Republic of Moldova

Republic of Moldova Health Impact Evaluation Study Area 3

HIV/AIDS report

Report written by Otilia Scutelniciuc

With collective contribution of: Stefan Gheorghita Valeriu Dobreanschi Valeria Dmitrienco Viorel Calistru Svetlana Popovich Mihai Ciocanu Oleg Barba Svetlana Cebotari Victor Burinschi Liliana Caraulan Gabriela Ionascu Vitalie Slobozian Veronica Andronachi Stela Bivol Rita Seicas

Chisinau 2008

1 Acknowledgements Our common goal is to present reliable and valid information in order to generate enough scientific evidence that is the necessary prerequisite for the elaboration of effective strategy that aims to protect the nation. Improvement of data quality is the priority. We would like to express our gratitude to those involved for their insistence, patience and competence expressed during the process of elaborating this report.

Special thanks are due to Fern Greenwell, WHO for her contribution provided during the implementation of 5YE activities and report elaboration.

2 Executive summary Since Global Fund has reached a point where the five-year lifecycle of first grants are nearing completion, a Five-Year Evaluation was launched. The results of this evaluation will be used by the Global Fund to review the functioning and performance and by the whole community of those engaged in improving global health and delivery of development finance. The approach of the Study Area 3, for which Moldova was selected, is to examine collective efforts, including those of other major agencies and programs. The Health Impact Evaluation has been designed to determine the impact of available financial resources on the delivery of services, on the coverage and quality of those services, and, to the extent possible, on the burden of HIV/AIDS in Moldova. The Health Impact Evaluation findings show that the scaling up in the national HIV response corresponds with the important external financing that started to be available since 2003, upon the GFATM first round grant and World Bank grant became operational. These funds have been used to sustain and scale up the national HIV response initiatives established before. Thus important investments in the infrastructure have been done (opening and capacity building of AIDS laboratories, ART centers); other tests like PCR, CD4 became available and increased according to needs. There are no waiting lists for ART and the number of patients is constantly increasing. In the last 3 years, upon implementation of PMTCT, there is a decreasing trend of vertical transmission of HIV infection. The number of beneficiaries of Harm Reduction Programmes and distributed commodities constantly increased. There has been an extention of activities in IDUs to rural area and on the left bank of Dniester River and scaling up of activities in CSWs. Harm Reduction activities extended the targets to the Leisbean Gay Bisexual and Transvestits (LGBT) community, truck drivers and migrants. The restrictive criteria for involvement in methadone substitution treatment have been removed and this fact increased substantially the access to this treatment. The implementation of subprojects for home and community support and care for People Living with HIV/AIDS (PLWHA) started. As a result of communication interventions, there is a consistent increase in knowledge on HIV/AIDS in youth, IDUs, CSWs and MSM. Also significant increase of condom knowledge was registered among youth. There are no other important changes registered for core attitudes’ and behavioral indicators. The HIV prevalence data registered a slight increase in IDUs, MSM and decrease in CSWs in the capital city. In the last 5 years, the number of reported cases of death due to AIDS did not register important variations. These are results of a collective effort of interventions funded also by other donors and implementing agencies like UNAIDS, UNICEF, USAID, Caritas Luxembourg, SIDA, MSF, UNDP, ILO, IOM and UNFPA et.al. The best national initiatives in HIV response got forms, content and sustainability. In all HIV activities there is an inequity in availability and access to services for potential beneficiaries from the left bank of Dniester River due to the frozen political conflict that reduces the collaboration against the spread of HIV infection.

3 Table of Contents Introduction...... 5 Epidemic background...... 5 Evaluation background...... 7 Methodology...... 8 Evaluation framework...... 8 Evaluation components...... 9 Source of data...... 10 Description of HMIS...... 10 Data sources & data quality...... 12 Routine statistics...... 12 Surveys and other sources...... 14 Study Question 1: Trends in Funding...... 17 Study Question 2: Coverage and Quality of HIV services...... 21 Trends in Coverage of Services...... 21 Trends in Quality...... 33 Trends in Behaviour Changes...... 34 Study Question 3: Trends in Impact...... 37 HIV prevalence...... 37 Mortality due to AIDS...... 38 Conclusions...... 39 Recommendations...... 40 List of Tables...... 41 List of Figures...... 42 Works Cited...... 43

4 Introduction

Epidemic background In the Republic of Moldova, like in other countries from Eastern European region of the former Soviet Union, the early stages of the HIV epidemic in the 1990s were driven by Injecting Drug Users (IDUs) who spread the virus through sharing contaminated needles. Away from few sporadic HIV cases registered prior to 1995 (since 1987, 19 HIV cases were registered cumulatively) with probable route of transmission other than injecting drug use, the onset of the epidemic is considered to be 1996 (National Drug Observatory, 2006). The first known case of HIV in injecting drug user registered in 1995 was considered to be in contact with other drug users from Odessa region, Ukraine, which is one of the most HIV affected region in Ukraine due to high rate of injecting drug use. Since 1996, the mandatory testing for HIV in officially registered Injecting Drug Users (IDUs)1 has applied. In 1997, the number of newly registered HIV cases increased progressively and the newly registered HIV cases associated with the injecting drug use reached the biggest number (355 registered new HIV cases) and the highest rate among newly registered HIV cases (87.9%). During the period 1996 – 2004 in the majority of newly registered HIV cases the route of transmission was associated to injecting drug use. In 1999, the number of newly registered HIV cases in drug users sharply decreased. In the last 5 years there is a growing trend of the number of newly registered HIV cases in drug users. After the late 1990s, however, the rate of cases transmitted by injecting drug users began declining while the rate of sexually transmitted cases began increasing. In 2005, for the first time, more newly registered HIV cases were associated to sexual route of transmission than injecting drug use route. Another shift was occurring in infection rates by sex. That is, until 2000, females represented only about one-quarter of all persons infected with HIV; by 2004, they represented 45 percent. The shift in the structure of newly reported HIV cases according to their route of transmission increases the vulnerability of women. In last 3 years, women are in majority among newly reported HIV cases with sexual route of transmission (2007 – 62.2%, 2006 – 57.2%). In time there is an increase in the number of newly reported HIV cases among pregnant women. According to the data of the National Centre of Health Management in 2007 (National Center of Health Management, 2007), the HIV prevalence among pregnant women reached 0.23%2 that is approximately the same as in 2006 (0.21%). In the due time, the newly reported HIV cases among blood donations3 register also a slight increase. Thus, in 2007 the number of newly reported HIV cases per 100 000 blood donations reached 59.4 compared to 48.9 new HIV cases per 100 000 blood donations registered in 2006 (National Scientific and Practical Centre of Preventive Medicine, AIDS Centre, 2008). The epidemiological situation on the left bank of the Dniester River is alarming. Historically, the number of registered Injecting Drug Users (further IDUs) per 100 000 inhabitants, was higher on the left bank of the Dniester River comparing with the one registered on the territory of the right bank of the Dniester River. In the context of the frozen political conflict on the Dniester River, the implementation of HIV prevention and control interventions both in Key Populations at Higher Risk (KPARs) and in the general population started later than on the right bank. In 2007 the HIV

1 Injecting drug user who are entered into the Narcological Register (officially registered) 2 Number of HIV positive pregnant women reported to the number of officially registered pregnant women. In 2007, 99.2% of birth took place in medical institutions. 3 The pre-test screening of potential donors is performed (checking of the HIV cases data base, behavioural screening). 5 prevalence in pregnant women from the left bank of the Dniester River (0.42%) is three times higher than the one from the right bank of Dniester River (0.13%) (National Scientific and Practical Centre of Preventive Medicine, AIDS Centre, 2008). According to this data source from in 2007, the number of newly reported HIV cases per 100 000 blood donations from the left bank of the Dniester River is almost double (100.3 newly reported HIV cases per 100 000 blood donations) in comparison with the right bank of the Dniester River (55.9 HIV newly reported cases per 100 000 blood donations). Trend analysis of the HIV epidemic in the general population in the Republic of Moldova based on the annually reported new HIV cases implies limitations depending on the country capacity in HIV testing, the testing regulations applied, especially for IDUs which have been subject to changes in time as well as are highly dependent on the political context (where the role of the conflict on the Dniester River plays a major role4). The confirmation HIV test is performed only in Chisinau, the capital city of the Republic of Moldova. According to the results of the HIV prevalence survey conducted in Key Populations at Higher Risk (KPARs) in 2007, the HIV prevalence in IDUs reached 21%, in Commercial Sex Workers (CSWs) - 11% and in Men having Sex with Men (MSM) - about 4.8% (Scutelniciuc & Bivol, 2008). This research has been conducted among beneficiaries of Harm Reduction Programmes. An increase of HIV prevalence has been registered in 2007 prevalence study comparing with 2004 HIV prevalence study among IDUs and Men having Sex with Men (MSM). While comparing the results for 2003, 2004 and 2007 from the capital city of the country only, there is a decreasing trend in the HIV prevalence among Commercial Sex Workers (further CSWs) and an increase among Men having Sex with Men (further MSM). All HIV prevalence surveys among MSM were conducted in the capital city only. The HIV epidemic in the Republic of Moldova is still considered to be concentrated mostly in IDUs population with sign of spreading into the general population. The high level of external migration which is specific for the left bank of the Dniester River as well creates favourable conditions for the rapid spread of HIV infection in the general population.

4As a result of the frozen conflict on the Dniester River (1991 - 1992), the territory of the Republic of Moldova is divided in the territory on the right bank and territory on the left bank (Transnistria) of the Dniester River. The territory on the right bank of Dniester River is controlled by the Chisinau authorities , while that on the left bank is controlled by the self proclaimed, unrecognized authorities from Tiraspol - the main city of this region. 6 Evaluation background The Global Fund is a financing institution founded on principles of performance, flexibility and learning. From its inception in 2002, the organization has grown from creation to a portfolio of 450 grants in 136 countries worth nearly US$ 8 billion (TERG, 2007). Since it has reached a point where the five-year lifecycle of first grants are nearing completion, the Global Fund has launched a Five- Year Evaluation, which marks an exciting and critical milestone in the development of the Global Fund. During its 14th meeting held 31 October - 3 November 2006, the Global Fund Board approved the Five-Year Evaluation plan as presented by the Technical Evaluation Reference Group (TERG), including its overall timeframe, budget and implementation arrangements. Under the guidance of the TERG, the Five-Year Evaluation is a major effort to review the functioning and performance of the Global Fund and to identify areas of strength and weakness that will lead to improving day-today operations. In addition, the Five-Year Evaluation provided an opportunity to build a platform for impact evaluation to assess the reduction in the burden of the three diseases associated with scaling up prevention and treatment activities. The results of this evaluation will be useful for the whole community of those engaged in improving global health and delivery of development finance (TERG, 2006). Study Area 3 is a broad and comprehensive examination of the overall reduction of the burden of the three diseases and the Global Fund’s contribution to that reduction. The approach of the Study Area is to examine collective efforts, including those of other major agencies and programs in recognition of the fact that, in many countries, the Global Fund is not the only major international donor. The impact evaluation sets out to assess overall impact on the burden of cases and deaths due to the three diseases. The evaluation describes the contribution of the Global Fund without direct attribution to any individual agency or effort (TERG, 2007). The Republic of Moldova was selected to participate in the Evaluation, Study Area 3 with both HIV/AIDS and Tuberculosis components. The impact evaluation in Moldova is designed to compile and examine mainly existing data to establish trends in the burden of two diseases over the past decade, if available. To better understand the course of trends, changes in related treatment and prevention patterns also were examined, as well as behaviour and knowledge. In addition, validation of existing data comprised an important cross-cutting activity.

7 Methodology

Evaluation framework The Health Impact Evaluation has been designed to determine the impact of available financial resources on the delivery of services, on the coverage of those services, and, to the extent possible, on the burden of HIV/AIDS in Moldova. The evaluation framework is detailed in Error: Reference source not found.

Figure 1 Basic Framework for 2008 Impact Evaluation, GFATM

With Data Sources

Contextual Factors Other international resources Provision and Provision and Disease utilizationutilization of of Disease core incidenceIncidenc,e core prevalence GlobalGlobal interventionsinterventions prevalence Fund againstagainst Fund DiseaseDisease Resources consequences Resources AIDSAIDS consequences TB mortalitymortality TB ill-health Malariamalaria ill-health

Domestic resources

Resource tracking and Service delivery and Surveys and surveillance National Health Accounts coverage assessment; of disease and mortality, by disease national and sub-national national and sub-national facility data and surveys

Based on this framework the main hypothesis for the proposed analysis was phrased as follows: - Increases in financial resources have led to à - Improved services (quality, quantity, coverage) which in turn have led to à - Reductions in the burden of disease (incidence, prevalence and mortality). This hypothesis was divided into three study questions with additional sub-questions where are available: a. Has funding/spending increased for HIV/AIDS program in Moldova? b. Has the availability of services (both treatment and prevention) increased? • Has the quantity of services increased? . Are services more equitably (geographic, gender, age) distributed? • Has the coverage of services increased? . Is coverage more equitable? • Has the quality of services improved? • Have knowledge and risk behaviors changed? 8 b. Have the HIV incidence, HIV prevalence and mortality related to AIDS changed? The evaluation framework applies both to the national and the sub-national level. Analyses were focused on trends in spending, service provision, changes in behavior, and disease burden. The main sources for national-level data for are from existing national HIV/AIDS service statistics, behavioral and sentinel surveillance data, KAP surveys and other available data sources.

Evaluation components The data collection and analysis were divided into four components which are described below. Component 1: National Record Review The routine information about HIV/AIDS services available was collected from available paper based records. In 2007 a new HIV electronic system for case registration and follow up was developed in Moldova and it started to cover HIV/AIDS cases data in details from 1987. Within the framework of the 5YE a retrospective data entry of registered HIV cases was performed. Component 2: Review of Secondary Data A standard set of pertinent information from national surveys, operational researches and other sources of information were abstracted. The available data was sorted based on the following criteria: (1) national policies and strategies; (2) national HIV/AIDS related reports; (3) relevant published articles and (4) surveys and studies reports. The logbook was created. Component 3: National HIV/AIDS Spending and Financing A National HIV/AIDS Spending and Financing exercise was conducted. As a result the information about the trend in resources invested to prevent and control HIV/AIDS was obtained. The output tables are attached (Attachment 2). Component 4: Evaluation report, ARV drug supply The evaluation of ARV drugs supply was conducted based on the main components of the pharmaceutical product supply cycle (Seicas & Scutelniciuc, 2008).

9 Source of data

Description of HMIS Following the approval of the recommendations of the Washington Conference organized by the UNAIDS and the main donors in HIV/AIDS from April 25, 2004, regarding the necessity to implement “The Three Ones” Principle, the Ministry of Health of Moldova, together with its partners, including the Global Fund, the World Bank and UNAIDS created the concept of the national monitoring and evaluation system for National Program on Prevention and Control of HIV/AIDS/STIs. The M&E system is designed to collect information to support the activities and outcomes of the initiatives, taken by the Government of Moldova to fight against this disease (Cercone, 2005). The outputs would serve wider govermental needs for reporting on the health dimensions at national and international levels. The M&E of National Health Programmes Department as part of the National Centre of Health Management of the Ministry of Health of the Republic of Moldova represents the only monitoring and evaluation mechanism at the country level. The HIV M&E system model has been replicated to other national programmes (TB, illegal drugs etc.). The data flow within the HIV M&E system is presented in the Figure 1. The involvement of the private – for – pay sector as data source is not part of the system due to the fact that HIV services are no provide by the this sector.

10 Figure 1 Data flow, HIV M&E system, Republic of Moldova, 2008

Ministry of Health Country Coordination Mechanism

NGOs routine statistics Intersectorial routine statistics National Centre of Health Management Department of Monitoring and Evaluation of Health Programmes Vital statistics (data depository) Health sector routine statistics

Surveys and surveillance National Centre of Health Management Department of Monitoring and Evaluation of Health Programmes (data base)

HIV cases registration HIV cases follow up

AIDS Centre Republican Dermato – Venereal ARV treatment, electronic data base (individual data, lab HIV caee Dispensary (RDVD) activity data) confirmation, HIV cases follow up, CD4/CD8, Western Blott ARV treatment department PCR, other tests, HIV testing, PMTCT ELISA teste results

Collection of epidemiological data AIDS labs Centers of Preventive HIV cases HIV cases follow up, infectionist, local Medicine, local level follow up level

11 In order to improve the routine statistics data, with the support of the World Bank, the GFTAM and UNAIDS, a new software was developed for HIV cases reporting and treatment follow-up. A separate module was developed for STIs cases reporting. According to the design of the SIME AIDS system, the information should be centralized and stored in electronic version in the M&E Department. Currently, the SIME AIDS software is available and within the framework of the 5 Year Evaluation, data on registered HIV cases have been entered retrospectively in the data base at national level (about 4000 cases) and located in AIDS centre. Upon approval of the new law on AIDS prevention in February 2007, the informational flow needs adjustments due to new regulations on access rights at different levels regarding HIV related individual information. This new legal framework creates difficulties in extension of the system till the adjusted design will be approved by the M&E Technical Working Group (TWG) and implemented. Till this approval will be available, the software will be used only by the AIDS Centre, as the single allowed institution to storing nominal data at national level. The use of the new software will reduce the burden of errors occurring during manual processing of data. The issue of connectivity between the different levels and institutions involved in the collection of data is critical for the design and implementation and is based on the existing connectivity to assure the sustainability of the service when funding is over. The equipment has been procured to ensure connectivity within the system. Creation of the data depository that will store validated data from all available sources is the next step in the M&E data use and dissemination strategy.

Data sources & data quality

Routine statistics 1. The diagnosis is established when the person undergoes 2 positive screening test type ELISA and confirmed by the Western Blot test. Upon a new HIV case is confirmed, the personal data (name, address, year of birth, gender) are sent to the local level and the data collection on newly registered HIV case is under the responsibility of the local level preventive medicine doctors. Demographics, probable route of transmission, family members’ data, employment, pregnancy data, and risk factors are the main data to be collected. The fulfilled forms are sent on paper to the AIDS Centre where are incorporated into the national database (retrospectively entered into the SIME AIDS data base, first case registered in 1987). The quality of collected data is checked at national level in terms of completeness, timeless and accuracy. In situation when the person that has been registered as new HIV case is not found by the local level preventive medicine doctors for data collection, then the reason for testing is accounted as probable route of transmission. There is no still today established a way to validate data. The registration date is considered the date of confirmation test – Western Blot. The confirmation test is performed only at national level, by the AIDS Centre, and that is why there is no variation in the number of newly registered cases. Due to the fact that the Western Blot confirmation date is counted as registration time, the data based on newly registered cases could late the epidemic’s trends provided by such statistics. There is no data on the average length between the first positive ELISA and the Western Blot confirmation test due to the lack of validation study and electronic system before. The inconsistency in this type of data – specifically those regarding the left bank of the Dniester River – is explained by the fact that the political context has reduced the number of ELISA

12 positive samples referred for confirmation (Western Blot test) from the left bank of the Dniester River and has delayed the confirmation since the only reference laboratory which confirms the HIV cases is located on the right bank of the Dniester River (capital city of Chisinau). 2. The follow up of HIV cases is conducted by the infectionist at local level and by the ARV department in the Republican Dermato – Venereal Dispensary (RDVD). The data collected at this level are related mainly to the pre ART follow up and ART monitoring. Upon the legal problem related to the SIME AIDS data base will be solved, the Republican Dermato – Venereal Dispensary (further RDVD) will start the retrospective data entry of HIV cases ever been under follow up. To process data for current evaluation, an excel spread sheet has been developed that uses few variables (year of birth, gender, year of start of pre ART follow up, year of start of ART, ART line, right/left bank, treatment results). Due to the low number of patients in treatment, centralized ARV medicines release and single institution involved, the probability of significant bias is low. 3. The reporting system on HIV testing is part of the preventive medicine reporting system. The system is a vertical one in terms of distribution of tests and reporting. The reporting on the amount of HIV testing, gender of testees, reasons and results is done by the regional AIDS laboratories based on the paper recordings and sent to the National Reference AIDS Laboratory. The gaps in quality are due to the paper based recording and reporting errors (duplication of data, lost, wrong counted number of tests versus number of tested persons). The reports are sent on monthly basis. The available disaggregation is by gender and district (rayon). Not available by age group and residency area. The age is indicated on the request paper, but is not included in the data aggregation process. The sub national data quality is checked at national level in terms of completeness, timeliness and comprehensiveness and during field visits conducted by the National Reference AIDS Laboratory. No data validation operational research has been conducted prior to 2008. At national level the data are disaggregated by territorial units. Due to the fact that in 2004 the Parliament promoted a new administrative - territorial division of the country, overtime the comparability of data disaggregated by territorial units is reduced. Within the framework of the 5YE any data quality control at district level was conducted. The repeated retrospective aggregation has been performed based on the received reports. Number of pregnant women covered by HIV testing is provided by the preventive medicine reporting system, AIDS laboratories. Duplication of data is possible. 4. The reporting system on syphilis testing is part of the RDVD reporting system. The system is a vertical one in terms of distribution of tests and reporting. Due to centralized TPHA tests release and single institution involved, the probability of significant bias is low. Available only for the right bank of Dniester River. 5. Blood safety system has its own information system to store data on donors. The probability of duplication/losing of cases is low. Available only for the right bank of Dniester River. 6. Harm Reduction routine statistics data were extracted from quarterly reports provided by the NGOs according to the signed grant contract. The quality of data in terms of completeness, timeliness, comprehensiveness and accuracy is checked during field visits of M&E officer from Soros Foundation – the umbrella organization for NGOs working in the

13 field of Harm Reduction. Within the framework of the 5YE any data quality control at projects level was not conducted.

Surveys and other sources

Studies on Knowledge, Attitudes and Practices related to HIV/AIDS among general population Quantitative researches, household surveys, that targeted general population aged 15-65 (2007) and 15 – 50 (2005) who live permanently on the territory of the Republic of Moldova (the right bank of the Dniester River5) have been conducted in 2005 (1204 respondents) (AFEW, 2005) and 2007 (1300 respondents)(USAID Preventing HIV/AIDS and Hepatitis B and C Project (PHH), 2007). Sampling was stratified, multistage and quasiprobabilistic. The surveys are considered as being representative for the general population of targeted age groups, that live on the territory of the Republic of Moldova (the right bank of the Dniester River). The estimated sampling error is ±3% for both surveys. The data collection tool has been adjusted to international reporting standard for core indicators that makes the results comparable at global level. The Demographic and Health Survey, conducted in 2005 (30,491 respondents), addressed issues related to HIV/AIDS (National Scientific and Applied Center for Preventive Medicine (NCPM) [Moldova] and ORC Macro, 2006).

Studies on Knowledge, Attitudes and Practices related to HIV/AIDS among youth Quantitative research conducted in 2006 (1190 respondents) (Scutelniciuc, 2006) and repeated in 2008 (1182 respondents) (Scutelniciuc, 2008) a household survey, that targeted youth aged 15 - 24 years old who live permanently on the territory of the Republic of Moldova (the right bank of the Dniester River). Sampling method: stratified, multistage, quasiprobabilistic. The surveys are considered as being representative for the general population of the Republic of Moldova comprising the age groups 15 - 24 years old who live permanently on the territory of the Republic of Moldova (the right bank of the Dniester River). The estimated sampling error was ±3% in both cases. Both surveys used the same data collection tool and the same sampling methodology that make them comparable. The data collection tool has been adjusted to international reporting standard for core indicators that make the results comparable at global level.

Behavioural and Sentinel Surveillance Surveys (BSS) related to HIV/AIDS among IDUs The fisrt Behavioural and Sentinel Surveillance Survey (BSS) in IDUs was conducted in 2001 (200 respondents) (CIVIS, 2001), repeated in 2003/2004 (507 respondents) (Bivol, 2004) and 2007 (630 respondents) (Scutelniciuc & Bivol, 2008). All surveys targeted exclusively the beneficiaries of Harm Reduction Programmes services. The first two surveys used the time location cluster sampling, multicentric, cross-sectional, questionnaire based and was not combined with qualitative testing on the presence of antibodies to HIV. The HIV prevalence data were generated based on testing of used syringes collected from sentinel sites. The 2007 BSS used probabilistic sampling and a two- stage cluster sampling design, multicentric, cross-sectional, questionnaire based and combined with qualitative testing on the presence of antibodies to HIV, VHC, VHB, and syphilis. The data collection tools have been adjusted to international reporting standard for core indicators that make the results comparable at global level. Overtime the international recommendations for construction of core indicators has been changed that reduce the comparability between data

5As a result of the frozen conflict on the Dniester River (1991 - 1992), the territory of the Republic of Moldova is divided in the territory on the right bank and territory on the left bank (Transnistria) of the Dniester River. 14 points.The fact that the target of these surveys were exclusively the IDUs - beneficiaries of Harm Reduction Programmes - reduce the representativity of the survey and could not be extrapolated to the entyre population of IDUs. The staff and volunteers of the Harm Reduction Programmes have been recruited as interviewers which could have inspired the respondents to provide desired answers to the questions which reflect the prevention activity of the projects.

Behavioural and Sentinel Surveillance Surveys (BSS) related to HIV/AIDS among CSWs The fisrt Behavioural and Sentinel Surveillance Survey (further BSS) in Commercial Sex Workers (CSWs) was conducted in 2003 (150 respondents) (Wolrd Health Organization Regional Office for Europe, 2004), repeated in 2004 (149 respondents) (Scientific and Practical Centre of Public Health and Sanitary Management, 2006) and 2007 (496 respondents) (Scutelniciuc & Bivol, 2008). All surveys targeted exclusively the beneficiaries of Harm Reduction Programmes services. In all three surveys the probabilistic sampling was not possible. All target group representatives, who accepted to participate in the studies, were included. In 2003 and 2004 the survey was unicentric (capital city only), cross-sectional, questionnaire based and combined with qualitative testing on the presence of antibodies to HIV, VHC, and syphilis. The 2004 BSS involved most of the respondents who participated in 2003 BSS. This fact explains the high values of core indicators registered in 2004. In 2007 the survey was multicentric (extended to four additional locations), cross-sectional, questionnaire based and combined with qualitative testing on the presence of antibodies to HIV, VHC, VHB, and syphilis. The data collection tools have been adjusted to international reporting standard for core indicators that make the results comparable at global level. Overtime the international recommendations for construction of core indicators has been changed (Join United Nations Programme on HIV/AIDS (UNAIDS), 2007) that reduce the comparability between data points. The fact that the target of these surveys were exclusevly the Commercial Sex Workers (CSWs) - beneficiaries of Harm Reduction Programmes - reduce the representativity of the survey and could not be extrapolated to the entyre population of Commercial Sex Workers (further CSWs). The staff and volunteers of the Harm Reduction Programmes have been recruited as interviewers which could have inspired the respondents to provide desired answers to the questions which reflect the HIV prevention activity of the projects.

Behavioural and Sentinel Surveillance Surveys related to HIV/AIDS among MSM The fisrt BSS in Men having Sex with Men (MSM) was conducted in 2003 (118 respondents) (Wolrd Health Organization Regional Office for Europe, 2004), repeated in 2004 (121 respondents) (Scientific and Practical Centre of Public Health and Sanitary Management, 2006) and 2007 (94 respondents) (Scutelniciuc & Bivol, 2008). All surveys targeted exclusively the beneficiaries of Harm Reduction Programmes services. In all three surveys the probabilistic sampling was not possible, being unicentric (capital city only), cross-sectional, questionnaire based and combined with qualitative testing on the presence of antibodies to HIV, VHC and syphilis. All target group representatives, who accepted to participate in the studies, were included. The 2004 BSS involved most of the respondents who participated in 2003 BSS. This fact explains the high values of core indicators registered in 2004. The 2007 BSS in Men having Sex with Men (MSM) is appreciated as poor quality due to the smaller sample size and broken rules in data collection process (Scutelniciuc & Bivol, 2008).

15 The data collection tools have been adjusted to international reporting standard for core indicators that make the results comparable at global level. Overtime the international recommendations for construction of core indicators has been changed that reduce the comparability between data points.The fact that the target of these surveys were exclusively the MSM - beneficiaries of Harm Reduction Programmes - reduce the representativity of the survey and could not be extrapolated to the entyre population of Men having Sex with Men (further MSM). The staff and volunteers of the Harm Reduction Programmes have been recruited as interviewers which could have inspired the respondents to provide desired answers to the questions which reflect the HIV prevention activity of the projects.

16 Study Question 1: Trends in Funding Retrospective data collection on funds allocated to the HIV response has been performed within the framework of 5YE activities. In the development of research methodology the NHA approach was applied. The output tables are presented in Attachment 2. The general funding to support the implementation of the National Programme on Prevention and Control of HIV/AIDS/STIs was continuously increasing from almost $1 M in 2003 to almost $4.1M in 2006, especially coming from external sources. The total amount of funds allocated in 2007 decreased ($3.7M) due to the final year of implementation of main grant (GFATM first round and World Bank) targeting the reduction of HIV burden. Overtime the national contribution was slightly and stably increasing but remains low comparing with the external sources (Figure 2 and Figure 3). Since 2004 there has been registered small contribution from the national private sector ($3,750 in 2004 to $8,030 in 2007). Figure 2 HIV funding divided by source, $, Republic of Moldova (right bank of Dniester River), 2003 - 2007

Overtime the biggest part of public funding comes from the Ministry of Health, througth the budget line for the implementation of the National Programme on Prevention and Control of HIV/AIDS/STIs (Figure 3). There is an increase of the amount of money allocated by the Ministry of Justice, due to the opening of the ART department in the Penitenciary hospital in 2003. The funds allocated by the National Health Insurance Fund has constantly increased overtime following the inclusion of hospitalization related to HIV treatment in the mandatory health insurance coverage.

17 Figure 3 HIV/AIDS public funding by source agency, $, Republic of Moldova (right bank of Dniester River), 2003 - 2007

Disaggregating by type of service providers, the biggest part was registered for institutions providing health related services (prevention) overtime (Figure 4). In this category were included the organizations providing prevention activities in Key Populations at Higher Risk (KPARs), vulnerable population and general population. As shown, in 2005 there was an injection of funds in capacity building providers (Figure 4) and training as function (Figure 5).

18 Figure 4 HIV/AIDS funding divided by service providers, $, Republic of Moldova (right bank of Dniester River), 2003 - 2007

Overtime there is an increase in the amount of funding allocated to communication function (Figure 5). In 2007, other functions than laboratories, have been slightly reduced in funding due to last year of implementation of main grants allocated for HIV response (GFATM first round, World Bank).

19 Figure 5 HIV/AIDS funding by functions, $, Republic of Moldova (right bank of Dniester River), 2003 - 2007

20 Study Question 2: Coverage and Quality of HIV services

Trends in Coverage of Services

Scale – up in infrastructure Prior 2007, there were no special centers for HIV testing. The blood for HIV testing could be taken in every health care institution. Density of medical health care institutions to take blood is geographically homogeneous distributed. After that the blood samples are sent to the regional AIDS Laboratory. During 2003 - 2007 5 new AIDS Laboratories have been open and equipped (), thus by the end of 2007, a total of 15 AIDS Laboratories are functioning on the entire territory of the Republic of Moldova (14 on the right bank6 and 1 on the left bank), including the one National Reference AIDS Laboratory within the framework of the AIDS Centre (Figure 6). Table 1 Number of AIDS Laboratories, Republic of Moldova, 2000 - 2007 2000 2001 2002 2003 2004 2005 2006 2007 Right bank 9 9 9 9 9 12 12 14 AIDS Laboratories Left Bank 1 1 1 1 1 1 1 1 Total Moldova 10 10 10 10 10 13 13 15 Source: National Scientific and Practical Centre of Preventive Medicine, AIDS Centre, Ministry of Health, Republic of Moldova The regional AIDS laboratories perform ELISA type tests only, the confirmation Western Blot test is under the responsibility of National Reference AIDS Laboratory only. The ELISA positive samples are sent to the National Reference AIDS Laboratory for confirmation from both banks of Dniester River. Within the GFATM first round grant there were no planned activities for the left bank of Dniester River. No additional AIDS laboratory has been open in the reporting period on the left bank of Dniester River. Figure 6 Geographical location of AIDS laboratories, Republic of Moldova, 2007 Source: National Scientific and Practical Centre of Preventive Medicine, AIDS Centre, Ministry of Health, Republic of Moldova Out of savings resulted from the implementation of the GFATM first round grant, performing equipment was bought for the AIDS laboratory in Tiraspol (left bank of Dniester River). In the 6th round GFATM grant there are planned activities for the left bank of Dniester River in order to ensure the equity in access to services for population from both banks of Dniester River. The increase in the geographical coverage by AIDS Laboratories and their homogenous distribution ensure a reduction in the waiting time for results of ELISA screening test. According to the regulatory framework testing of pregnant women to HIV is recommended twice during

6 Including AIDS Laboratory within National Blood Transfusion Centre (NBTC) and Regional Blood Transfusion Centre (RBTC) in Cahul 21 pregnancy, in cases when the pregnant woman comes to delivery with an unknown HIV status she is advised to undertake an HIV test. In 2002 the ARV treatment was initiated in Moldova when the first patient received medicines procured from the Ministry of Health funds. Since 2003 the ARV drugs have been procured with the financial support of the World Bank (AIDS prevention project in Moldova) and the Grant of Global Fund to Fight AIDS, Tuberculosis and Malaria (first round). Since 2003 there are two ART centers: the ART Department in the Dermato-Venereal Republican Dispensary (capital city) and in the hospital of the Penitentiary Department, both on the right bank of Dniester River. In 2007 an ART centre was open in Tiraspol, on the left bank of Dniester River (Table 2) with important support of Medecins Sans Frontieres. The ART centers provide PMTCT. Table 2 Number of ART centers, Republic of Moldova, 2000 - 2007 2000 2001 2002 2003 2004 2005 2006 2007 Right bank 0 0 1 2 2 2 2 2 ART centers Left Bank 0 0 0 0 0 0 0 1 Total Moldova 0 0 1 2 2 2 2 3 Source: Republican Dermato-Venereal Dispensary, Ministry of Health All 3 ART centers were renovated and fully equipped with collective support of donors working in the Republic of Moldova (WB, GFATM, Medecins Sans Frontieres, UNICEF, UNAIDS, Caritas Luxembourg). Within the GFATM first round grant there were no planned activities for the left bank of Dniester River. Out of savings resulted from the implementation of the GFATM first round grant, performing equipment was bought for the ART department in Tiraspol (left bank of Dniester River). According to the evaluation report developed within the framework of the 5YE activities (Seicas & Scutelniciuc, 2008) there was not break in the supply with ARV drugs overtime. The report states that in the period 2004 - 2007 the average number of days from request to delivery varied between 152 – 205 days. This length created a threat of breakage in the drug release to patients at the end of 2005. With collective effort the critical situation was solved. The national blood program is under the authority of the Ministry of Health and has a hierarchical structure with four levels (1 national centre – National Blood Transfusion Centre, 2 regional centers – Regional Blood Transfusion Centre, blood transfusion departments in hospitals and blood banks in small hospitals). During last 5 years equipment, ELISA tests, blood collection supply were procured and distributed yearly. There is relative uniformity in equipment used at the NBTC and RBTCs, representing newer technology. In general, both the NBTC and RBTC-Balti had a close approximation of the complement of critical equipment needed to operate a modern blood banking facility. RBTC in Cahul is currently under reorganization. Training programs were also conducted for the staff of NBTC and RBTC. All blood processed by the NBTC and RBTC is currently tested for HIV, hepatitis B, hepatitis C, and syphilis. ELISA methodology is used for HIV, hepatitis B, and hepatitis C, while syphilis is screened using Immutrep RPR and confirmed with TPHA. Taking into consideration that the HIV epidemic in the Republic of Moldova is concentrated in Key Populations at Higher Risk (KPARs), particularly in IDUs, one of the strategies of the National Programme of Prevention and Control of HIV/AIDS and Sexually Transmitted Infections is the Harm Reduction Strategy among the high risk and vulnerable groups (IDUs, LGBT, CSWs, truck drivers and migrants). The Republic of Moldova is an example of best practices in the implementation of the Harm Reduction Strategy in terms of quality of services and coverage. The history of implementation of the Harm Reduction activities for IDUs in Moldova lies in a strategy developed back in 1997. Since 2003 the implementation of Harm Reduction in the Republic of Moldova is in 22 the third phase of scaling up. About 90% of Harm Reduction activities are provided by NGOs. Members of the NGOs received large trainings in different key issues pertaining to the work of NGO like accounting, leadership, prevention of drug use, HIV prevention in KPARs. The basic components of the Harm Reduction Strategy for IDUs in free settings in the Republic of Moldova are as follow: . information/education/outreach about HIV and ways of their prevention in the context of high risk practices (distribution of informational materials, condoms, seminars), . referral to medical and social services (offering medical counselling, usually for sexually transmitted infections, psychological counselling, pre and post HIV-test counselling), . needle exchange, . methadone substitution therapy. The basic components of the Harm Reduction Strategy within the framework of penitentiary institutions are as follow: . information/education/outreach about HIV/AIDS and prevention in the context of high risk practices (distribution of informational materials, condoms, seminars), . needle exchange for IDUs, . methadone substitution therapy. Activities for inmates are conducted particularly within the medical services of the penitentiary institutions, with the involvement of the outreach employees recruited among inmates. Thus since 2003 the coverage by Harm Reduction projects has increased significantly (Table 3). Table 3 Harm Reduction in KPARs, service delivery points, Republic of Moldova, 2000 - 2007 2000 2001 2002 2003 2004 2005 2006 2007 IDUs Right bank 5 5 5 10 10 19 20 20 IDUs, civilian sector Left Bank 0 0 0 0 2 3 3 3 Total sector 5 5 5 10 12 22 23 23 Right bank 1 1 2 5 5 6 6 6 IDUs, penitentiary Left Bank 0 0 0 0 0 0 0 0 sector Total sector 1 1 2 5 5 6 6 6 Total Moldova IDUs 6 6 7 15 17 28 29 29 CSWs Right bank 0 0 0 3 5 5 5 5 CSWs Left Bank 0 0 0 0 0 0 0 0 Total Moldova CSWs 0 0 0 3 5 5 5 5 LGBT Right bank 0 0 0 0 1 1 1 1 MSM Left Bank 0 0 0 0 0 0 1 1 Total Moldova MSM 0 0 0 0 1 1 2 2 Truck drivers Right bank 0 0 0 0 1 2 2 0 Truck drivers Left Bank 0 0 0 0 0 0 0 0 Total Moldova truck drivers 0 0 0 0 1 2 2 0 Methadone treatment Right bank 0 0 0 0 1 1 1 2 Civilian sector Left Bank 0 0 0 0 0 0 0 0 Total sector 0 0 0 0 1 1 1 2 Penitentiary sector Right bank 0 0 0 0 0 1 3 3 23 Left Bank 0 0 0 0 0 0 0 0 Total sector 0 0 0 0 0 1 3 3 Total Moldova 0 0 0 0 1 2 4 5 Source: Soros Foundation – Moldova, Harm Reduction Programme Till the end of 2004 the activities targeting IDUs were mostly concentrated in the urban areas and since 2004 there has been an extention to rural area. Also, 2004 is a crucial year when the Harm Reduction activities in IDUs started on the left bank of Dniester River. Thus, by the end of 2007 there were 23 Harm Reduction delivery points for IDUs (needle exchange points&volunteers) in 21 administrative territories in civilian sector, 6 delivery points in penitentiary sector. The selection of geographical location (Figure 7) was based on the registered injecting drug use prevalence in population. The registered injecting drug use in the population is higher in the Northen part of the country, capital city and on the left bank of Dniester River. The geograpghical extension of Harm Reduction Programmes on the left bank of Dniester River is hardened by the reticence of local authorities. The Republic of Moldova established methadone substitution treatment program in Republican Narcological Dispensary in October 2004. In 2005, the methadone substitution treatment was initiated in Penitentiary Department institutions under the Ministry of Justice. Since the methadone treatment is available only in 3 institutions of the Department of Penitentiary and in two free settings institution (in capital city of Chisinau and Balti city) (Table 3), there is a risk that the methadone substitution treatment will be discontinued when a person is arrested or put in freedom.

24 Figure 7 Geographical location of Harm Reduction delivery points, Republic of Moldova, 2007

Source: Soros Foundation – Moldova, Harm Reduction Programme The first Harm Reduction project targeting CSWs was open in 2003. The Harm Reduction activities targeting CSWs are geographicaly located close to main roads (Ungheni, Orhei, Edinet) and in the biggest cities in the country (Chisinau and Balti) (Figure 7). No activities targeting CSWs were implemented on the left bank of Dniester River, due to refusal of local authorities to recognize the existance of such KPAR. For CSWs the basic components of the Harm Reduction Strategy in Moldova are as follows:  Information/education on HIV/AIDS transmission and prevention in the framework of high risk behaviour and outreach with distribution of information materials, needles and syringes, condoms and seminars,  Referral to medical institutions and social assistance (medical consultations, as a common practice for STIs, consultations for psychological rehabilitation, pre and post-test counselling),

25  Needle exchange. The first Harm Reduction project targeting LGBT community was open in 2004. LGBT community in Moldova would benefit of the Harm Reduction Strategy based on the following services:  Information/education on HIV/AIDS transmission and prevention in the framework of high risk behaviour and outreach with distribution of information materials, condoms and seminars,  Referral to medical institutions and social assistance (medical consultations, as a common practice for STIs, consultations for psychological rehabilitation, pre and post-test counselling). In 2006 an outreach worker was hired to distribute condoms and informational materials on the left bank, especially in Tiraspol city. Seminars were provided on the left bank by the NGO working on the right bank of Dniester River. The interventions in truck drivers staretd in 2004, taregeting the long distance truck drivers trained in the National Training Centre for Drivers in the capital city of Chisinau and those working in the bigest transportation company in Balti. The interventions in truck drivers consisted in seminars and distribution of informational materials and condoms. Informational materials related to HIV prevention have been developed and distributed on the border among people living the country. Before 2003, the idea of ‘Home and community-based Care and Support for People Living with HIV/AIDS (PLWHA)’ was conceptualized, but not actually implemented. Since 2005 Soros Foundation started subprojects for home and community based support and care for People Living with HIV/AIDS (further PLWHA) (Table 4). Table 4 Number of projects supporting PLWHA, Republic of Moldova, 2005 – 2007 2005 2006 2007 Right bank of Dniester River 3 3 6 Left bank of Dniester River 1 0 1 Total Moldova 4 3 7 Source: Soros Foundation – Moldova, Harm Reduction Programme The major activities are as follow:  Rendering palliative care services to people living with HIV/AIDS  Distributing informational materials, providing social care services, including distribution of food packages, facilitation of access to antiretroviral therapy, legal counseling, and primary health care.  Raising the awareness of socially vulnerable children on HIV/AIDS, increasing access to information, reducing risky behavior and attitudes, including tolerance for PLWHA, and promoting a healthy lifestyle.

26 Scale – up in services All ELISA tests are performed in the AIDS laboratory. During 2002 – 2007 the number of performed tests was stably increasing (Table 5) and the number of HIV tested persons as well (Figure 8). The number of newly registered HIV cases has increased, from 199 in 2002 to 731 in 2007. Figure 8 Testing for HIV and the number of newly reported HIV cases, Republic of Moldova, 1987 – 2007

Source: National Scientific and Practical Centre of Preventive Medicine, AIDS Centre, Ministry of Health Table 5 Number of tests performed, Republic of Moldova, 2002 – 2007 2002 2003 2004 2005 2006 2007 Republic of Moldova, both banks of Dniester River ELISA tests 116333 167930 253152 271433 301901 376495 Western Blot tests 306 344 366 630 804 834 CD4/CD8 tests - - 443 679 1892 2155 PCR test - - 156 850 1488 2390 Republic of Moldova, right bank of Dniester River MRS tests (Syphilis) 848803 874330 694836 799372 860991 968159 TPHA test (Syphilis) - 773 563 34895 33866 41800 Source: National Scientific and Practical Centre of Preventive Medicine, AIDS Centre and Republican Dermato- Venereal Dispensary, Ministry of Health Overtime, the disaggregation of performed HIV ELISA tests by reasons shows no important differences. After registration on 12 new HIV cases in pregnant women in sentinel sites in 2003, in 2004 the national regulations changed and according to these all pregnant women are recommended to be

27 counseled and tested for HIV twice during the pregnancy. This explains the increase in the number of pregnant women tested overtime (Figure 9). Figure 9 Number of pregnant women tested for HIV, tests made on pregnant women and number of new HIV cases in pregnant women, Republic of Moldova, 2002 – 2007

Source: National Scientific and Practical Centre of Preventive Medicine, AIDS Centre, Ministry of Health According to official statistics data, the coverage of pregnant women with HIV testing in the last 5 years varies between 95 – 98% on the left bank of Dniester River. There is no disaggregated data available on age group and residency area. Over time there is an increase in the number of tests performed on blood donated samples (Table 6). The difference between the number of blood donated samples tested and number of tests performed on blood donated samples is explained by the double testing of initially reactive samples and tests used for internal quality control procedures. Table 6 Number of blood donated samples, number of blood donated samples tested for HIV, VHC, VHB and syphilis and number of tests performed, Republic of Moldova (right bank of Dniester River), 2002 – 2007 2002 2003 2004 2005 2006 2007 Number of blood donated 44368 54102 62265 60188 74224 74013 samples Number of blood donated samples tested for HIV, VHC, 44368 54102 62265 60188 74224 74013 VHB and syphilis Number of HIV tests type ELISA performed on blood 51023 62758 69737 67411 82389 82895 donated samples Number of VHB tests type ELISA performed on blood 49148 61135 68491 66207 83131 84375 donated samples Number of VHC tests type 48806 58971 66001 65003 80904 81414 ELISA performed on blood 28 donated samples Number of tests for syphilis performed on blood 46143 57348 65378 63799 80162 82154 donated samples Source: National Blood Transfusion Centre, Ministry of Health In parallel there is an increase of the number of newly registered HIV cases in blood donors (Figure 10). Figure 10 Number of newly registered HIV cases per 100 000 donations, Republic of Moldova (right bank of Dniester River), 1998 – 2007

Source: National Scientific and Practical Centre for Preventive Medicine, Ministry of Health Overtime there is an increase in the number of performed test for diagnosis of syphilis in general population. Since 2003, Moldova started to use TPHA tests (Table 5). There is no data available on the number of persons tested for syphilis and the reasons for testing. The number of newly registered cases of syphilis slightly decreased in the last 5 years (Table 7). Table 7 Number of newly registered cases of syphilis, Republic of Moldova (right bank of Dniester River), 2002 – 2007 2002 2003 2004 2005 2006 2007 Newly registered cases, 3273 2779 2460 2404 2381 2262 general population Source: Republican Dermato-Venereal Dispensary, Ministry of Health Number of patients in ART has constantly increased from both banks of Dniester River (). ARV drugs are offered free of charge. Since 2003, when ART became available on routine basis there were no breaks in drug supply according to evaluation report (Seicas & Scutelniciuc, 2008).

29 Table 8 New entries in ART, Republic of Moldova, 2003 – 2007 2003 2004 2005 2006 2007 IDU 18 47 43 45 82 New entries right Sexual route 8 23 43 53 81 bank MTC 2 1 2 5 5 Total 28 71 88 102 168 IDU 0 3 6 4 14 New entries left Sexual route 1 9 15 12 20 bank MTC 2 0 0 2 1 Total 3 12 21 18 35 IDU 28 50 47 49 93 Sexual route 9 32 58 64 98 Total Moldova MTC 4 1 2 7 6 Total counted 31 83 109 121 203 Source: National Scientific and Practical Centre of Preventive Medicine, AIDS Centre and Republican Dermato- Venereal Dispensary, Ministry of Health Table 9 New entries in ART, adults, Republic of Moldova, 2003 – 2007 2003 2004 2005 2006 2007 Males 14 49 66 62 109 New entries Females 13 32 41 52 88 Total 27 81 107 114 197 Source: Republican Dermato-Venereal Dispensary, Ministry of Health Table 10 Cohort analysis of patients entered in ART 2003 – 2007, Republic of Moldova, end of 2007 2003 2004 2005 2006 2007 Initiated 31 83 109 121 203 Death 7 7 12 6 11 Default 5 22 11 9 1 In treatment by the end of 2007 19 54 86 106 191 Source: Republican Dermato-Venereal Dispensary, Ministry of Health By the end of 2007, there were 456 patients in ART out of 547 ever reached by the Republican Dermato-Venereal Dispensary on the right bank of Dniester River. In 2007, a new ART centre was open in Tiraspol, on the left bank of Dniester River. This ART centre offers services to the civilian sector and covers also the prisoners. According to their data, on the left bank of Dniester River by the end of 2007, there were 60 patients ever reached (including 13 detainees) and 45 patients in treatment (including 11 detainees) by the end of 2007. Since 2003, the ART to prevent the mother to child transmission is available on routine basis. The UNGASS indicator nr. 5 (National Centre of Health Management, 2008) is available only for 2006 – 2007 (). Table 11 Percentage of HIV positive pregnant women who received antiretroviral drugs to reduce the risk of mother to child transmission, Republic of Moldova, 2006 - 2007 2006 2007 Number of pregnant women that benefited from PMTCT 62 73 Estimated number of pregnant women HIV positive 75 86 Indicator value, % coverage by PMTCT 82.7 84.9 Source: Republican Dermato-Venereal Dispensary, Ministry of Health More pregnant women, diagnosed with HIV before the pregnancy, decide to get pregnant and keep their pregnancy, indicating more trust in the prevention ART services available in the country

30 (13 pregnant women in 2006 vs. 31 in 2007), at roughly the same values of primarily diagnosed pregnant women – 84 and 81 reported in 2006 and 2007 respectively. Due to the availability of PMTCT on routine basis, since 2004, the percent of vertical transmission of HIV has decreased (Table 12). Table 12 MTC of HIV, Republic of Moldova, 2002 - 2007 2002 2003 2004 2005 2006 2007 Number of children who are HIV+ 3 7 5 6 1 1 Number of children born to HIV+ 15 7 38 63 77 60 pregnant women % of annual cohort 20 100 13 10 1.3 1.7 Source: National Scientific and Practical Centre of Preventive Medicine, AIDS Centre and Republican Dermato- Venereal Dispensary, Ministry of Health Overtime there is an increase of the number of IDUs beneficiaries Harm Reduction Programmes (Table 13). Table 13Number of IDUs ever covered by Harm Reduction Programmes, Republic of Moldova, 2003 – 2007 2004 2005 2006 2007 Right bank of Dniester River 5293 7505 10662 11260 Left bank of Dniester River 88 454 632 678 Total Moldova 5381 7959 11294 11938 Source: Soros Foundation Moldova, Harm Reduction Programme In all implementation locations, the males constitute the majority among beneficiaries (Table 14), with small differences between locations. Thus, the rate of females using Harm Reduction services is higher than their rate among IDUs registered officially. The disaggregated data by gender on IDUs beneficiaries of HRPs are available since 2004. Table 14 IDUs officially registered and HRPs and the rates of male and female among them, Republic of Moldova (right bank of Dniester River), 2004 – 2007 IDUs registered in the data base of RND IDUs registered as beneficiaries of HRPs7 Total M % F % Total M % F % number number End of 2004 3133 87.4% 12.6% 5293 82% 18% End of 2005 3388 87.5% 12.5% 5757 81% 19% End of 2006 3210 87.6% 12.4% 7847 81% 19% End of 2007 X8 X X 8264 83% 17% Source: Soros Foundation Moldova, Harm Reduction Programme Republican Narcological Dispensary, Ministry of Health, Republic of Moldova According to 2007 BSS results, the rate of female among beneficiaries of Harm Reduction Programmes reaches 21.1% (Scutelniciuc & Bivol, 2008), which is higher than the rate of females among IDUs registered officially (Table 14). Currently we cannot report on the numbers of beneficiaries by service categories and residency area since there is no such distribution of beneficiaries based on these categories in the existing reporting system. Not all IDUs covered by Harm Reduction Programmes of IDUs are officially registered by the health care system and are counted in the official statistics. According to the last BSS data, only 45% of beneficiaries of HRPs stated that they are officially registered (Scutelniciuc &

7 The IDUs beneficiaries of HRPs from the left bank of Dniester River have not been counted to ensure the comparability between figures. 8 The reported number was inconsistent and was not included in the analysis 31 Bivol, 2008). The Harm Reduction Programmes offer services anonymously and this fact increases the access the services. Over time there is an increase in the number of syringes distributed by the projects that implement Harm Reduction activities out of the grants operated by the Soros Foundation Moldova (Table 15). Table 15 Number of syringes and condoms distributed, KPARs, Republic of Moldova, 2005 – 2007 2005 2006 2007 Number of syringes distributed 2009644 2278592 1983941 Number of condoms distributed 770149 845593 700085 Source: Soros Foundation Moldova, Harm Reduction Programme Due to the lack of reliable estimates of the number of IDUs nationwide, it is not possible to assess the coverage of the population of IDUs and the territorial coverage with HRPs. In 2007 the inclusion criteria for involvement in methadone substitution treatment change, becoming less restrictive. This fact produced an increase in the number of opiates users ever covered by methadone substitution treatment (Table 16). The methadone treatment is not available on the left bank of Dniester River. Table 16 Number of opiates users ever covered with methadone substitution treatment, Republic of Moldova (right bank of Dniester River), 2005 - 2007 2005 2006 2007 Ever covered 34 73 295 Source: Soros Foundation Moldova, Harm Reduction Programme Overtime there is an increase of the number of CSWs, MSM, truck drivers and migrants ever reached by Harm Reduction Programmes (Table 17). In 2007, the number of new entries of truck drivers and migrants was lower than in 2005 and 2006. The 2007 year was the last year of implementation of first round of grant GFATM and WB grant and the prioritization of financing was applied. The interventions targeting truck drivers and migrants were reduced and extension was planned for the 6th round FGATM grant. Table 17 Number of CSWs, MSM, truck drivers and migrants reached by Harm Reduction Programmes, Republic of Moldova, 2003 – 2007 2003 2004 2005 2006 2007 Number of CSWs, ever reached, 307 556 728 794 858 cumulative number Number of MSM, ever reached, n/a 612 638 735 751 cumulative number Number of truck drivers, ever n/a n/a 4001 7842 7868 reached, cumulative number Number of migrants, yearly n/a n/a n/a 84799 111810 Source: Soros Foundation Moldova, Harm Reduction Programme Since 2005, when the projects targeting PLWHA became operational, the number of beneficiaries ever reached increased overtime (Table 18). Table 18 Community Support for PLWHA, number of beneficiaries ever reached, Republic of Moldova, 2005 - 2007 2005 2006 2007 Right bank of Dniester River 643 1181 1404 Left bank of Dniester River 93 0 151 Total Moldova 736 1181 1555 Source: Soros Foundation Moldova, Harm Reduction Programme 9 Reached on the right bank of Dniester River only 10 Reached on the left bank of Dniester River only 32 In all HIV activities there is an inequity in availability and access to services for potential beneficiaries from the left bank of Dniester River due to the frozen political conflict that causes reluctance from the part of left bank authorities to expend the activities geographically and to recognize the existence of KARPs.

Trends in Quality Prior 2007, there was not a national Voluntary Counseling and Testing (VCT) approach. Pre and post counseling, if any, is provided by the physicians. Through the Order of the Ministry of Health Nr. 344 of 05.09.2007 (Ministry of Health of the Republic of Moldova, 2007) there has been established a network of Voluntary Counseling and Testing (VCT) Centers for counseling to HIV and viral hepatitis B and C. The first centers have been piloted in December 2007. No standard operation procedures (SOPs) available till 2007 in HIV testing. SOPs have been implemented in the blood service since the end of 2007. External quality control is done by the National Reference AIDS Laboratory during monitoring visits to the regional AIDS labs. There is no international control available. In October 2006, with the technical assistance of USAID Preventing HIV and Hepatitis Project and the technical inputs from American Association of Blood Banks (AABB) consultants, the blood service in Moldova has started a process of implementing a new quality management program. The SOPs on HIV testing procedures were reviewed, validated and approved in 2007 in the NBTC (Table 19). All the personnel from NBTC and RBTS were trained on using the new SOPs in transfusion transmissible diseases. The labs from Cahul and Balti RBTCs are going to adjust and approve the SOPs on HIV testing in 2008. Table 19 Donated blood units screened for HIV in a quality assured manner, Republic of Moldova (right bank of Dniester River), 2007 Name of the blood Quality assurance in HIV screening Blood units centre or blood Standard External Quality Donated Screened Blood screened screening Operating Assurance Scheme blood blood in quality – laboratory Procedures assured manner Chisinau (NBTC) Yes Yes 54,248 54,248 54,248 Balti (RBTC) No Yes 17,615 17,615 0 Cahul (RBTC) No Yes 2,550 2,550 0 No Yes 74,013 74,013 54,248 Total 73.3% Source: National Blood Transfusion Centre, Ministry of Health At this point all the blood centers take part in an external quality assurance scheme provided by the National Reference AIDS Laboratory of Moldova. The procedure of external quality control includes testing one negative sample from each 10th testing plate at the NBTC; each 6th negative sample from all tests performed in regional centers are sent to the National Reference AIDS Laboratory for second testing. At this point the National Reference AIDS Laboratory does not use the known, but undisclosed samples procedures to check the blood service testing quality. The quality of testing is checked during the accreditation procedure that takes place every 5 years. The NBTC plans to review the possibilities to enter an international EQA scheme starting with year 2009, after all the equipment has been bought and all the personnel in the blood service has been trained in new operations. Regional AIDS Laboratories take part in an external quality assurance provided by the National Reference AIDS Laboratory of Moldova. 33 The list of ARV drugs, which were selected and included in the National Protocols on HIV/AIDS treatment and care currently applied (Ministerul Sanatatii al Republicii Moldova, 2005), are consistent with the WHO treatment standards (World Health Organization, 2003). There is only one health care institution providing ARV treatment in the country covering both banks of Dniester River – Dermato Venereal Dispensary, AIDS Treatment department. The second one was open in 2007 in Tiraspol (AIDS Centre), covering patients from the left bank only. From one point of view the centralized approach in ART delivery reduces the probability of drug resistance development due to misuse of drugs. From accessibility point of view this approach reduces the accessibility. Since 2007, within the framework of project aiming the increase of adherence to treatment the expenditure covering the travel for pre ART and ART proposes are reimbursed. The implementation of the Harm Reduction Strategy has comprised the activities of information/education/outreach, needle exchange, referral towards medical and social services and methadone substitution therapy. The bulk of such activities are performed by the projects funded out of the grants provided by the Soros Foundation - Moldova in both the free settings and the penitentiary sector. No standards for Harm Reduction activities have been developed prior to 2008. In 2007 the restrictive criteria for involvement in methadone substitution treatment have been excluded and this fact increased substantially the access to methadone substitution treatment. The availability of methadone treatment only in two localities reduces the access of IDUs willing to benefit of such service.

Trends in Behaviour Changes Overtime the international standards in the data collection and calculation of core indicators have changed. This fact reduces the comparability, but gets a general picture on trends in knowledge, attitudes and practices related to HIV/AIDS. There is a consistent increase in knowledge in youth, IDUs, CSWs and MSM (Table 20). According to the result of the repeated survey conducted in youth in 2008 (Scutelniciuc, 2008), comparing to the 2006 one (Scutelniciuc, 2006), there was registered an increase in the level of knowledge on HIV/AIDS. Thus, the difference between the values of integrated indicator of HIV/AIDS knowledge records an increase by 14.8% (26.0% in 2006 and 40.8% in 2008), what goes beyond of the sum of standard error limits of both surveys. Also a significant increase was registered among youth, about 11.6%, recorded integrated indicator about condom knowledge (51.9% in 2006 and 63.5% in 2008). In terms of HIV testing the figures show lower values in last data points (Table 20) in KPARs. Actually the repeated 2004 BSS in CSWs and MSM involved most of the respondents who participated in 2003 BSS (Scientific and Practical Centre of Public Health and Sanitary Management, 2006). This fact explains the high values of core indicators registered in 2004.

34 Table 20 Key indicators on knowledge, attitudes and practices regarding HIV/AIDS, Republic of Moldova, 2001 - 2008 TheIndicator rate of respondentsTarget who stated Group about tolerant2001 attitudes2003 towards2004 PLWHA2005 is very2006 low,2007 especially2008 HIV testing General Population, 15 – % - - - - - 8.5 - during the 49 years old last year and Injecting Drug Users % - - 47.9 - - 34.1 - know the Comercial Sex Workers % - 13.3 53.1 - - 31.7 - result, Men having Sex with Men % - 46.1 60.0 - - 38.3 UNGASS Youth, 15 - 24 years old % - - - - 5.5 - 7.4 indicator HIV Injecting Drug Users % - - 37.0 - - 64.4 - knowledge, Comercial Sex Workers % - 19.1 34.7 - - 57.7 - UNGASS Men having Sex with Men % - 30.5 38.3 - - 46.8 - indicator Youth, 15 - 24 years old % - 12.3 - 28.3 26.3 - 40.8 Ready to Injecting Drug Users % - - 58.7 - - 45.9 - share meal Comercial Sex Workers % - - - - - 24.8 - with an HIV Men having Sex with Men % - - - - - 43.3 - positive person Youth, 15 - 24 years old % - - - - 18.0 - 16.7 Youth, 15 - 24 years old, Sex before out of the total sample % - - - 5.5 3.6 - 6.7 the age of 15 size Higher risk General Population, 15 – % - - - - - 8.3 - Sex 49 years old Condom Use During General Population, 15 – % - - - - - 49.3 - Higher Risk 49 years old Sex Condom Use at last Comercial Sex Workers % - 82.1 98.4 - - 93.3 - commercial intercourse Condom Use at last anal Men having Sex with Men % - 60.3 63.0 - - 48.1 - intercourse Condom Use at last Injecting Drug Users % - - 74.2 - - 67.9 - intercourse Injecting Drug Users, steril needles at last injection % - - 90.4 - - 95.9 - Safe Injecting during last month Practices Injecting Drug Users, steril needles always during the % 93.0 - 83.0 - - 85.6 - last month

35 The condom use at last anal intercourse in MSM declined in the last data point comparing with the previous ones. The data collection for the last data point was poor quality and this could bias the results. The safe practices were reported in IDUs and CSWs frequently or at the same level in last data points as in previous ones. The target group of these data collection was strictly the beneficiaries of Harm Reduction Programmes and the staff of NGOs were employed as interviewers. These circumstances could reduce the credibility of answers (Scutelniciuc Otilia, 2008).

36 Study Question 3: Trends in Impact

HIV prevalence Prior 2008, three HIV prevalence surveys have been conducted in Moldova (Wolrd Health Organization Regional Office for Europe, 2004; Bivol, 2004; Scutelniciuc Otilia, 2008). The methodological differences between could generate bias in the comparability, but get a general picture on trends. Table 21 HIV prevalence in IDUs, Republic of Moldova, 2001- 2007 Data 200111 2003 - 200412 200713 collection site Sample HIV prev Sample HIV prev Sample HIV prev Chisinau, 209 15.8 % 306 14.4 % 183 17.5 % capital city Balti 184 60.3 % 230 36.5 % 145 44.8 % Causeni n/a n/a 10 40.0 % 11 27.3 % Donduseni n/a n/a n/a n/a 10 10.0 % Edinet n/a n/a 7 14.3 % 20 15.0 % Falesti 50 22.0 % 67 11.9 % 28 10.7 % Orhei 13 23.1 % 44 2.3 % 21 0 % Rezina n/a n/a 43 11.6 % 30 16.7 % Soroca 87 1.15 % 116 0.0 % 41 0 % Tiraspol n/a n/a n/a n/a 68 20.7% Ungheni n/a n/a 47 2.3 % 63 6.3% Total 543 29.3 % 517 17.0 % 620 21.0%

Table 22 HIV prevalence in CSWs (blood samples, “take all” sampling), Republic of Moldova, 2003 - 2007 Data 2003 2004 2007 collection site Sample HIV prev Sample HIV prev Sample HIV prev Chisinau, 150 4.6% 151 8.5% 243 2.9% capital city Balti n/a n/a n/a n/a 122 32. 8% Edinet n/a n/a n/a n/a 34 2.9 % Orhei n/a n/a n/a n/a 69 0 % Ungheni n/a n/a n/a n/a 20 25.0 % Total 150 4.6% 151 8.5% 488 10.9 %

Table 23 HIV prevalence in MSM (blood samples, “take all” sampling), Republic of Moldova, 2003 - 2007 Data 2003 2004 2007 collection site Sample HIV prev Sample HIV prev Sample HIV prev Chisinau, 118 1.7 % 121 2.5% 83 4.8 % capital city Comparing overtime the HIV prevalence rate in the capital city only, according to UNGASS recommendations (Join United Nations Programme on HIV/AIDS (UNAIDS), 2007), there is an 11 Used syringes, “take all” sampling 12 Used syringes, time location sampling 13 Blood samples, random sampling 37 increase of the HIV prevalence rate in MSM, IDUs and a decrease in CSWs. The HIV prevalence survey in CSWs conducted in 2007 extended to four additional sentinel sites (National Centre of Health Management, 2008). In 2007, the overall HIV prevalence in CSWs reached 10.9% (Table 22). According to 2007 BSS in CSWs the rate of injecting drug use in the last 12 months reached 15.6% (Scutelniciuc & Bivol, 2008).

Mortality due to AIDS In countries with low levels of HIV prevalence, such Republic of Moldova is, AIDS mortality does not have major demographic impacts on populations. According to the regulation, the registered AIDS cases should be reported to the AIDS Centre. Table 24 Registered cases of death due to HIV/AIDS, Republic of Moldova, 2000 -2007 2000 2001 2002 2003 2004 2005 2006 2007 Right bank of Dniester River 4 1 14 27 17 20 23 26 Left bank of Dniester River 0 0 0 2 1 0 0 4 Total Republic of Moldova, yearly 4 1 14 29 18 20 23 30 Total Republic of Moldova, 27 28 42 71 89 109 132 155 cumulative Before 2000, 23 AIDS death cases have been registered. By the end of 2007 a cumulative number of 155 cases of death due to AIDS have been ever registered in the Republic of Moldova. The number of AIDS cases from the left bank of Dniester River is underreported (Table 24). In the last 5 years, the number of reported cases of death due to AIDS do not registers important variations.

38 Conclusions The scaling up in the national HIV response corresponds with the important external financing that started to be available since 2003, upon the GFATM first round grant and World Bank grant became operational. These funds have been used to sustain and scale up the national initiatives established before. Before 2003, the needs in ELISA and Western Blot tests were supplied by procurements from budget sources. Since 2003 important investments in the infrastructure have been done. Additional 5 AIDS laboratories were open on the right bank of Dniester River. The AIDS laboratories were renovated and equipped, the staff trained. Other tests like PCR, CD4 became available and constantly increased according to needs. The blood safety is one of the strategic priorities for the national security. Thus, the investments done during the last years in the blood service from national and external sources are impressive (equipment, tests, trainings and quality control). In 2002 the ARV treatment was initiated in Moldova and since 2003 the ARV drugs have been procured with the external financial support. Since 2003 there are two ART centers on the right bank of Dniester River (in civilian and penitentiary sectors). In 2007 an ART centre was open on the left bank of Dniester River (civilian sector covering the penitentiary sector also). There are no waiting lists for ART and the number of patients is constantly increasing. In 2004 the national regulations changed and according to these all pregnant women are recommended to be counseled and tested for HIV twice during the pregnancy. This explains the high coverage of pregnant women with HIV testing overtime (95 – 97%). The ART centers provide PMTCT. Since 2004 there is a trend of reduction of vertical transmission of HIV infection. The history of implementation of the Harm Reduction activities for IDUs in Moldova lies in a strategy developed back in 1997. Since 2003 the implementation of Harm Reduction in the Republic of Moldova is in the third phase of scaling up. In 2004 there has been an extention of activities to rural area and on the left bank of Dniester River and scaling up of activities in CSWs. In 2004/2005 the Harm Reduction activities in LGBT community, truck drivers and migrants started. The number of beneficiaries of Harm Reduction Programmes and distributed commodities constantly increased. In 2007 the restrictive criteria for involvement in methadone substitution treatment have been removed and this fact increased substantially the access to this treatment. Since 2005 Soros Foundation started the implementation of subprojects for home and community support and care for PLWHA. As a result of communication interventions, there is a consistent increase in knowledge on HIV/AIDS in youth, IDUs, CSWs and MSM. Also significant increase of condom knowledge was registered among youth. There are no other important changes registered for core attitudes’ and behavioral indicators. Actually all BSS conducted in KPARs targeted the beneficiaries of Harm Reduction Programmes. This fact explains the high values of core behavioural indicators registered overtime. The HIV prevalence data registered an increase in IDUs, MSM and decrease in CSWs in the capital city. In the last 5 years, the number of reported cases of death due to AIDS do not registers important variations. In all HIV activities there is an inequity in availability and access to services for potential beneficiaries from the left bank of Dniester River due to the frozen political conflict that causes reluctance from the part of left bank authorities to expend the activities geographically and to recognize the importance of collaboration to reduce the spread of HIV infection.

39 The impact could not be attributed to a separate source. This is a result of a collective effort of interventions funded also by other donors and implementing agencies like UNAIDS, UNICEF, MSF, USAID, Caritas Luxembourg, SIDA and UNFPA et.al. The best national initiatives in HIV response got forms, content and sustainability. Within the 6th round grant, the further scale up of abovementioned activities was planned. To maintain the activities, the reduced purchase power of $ imposes the reorganization of NGOs providing services, especially for KPARs. For scaling up additional funds are required. Recommendations Following the increased inputs, significant outputs and results have been achieved in national HIV response. However, the sustainability and further scaling up of interventions are crucial to achieve the goal of the national HIV strategy, universal access and MDGs. According to the evaluation’s findings, the recommendations are as follow: 1. Increasing funding for HIV control. The national funding for HIV control has slightly increased in the last 4 years, but it is so far insufficient to ensure the sustainability of HIV related activities without external support. Within the 6th round grant of GFATM, the further scale up of activities was planned. The reduced purchase power of $ imposes the reorganization of provided services, especially for KPARs/other vulnerable populations and PLWHA. Such activities are implemented mostly by NGOs and the funding mechanism from internal sources should be on the agenda. Being a concentrated HIV epidemic, the scaling up of Harm Reduction activities are as a must. In this context additional internal and external funds are required. 2. Increasing coverage and intensity of interventions in mobile population. Taking into account the shift in the major routes of transmission in registered HIV cases and the national migrational context, the mobile population and migrants should be so far an important target for HIV prevention activities. 3. Extension of intervention on the left bank of Dniester River. In all HIV activities there is inequity in availability and access to services for potential beneficiaries from the left bank of Dniester River. In the context of the alarming epidemiological situation on the left bank of Dniester River, the scaling up of HIV related activities (increasing coverage and intensity) are an urgent matter. 4. Quality control. The quality assurance in all types of interventions: prevention, treatment, care and support are on the agenda. 5. Enhancing the intersectoral and interinstitutional collaboration in the implementation of national HIV response. The HIV related activities are implemented by many governmental and nongovernmental organizations. The cooperation and collaboration between them needs strengthening. 6. National capacity building in M&E. Important achievements in implementation of an M&E system have been registered, but the present M&E System needs a continuous support in extending the data coverage, increasing the data quality and in strengthening the existent results.

40 List of Tables Table 1 Number of AIDS Laboratories, Republic of Moldova, 2000 - 2007...... 21 Table 2 Number of ART centers, Republic of Moldova, 2000 - 2007...... 22 Table 3 Harm Reduction in KPARs, service delivery points, Republic of Moldova, 2000 - 2007...... 23 Table 4 Number of projects supporting PLWHA, Republic of Moldova, 2005 – 2007...... 26 Table 5 Number of tests performed, Republic of Moldova, 2002 – 2007...... 27 Table 6 Number of blood donated samples, number of blood donated samples tested for HIV, VHC, VHB and syphilis and number of tests performed, Republic of Moldova (right bank of Dniester River), 2002 – 2007...... 28 Table 7 Number of newly registered cases of syphilis, Republic of Moldova (right bank of Dniester River), 2002 – 2007...... 29 Table 8 New entries in ART, Republic of Moldova, 2003 – 2007...... 30 Table 9 New entries in ART, adults, Republic of Moldova, 2003 – 2007...... 30 Table 10 Cohort analysis of patients entered in ART 2003 – 2007, Republic of Moldova, end of 2007 ...... 30 Table 11 Percentage of HIV positive pregnant women who received antiretroviral drugs to reduce the risk of mother to child transmission, Republic of Moldova, 2006 - 2007...... 30 Table 12 MTC of HIV, Republic of Moldova, 2002 - 2007...... 31 Table 13Number of IDUs ever covered by Harm Reduction Programmes, Republic of Moldova, 2003 – 2007...... 31 Table 14 IDUs officially registered and HRPs and the rates of male and female among them, Republic of Moldova (right bank of Dniester River), 2004 – 2007...... 31 Table 15 Number of syringes and condoms distributed, KPARs, Republic of Moldova, 2005 – 2007 ...... 32 Table 16 Number of opiates users ever covered with methadone substitution treatment, Republic of Moldova (right bank of Dniester River), 2005 - 2007...... 32 Table 17 Number of CSWs, MSM, truck drivers and migrants reached by Harm Reduction Programmes, Republic of Moldova, 2003 – 2007...... 32 Table 18 Community Support for PLWHA, number of beneficiaries ever reached, Republic of Moldova, 2005 - 2007...... 32 Table 19 Donated blood units screened for HIV in a quality assured manner, Republic of Moldova (right bank of Dniester River), 2007...... 33 Table 20 Key indicators on knowledge, attitudes and practices regarding HIV/AIDS, Republic of Moldova, 2001 - 2008...... 34 Table 21 HIV prevalence in IDUs, Republic of Moldova, 2001- 2007...... 37 Table 22 HIV prevalence in CSWs (blood samples, “take all” sampling), Republic of Moldova, 2003 - 2007...... 37 Table 23 HIV prevalence in MSM (blood samples, “take all” sampling), Republic of Moldova, 2003 - 2007...... 37 Table 24 Registered cases of death due to HIV/AIDS, Republic of Moldova, 2000 -2007...... 38

41 List of Figures Figure 1 Basic Framework for 2008 Impact Evaluation, GFATM...... 8 Figure 2 Data flow, HIV M&E system, Republic of Moldova, 2008...... 11 Figure 3 HIV funding divided by source, $, Republic of Moldova (right bank of Dniester River), 2003 - 2007...... 17 Figure 4 HIV/AIDS public funding by source agency, $, Republic of Moldova (right bank of Dniester River), 2003 - 2007...... 18 Figure 5 HIV/AIDS funding divided by service providers, $, Republic of Moldova (right bank of Dniester River), 2003 - 2007...... 19 Figure 6 HIV/AIDS funding by functions, $, Republic of Moldova (right bank of Dniester River), 2003 - 2007...... 20 Figure 7 Geographical location of AIDS laboratories, Republic of Moldova, 2007...... 21 Figure 8 Geographical location of Harm Reduction delivery points, Republic of Moldova, 2007...... 25 Figure 9 Testing for HIV and the number of newly reported HIV cases, Republic of Moldova, 1987 – 2007...... 27 Figure 10 Number of pregnant women tested for HIV, tests made on pregnant women and number of new HIV cases in pregnant women, Republic of Moldova, 2002 – 2007...... 28 Figure 11 Number of newly registered HIV cases per 100 000 donations, Republic of Moldova (right bank of Dniester River), 1998 – 2007...... 29

42 Works Cited AFEW. (2005). Knowledge, attitudes and practices related to HIV/AIDS in general population. Chisinau. Bivol, S. (2004). HIV/AIDS Surveillance, Moldova 2004, Injecting Drug Users, Commercial Sex Workers, Inmates. Chisinau: Tehnica Info. Cercone, J. (2005). Design of a Monitoring and Evaluation System for TB and HIV/AIDS. Chisinau. CIVIS. (2001). Behavioural and Sentinel Surveillance Survey in IDUs. Chisinau. Join United Nations Programme on HIV/AIDS (UNAIDS). (2007). Monitoring teh Declaration of Commitment on HIV/AIDS: Guidelines on Construction of core indicators, 2008 reporting. Geneva: UNAIDS. Ministerul Sanatatii al Republicii Moldova. (2005). Protocoalele Nationale privind acordarea asistentei medicale si tratamentul in infectia HIV/SIDA. Chisinau. Ministry of Health of the Republic of Moldova. (2007). Order nr. 344 from 05.09.2007 on the establishment of VCT services. Chisinau. National Centre of Health Management. (2008). National Report, Monitoring the Declaration of Commitment on HIV/AIDS. Chisinau. National Drug Observatory. (2006). Annual Report 2005 Drug Situation. Chisinau: Reclama. National Scientific and Applied Center for Preventive Medicine (NCPM) [Moldova] and ORC Macro. (2006). Moldova Demographic and Health Survey 2005. Calverton, Maryland: National Scientific and Applied Center for PreventiveMedicine of the Ministry of Health and Social Protection and ORC Macro. National Scientific and Practical Centre of Preventive Medicine, AIDS Centre. (2008). Informative bulletin on the epidemiological situation, implementation of the National Programme on Prevention and Control of HIV/AIDS in 2007 and activities in the prevention of HIV/AIDS. Chisinau. Scientific and Practical Centre of Public Health and Sanitary Management. (2006). , Declaration of Commitment of the United Nations General Assembly Special Session (UNGASS), Progress report 2003-2005. Chisinau. Scutelniciuc, O. (2006). Youth knowledge, attitudes and practices related to HIV/AIDS. Evaluation report. Chisinau: Rolsi Media. Scutelniciuc, O. (2008). Youth knowledge, attitudes and practices related to HIV/AIDS. Evaluation report. Chisinau: Rolsi Media. Scutelniciuc, O., & Bivol, S. (2008). Behavioral and sentinel HIV surveillance, Moldova 2007. Chisinau. Seicas, R., & Scutelniciuc, O. (2008). Evaluation Report Supply with Anti-Retroviral (ARV) Drugs for HIV/AIDS patients in Moldova 2002-2007. Chisinau. TERG. (2007, June). NEWSLETTER. Retrieved May 20, 2008, from http://www.theglobalfund.org: http://www.theglobalfund.org/en/about/terg/announcements/five_year_evaluation/newsletter- en/ TERG. (2006, October). The Fie Year Evaluation of The Global Fund. Retrieved May 20, 2008, from http://www.theglobalfund.org: http://www.theglobalfund.org/en/files/terg/14_tech_report.pdf TERG. (2007, February). The Five Year Evaluation of the Global Fund. Retrieved May 20, 2008, from www.theglobalfund.org: http://www.theglobalfund.org/en/files/terg/Eval_BriefNo5.pdf

43 USAID Preventing HIV/AIDS and Hepatitis B and C Project (PHH). (2007). KNOWLEDGE, ATTITUDES AND PRACTICES ON HEPATITIS B AND C AND ON VOLUNTARY COUNSELLING AND TESTING FOR HIV AND VIRAL HEPATITIS IN THE GENERAL POPULATION OF MOLDOVA. Chisinau: Pergament Plus. Wolrd Health Organization Regional Office for Europe. (2004). HIV Sentinel Surveillance in High- Risk Groups in Azerbaijan, Republic of Moldova and in the Russian Federation. Copenhagen: World Health Organization. World Health Organization. (2003). SCALING UP ANTIRETROVIRAL THERAPY IN RESOURCE-LIMITED SETTINGS:TREATMENT GUIDELINES FOR A PUBLIC HEALTH APPROACH, 2003 revision . Geneva: WHO. World Health Organization. (2007, March). WHO Model List of Essential Medicines 15th list. Geneva.