Evaluation of HIV Prevention Programmes in the Republic of Moldova 2010
DRAFT
February 2011
Contributions
Data collection team
Ecaterina Busuioc,Prevention and Communication Specialist, CoordinationDepartment, National AIDS Center
Silvia Stratulat, VCT Specialist, CoordinationDepartment, National AIDS Center
Lilia Toderascu, M&E consultant, VCT, M&E Unit, National Center for Health Management
Tatiana Cotelnic, M&E consultant, SIME-HIV,M&E Unit, National Center for Health Management
Coordination and assistance
Otilia Scutelniciuc, Chief of M&E Unit, National Center for Health Management
Stefan Gheorghita,Deputy Director, National Center for Public Health, AIDS Center)
Lilian Gutu, Chief of Prevention Unit, Tiraspol AIDS Center
Alexandrina Iovita, M&E Adviser, UNAIDS
Authors
Stela Bivol, independent consultant
Natalia Vladicescu, Director, "Iligaciu" SRL
Larisa Lazarescu, independent consultant
Angela Dumitrasco, independent consultant
Olga Osadcii, independent consultant
Acronyms
AIDSAcquired Immunodeficiency Syndrome
ARVAntiretroviral
BCCBehavior Change Communication
BSSBehavioral Surveillance Survey
FSWFemale Sex Workers
GFthe Global Fund
GFATMthe Global Fund to Fight AIDS, Tuberculosis and Malaria
HIVHuman Immunodeficiency Virus
HRHarm Reduction
IBBSIntegrated Bio-Behavioral Survey
IECInformation, Education and Communication
IDUInjecting Drug User
KAPKnowledge, Attitudes and Practice
LGBTLesbian Gay Bisexual Transgender
MARAMost-At-Risk Adolescents
MARPMost-At-Risk Population
MoHMinistry of Health
MSMMen Having Sex with Men
M&EMonitoring and Evaluation
NAPNational AIDS Programme
NCHMNational Center of Health Management
NCCNational Coordination Council
NGONon-governmental Organization
NHIFNational Health Insurance Fund
OSTOpioid Substitution Therapy
PLWHPeople Living with HIV
PMTCTPrevention of Mother-to-Child Transmission
RNDRepublican Narcology Dispensary
SFMSoros Foundation Moldova
STISexually Transmitted Infections
TBTuberculosis
TWGTechnical Working Group
UNUnited Nations
UNAIDSUnited Nations Joint Programme for HIV/AIDS
UNDP United Nations Development Programme
UNFPAUnited Nations Population Fund
UNGASSUnited Nations General Assembly Special Session
UNICEFUnited Nations Children’s Fund
WHOWorld Health Organization
VCTVoluntary Counseling and Testing
YFHCYouth Friendly Health Clinics
YFHSYouth Friendly Health Services
Contents
Background
Evaluation Purpose and Methodology
Goal of prevention evaluation
Methods
Results
Legislation, policies and recommended strategies in HIV prevention
Prevention Programs Targeted to Most-at-Risk Populations
Injecting Drug Users – Needle and Syringe Programs
Injecting Drug Users – Opioid Substitution Therapy
Female Sex Workers
Men having sex with men
Prevention Programs Targeted to General Population
Young people
Other key populations perceived as higher risk in the general population
Supporting HIV Prevention Activities and Services
HIV Voluntary Counseling and Testing
Behavioral Interventions to Reduce Sexual Transmission of HIV
Positive Prevention
Background
Currently, the HIV epidemic in the Republic of Moldova is considered to be concentrated among most-at-risk populations (MARPs) mostly Injecting Drug Users (IDUs) in civilian and prison sectors, female sex workers (FSWs) and men who have sex with men(MSMs)) and their sexual partners. The HIV prevalence among IDUs andFSWs is significantly higher (5% and above) compared to other screened sub-populations(migrants, young people, blood donors, pregnant women) in the Republic of Moldova. The HIV prevalence in IDUs and FSWs shows signs of decrease in the city of Balti and shows fluctuating results in Chisinau. The official HIV/AIDS statistics allow for breakdown of HIV cases by mode of transmission and not by MARP category, so at the end of year 2010, the IDU mode of HIV transmission accounted for 43% of cumulative cases, sexual mode for 55%, vertical transmission for 1.5% and undetermined mode for 1.2%[1]. There are signs of spread into sexual partners of MARPs. The estimations based on the Modes of Transmission Modeling show that in 2010 sexual partners of IDUs would have accounted for 30% of the heterosexual transmission of HIV, the single highest category compared to other subpopulations. [2] The official statistics show for the year 2010 some 8.1% of HIV cases transmitted through injecting drug use, heterosexual transmission was responsible for 85.9%, homosexual for 0.85%, mother to child for 1.42% and undetermined for 3.7%.[3]
Since year 2002, the HIV epidemic process is characterized by an increase in heterosexual mode of transmission, feminization of the epidemic and geographical spread in all administrative units of the country, including rural areas. As of January 2011, the HIV cumulative incidence of registered cases constituted 120.11 on the Right Bank and 378.6 on the Left Bank (Transnistrian region), with an average total cumulative incidence of 155.9 per 100,000 population. The hardest hit regions are the cities of Balti with HIV cumulative incidence of 861.0, Chisinau, capital city (146.4) and on the Left bank, Rybnitsa (609.6) and Tiraspol city (579.5). As of January 1, 2011, a cumulative number of 6,404 HIV cases were registered, including 2,127on the Left Bank.The annual incidence of registered cases has increased more than two-fold to 17.12 in year 2010 compared to 8.4 in year 2004.[4] In the past six years the majority of newly registered HIV cases in the Republic of Moldova report heterosexual transmission as probable route (85.9% in 2010). Although still bellow 1%, some screened subpopulations in the general population become increasingly affected (migrants, youth, pregnant women, blood donors). The number of newly registered HIV cases among blood donors has been constant in the past years (60.6 newly registered HIV cases per 100,000 blood donations in 2007 compared to 59.9 in 2010) and among pregnant women has registered on a stab le trend(83 newly registered HIV cases in 2008 compared to 69 in 2009 and87in 2010[si1]).[5] HIV affects mostly young adults, as 85% of total HIV cases have been registered in the age group 15-39 years (including 29.7% among those aged 15-24 years).[6] The gender ratio has significantly changed towards an increase of the share of HIV-infected women in the number of new HIV cases from 26.5% in year 2001 to 39.2% in year 2010.[7]
The Government is committed to fight the epidemic and allocates financial, human and infrastructural resources for this purpose. However, substantial financial and programmatic gaps exist, especially in regard to the complex interventions in HIV/AIDS prevention activities among most-at-risk population groups.HIV Prevention in MARPs has been implemented with substantial Global Fund Rounds 1 and 6 support through community-based organizations.
Evaluation Purpose and Methodology
Goal of prevention evaluation
- Determine the effectiveness of an HIV prevention project in changing the risk behaviour among IDUs in the NAP implementation period 2006 – 2010, on the right bank of Nistru. Determine the key factors contributing to or impeding project results. The findings of the evaluation will be used to inform government and NGO partners of the viability of scaling up the harm reduction programme to rural areas.
- Assess the effectiveness of HIV prevention interventions focusing on behavior change in the general population, with a particular focus on young people, in the NAP implementation period 2006 – 2010, on the right bank of Nistru. Determine the key factors contributing to or impeding results. The findings of the evaluation will be used to inform government and NGO partners in planning Behavior Change Communication in the framework of the NAP 2011 – 2015.
Methods
A working group consisting of 12 national experts and stakeholders conducted an internal evaluation of the HIV prevention efforts. The assessment was conducted in the period September 2010 [si2]- February 2011. The evaluation team conducted the following activities:
Desk Review[si3] and Secondary Data Analysis
The main quantitative information sources were HIV national statistics, studies on size estimations of at-risk groups, and IBBS, Youth KAPs and General Population Surveys, as well as other evaluation studies, prevention program reports and program reviews. The most recent reports, databases and preliminary results of the most recent studies have been used, thus many sources are still in draft version and unpublished and include preliminary data.
Focus groups and in-depth interviews
With the intent to complement quantitative data with ethnographic understanding of underlying behaviors related to HIV transmission, the prevention evaluation team developed interview guides for evaluation of behaviors and coverage and access to HIV prevention services for IDUs (male and female), FSWs, MSMs (Chisinau and Balti), young people in the age groups 15-19 years and 20-24 years (rural and urban) and PLWH. Professional investigators conducted focus groups and in-depth interviews in the period October 2010 - February 2011. The detailed list of focus-groups schedules and the number of people who participated is included in the table below.
Table 1. Distribution of focus groups and in-depth interviews by categories
Category / Date / # participants- General population
Young people (15 – 19) rural, male / 7.11.2010 / 7
Young people (15 – 19) rural, female / 31.10.2010 / 7
Young people (20 – 24) rural / 24.10.2010 / 9
Young people (20 – 24) rural / 14.11.2010 / 11
Young people (15 – 19) urban / 23.10.2010 / 7
Young people (20 – 24) urban / 30.10.2010 / 7
- MARPs
IDUs, men / 16.11.2010 / 11
IDUs, women / 17.11.2010 / 9
FSW / 10.02.2011 / 5
MSM / 10.11.2010 / 11
MSM / 11.11.2010 / 11
MSM / 19.11.2010 / 9
- People living with HIV
Men living with HIV / 28.12.2010 / 11
Women living with HIV / 29.12.2010 / 12
In addition, in order to evaluate the quality of VCT services, 6 VCT counselors and 20 VCT clients who underwent either pre-test or post-test counseling were interviewed in 5 different locations, of which three cities, Chisinau, Balti and Bender and two rayon centers, Soroca and Cantemir.
Table 2Distribution of qualitative interviews with VCT clients
Location / Date / Female / Male / Self-referral / Provider-initiatedChisinau, AIDS Center / Dec 21, 28, 2010 / 3 / 6 / 5 / 4
Chisinau, District Center of Family Medicine / 28-Jan-11 / 0 / 2 / 0 / 2
Balti city / 10-Feb-11 / 2 / 1 / 0 / 3
Cantemir
(Sourthern region) / 4-Feb-11 / 0 / 2 / 0 / 2
Soroca
(Northern Region) / 3-Feb-11 / 0 / 2 / 1 / 1
Bender
(Left Bank) / 21-Jan-11 / 1 / 1 / 1 / 1
Total / 20 clients / 6 / 14 / 7 / 13
Analysis
Information/data from document reviews and qualitative interviews was aggregated according to the evaluation questions to ensure that team conclusions would be based on data derived from several sources. Qualitative research findings were used to interpret quantitative indicators and to formulate realistic conclusions and recommendations. The team presented preliminary findings and recommendations to the National AIDS Center, TWG on Communication and HIV prevention andUNAIDS Moldova.
Results
Legislation, policies and recommended strategies in HIV prevention
Likewise other countries, the Government of Moldova signed the Declaration of Commitment on HIV/AIDS approved by the General Assembly Resolution S-26/2 of 27 June 2001. Also, the Government committed in achieving the MDGs targets[8] by 2015, including the MDG 6: Combating HIV/AIDS, tuberculosis, malaria, and other diseases. After an assessment on the progress achieved in reaching the MDG targets carried out in 2009revealed an increase in the HIV incidence and mortality associated with tuberculosis, the Government decided to revise the MDG 6 targets along with the others, having also a special target focusing on youth sub-population, age 15-24 group. However, the political instability and economic and financial crisis which deepened in the last years hinder the poverty reduction and questions the realistic achievement of the MDGs targets.
Many social policies and legal framework that demonstrate country’s political commitment in responding to the HIV epidemic have been developed in recent years, including those related to general health policy and HIV/AIDS issues. HIV prevention is an integral part of a number of broader national initiatives, including the National Development Strategy (NDS) for 2008-2011 that foresees accomplishment of MDG 6 Fight HIV/AIDS and Tuberculosis; National Health Policy approved in 2007, part of National Development Strategy for 2008-2011, National Strategy for Health System Development for 2008-2017, which foresees consolidation of actions in area to stop the increase in HIV incidence. The legislative tools include a set of laws which have been adopted to ensure sustainability of actions: Law on Health Protection (1995), Law on Reproductive Health and Family Planning (2001), Law on Migration (2003), Law on Equal Opportunities (2006), Law on AIDS Prevention and Control (2007), Law on Combating Domestic Violence (2008), Law on Social Assistance (2008), Law on donors and blood transfusions (2009).
The Moldovan Government developed and approved the Law on Prophylaxis of HIV/AIDS (Law Nr. 23-XVI dated 16.02.2007) which is considered to be one among the few laws developed in compliance with the human rights-based approach. Under the circumstances of non-approval of Anti-Discrimination Bill[9]by the Parliament, the given Law on Prophylaxis of HIV/AIDS is currently the only biding document which provides the legal basis for interdiction of discrimination of people leaving with HIV at the work places, provision of medical treatment and services, education, travel and choosing the place of residence. It also contains provisions ensuring the right on confidentiality of people leaving with HIV, voluntary counselling and testing. The Law also targets the prevention measures for several sub-populations, which include children and youth, women, including pregnant women, IDUs, representatives of armed forces/uniformed services, prisoners, as well as mobile groups (immigrants, emigrants, refugees and asylum seekers. However, the Law in its final adopted version has excluded specific provisions on prevention measures for other vulnerable subpopulations like MSM and sex workers. Also, the Art. 24 of the present Law and other related oneshad some discriminatory and restrictive provisions related to the entry and stay of the foreign persons with HIV positive status on the territory of Moldova. With the support and advocacy of specialized NGOs (namely, NGO “IDOM”) and in accordance with the Ministry of Health Order Nr. 347 dated 26.05.2010, the Ministry of Health initiated a working group to revise a series of Laws, including the Law on Prophylaxis of HIV/AIDS, the Law on Migration, the Law on the Legal Regime of foreigners, etc., as well as subordinated normative documents (i.e. Instruction on HIV Testing of Young People before Registration of Marriage, Instruction on HIV Testing of Pregnant Women etc.). In accordance with the Ministry of Health Order Nr. 36 dated 17.01.2011, a series of amendments containing discriminatory elements were operated to the aforementioned legal documents. While most of them were approved by the Government, still, the amendments to the Laws which require the endorsement of other line ministries, including the Law on Prophylaxis of HIV/AIDS is still under examinations by the related line ministries and awaiting approval.
Significant efforts were invested to develop harmonized national standards and instructions related to the prevention and prophylaxis of HIV/AIDS. These include a series of national standards and guidelines related to HIV services (VCT, PMTCT, HIV surveillance, Infection Control, HIV Care and Treatment etc). However, in practice, the enforcement of these normative documents is still not perfect and there are discriminatory episodes in provision of medical treatment and services.
The exposure to or transmission of HIV is still prosecuted under the Criminal Code (amended by Law Nr. 985-XV dated 18.04.2002) with specific provisions under articles 211 and 212. While the move towards criminalising HIV transmission has often been prompted by governments’ attempts to respond to the rising numbers of HIV infections in their countries and prevent the deliberate contamination with HIV, yet, human rights campaigners have expressed concerns that these laws lead to a violation of the rights of people living with HIV, exacerbating their marginalization. Hepatitis and TB are also considered to be diseases of a same level of threat for public health, still, their transmission is not prosecuted. However, it is worthwhile mentioning that Moldovan legal framework does not contain an offence for a man to have sex with another man (MSM).Moldova has one the most progressive legal environments around harm reduction and decriminalising drug possession. Since 2004 there has been a marked shift in drug enforcement strategy towards prioritising the prosecution of drug dealers alongside the detection of drug trafficking networks and drug producers, rather than criminalisation of drug use In addition, in 2008, personal drug use was decriminalised. Major amendments to the Penal Code and Administrative Offences Code reformed criminal punishment, including by promoting alternative punishments to imprisonment, and by excluding the application of arrest for personal drug use, now constituted an administrative rather than criminal offence. The illegal purchase or possession of narcotic drugs or psychotropic substances in small quantities without the intention to distribute them, as well as their consumption without a medical prescription, is sanctioned by a fine or community service.
Due to some political and administrative limitations, this report does not contain a thorough analysis of the legal framework on HIV/AIDS present in the Transnistrian region. However, it is worthwhile mentioning that, de jure, the so-called Transnistrian authorities put in place the legal framework on HIV/AIDS which, in principle, can be considered developed in accordance with the basic international standards. HIV prevention and combating is regulated by the so-called Law Nr. 32-3 on HIV Prevention in Trasnistria dated 7.02.1997, Law Nr. 29-3 on Fundamentals on Public Health, so-called Criminal Code (art. 119 and art. 134) and other subordinated normative documents. While Transnistrian Law on HIV Prevention and other related legal documents contain non-discriminatory provisions (i.e. HIV testing is not compulsory for young people who want to register their marriage), de facto, there are many inconsistencies between these laws and the subordinated normative documents and mechanism of their implementations is ineffective. Records on the discrimination and infringements of the rights of the people leaving with HIV/AIDS, including HIV testing of migrants, from this region are highly observed.
National AIDS Programme: 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 2011–2015(National AIDS Programme – NAP), just approved by the Government of the Republic of Moldova on December 16, 2010. The current NAPfollows the previous three programs implemented in years 1996-2000, 2001-2005 and 2006-2010. The last NAP has been primarily funded by international donor assistance, with the Moldovan government contributing about 20% overall.
The NAP has the following main expected outcomes by 2015: