“HIV Data triangulation and Modes of Transmission for public health actions”
Data Synthesis on Tendencies of the HIV epidemicin the Republic of Moldova 2011
Chisinau, 2011
Keywords: Epidemiology; Data Triangulation; HIV/AIDS; incidence; mathematical modeling; Modes of Transmission; Moldova; prevalence; prevention; risk behavior; synthesis.
Contributions
Coordination:
Otilia Scutelniciuc, Head of M&E unit, NationalCenter for Health Management
Lev Zohrabyan, UNAIDS RST Moscow
Aliona Serbulenco, Ministry of Health of the Republic of Moldova
Alexandrina Iovita, M&E Adviser, UNAIDS Moldova
Implementing institutions
NationalCenter for Health Management, M&E unit
NationalCenter for Public health and its subordinated National Center of AIDS Prevention and Control
Tiraspol AIDS center
Technical working group on HIV triangulation
- Aliona Serbulenco, Ministry of Health of the Republic of Moldova
- Ştefan Gheorghiţă, Director, AIDS Center
- Ecaterina Rotari, Epidemiologist, AIDS Center
- Valeria Dmitrienco, Head of AIDS Reference Lab, AIDS Center
- Otilia Scutelniciuc, Head of M&E unit, National Center for Health Management
- Tatiana Cotelnic – Harea, M&E unit, National Center for Health Management
- Victor Diatişen, SCBI “Toma Ciorbă”
- Vitalie Slobozian, Program Coordinator, Soros Foundation-Moldova
- Mihai Oprea, Republican Narcology Dispensary
- Olga Osadcii, AFEW
- Alexei Leorda, UORN
- Vasile Ghileţchi, DDVR
- Mircea Beţiu, head specialist STIs
- Alexandru Goncear, director, Tiraspol AIDS Center
- Regina Povar, LPTH
- Silviu Ciobanu, coordinator, WHO Moldova
- Alexandrina Iovita, M&E adviser, UNAIDS Moldova
National consultants
Stela Bivol, PASCenter, report writing
Valeria Dmitrienco, NationalAIDSCenter, coordinator of testing data collection
Ecaterina Rotaru, NationalAIDSCenter, coordinator of case registration data collection
External consultants
Donna F. Stroup, consultant, Data for Solutions
Paloma Cuchi, Senior Adviser, UNAIDS HQ
Kelsey Case, MoT consultant, Imperial College of London
Correspondence to:
Lev Zohrabyan, UNAIDS RST Moscow, 9, Leontyevsky side-street, Moscow 125003, Russia
Tel.: (7 495) 663-6781; Fax: (7 495) 663 6799; E-mail:
Otilia Scutelniciuc, UNAIDS Country Office, UN building, 67 Tole Bi St . 050000, Almaty, Kazakhstan Phone:+ 7 727 258 26 43 (ext. 1303) Fax:+7 727 258 26 45;
Alexandrina Iovita, M&E Adviser, UNAIDS Moldova 67, Bucuresti Street,2012 Chisinau, Republic of Moldova, Tel: +373 22 244815/ Fax: +373 22 855971 E-mail:
Acknowledgements
The HIV Data Triangulation Study (DT), Modes of Transmission (MoT) Analysis in Moldova projectswere funded by the JointUnited Nations Programme on HIV/AIDS (UNAIDS). The HIV Strategic Information Synthesis Project in the countries of the Eastern Europe and Central Asia is designed to build rigorous, scientifically robust evidence to support countries in the development of targeted and cost effective national strategies.
The study team is grateful to all the persons who participated in the national DT/MoT workshops and stakeholder meetings held in Moldova and who provided valuable data and information onkey characteristics and indicators of the HIV epidemic in Moldova.
We would like to especiallyacknowledge UNAIDS headquarters, UNAIDS Regional Support Team for ECA and UNAIDS Moldova country office, Ministry of Health and National AIDS Programme, researchers, NGOs, and various other key public healthexperts and practitioners working in this field.
Acronyms
AIDSAcquired Immunodeficiency Syndrome
ARVAntiretroviral
BCCBehaviour Change Communication
BSSBehavioural Surveillance Survey
CHSCasual Heterosexual Sex
DTData Triangulation
EPPEstimates and Projections Package
GFthe Global Fund
GFATMthe Global Fund to Fight AIDS, Tuberculosis and Malaria
GPSGeneral Population Survey
HIVHuman Immunodeficiency Virus
HRHarm Reduction
IBBSIntegrated Bio-Behavioral Survey
IECInformation, Education and Communication
IDUInjecting Drug User
KAPKnowledge, Attitudes and Practice
Left BankTransnistrian Region
LGBTLesbian Gay Bisexual Transgender
MARAMost-At-Risk Adolescents
MARNMost-At-Risk Network
MARPMost-At-Risk Population
MDGMillennium Development Goals
MoHMinistry of Health
MoTModes of Transmission
MSMMen Having Sex with Men
M&EMonitoring and Evaluation
NAPNational AIDS Programme
NCHMNationalCenter of Health Management
NGONon-governmental Organization
OSTOpioid Substitution Therapy
PLWHPeople Living with HIV
PMTCTPrevention of Mother-to-Child Transmission
Right BankRepublic of Moldova, excluding Transnistrian Region
STISexually Transmitted Infections
SWSex Workers
TWGTechnical Working Group
UNUnited Nations
UNAIDSUnited Nations Joint Programme for HIV/AIDS
UNAIDS RST ECAUNAIDS Regional Support Team for Europe and Central Asia
UNFPAUnited Nations Population Fund
UNGASSUnited Nations General Assembly Special Session
WHOWorld Health Organization
VCTVoluntary Counseling and Testing
Executive summary
HIV Data Triangulation and Modes of Transmission Modeling Context
Since 1987, a total 6,404 cases of HIV have been registered in the Republic of Moldova. The HIV prevalence (according to IBBS 2009-2010) is 16.4% among persons who inject drugs (IDU), 6.1% in female sex workers (SW), and 1.7% in men who have sex with men (MSM) in Chisinau, the capital city. National estimates for prevalence of HIV in prisoners are 3.5% for 2009. Since 2004 the national statistics report a shift from injecting drug to heterosexual mode of transmission and in 2010, official statistics report 704 newly registered cases with 86.8% due to sexual transmission.However, there was no sufficient detail in the national data about the sub- populations involved in the sexual transmission.
The current HIV epidemiologic and strategic information is not sufficiently detailed about which groups of populations are currently most affected by the HIV epidemic. Given the availability of a relatively good volume of HIV data, the sustained HIV response efforts at the national level and the presence of a highly active civil society and NGOs working on HIV prevention and treatment services, in December 2009UNAIDS has taken decision to conduct data triangulation (DT) and Modes of Transmission (MoT) processes in Moldova.The results of the DT and MoT processes will help the national key stakeholders in developing an evidence-based biannual National Operational Plan for HIV prevention as part of the National AIDS Program. The additional purposes were to strengthen the capacity of national stakeholders to analyze and use national HIV data in decision-making on prioritieis in allocating scarce resources for HIV prevention purposes.
Goals of DT and MoT processes
The goals of DT in Moldova were: (1) to assess trends in HIV in Moldova in key subgroups of the population; (2) to evaluate the effectiveness of selected prevention efforts and (3) to provide recommendations to strengthen the analysis of existing data and address limitations when planning future data collection activities.
The goals of MoTmodeling in Moldova were to: (1) understand sources of new HIV infections and the importance of each in the distribution of new HIV cases in 2010 in the Republic of Moldova; (2) to use the MoT modeling results as an additional data source for triangulation question no. 1: What are the tendencies of the HIV epidemic evolution in Republic of Moldova?
Methods
The DT process in the Republic of Moldova has followed the 12-step process recommended by the HIV Data Triangulation Resource Guide (GFATM/WHO/UNAIDS, 2009). The analytical approach is a synthesis of the following data sources: routine statistics for HIV cases and case-reporting for the new HIV cases for years 2004-2009, data from PLWH clinical follow-up, HIV surveillance data based on IBBS, STI surveillance and programmatic data; program-based statistics for MARPs; behavioral indicators from GPS, IBBS, KAPs, and migrant studies; HIV projection scenarios from EPP and Spectrum models through 2009 and Modes of Transmission 2010 results.
The final investigation questions for DT exercise were:
- What are the tendencies of the HIV epidemic evolution (due to migration/mobile populations, in the rural sector, youth, MARPs) in Republic of Moldova?
- What are the impacts of HIV prevention measures on behavior changes among the key populations (MARPs, youth, migrants)?
For the MoT process, the MoT mathematical model built by the UNAIDS Reference Group on Estimates, Modelling and Projections was used. (UNAIDS, 2007) It uses input data on the current prevalence of HIV infection in a population risk group, the number of individuals in particular risk groups, the risk of exposure to infection within each group, the STI prevalence and the prevalence of protective behaviors. The main data sources were the most recent integrated bio-behavioral surveys conducted in MARPs in years 2009-2010, size estimations exercises from 2009, general population surveys, as well as national HIV statistics and Demographic statistics from the National Bureau of Statisitcs . To check the input values, the trends were checked with prior similar surveys. In the few instances where data was not available we have used regional estimates using the same method to derive values as the published articles reported.The MoT modeling process in Moldova has benefited from logistics piggy-backing on the DT, thus bringing significant cost-savings.
Limitations in the DT process include data quality issues related to routine statistics, data registration methods, as well as inconsistency of methods, generalisability issues in survesy of MARPs that significantly limited trend analysis. There was insufficient data to answer the investigation question about prevention effectiveness among SWs, MSMs and migrants. MoTlimitations include some inherent to MoT model and a set of limitations related to quality, power and representativeness of surveys that were data sources for inputs for the MoT model, whichresulted in large confidence intervals for new incident cases, which significantly limits data interpretation.
Key findings
The results of both MoT and DT processes have indicated to a largely MARP-driven epidemic in the Republic of Moldova. The MoT has estimated that almost two-thirds of HIV incidence would be MARP-related and the DT results show a still largely male and urban epidemic (MARPs), as captured by the national case-reporting system in the years 2005-2009.
DT shows that unsafe drug injecting mode of transmission is decreasing in importance for younger people and new HIV casesas a result of unsafe injecting occur mostly in the older IDUs. The IDU population appears to still be the major driver of the HIV epidemic in Moldova given the highest HIV prevalence. If unsafe behaviors are not underreported,HIV transmissionoccurs less through unsafe injecting of drugs, given the normative single syringe use, decreasing injection frequency and the much lower proportion of HIV and HCV prevalence in the younger IDUs. The main pool of new HIV infections are likelytheir sexual partners, as estimated by MoT, with the limitations of wide confidence intervals.
Figure 1Estimated HIV Incidence for 2010, MoT, Republic of Moldova
A much more important size and role of the MSM population in the HIV epidemic is estimated by MoT. MSMs are the most hidden population because of high stigma in the Republic of Moldova. Some 33% of MSMs have female partners, thus this subpopulation of MSMs serves as an important bridge population that is mainly uncovered by prevention message and practices a high-risk behavior as qualitative research has shown. The gay community also acknowledges the difficulty in targeting MSM that do not identify themselves as homosexuals.
While the MoT estimates a moderate role of SWs and their network, based on the current evidence, the clients of SWs and SWs have the highest STI prevalence (18.1%) and SWs (10.5% had syphilis), probably indicating that a higher rate of unprotected commercial sex occurs and an over-reporting of consistent condom use by SWs in the IBBS. The HIV prevention evaluation confirms it by qualitative research that there areimportant financial incentives to practice unprotected commercial sex.
The HIV epidemic is currently concentrated among males in urban areas of Moldova. The HIV epidemic in 2010 continues to be determined by MARPs and their sexual partners. The share of new cases is shifting from younger IDUs to older age groups. Distribution of transmission routesindicates to an increase of heterosexual and homosexual risks in MARPs.
A newer tendency an increase in the number of cases in women and in rural areas, but data is not sufficient to assess if this is related to a less documented IDU network or extension of sexual networks of IDUs to rural areas. Generally, adults in Moldova have much higher prevalence of syphilis compared to Western Europe, and although studies did not show a high number of overall and casual and commercial sexual partners, when consistent condom use is not a norm and qualitative research shows low condom acceptability in the general population. The national HIV case reporting documents an increasing proportion of labor migrants among the new HIV cases, but there are few other data sources to examine into more detail the factors associated to transmission and need furtherstudies. The lack of data prior to 2004 limits the ability to assess trends.
While prevention activities thus far had an outcome and impact over the HIV transmission through promotion of safer injecting, the HIV prevention efforts to decrease sexual transmission from IDUs werenot as successful in increasing protective behaviors. The only sustained effort on promoting condom use and acceptability has been shortly implemented for youth for only two years.
Recommendations
Use and Dissemination of Data
Findings from Data Triangulation and trend analysis should be reflected in national strategies and priorities on HIV/AIDS prevention and control.
- Reinforce the importance of primary focus on HIV prevention among MARPs in the NAP. Use the results from this analysis as an advocacy tool to improve and re-target funding for national HIV/AIDS response according to epidemiological evidence. The prevention activities should focus on improving the quality of harm reduction programs targetings IDUs, sex workers and MSM and their sexual partners to maintain their protective behaviors. In addition, there is a need to strengthen the focus on safer sex behaviors of MARPs and their sexual partners.
- Develop effective data collection and monitoring and evaluation mechanisms to measure the effectiveness of HIV prevention and intervention efforts.
- Add Hepatitis C testing and CD4 count and viral load testing at the time of HIV diagnosis by the NationalAIDSCenter. This will significantly improve the ability of national statistics to better assess transmission routes and identify late presenters.
Future Data Collection and Analysis
- Coordinate data collection tools in HIV surveillance and routine HIV case reporting to improve quality and reliability of the routine case-reporting and surveillance.
- Consistently use sampling methods and same data collection tools among the same populations (BBS) to ensure high quality and comparable data for trend analysis.
- Establish systematic surveillance and programmatic data collection from both Right and Left Banks.
- Develop automated data collection systems from the regions. Consider Epi Info ( for implementation in regional labs with routine reporting and analysis of testing data.
- Develop an approach to assessing the incompleteness of testing data for IDUs. Estimation of size methods can be useful here. For example, data from IBBS could be combined with testing data if the question about testing is included in IBBS questionnaire and if records can be matched probabilistically from one source to another. Other sources of data for IDUs can also be used: narcology clinics, NGO clients, other treatment registries, and police data.
- Further investigate HIV prevalence data in labor migrants through studies.
Key messages for prevention efforts
- Risk behavior networks involving IDUs, MSMs and SWs and their sexual networksstill predominantly drive the HIV sexual transmission in Moldova. These are the populations for whichHIV response and programming efforts continue to be prioritized.
- HIV transmission through unsafe injecting drug use is on decrease probably some due to effectiveness of prevention efforts of changing the norms about syringe sharing, but over-reporting in IBBS is also possible. Most incident cases are registered in adult drug users over 25 years. The major transmission route is probably sexual transmission from IDUs and other MARPs, for which prevention programs have not been as effective.
- More than half of new HIV cases still arise in men in the urban areas. Less than half of new HIVinfections are registered among women, and given current evidence, the majority of women acquires their infections from their partners, MARPs or non-MARPs.
- A significant share of new HIV cases report a history of labor migration, thus the migration factor needs to be investigated into further detail, in order to provide more evidence about its role in the epidemic.
- Compared to a high rate of sterile syringe use, consistent condom use rates are lower because of personal factors of condom acceptability, an area that has not been as effectively addressed in the current prevention programs targeting key populations. This needs to be the primary focus of future prevention of HIV sexual transmission efforts.
- There are still gaps in understanding the HIV sexual transmission in Moldova, as the reporting of heterosexual transmission route does not distinguish between different types of sexual spread.
Contents
Acronyms
Executive summary
HIV Data Triangulation and Modes of Transmission Modeling Context
Goals of DT and MoT processes
Methods
Key findings
Recommendations
Use and Dissemination of Data
Future Data Collection and Analysis
Key messages for prevention efforts
Contents
List of figures and tables
Background
HIV epidemiology in the Republic of Moldova
Rationale for data triangulation and modes of transmission processes
Data Triangulation Methods
Data Triangulation Process
Data sources
Ethics
DT findings dissemination and use
Limitations of data triangulation
Data Triangulation Results
Investigation question no. 1: What are the tendencies of the HIV epidemic in the Republic of Moldova?
HIV Testing Trends
HIV New Cases
New Cases: Geographic Distribution
Distribution of HIV Transmission Routes
HIV trends in people who inject drugs