIV positive in Ukraine. Among HIV positive people, 25 percent live, or used to live, in the area of Donetsk and Luhansk where the war is being fought today. "We are waiting for a rise in contagion, especially in the East," says Olga Rudneva, "especially among the people who use intravenous drugs, and this is because of the restrictive policies of separatist governments, like the LPR (Luhansk People's Republic). But we also foresee a rise in all the other groups at risk, because there are many factors which affect the epidemic: cuts in financing, the displacement of hundreds of thousands of people, and the economic crisis." These projected numbers could be further influenced if in the Global Found opts to cut its investments in Ukraine, something people I spoke to fear. When, in 2010, the Global Fund ended it's financing for prevention and harm reduction projects in Romania the share of new infections among injecting drug addicts rose from 3 percent in 2010 to 29.23 percent in 2013, according to the "UNAIDS Country Progress Report on AIDS—Reporting period January 2013" for Romania.
Visiting the outskirts of Kiev, finding oneself immersed in the dirty gray blocks of the Troeschina district, its easy to see how far drugs have spread in this country, especially among the poor. Krokodil, heroin, morphine, and amphetamines—you can find anything you want in Troeschina. Many of these drugs are actually synthesized in local apartments, transformed into laboratories, like Victor's home. A Kiev native, he studied at the best high school in the city, attended university for two years, and then everything went to hell. Drugs are the only thing that keeps him alive, no matter the consequences or dangers. Syringes at Victor's place go from one arm to the next, and the drug is at times intentionally diluted with blood. "I am HIV positive, all my friends are. Still, this is my life, it's worth nothing and I'm not afraid of losing it," he says, while holding a red-hot pan in which he is melting medicines to extract the codeine used to produce krokodil, the now infamous homemade drug which destroys internal tissues before it starts to attack the user's skin.
One of the doctors from Hospital N2 in Kiev in her office.
Slava, 35 years old, with his mother in their apartment in Poltava. Slava has lost the use of a leg due to a heavy use of intravenous homemade drugs. Historically Poltava has been a city with high figures of HIV infection and drug consumption, but in recent years, thanks to some great work done by a couple of NGOs the numbers are decreasing.
Although historically drug addicts have always been the group most at risk here in Ukraine, now, with the precarious economic situation, and most of all because of the war in the East of the country, the risk of contagion is spreading further. This is also part of the war, it is not only about the deaths in the trenches to the East.
Some people quoted in this article requested that their surnames were not included in order to protect their privacy.