New Study Offers Insights into an Old Problem—The Links Between War and Infectious Diseases: Public Health Watch

War is hell.

Unfortunately, it also provides the perfect setting for infectious disease outbreaks.

In a study published online on January 16, 2018, by the journal Proceedings of the National Academy of Sciences (PNAS), a multinational team of investigators revealed a “link between conflict-induced displacement of people and the spread of HIV within Ukraine.” Ukraine has been engulfed in a civil war—although it hasn’t always been referred to as such—since the Russian Federation’s annexation of the region of Crimea in early 2014.

The conflict has been marred by human rights abuses, as well as tens of thousands of civilian casualties. Various organizations estimate that nearly 1.5 million Ukrainian civilians have been displaced as result of the fighting.

And it is this latter group that has been particularly vulnerable to infectious disease outbreaks.

Indeed, as the authors of the PNAS paper note, Ukraine has among the worst epidemics of HIV/AIDS in the world, with an estimated 240,000 individuals living with HIV, 17,000 new cases annually, and a prevalence among adults of 0.9% (data as of 2016). Needless to say, the ongoing conflict hasn’t helped matters.

The authors analyzed HIV-1 subtype A polymerase DNA sequences collected from 427 patients at 24 regional clinics in Ukraine between 2012 and 2015. The study period spans the years immediately prior to the conflict in the country, as well as the first year following the annexation of Crimea.

Perhaps not surprisingly, the regions of the eastern part of the country that have served as the primary battlegrounds—Donetsk and Lugansk, both of which were already home to roughly a quarter of the country’s HIV-positive population—were the “main exporters of viral lineages within the country,” based on the authors’ analysis of epidemiological and phylogeographic data. From there, they found, the virus spread to the central and southern regions of the country and to the major cities of Kyiv and Odessa.

Further analysis revealed that viral dissemination within the country evolved after the start of the conflict in early 2014, with incoming virus flow correlating to “the number of HIV-infected internally displaced people,” as well as a link between “more intensive virus movement and locations” and higher populations of people who inject drugs and/or practice risky sexual behaviors (eg, not using a condom during sex). The authors believe their findings highlight the need for enhanced HIV surveillance and prevention measures in regions “directly affected by armed conflict.”

“Our findings suggest that effective prevention responses should involve internally displaced people and people who frequently travel to war-affected regions,” they write. “Scale-up of harm reduction services for [people who inject drugs] will be an important factor in preventing new local HIV outbreaks in Ukraine.”

The PNAS report is hardly the first to link conflict with public health challenges. A landmark study in PLOS Pathogens published in 2014 described the rise of poliomyelitis, measles, cutaneous leishmaniasis, and other communicable diseases during the Syrian Civil War, which began in 2011 and continues to this day. Remarkably, the authors of that paper chronicle more than 50,000 new cases of cutaneous leishmaniasis, more than 2,000 cases of hepatitis A, and more than 1,000 cases of typhoid fever in the country in 2012 alone.

In fact, in a commentary published in The Lancet in 2002, authors Máire A. Connolly (then of the World Health Organization [WHO] and now of the outbreak watchdog group PANDEM) David L. Heymann (of the WHO and Chairman of the Board of the Health Protection Agency in the United Kingdom) describe war and infectious diseases as “deadly comrades… [that] have accounted for a major proportion of human suffering and death. Infectious diseases ruthlessly exploit the conditions created by war, affecting both armies and civilians.”

And so, while researchers struggle to find cures for troubling infectious diseases such as HIV/AIDS, there is plenty of data suggesting that the most effective prophylaxis and/or treatment may be, well, peace.

How’s that for a radical idea?

Brian P. Dunleavy is a medical writer and editor based in New York. His work has appeared in numerous health care-related publications. He is the former editor of Infectious Disease Special Edition.