Situation and response analysis

1. Situation and response analysis National Strategy Joint Assessment mission, debriefing session 27th of June, 2011 Chisinau, Republic of Moldova Presenter: Otilia Scutelniciuc

2. Index • HIV epidemic burden and trends • Where the last 1000 cases occurred? • People who Inject Drugs • Commercial Sex Workers • Men having Sex with Men • Migrants • Youth • Blood safety • Prevention from mother to child transmission • Living with HIV and AIDS

3. National HIV surveillance system • Case registration - data on facility based HIV testing (according to national recommendation: pregnant women to be tested twice during the pregnancy, TB patients, patients with STIs, prisoners, IDUs, screening of donated blood samples etc.) • Integrated bio-behavioural surveillance in key population in higher risk - IDUs, CSWs, MSM and prisoners) • Behavioural surveillance in general population and youth • Service providers administrative statistics • Civil registration (mortality data)

4. HIV epidemic burden and trends

6. Cross-comparison of disease trends

7. Not achieving the MDG 6 (HIV) • “The incidence of HIV rose from 4 cases per 100,000 population in 2000 to 19.4 cases per 100,000 population in 2008, and slightly declined to 17.2 cases per 100,000 members of the population in 2009 • As HIV/AIDS is steadily growing it is difficult to understand if the slight decline of the incidence of HIV/AIDS in 2009 and 2010 represents a turning point in the evolution of the epidemic, or is merely an episode of no real importance • A particularly alarming situation can be found in Transnistria. While slightly improved in 2009, the situation remains complicated, with an incidence indicator of 42.25 cases per 100,000 inhabitants, as compared to 12.42 cases per 100,000 inhabitants on the right bank”

9. Other disaggregation of new HIV cases

10. Summary • Although the epidemic is concentrated among males in urban areas, trends in new cases show increase in HIV cases from rural area • Route of transmission shows an increase of heterosexual and homosexual risk, but there is still insufficient data to validate the sharp decrease in IDU transmission route (decrease or underreporting) • Among new cases, migration is strongly associated with becoming infected with HIV • The share of new cases is shifting from youth to older age groups • IDU declining as mode of transmission in youth • New cases due to heterosexual transmission among youth have doubled between 2004 and 2009. Females predominate and there is a shift to rural areas. • On the Left bank, cases among youth are primarily from urban areas. And youth from the Left Bank are more likely to have been abroad • Link to HIV and migration is stronger for Right Bank

11. 100 93 89 90 88 82 81 87 80 81 80 74 75 70 60 Urban 50 Rural Western Europe 40 30 20 10 4 4 4 4 4 0 Yr 2005 Yr 2006 Yr 2007 Yr 2008 Yr 2009 High STIs prevalence country (right bank)

12. High TB prevalence country

13. New TB cases resistance profile, %

14. HIV prevalence in TB cases

15. Not achieving the MDG 6 (TB) • “The situation is not much better as regards the third target of reducing the tuberculosis-associated mortality. Death rates associated with tuberculosis fell in 2008 for the first time in three years (going from 20.2 cases per 100,000 people in 2007 to 17.4 cases per 100,000 people in 2008), but the that seems to be more a short-lived episode and in 2009 the tuberculosis-associated mortality grew again”

16. Knowing our epidemic Where the last new HIV 1000 cases occurred (right bank)?

19. Key conclusions • The HIV epidemic in 2010 continues to be determined by MARPs and their sexual partners • A new tendency – an epidemic process in adult population having occasional sex with more than one partner (38%) (corroborated by Data Triangulation – a new parallel epidemic process with an increasing tendency in the rural sector related to migration)

20. Severe HIV epidemic concentrated in 25 000 living on the right bank, less than quarter covered with HIV prevention People who inject drugs

21. HIV prevalence

22. HCV, HBV and syphilis prevalence

23. Prisoners (right bank) • About 6500 by the end of 2010 • In 2007, 27.9% have ever used drugs, 13.4% have ever injected drugs, 4.7% injected in last 12 months (underreporting) • In 2010, 25.5% have ever used drugs, 8.9% have ever injected drugs, 3.0% injected in last 12 months (underreporting)

24. Availability of services

25. Beneficiaries of services (right bank)

26. 1st phase of the GF grant, round 1 New entries, free settings 2nd phase of the GF grant, round 6 Failure of applications targeting the MARPs to the 9th and 10th rounds of GF

27. Distributed syringes

28. Coverage with HIV prevention

29. Numberofpatientsenrolledin OST inthecitiesofChisinauandBalti, 2006-2010 Numberofpatientsenrolledin OST inthepenitentiary sector, 2006-2010

30. Key achievements in PWID

31. Scale up and behavior changes

32. Key achievements in prisoners • Increase of the HIV knowledge: from 30.8% in 2007 to 43.4% in 2010 • Increase of the HIV testing: from 7.7% in 2007 to 14.2% in 2010 • Reported injecting behavior is safe in 2010 (small number of reported drug injection practicing respondents) • No changes in the sexual behavior

33. Identified gaps • Minimal set of services: syringe, condom and IEC provision, and do not provide the internationally recommended comprehensive package necessary for an effective HIV prevention • Uneven geographic distribution of needle-syringe programs and other harm reduction activities • Lack of focus on evidence-based behavior change towards safer sex practices • Majority of current prevention services do not reach those most hidden and vulnerable populations, and are not well-suited to address emerging sub-groups, such as members of sexual network of IDUs • Remaining issues in OST relate to the low coverage and quality.

34. About 6000 CSWs, overlapping with PWID population Commercial sex workers

35. Where CSWs find clients? • CSWs from Chisinau municipality, first commercial sex on average at 22.5 years old • 8.6% have ever injected drugs and 2.9% did it in last 12 months • CSWs from Balti municipality, first commercial sex on average at 21.0 years old • 7.3% have ever injected drugs and 2.3% did it in last 12 months

36. HIV prevalence

37. HCV, HBV and syphilis prevalence

38. Availability of services

39. Beneficiaries of services (right bank)

40. Distribution of condoms and coverage

41. Key achievements in CSWs

42. Identified challenges • Needs vary greatly depending on context and situation (e.g., economic status, apartment-, street-, and highway- based; static or migratory status; injecting drug use) ; • Overall, HIV prevention programs targeted to FSWs focus on condom distribution and referral to facility-based VCT and STI management; • Condom distribution is not accompanied with a strong behaviour change communication (BCC) component ; • Lower condom use at anal sex • The nature and extent of referrals and supporting follow up to Positive Prevention and otherservices is unclear ; • Not all elements within a state of the art package of HIV prevention services targeted to FSWs are provided; • HIV prevention activities are not targeting clients of FSWs’, as well as regular and casual partners.

43. Still unknown, estimated to about 20,000 Men having sex with men

44. Seroprevalence

45. Availability of services

46. Beneficiaries of services (right bank) • In 2010, the coverage with HIV prevention reached 25.7% in Chisinau and 6.5% in Balti

47. Key achievements in MSM

48. Identified challenges • Overall coverage of MSM with HIV prevention programs is low, particularly among non-gay identified MSM, “hidden” MSM, MSM with overlapping risk behaviours (e.g. injecting drug use), and among the female partners of MSM • Programs implement a partial package of HIV prevention services as per international standards for MSM • There are gaps in delivering interventions outside of familiar venues to underserved or most-at-risk MSMs (e.g. male sex workers) • There are few MSM-friendly health providers which decreases access to specialized services • Homosexuality and sodomy are not illegal in Moldova, but there is a strong cultural and religious bias against MSM • Stigma and harassment, especially by informal hate groups and some elements within law enforcement

49. NAP provisions • Specific Objective II. Ensuring the access of at least 60% of the estimated number of high risk groups (CSW, MSM, IDU) to prevention services by 2015: • Ensure the curtailing of HIV and STI spread, differentiated by age specific and gender specific needs, among CSW and their clients; • Ensure HIV and STI prevention, differentiated by age specific and gender specific needs among MSM; • Ensure the access of IDUs, differentiated by age specific and gender specific needs, to comprehensive HIV prevention services and substitution therapy, including in the prison sector. • Specific Objective IV. Providing 80% of patients diagnosed with an STI with treatment: • Provide for the testing, diagnosis and treatment of STIs for all groups of population, including high-risk groups.

50. Spread in the general population migrants