Sustainability at core of new HIV strategy in Moldova
In developing its new national strategy for HIV/AIDS, Moldova is, equally, drafting a transition plan that is predicated on the assumption that there will be no more Global Fund support for prevention, treatment and care interventions from 2018.
The plan still follows the three-pronged approach presented in the HIV grant, worth 11.5 million euros, for which implementation began in January 2015. Core objectives of the three-year grant include prevention of transmission, universal access to treatment and effective program management. The grant proposal hews closely to guidance provided in the 2014-2016 EECA Investment Framework and as part of new funding model (NFM) sustainability principles.
According to Liliana Caraulan, HIV program manager of the Center for Health Policies and Studies (PAS), a Fund principal recipient, the transition strategy will not only include program management but also resource management and advocacy at the government level to ensure there is no budget vacuum.
Maintaining focus on prevention of HIV in key populations will be among the key challenges to be addressed in the transition strategy, alongside ensuring program and human resource capacity in order to assume leadership of the existing programs from 2018. Finding the right people and ensuring they remain part of the structure of the National HIV program will be critical to keeping the programs going.
As in other countries in the region, the HIV epidemic has been driven primarily by injecting drug use. An outbreak of HIV among people who injected drugs occurred in 1997. While safe injecting practices have become the norm within this vulnerable group, there has been slow progress in adopting safe sexual behavior.
Responding to the dual challenges of rising MSM and containing HIV from spreading to sexual contacts of key populations is also central to the transition and future NSP.
There have been some 9,389 HIV cases registered in Moldova as of January 2015, with around 700 new cases recorded annually from 2009-2013. UNAIDS estimates the total disease burden to be roughly twice the number of registered cases, at around 18,000. An IBBS study conducted in 2013 demonstrated some of the successes of harm reduction programming, noting a decline of nearly 50% in prevalence among injected drug users from 2009 to 2013 in the capital Chisinau and only a marginal increase in the second city of Balti (from 39.8% in 2009 to 41% in 2013).
Global Fund support has helped to drive the expansion of ART services in Moldova. First available to the general population in 2002, ARVs are now provided within the penitentiary system as well as outside. The state began funding ART in 2014, with 400 patients on treatment. Of a planned 4,131 registered state-supported people living with HIV, there are now 2,483 receiving first line treatment. The state will, by 2017, also assume responsibility for second-line medication for 607 patients.
According to NGO representatives, HIV prevention services are the most vulnerable to budgetary shortfalls without Global Fund support, whereas state support for ART is quite strong. There is currently no waiting list for patients seeking to be enrolled in the ART program. However, low adherence and late involvement in ART continues to plague the public health system, demonstrating the need for improved access to testing for key populations and a strengthening of community-based and referral services.
Under the new strategy, how to retain and eventually expand HIV prevention services is the primary goal. There is a long tradition of supporting harm reduction services as part of the slate of HIV prevention activities, and community and civil society groups are well-versed in advocacy on behalf of these types of services. There has been a state-approved harm reduction and OST strategy in Moldova since 2005, which has also expanded to cover penitentiaries. Moldova was among the first countries in EECA to introduce OST, with methadone, in prisons.
Psycho-social components of the OST program are, however, supported by the Global Fund, leaving a possible gap once the program becomes entirely state-funded. According to the NFM financial gap analysis, the annual budget for the HIV program is some 12.6 million euros, of which government is responsible for nearly 3 million euros.