UNGASS Indicators Country Report Template Romania National Multi-Sectoral HIV/AIDS Commission Reporting period: January 2003 December 2005
Abbreviations 3 Status at a glance 4 Overview of the AIDS epidemic 6 National Response to the AIDS epidemic 9 Most-at-risk populations: HIV testing 9 Most-at-risk populations: prevention programmes 12 Most-at-risk populations: knowledge about HIV prevention 13 HIV treatment: antiretroviral combination therapy 13 Blood safety 14 Knowledge and Behaviour indicators 14 Sex workers: condom use 14 Men who have sex with men: condom use 14 Injecting drug users: safe injecting and sexual practices 14 Major challenges faced and actions needed to achieve the goals/targets16 Support required from country s development partners 16 Monitoring and evaluation environment 16 Annex 1: Consultation/preparation process for this national report 17 Annex 2: National Composite Policy Index Questionnaire 17
Abbreviations ACCEPT Asociatia ACCEPT (ACCEPT Association), NGO ANA Agentia Nationala Anti-Drog (National Anti Drug Agency), GOV ANP Administratia Nationala a Penitenciarelor (National Administration of Penitenciaries), Ministry of Justice, GOV ARAS Asociatia Romana Anti SIDA (Romanian Association Against AIDS), NGO ARV Anti RetroViral Treatment CRIS Country Response Information System CSWs Commercial Sex Workers CTY Close to You, NGO IDUs Injecting Drug Users IEC Information Education Communication MARP Most-at-Risk-Populations MSM Men having sex with men NGO Non-governmental Organization PLWHA People Living with HIV/AIDS PMTCT Prevention of Mother-to-Child Transmission PSI Population Services International, NGO RAA Romanian Angel Appeal, NGO TNT Tineri pentru Tineri (Youth for Youth), NGO UNGASS United Nations General Assembly on HIV/AIDS USAID United States Agency for International Development UNICEF United Nations Children s Fund JSI John Snow Inc., Research and Training Institute VCT Voluntary Counselling and Testing Page 3 of 17
Status at a glance Romania is one of the few countries in Central and Eastern Europe with a significant number of people affected by HIV/AIDS. In September 2005, 15,850 cumulative cases of HIV/AIDS were registered. At the same moment 11,035 people were living with this virus. The official data indicate that 7,633 of the PLWHA have reported at least once in 2005 to a specialized medical service and from those 6,181 are in ARV treatment. The specific of the HIV/AIDS epidemic in Romania is the massive HIV incidence registered at the end of the 80 s among children. It is considered that the use of nontested blood and blood products, as well as the use of non-sterile medical instruments during 1987-1991, resulted in the spreading of the HIV infection among thousands of new born, little babies and young children. A steady increase of the HIV/AIDS incidence among young adults was registered, after 1994. The sexual transmission of HIV continues to lead the epidemic among adults, this data being confirmed by corroboration with the annually increases in the incidence rates for syphilis. Romania has also a high rate of syphilis, and evidence points to common high-risk practices and a significant lack of awareness in key areas such as HIV transmission, prevention and safe behavioural patterns. Injecting drug use comes also as a major risk factor especially for the capital city Bucharest were it is estimated that 1% of the population is injecting heroin. Latest studies show that commercial sex work is flourishing dominated by unsafe practices and closed associated with injecting drug use and trafficking in human beings. Over 7,000 of the children infected in the late 80s are living now and most of them are in the age group 16 18. They represent an important challenge as these adolescents are entering now in their adult life (meaning sex life, with the possibility of HIV transmission to their sexual partners and children, but also new needs related to their integration in the community and independent living jobs, housing, etc). HIV awareness is very high in Romania, with nearly all adult women and men (99.5%) having heard about HIV/AIDS, as results from the most recent Reproductive Health Survey (2004). Despite this high level of awareness the complex knowledge indicator and the discrimination indicators are showing very low percentages, 4% for knowledge and 17% for acceptance. Page 4 of 17
Country Romania People who have heard about HIV/AIDS by sex and residence 10 0 Sum of Value 99.79 99.5 99 99.17 99.02 99.01 Indicator Name 98.5 98 98.16 People who have heard about HIV/AIDS by sex and residence 97.5 97 2004 2004 2004 2004 2004 All Females M ales Females M ales All Rural Urban Urban/Rural Gender As Of Date Page 5 of 17
Overview of the AIDS epidemic 20 15 10 5 0 1985 1986 1987 1988 1989 1990 Incidence among Children 1991 1992 1993 1994 1995 1996 1997 Incidence among adults 1998 1999 2000 2001 2002 2003 2004 At the end of 2004, the AIDS prevalence in Romania was of 42.7 cases on 100,000 inhabitants (versus 38.95 AIDS cases to 100,000 inhabitants in 2003). Unfortunately, the lack of a wider scale, systematic and transversal monitoring of the prevalence in the entire population may have introduced biases so the real value of this indicator could much higher. A steady increase of the HIV/AIDS incidence among young adults was registered, after 1994. This phenomenon seems to be determined by the sexual mode of transmission (mainly heterosexual). Impact indicators Most-at-risk populations: reduction in HIV prevalence Most at risk populations for Romania (as defined also by the National HIV/AIDS Strategy) include IDUs, CSWs, MSMs and prisoners. IDUs The Romanian General Population Survey for 2005 showed that over 0.2% of the population used at least once over the life-time heroine, while cocaine prevalence is of 0.3%. The prevalence rates are a lot bigger in the capital city - Bucharest and reach 1% for heroine and 1.9% for cocaine. Until now 16 IDUs were diagnosed as HIV +, 10 of them being in the AIDS stage. CSWs No estimation of the CSWs population in Romania is currently available. The only reference data may be drawn from the WHO 2003 Report that offers an estimation for both female and male sex workers in the range of 23,000-47,000. Different behavioural studies revealed the presence of common high-risk practices and a significant level of association with drug use and trafficking in human beings in this population. The number of HIV tests performed among CSWs is very small (300 Page 6 of 17
tests were reported in 2004). Stigma to which CSWs are exposed and the illegal status of prostitution result in a still low access to services (that are now becoming more client-friendly) and a high under-reporting rate as members of the population often failing to declare their belonging to the group. In order to address these issues recent interventions have tried to focus on HIV testing by using rapid tests, performed in the framework of outreach programs developed by NGOs which work closely with this population in the field. The GFATM funded Programme in Romania (started in 2004) offered the opportunity to intensify and expand existing services targeting female CSWs in capital city to other 9 counties (out of 42). These services are for the moment offered exclusively by non-governmental association ARAS. Available studies are referring only to female commercial sex workers, as the number of male sex workers is lower and the population is not yet very well known. Specific HIV prevention interventions targeting male sex workers recently started. Different NGOs (ACCEPT, ARAS, PSI) are now developing outreach and IEC activities for this target population. MSMs MSMs are another population facing high stigma and discrimination in Romania, even if starting 2001 sexual activities involving same sex people stopped being illegal. In the same way as for CSWs, very low numbers of HIV tests are performed among MSMs (30 tests in 2004, no one positive). Data obtained from ACCEPT indicates that at least 6 MSMs are known to be living with HIV in Romania in 2005, while Ministry of Health reports over 77 cases of AIDS among MSMs since 1985. No estimation of the MSM population has been made until now in Romania. The only available data are drawn from the WHO 2003 Report that estimates for Romania a population between 60,000-120,000. The average number of inmates residing in Romanian penitentiaries is about 40,000. Consistent HIV prevention interventions targeting inmates were developed by the National Administration of the Penitentiaries starting 2004 in the framework of the GFATM programme. The IEC activities were mainly based on a network of peereducators, while a network of professionals who were trained sustained VCT activities. 36 HIV infected prisoners were registered in prisons in 2005, from which 9 newly diagnosed cases. Reduction in mother-to-child transmission A special attention was paid in Romania to the prevention of mother-to-child transmission. The first PMTCT interventions were developed in 2 pilot districts starting in 2000. The Global Fund Programme allowed the extension of the PMTCT interventions in 18 districts (of a total of 41 districts) and in the capital city. The PMTCT coverage average resulted was of 40-50% of the pregnant women in the targeted areas. In the second phase of the GFATM program the Ministry of Health in collaboration with the NGOs that developed this service (Romanian Angel Appeal, Close to You) should ensure national coverage. Please see the total number of pregnant women counselled and tested (including the ones having a positive HIV test) out of the total number of registered pregnant women in the targeted areas for 2005 (RAA and CTY M&E reports). Page 7 of 17
Jan-Dec 2005 District Pregnant women registered Pregnant women counselled Pregnant women tested for HIV HIV+ pregnant women Bacau 5346 2625 2619 1 Brasov 4482 3533 3528 0 Bucuresti 22215 3472 1112 0 Cluj 5166 2781 2486 0 Constanta 3267 3953 2855 7 Dambovita 4372 3735 3735 3 Dolj 5456 3377 3362 0 Galati 5051 4671 4671 4 Suceava 6276 2987 2987 0 Timis 3777 3348 3163 1 Braila 1967 999 999 0 Deva 2072 1128 1126 1 Olt 2294 1851 1849 0 Resita 3066 1068 1047 0 Sibiu 2952 2425 2417 1 Bihor 1458 256 228 0 Prahova 2010 335 324 0 Iasi 15514 1948 1948 0 Tg. Mures 2656 946 844 0 TOTAL 99,397 45,438 41,300 18 Page 8 of 17
National Response to the AIDS epidemic Romania s reponse to the HIV/AIDS challenge became more structured in 2000, when the 2000-2003 National HIV/AIDS Strategy was launched. In 2001, the Ministry of Health declared HIV/AIDS as a public health priority and developed the Plan for Universal Access to Tratment and Care, aiming to increase the access of PLWHA to antiretroviral (ARV) drugs and improve the quality of treatment. As a result of this action, the number of people receiving ARV therapy raised from 3.800 in 2001 to over 6.100 in 2004. In 2003 the WHO/UNAIDS evaluation confirmed that the access to ARV therapy is universal. Romania is the only country in Central and Eastern Europe which ensures universal free access to ARV treatment and care for more than 6,100 people living with HIV/AIDS (treatment received in accordance with international standards) from a total number of over 7,600 people under medical surveillance. Starting with 2001, a strong public-private partnership was launched, under the facilitation of the United Nations. These efforts resulted in price cuts and donations of ARVs from the most important six pharmaceutical companies. In 2002, a special law regarding HIV infection prevention and care for PLWHA was adopted. This law foresees benefits as free of charge medical treatment and nutritional supplements for PLWHA. The whole program is funded from public sources, according to the existing needs. This commitment is mirrored also by the important amount of money allocated to PLWHA care. The same law stated the foundation of the National MultiSectoral HIV/AIDS Commission (CNMS), which was placed under the Prime-Minister authority. The Commission includes representatives of 16 ministries and government agencies, seven non governmental organizations, of the private sector, United Nations Agencies, as well as other donors. The people living with HIV/AIDS are represented at the Commission level by UNOPA (National Union of the Affected People Associations), which is also a vice-chair of the CNMS. The Government in 2004 approved a new HIV/AIDS Strategy covering the period 2004-2007. The main objectives of this strategy is to maintain the HIV prevalence for 2007 at the level registered in 2002 and to ensure the universal access to treatment, care and social services for infected and affected people. Special attention is paid to the The Three Ones objective (One agreed HIV/AIDS Action Framework that provides the basis for coordinating the work of all partners, One National AIDS Coordinating Authority, with a broad-based multisectoral mandate, One agreed country-level Monitoring and Evaluation System). Starting 2004, Romania benefited of a $26.8 million grant for HIV/AIDS from Global Fund. The approval of the second phase of the Programme (US$ 5,060,313) was recently announced and will offer to a large partnership of governmental and nongovernmental institutions the opportunity to consolidate and expand services established during first phase implementation. Most-at-risk populations: HIV testing HIV testing among most at risk groups is a real challenge. Even if outreach interventions were developed in order to target such populations (IDUs, CSWs, Page 9 of 17
MSMs) the number addressing VCT centers is still very low. National statistics of the Ministry of Health are talking about 310 tests performed among IDUs in 2004, 146 among female CSWs and 30 among MSMs. The development of new VCT centres in the framework of the Global Fund Programme in Romania, increased the accessibility of the service, but didn t change in a significant way the number of tests reported among these populations. This is the result of the fact that people avoid to identify themselves as belonging to one of those MARPs. The outreach interventions developed by different NGOs had as a secondary result the establishment of a trustful relationship between the beneficiaries and the professionals assisting them, that often allowed the collection of good quality data regarding the VCT access or even the tests result. Different studies targeting MARPs (May-June 2005 394 CSWs in 12 locations, October-November 2005 300 IDUs in Bucharest, 2004 319 MSMs) showed the following: Country Romania Percentage of female sex workers who received HIV testing in the last 12 months and who know the results 45 Sum of Value 41.61 40 35 31.83 35.53 Percentage 30 25 20 15 Indicator Name Percentage of female sex workers who received HIV testing in the last 12 months and who know the results 10 5 0 <25 25+ All 2005 As Of Date Age Group Page 10 of 17
Country Romania Percentage of MSMs who received HIV testing in the last 24 months and who know the results 66 64 Sum of Value 63.9 62 60 59.36 Percentage 58 56 54 54.1 Indicator Name Percentage of MSMs who received HIV testing in the last 24 months and who know the results 52 50 48 <25 25+ All 2004 As Of Date Age Group Page 11 of 17
Most-at-risk populations: prevention programmes Count ry Romania 60 Sum of Value 51.26 50 Indicat or Name 40 30 33.11 Percent age of IDU (IV Drug users) reached wit h HIVprevent ion programmes Percent age of MSM (men who have sex wit h men) reached wit h HIV-prevent ion programmes 20 10 2.3 1.88 9.29 3.12 3.56 Percent age of Prisoners reached wit h HIVprevent ion programmes Percent age of Sex Workers reached wit h HIVprevent ion programmes 0 All All 2004 2005 As Of Date Age Group The above graphic shows the positive impact of the Global Fund Programme both in respect of outreach interventions (IDUs, CSWs, MSMs) and of the IEC program developed in prisons. The year 2004 brought also the extension of the interventions from the level of the capital city to other areas of the country (9 districts for CSWs and MSMs). Using trained peer educators in prisons proved to be a good strategy, more than 50% of the prison inmates being targeted at least once in 2005. One common and very important issue regarding these indicators is the estimation of the target population. As no other estimates were available for CSWs and MSMs, WHO data was used (WHO EURO data collection 2003). Rapid surveys made in 2003 and 2004 allowed the estimation of the IDUs population at capital city level (24,006 for 2003 and 23,949 for 2004). Technical observations: It was difficult to include available data in the categories indicated in the UNGASS indicator as most of the interventions are based on outreach (including IEC, condom distribution, needle exchange, etc). As disaggregated data were not available, we included all data in the 25+ category. Page 12 of 17
Most-at-risk populations: knowledge about HIV prevention Indicator Data Origin Period Value CLPE5 : Percentage of Sex Workers who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission Romania 2005 14.10% CLPE5 : Percentage of IDU (IV Drug users) who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission 2004 18.00% The same surveys mentioned above provided the inputs for the knowledge indicators. It is important to note the fact that four of the UNGASS knowledge indicator questions were also included in the Reproductive Health Survey developed in Romania in 2004 (the HIV transmission through mosquito bite was not inquired). The results were poorer than the ones registered for IDUs and CSWs (only 2.7% of the males and 5.6% of the females from the general population responded correctly to all four questions). HIV treatment: antiretroviral combination therapy Romania ensures universal access to ARVT for all people living with HIV that qualify to it. The qualifying criteria are included in a National Treatment Guide developed in line with WHO and international recommendations. The entire cost of the ARV treatment is covered by public sources ($36,7 million in 2005). Since 2001 Romania benefits from important price reductions and donations from the pharmaceutical companies as a results of its inclusion in the Accelerated Access Initiative. Bellow are presented data provided by National Commission for Fight against AIDS (MoH) on the number of PLWHA under ARV treatment, as well as people under medical surveillance. They show significant increase in the number of people in ARVtreatment in the last 3 years. Country Romania 9000 8000 Sum of Value 8124 7771 7854 7000 6116 6000 5000 4000 4410 4769 5547 Indicator Name Number of HIV/AIDS patients enrolled in HAART in accordance with the existing standards Number of HIV/AIDS patients under medical surveillance 3000 2000 1000 0 Page 13 of 17 2001 2002 2003 2004 As Of Date
Blood safety After the epidemiological accident registered between 1986-1991 through nosocomial transmission, blood safety became a first priority. All the blood units donated are mandatory screened for HIV. One of the problems is that blood donation is rewarded (ticket restaurant, free local transportation, etc) and members of risk groups are often becoming blood donors. 11% of the 394 CSWs included in the 2005 study reported that they donated blood during the last 12 months. Starting with 2004, a voluntary blood donation programme was developed within the Global Fund Programme, but despite its good results (40,000 blood units voluntarily donated over two years), there is no strategy to ensure continuation of this programme. Knowledge and Behaviour indicators Sex workers: condom use Between May and June 2005, 394 female CSWs responded to a questionnaire inquiring about their knowledge, practices and behaviours. About 85% of them declared that they have used a condom with their most recent client, but there are reasons to believe that this indicator is over estimated. If we look also to the fact that only 9.4 % of them use a condom with the regular partner, even if they are aware of his lack of faithfulness, we may get a more realistic picture of the risks involved. Men who have sex with men: condom use Data gathered for this indicator refers to an already existing study, finalized in December 2004. The MSMs behaviour was analysed based on a 24 months period of time. The study included 319 MSMs in different locations, but only 291 MSMs responded to this question. It resulted that only 24.4% of them declare that they are always using condoms, while other 7.9% use them only with occasional partners. Injecting drug users: safe injecting and sexual practices The situation becomes even worse when referring to the IDUs. A behavioural surveillance survey was conducted from February to June 2004, including 500 IDUS in Bucharest. The results of the study showed that only 2% of the sample had avoided sharing injecting equipment and used a condom at last sexual contact with the partner. Technical observations: As disaggregated data were not available in a split on ages, we included all existing data in the 25+ category. Page 14 of 17
Count ry Romania 90 Sum of Value 85.02 80 70 60 50 40 30 20 22.25 Indicat or Name Percent age of f emale sex workers report ing t he condom use wit h t heir most recent client Percent age of IDUs who have adopt ed behaviours t hat reduce t ransmission of HIV, i.e. who bot h avoid sharing inject ing equipment and use condoms Percent age of men report ing consist ent use of condom wit h male part ners over t he last 24 mont hs 10 0 5.48 2004 2005 year As Of Date Page 15 of 17
Major challenges faced and actions needed to achieve the goals/targets The period 2003 2005 witnessed important progresses made in the area of HIV/AIDS in Romania. Political commitment was strong and resulted in new and modern legislation, in major financial commitment and in the full involvement of all partners and especially people living with HIV/AIDS in developing and implementing policies and programmes. The strong partnership of GOs and NGOs acting to implement the new national strategy was successful. Major prevention interventions were expanded to national level and access to services and programmes for risk groups was improved. A major role was played by the significant Global Fund contribution to the strategy implementation (~$20 million for 2004 2005) almost exclusively for prevention interventions and the important public contribution dedicated to treatment, care and social support. For the next period of the strategy implementation the major challenge will be to maintain and expand prevention interventions already developed and to maintain the universal access to treatment and care. This will require an increased contribution from the public budget. Despite the progress made, the programmes targeting high vulnerable groups are far from reaching enough to make an impact. Alternative strategies and innovative approaches have to be implemented together with a revision of legislation to encourage programmes were necessary. Support required from country s development partners The EU accession process expected to end in 2007 determined a gradual withdrawal of the development assistance providers and a reduction in funds provided. In exchange, EU financial assistance has increased, but it does not target specifically public health of HIV/AIDS. The development partners that are still in the country, including UN System will have to continue their support for ensuring continuation of a sustainable and comprehensive HIV/AIDS programme based on domestic financial and technical resources and implemented in a large partnership. Monitoring and evaluation environment National HIV/AIDS Strategy foresees the establishment of a National Office for HIV/AIDS Monitoring and Evaluation under the national Multisectoral HIV/AIDS Commission. M&E efforts resulted up to now in harmonization of the instruments for UNGASS with the National Strategy and the Global Fund project. UN/UNAIDS and other development partners have to continue their support in building the national capacity for M&E and ensuring its sustainability. Page 16 of 17
Annex 1: Consultation/preparation process for this national report The entire preparation process for the national report was a highly transparent process, equal access being granted to governmental institutions, NGOs and other stakeholders. After receiving the new UNGASS indicators in September 2005, a data collection planning meeting was scheduled on 21 September 2005. About 15 representatives of the NGOs (ACCEPT, ARAS, RAA, TNT), public institutions (ANA, ANP), as well as other international organizations (USAID, UNICEF, JSI) were invited to attend and were informed about all Romania reporting needs (UNGASS due 31 December 2005, Global Survey on Coverage, National HIV/AIDS Strategy Interim Evaluation). Participants were also provided with a centralized list of indicators and data needs and a common workplan was agreed. During October and November 2005 a UNAIDS consultant visited the organizations (ANP, ANA, RAA, TNT, ACCEPT) and the institutions that had to provide data and scheduled with their representatives a data collection plan. For data that was not already available and were it was feasible new short studies were developed (see HIV testing among IDUs). Another UNAIDS consultant provided all the technical support for data collection and compilation so that on 1 st December 2005 a first draft was sent to all stakeholders with the invitation to participate to the national vetting workshop (12 December 2005). During the workshop participants made different comments and finally agreed on the data to be submitted. Between 14-16 December 2005, one of the consultants involved in the report preparation participated to the UNGASS Data Entry Workshop held in Istanbul, occasion in which all available data were entered in CRIS. Between 19-22 December 2005 a draft form of the present report was developed and then circulated among interested stakeholders, who had the possibility to comment and integrate it untill 13 January 2006. Annex 2: National Composite Policy Index Questionnaire The NCPI was filled based on the responses received from the representatives of different governmental and non-governmental institutions. All respondents appreciated the quality of the strategies and policies developed as far, highlighting the need to ensure adequate resources to their implementation. Discussions in the vetting workshop focused on the financial sustenability of existing programs, the need for a more significant involvement of the government in financing prevention activities. Page 17 of 17