March 2011 FINAL EVALUATION REPORT XEE/J20 HIV/AIDS preve ntio n and care among injecting drug users and in prison settings in Estonia, Latvia and Lithuania Bertrand Redonn et Disclaimer Independent Project Evaluations are scheduled and managed by the project managers and conducted by external independent evaluators. The role of the Independent Evaluation Unit (IEU) in relation to independent project evaluations is one of quality assurance and support throughout the evaluation process , but IEU does not directly participate in or undertake independent project evaluations. It is, however, the responsibility of IEU to respond to the commitment of the United Nations Evaluation Group (UNEG) in professionalizing the evaluation function and promoting a culture of evaluation within UNODC for the purposes of accountability and continuous learning and improvement. Due to the disbandment of the Independent Evaluation Unit (IEU) and the shortage of resources following its reinstitution, the IEU has been limited in its capacity to perform these functions for independent project evaluations to the degree anticipated. As a result, some independent evaluation reports posted may not be in full compliance with all IEU or UNEG guidelines. However, in order to support a transparent and learning environment, all evaluations received during this period have been posted and as an on-going process, IEU has begun re-implementing quality assurance processes and instituting guidelines for independent project evaluations as of January 2011 UNITED NATIONS OFFICE ON DRUGS AND CRIME Vienna 1 CONTENTS Page Acronyms 3 Summary matrix of findings, supporting evidences and recommendations 3 Executive summary 6 I. Introduction A. Background and context of the project 12 B. Purpose and scope of the evaluation. 14 C. Executing modalities of the project 15 D. Evaluation methodology 15 E. Limitations to the evaluation 17 II. Major findings and analysis A. Relevance of the project 18 B. Attainment of the project objectives and achievement of outputs 18 C. Institutional and management arrangements and constraints 34 III. Outcomes, impact and sustainability. A. Outcomes and impact 40 B. Sustainability 41 IV. Lessons learned and best practices A. Lessons learned 46 B. Best practices 48 V. Recommendations 48 VI. Conclusions 50 Ann exes 1. Terms of reference of the evaluation 52 2. List of persons interviewed and field visit schedule 61 3. List of documents reviewed 65 2 Acronyms AIDS Acquired Immunodeficiency Syndrome ART Antiretroviral treatment ASAP AIDS Strategy and Action Plan EE Estonia EU European Union GDP Gross Domestic Product GP General Practioner HIV Human Immunodeficiency Virus HQ Headquarters IDU Injecting Drug User LT Lithuania LV Latvia MMT Methadone Maintenance Therapy NGO Non-Governmental Organisation NIHD National Institute for Health Development NPO National Project Officer NSP Needle and Syringe Programme PLWH Person/People Living with HIV PSC Project Steering Committee RU Russian SMART Specific Measurable Achievable and Time-bound TB Tuberculosis UNAIDS Joint United Nations Programme on HIV and AIDS UNDP United Nations Development Programme UNODC United Nations Office on Drugs and Crime USD United States Dollar VAT Value Added Tax WHO World Health Organisation Summary matrix of findings, supporting evidences and recomm endations Findings: problems and Supporting evidences Recommendations issues identified A consensus has emerged A good level of cooperation For UNODC: Carry out an ex- on effective between Ministries of Health post evaluation of the project, implementation strategies and Ministries of Justice has for example a year after to address HIV/AIDS been achieved, as well as with completion, to provide further among injecting drug Ministries of Interior. insights on the sustainability of users and in prisons. One Ministries of Justice and activities and a reminder, if of the main achievements prison departments are necessary, on the need to of the project is that is has involved in national responses. support evidence based services helped shape policy Harm reduction is on the as part of comprehensive HIV making and develop political agenda in the three strategies. Depending on strategic approaches. countries and included in the funding opportunities, provide national HIV strategies in technical assistance through Estonia and Latvia. renewed projects in the three Pharmacotherapy for opioid Baltic States. dependence is widely acknowledged as a crucial 3 Findings: problems and Supporting evidences Recommendations issues identified element of the national responses developed. A lack of consensus Harm reduction and MMT are Engage in dialog at political remains on the problematic issues among and society level in Lithuania on implementation of an policy makers (Parliament the necessity of HIV prevention effective HIV strategy in Drug Control Commission and and care services for IDUs and Lithuania. Health Committee) and in in prisons, i.e. harm reduction public opinion. In this context, services, based on available NSP in prisons is not evidence. envisaged, MMT in the Establish and support an HIV community is criticized and Coordination Commission to good progress up to now for implement an effective national the provision of MMT in response. Building on the work prisons has stopped. The of the Project Steering Centre for Communicable Committee, support the Public Diseases and AIDS did not Health Department of the engage in project activities Ministry of Health in this aimed to scale-up MMT and coordination role. Include NSP. NGOs in future national HIV Coordination Commission. Promote NGO involvement in relevant areas of work. Considerable focus has Capacity building activities In the case of a renewed been placed on capacity have included: developing UNODC project, include a building and training technical guidelines, training capacity building and training activities, which has modules and information component, allocate adequate enhanced institutional and materials. Participatory resources and actively promote human capacity in the approaches were sought. findings on achievements. three countries to steer Intervisions promoted and implement effective methodological discussions on responses to HIV among what constitutes effective IDUs and in prisons. implementation of services. Coverage of Methadone MMT coverage in 2010 is Scale-up MMT and NSPs in Maintenance Treatment 5.2% in Estonia, 1.9% in community settings in the three (MMT) and Needle and Latvia, 13.1% in Lithuania. In countries. Syringe Programmes Estonia, geographic expansion (NSPs) has increased of services especially MMT is overall but remains low in needed, in particular in the Latvia and Lithuania, and South of the country, e.g. to a lesser extent in Tartu. Estonia for MMT. 36 NSPs in Estonia, 18 in Latvia and 12 in Lithuania in 2010. There have been some MMT is available in all Pursue advocacy for access and achievements with regard prisons in Estonia only. In scaling-up harm reduction to HIV prevention and Lithuania and Estonia, MMT services in prisons, especially care activities in prisons. is available for drug users in MMT and harm reduction 4 Findings: problems and Supporting evidences Recommendations issues identified police arrest houses. education, condom provision Introducing training on harm and support pilot NSP projects reduction in prisons is a strong where feasible. achievement of the project. - Ensure the equivalence of access to health care services in the community and in prisons. Even more so given that access to MMT in police arrest house s is possible in Lithuania and Estonia. The equivalence of access to services in the stages of arrest, trial and detention will be beneficial in the short and medium term given the importance of the criminal justice system for implementing HIV/AIDS responses. - Continue educational and training activities directed to prisoners and staff. The focus on harm reduction should be sustained and activities should also address psychosocial support and rehabilitation/ resocialisation. MMT is not available in MMT is not available in Ensure the availability of MMT Lithuanian prisons and in Lithuanian prisons and in in prisons in Latvia and Latvian prisons and Latvian prisons and police Lithuania. police arrest houses. arrest houses. Pursue specific advocacy MMT in prisons. Intensify cooperation between Ministry of Health and Ministry of Justice. The small grants 79 initiatives were funded in Future UNODC projects for programme has made 2007-2010, representing 40% HIV prevention and care among important contributions to of total project expenditure. injecting drug users and in developing HIV Increased coverage of HIV prisons should include a small prevention and treatment prevention services by grants programme, as this services among injecting supporting existing services or considerably strengthens the drug users and in prisons. establishing new ones. development of relevant services. In the case of a new UNODC project, include a small grants component. Overall, activities and In Latvia, 4 MMT sites, 7 Sustain funding for activities at systems established NSPs and 6 prison risk of discontinuation in Latvia during the project are interventions were identified and Lithuania, either through sustainable, except for as being at medium or high Government funding or, by some small grant funded risk of not being sustained at default, donor assistance. 5 Findings: problems and Supporting evidences Recommendations issues identified activities