Needs Assessment Study
Prevention of Mother to Child Transmission Programme

in the Republic of Moldova

Final Report

Chisinau 2009

The assessment was conducted at the request of UNICEF Moldova by an independent international consultant Dr. Zhanna Parkhomenko in August - September 2009.

Acknowledgements

I would like to express my gratitude to the staff of UNICEF Moldova – Alexandra Yuster, Representative and Sandie Blanchet, Deputy Representative – for framing evaluation mission with advancedapproaches, Larisa Lazarescu-Spetetchi and Valeria Illies, for their assistance and immense support throughout the mission.

I am also grateful to the following colleagues: Rodica Scutelnic and Galina Morari from the Ministry of Health of Moldova, Otilia Scutelniciuc, Viorina Budesteanu and Tatiana Cotelnic from the National Centre of Health Management, Stela Bivol, UNICEF consultant, Viorel Calistru, deputy director of Republican Dermato-Venerological Dispensary as well as representatives of health administrations, different medical facilities and non-governmental organisations in Baltsi, Chisinau, Orhei and Tiraspol for their valuable insights and contribution.

I would like to express appreciation to representatives of the League of PLHIV: Igor Chilcevschi, Ludmila Untura and special gratefulness to women living with HIV who participated in the focus groups.

Table of Contents

Acronyms

Key assessment findings and conclusions

1. Introduction

  1. Design, purpose and focus of the Study
  2. Methodology and timeframe
  3. Overview of the situation in Moldova
  4. UNICEF technical assistance on PMTCT in Moldova

2. Structure of the observed PMTCT services: primary care, specialized services

3. Referral systems between various levels and additional services

4. Four key PMTCT strategy interventions:

  • Primary HIV prevention in women of reproductive age
  • Family planning and prevention of unwanted pregnancies in HIV-infected women
  • Prevention of mother-to-child transmission of HIV

- Antenatal care

- Intranatal care and optimal delivery for HIV positive women

  • Care and support to HIV positive women, infants and their families

- Care for HIV+ mothers (after delivery)

- Care for children born to HIV+ mothers

5. Cross-cutting issues

- 5.1. Legislation and human rights

- 5.2 Leadership and coordination

- 5.3. Advocacy, stigma and discrimination

- 5.4 Monitoring and evaluation, including routing data collection and sentinel surveillance

- 5.5 Human resource development

6. Transdniestrian region

List of recommendations

Recommendations for UNICEF

References

Annexes:

Annex 1: Individuals contributing to the Study: Chisinau, Bălţsi, Orhei and Tiraspol.

Annex 2: Agenda of the in-country visit, August 2009

Annex 3: Agenda of the in-country visit, September 2009

List of acronyms

ANC Antenatal Care

ARVAntiretroviral

C-sectionCeasarian section

CCMCountry Coordination Mechanism

ELISAEnzyme-linked immunosorbent assay

FPFamily planning

GFGlobal Fund

GFATMGlobal Fund to Fight AIDS, Tuberculosis and Malaria

HAARTHighly active antiretroviral therapy

HCWHealth care worker

HIVHuman immunodeficiency virus

HIV+HIV-positive

IDUInjecting drug user

IECInformation, education and communication

MARPMost-at-risk population

MCHMaternal and child health

M&EMonitoring and evaluation

MHMaternity house

MOHMinistry of Health

MTCTMother-to-child transmission (of HIV)

NCCNational Coordination Council

NGONon-governmental organization

OSTOpioid substitution therapy

PEPPost-exposure prophylaxis

PLWHPeople Living with HIV

PMTCT Prevention of mother-to-child transmission

PSMProcurement and supply management

PCP Pneumocystic pneumonia

RDVDRepublican Dermato-Venerological Dispensary

RHReproductive Health

STISexually transmitted infections

TBTuberculosis

VCTVoluntary counselling and testing (for HIV)

UNUnited Nations Organisation

UNAIDSJoint United Nations Programme on HIV/AIDS

UNGASSDeclaration of Commitment on HIV/AIDS. United Nations General Assembly Special Session.

UNICEFUnited Nations Children's Fund

QCQuality control

WGWorking group

WHOWorld Health Organisation

Key assessment findings and conclusions

  1. Elaborated legislative documentation in the area of HIV/AIDS needs some revisions aimed at elimination of discriminatory provisions and subsequent monitoring of its implementation
  1. M&E system for PMTCT programme needs urgent revision, with inclusion of essential, internationally recognized indicators. This process should be also supported by improvement in a mechanism of coordination (clear distribution of roles and responsibilities for collection, analysis and reporting).
  1. Aiming at sustainability of PMTCT programme and other HIV related services, currently covered by Global Fund (GF), there is a need to conduct a strategic planning of take-over of all services, assuring their continuation, sufficient coverage and uninterrupted provision.
  1. There is a significant need to create a national, cross-sectoral comprehensive continuum-of-care system for HIV-positive and exposed children.
  1. People living with HIV (PLWH) are socially vulnerable and many of them are marginalised, having a low socio-economic status, low employment rates and low income, this affects directly children that are living in such families. Socially vulnerability of PLWH should be accounted for in planning resources for social and economic needs and developing a more accessible model of care delivery. Geographical accessibility and affordability should be taken into consideration allowing PLWH living at district/locality levels not to undertake long-distance travelling.
  1. There is a need to enhance the quality and increase a range of counselling offered to women, families, people living with HIV, women during pregnancy and parents of HIV-exposed children.
  1. System of human resources development in medical facilities should be improved in terms of development of skills and change of attitude, oriented at patient-centered approach, with inclusion of elements of monitoring and evaluation (M&E) and quality control.
  1. Current level of stigma and discrimination evident among general population and health care workers demands implementation of destigmatisation and anti-discrimination activities among medical staff as well as to execute relevant advocacy interventions by a third sector, after its significant capacity building.
  1. Certain successes are reached in ART coverage for both adults and children. Still, there should be improvements made in decentralisation of medical and social care; paediatric care should be ensured at higher quality for HIV-exposed and positive children.
  1. Ambiguities and lack of clarity determining the weak leadership in the coordination and implementation mechanism of the national response HIV/AIDS/STIs should be addressed by advancing the regulatory framework,with a particular focus on distinct responsibilities of stakeholders with clearly defined linkages between them, as well as designating a single unit responsible for functioning of effective system of monitoring and information flows.
  1. Efficacious and productive patients’ and beneficiaries involvement into planning, implementation and feedback provision systems are not in place for PMCTC component and should be established.

1. Introduction

a. Design, purpose and focus of the Study

This study was designed by UNICEF Moldova in collaboration with its national counterpart National Centre of Health Management, Department of Monitoring and Evaluation of National Health Programmes, in the framework of the technical assistance extended to the Government of Moldova in order to make recommendations for the Ministry of Health of Moldova on reduction of risk and prevention of HIV infection in infants and young children, based on the Strategy on prevention of HIV infection in infants and young children in the European Region.

The objectives of the Study were to:

a) Conduct an independent assessment, draw conclusions and formulate recommendations on Moldova’s PMTCT Programme based on review of regulatory framework, national statistics on PMTCT, data collected by PMTCT evaluation, visits to existing services and results of the meetings with main counterparts from governmental institutions and civil society organisations;

b) Revise report produced by the national team, write sections on results and recommendations, on legal and M&E frameworks.

This objective was achieved through:

  • Reviewing of the current status of the PMTCT programme, including relevant Laws, Regulations and Policies; activities in support to PMTCT programme in Moldova and history of the national response in the area;
  • Reviewing of the national available data and recommendations to existing M&E framework in the area of PMTCT;
  • Reviewing the quantitative and qualitative evaluation reports produced by the national team and providing recommendations on key priorities, evidence of effectiveness, gaps and shortcomings; special attention should be given to access to PMTCT by most-at-risk population, including drug dependent pregnant women;
  • Conducting spot checks in specialized health institutions (Chisinau, Balti and Tiraspol)
  • Conducting consultations and interviews with relevant stakeholders and main governmental partners, including civil society organisations, with regard to clarification of the national targets and developments in the area of PMTCT (during the in-country phase of the evaluation);
  • Suggesting practical tools and action that could strengthen and make sustainable National PMTCT programme;
  • Keeping respective communication with evaluation team in electronic and hard copy forms;
  • Briefing representatives of both government and UN Joint Team on HIV/AIDS on findings and recommendations by the end of the mission.

The Study consultant worked under the supervision of the Chief of HIV/AIDS Programme and in close collaboration with the National Evaluation team established by the MOH.

The main emphasis of the Study was on the evaluation of the programmes, activities, processes and results at the national level. While there are some differences between different parts of the country and some challenges associated with it (e.g. situation with Transnistria), the Study did not purport to conduct an in-depth comparison of regional peculiarities and concentrated on the national level (however, some findings and conclusions do address the regional issues).

The list of evaluation areas covered by the study represents a comprehensive overview of four key PMTCT strategy interventions to be implemented as integral components of essential maternal and child health (MCH) services, as specified by the World Health Organisation.

The Study focused on these main areas:

  • primary prevention of HIV among women of reproductive age
  • prevention of unintended pregnancies among HIV-infected women
  • prevention of HIV transmission from infected women to their infants during pregnancy, delivery and breastfeeding
  • provision of appropriate care, treatment and support to HIV-infected women, affected children, and their partners and families.

In addition to the areas specified above, the Study also focused on the several crosscuttingissues of significant importance such as legislation, leadership and coordination, advocacy, human rights, monitoring and evaluation, human recourse development, stigma and discrimination.

A separate objective of this Study is to evaluate and advise on possible gaps in implementation of effective PMTCT interventions by UNICEF. UNICEF is preparing a gradual hand-over of PMTCT programme to the national stakeholders and recommendations were requested as to identify the gaps and subsequently address them during the hand-over process.

b. Methodology and timeframe

In preparation for the in-country visit, background documents and some data on the current status of PMTCT Programme in Moldova were studied. During the in-country visit, local team also assisted with additional documents such as National guidelines, reports, presentations of national counterparts and other data as and when was necessary.

The primary source of information was interviews with key respondents (see the complete list in the Annex): relevant government officials at the national and regional level, members of the UN agencies, senior management and staff of medical facilities of various levels,

representatives of non-governmental organizations and civil society. The introduction/orientation provided by the UNICEF team at the beginning of the visit proved to be effective in creating a cohesive overall picture of the situation in the country as well as in finalizing objectives and expectations of this mission.Focus groups with HIV+ mothers conducted during the second in-country mission allowed to enrich the data received from the Survey conducted in 2009 and gain more information on services from services’ beneficiaries standpoint.

To enable the consultant to get first hand impression and assess the achievements and challenges faced, site visits were undertaken to Baltsi and Tiraspol (Transnistria).

Assessment phases and relevant time-frame:

Phase 1: Desk review and development of instruments (July 2009)

Phase 2: In-country mission (August 3-7, 2009)

Phase 3: Preparation of Draft Report (August18, 2009)

Phase 4: In-country mission (September15-18, 2009)

Phase 5: Consultations and Completion of the Final Report (September 27, 2009)

c. Overview of the situation in Moldova

HIV/AIDS, sexually transmitted infections (STIs) and tuberculosis (TB) are among the most urgent public health problems in Moldova. Moldova's early actions to fight HIV/AIDS and tuberculosis have slowed the growth of these two epidemics in the country. Nevertheless, HIV/AIDS transmission in Moldova remains a matter of major public health concern.

The Republic of Moldova is classified as a concentrated/low prevalence country with an HIV epidemics concentrated in Injecting Drug Users (IDUs) with signs of spread in the general population. Despite the significant scale-up of prevention programmes, supported largely by the current Global Fund grant, HIV continues to spread. In the last 8 years there is a stable increase in the number of newly reported HIV cases, with 795 new cases of HIV officially registered in 2008. 343 cases of 795 were registered in Transnistria – the highest number of new annually registered cases since the beginning of surveillance in 1987. By the end of 2007 cumulatively there have been reported 4131 new HIV cases for both banks of Dniester River, of which about 33% have been registered in 2006-2007[1]. As of December 2008, a total number of PLWH was 4,996, however, the real figure is likely to be much higher as these are mostly diagnostic results. UNAIDS estimates there are 15,000 – 69,000 people living with HIV in Moldova (for a population less than 4 million).

A serious factor contributing to a spread of HIV in the country is its high economic migration. The fall in Moldova’s living standards has led to a to the emigration of a large part of the population mainly to the countries of Western Europe (Italy, Spain, Portugal, France) and Russia in search of jobs and economic opportunities; e.g. in 2005 367,000 Moldovan citizens or 10% of the population[2] left the country in search of employment opportunities abroad. The expansion of the European Union eastwards, which has favored labor migration and labor mobility within Europe, has also contributed to the increased labor emigration of Moldovans. According to the World Bank, Moldova, as a proportion of the population, is one of the largest emigration countries in the world. Large-scale emigration by people in search of work, particularly to neighbouring countries like Russia and Ukraine – countries which have HIV epidemic even at the higher scale – mean there are many migrant workers who may be more vulnerable to HIV infection. It may become a determinant in the further evolution of HIV epidemic in Moldova.

The sexual route is the major route of transmission among newly reported HIV cases – 63.2% in 2007 (out of 731 new cases), among those, the rate of women reached 62.2% in 2007. Since 2005, the sexual route of transmission has got the majority andthere is a stable trend towards increasing in this route of transmission among newlyreported HIV cases (2007 – 62.2%, 2006 – 57.2%). The shift in the structure of newly reported HIV cases pointes to an increased vulnerability of women and signify a continuous feminization of HIV epidemic in Moldova.

The significant coverage of pregnant women with HIV testing during 2003-2007 (varies within 96-99.4% interval) [3] which allowed obtaining accurate data on HIV prevalence among pregnant women, indicates that there is also an increase in the number of newly reported HIV cases among pregnant women. HIV prevalence among pregnant women continues to go up: 0.1% in 2005; 0.21% in 2006; 0.23% in 2007. Also more HIV positive womenwho have learnt about their HIV status previouslydecide to give birth (13 HIV-positive women in 2006 and 31 HIV-positive women in 2007). The proportion of HIV cases due to perinatal transmission is relatively small (1.15 per cent of the total number of recorded cases), but this indicator has the worsening tendency.

Government of the Republic of Moldova undertakes through a system of relevant institutions and agencies a whole range of activities in HIV/AIDS field aimed at curbing the growth of epidemics.

At the national level, the state policy in the area of HIV/AIDS in Moldova is implemented through the National Programme on Prevention and Control of HIV/AIDS and STIs for 2006–2010(National Programme), which determines national strategies of priority for prevention, epidemiological surveillance and treatment. In 2007 the Parliament of the Republic of Moldova has approved a new Law on Prevention of HIV/AIDS (HIV Law) which has been developed based on the international recommendations of observance of human rights and ensuring universal access. Its implementation faces some challenges as stigma against PLHIV remains and discrimination is common. In 2007, based on the Order of the Ministry of Health Nr. 344 of 05.09.2007 a network of VCT centres has been established which could ensure universal access of the general population to counselling and testing to HIV. PMTCT has been identified as a government priority in Strategy VII of the current National Programme and significant progress has been achieved in decreasing the rate of HIV transmission from mother to child. To ensure quality of the donated blood the Ministry of Health initiated the development of quality standards for blood safety. Public response to HIV prevention programme has been generally positive, although opposition from the religious sector to condom use and health education programmes is emerging as an obstacle.Moldova has succeeded in implementation of the harm reduction Strategy, with main activities comprising information/education/outreach, needle exchange, referral towards medical and social services and methadone substitution therapy (including penitentiary institutions).M&E Unit was created in the NationalCenter for Health Management bearing the full responsibility for general data collection and surveillance mechanisms in HIV/AIDS area. Significant progress has been made in the provision of medical care and treatment for people living with HIV and AIDS, at present the ART coverage rate in Moldova is among the highest in the region.

The government of Moldovahas consistently allocated resources towards the implementation of activities within the framework of the national response to HIV/AIDS (mainly within National Programme); the state budget contributions represent a proof of the government commitment.Financing of the current National Programme has been supported from: