From HIV testing to ART initiation under fire: joinpoint regression analysis of regional disparities during the full-scale war against Ukraine.

backgroundThe full-scale Russian invasion of Ukraine in February 2022 caused large-scale displacement and major disruption of health services. We assessed national and subnational trends in HIV testing, test positivity, number of newly registered HIV cases, and antiretroviral therapy (ART) initiation during 2020-2023, and examined whether trajectories differed by regional exposure to hostilities.

methodsThis ecological time-series study analyzed routine national surveillance and program data from January 2020 through December 2023. Joinpoint regression was used to identify trend breakpoints and estimate quarterly percent change (QPC), average quarterly percent change (AQPC), monthly percent change (MPC), and average monthly percent change (AMPC), with 95% confidence intervals. Subnational analyses were stratified into three categories of exposure to hostilities: active hostilities in 2023, history of active hostilities in 2022 but not in 2023, and no active hostilities or occupation during 2022-2023.

resultsNational HIV testing declined through 2021 and dropped sharply at invasion onset, followed by sustained increases after Q2 2022 (QPC + 9.14% [95% CI: 3.89; 22.47]), exceeding pre-war levels by late 2023. However, the number of positive tests decreased steadily from 5,458 in Q1 2020 to 3,590 in Q4 2023 (AQPC -3.25% [-4.86; -1.56]) and test positivity dropped from approximately 1% to 0.5% after Q2 2022 (QPC -10.48% [-22.04; -5.99]). Newly registered HIV cases were stable through 2021, declined sharply at invasion onset, briefly rebounded, and then decreased through December 2023 (MPC -1.12% [-2.39 to -0.31]). ART initiation decreased steadily from 1,495 in January 2020 to 797 in December 2023 (AMPC -1.11% [-1.40; -0.81]), without breakpoints. Post-invasion trajectories diverged regionally: regions exposed to prolonged hostilities experienced the deepest and most persistent disruptions, whereas less affected regions demonstrated gradual increases in registrations and ART initiation.

conclusionsThe full-scale war caused substantial disruption in key HIV services. Although testing increased after the initial shock, it did not translate into higher case detection, reflecting a shift from testing high-risk populations toward war-related expanded screening of blood donors, military personnel, and displaced individuals. Regional divergence in trends was consistent with population displacement and redistribution of HIV service delivery. Interpretation of wartime HIV indicators requires attention to changes in the tested population and regional service capacity. Sustaining epidemic control under prolonged war will require combining targeted case-finding with broader screening, and strengthening cross-region linkage from diagnosis to ART initiation.