REPUBLIKA E KOSOVËS REPUBLIKA KOSOVA – REPUBLIC OF KOSOVO Ministria e Shëndetësisë/Ministarstvo Zdravdsva/ Ministry of Health
National HIV/AIDS Strategic Action Plan Kosovo 2018-2022
Ministry of Health of Republic of Kosovo
Contents Acronyms ...... 3 Introduction ...... 5 Kosovo – Country Context ...... 6 HIV/AIDS: Background and situation analysis ...... 7 Organizational structure of the National HIV response ...... 9 CSO landscape/engagement in HIV response ...... 10 Funding sources for HIV national response ...... 11 HIV/AIDS National Strategic Plan (NSP) for 2018-2022 ...... 14 Overarching Goal of the HIV/AIDS NSP ...... 14 SPECIFIC OBJECTIVE 1. Reduce the impact of HIV in general population and key populations by strengthening HIV prevention interventions and improve access to services ...... 14 SPECIFIC OBJECTIVE 2. Improve the health status and quality of life of people living with HIV by providing universal access to treatment, health care and other support services ...... 18 SPECIFIC OBJECTIVE 3. Ensure sustainable response to HIV through strengthening coordination, leadership and financial and political commitment of the Government...... 19 SPECIFIC OBJECTIVE 4. Ensure sustainable response to HIV through resilient health systems strengthening interventions ...... 23 SPECIFIC OBJECTIVE 5. Empowerment and engagement of CSO in HIV policy, programming, advocacy and HIV services in the community through Community Systems Strenghtening ...... 25 Costing HIV/AIDS NSP ...... 26 Monitoring and Evaluation ...... 27 Appendices ...... 28 Bibliography ...... 29
Acronyms
AIDS Acquired Immune Deficiency Syndrome AP Action Plan ART Anti-Retroviral Treatment ARV Anti-Retroviral CCM Country Coordination Mechanism CDF Community Development Fund CSO Civil Society Organizations CSS Community systems strengthening FSW Female Sex Worker GDP Gross Domestic Product GF Global Fund HDI Human Development Index HIV Human Immunodeficiency Virus IBBS Integrated Bio-behavioral Surveillance Survey KP Key Populations LGBT Lesbian, Gay, Bisexual and Transgender LMIC Lower-middle income country M&E Monitoring and evaluation MICS Multi Indicator Cluster Survey MMT Methadone Substitution Therapy MOH Ministry of Health MSM Men who have Sex with Men NASA National AIDS Spending Assessment NGO Non-Governmental Organization NEP Needle and Syringe Exchange Programs NRL National Reference Laboratory NSP National Strategic Plan OST Opioid Substitution Therapy PHC Primary Health Care PIT Provider Initiated Testing PLHIV People Living with HIV PMTCT Prevention of Mother-to-Child Transmission PSM Procurement supply chain management PWID People Who Inject Drugs SHA System of Health Accounts SHC Secondary Health Care SO Specific objectives (NSP) STI Sexually Transmitted Infections SW Sex Worker THC Tertiary Health Care TG Transgender People TGF The Global Fund TPA Transition Preparedness Assessment VCT Voluntary Counselling and Testing WHO World Health Organization
Introduction Current national HIV/AIDS Strategic Plan for 2018-2022 years in Kosovo is based on the previous national HIV/AIDS plans, the Global Fund HIV grants, as well as on the recommendations provided by the WHO mission commissioned in 2014 to review previous strategic plan and HIV programme, and on the findings and recommendations from the Transition Preparedness Assessment study completed in 2017.
Preceding National Strategic Plans for HIV 2009-2013, and 2015-2019identified strategic objectives and priority areas, however none of the plans included comprehensive M&E framework and national indicators to measure the progress achieved and assess program challenges. Previous Strategic Plans werenot either costed, or approved by the Government to have enforceable power.
Transition Preparedness Assessment (TPA) completed by Curatio International Foundation through the financial support from the Global Fund grants in Kosovo involved desk review and in-depth interviews (IDIs) with key stakeholders from the Government institutions, donor organizations, civil society organizations and constituencies. The quantitative and qualitative data were entered into the TPA excel- based tool and a summary score for transition risk was set at 18.33% indicating high risk for HIV programme transition in the country. Based on the TPA findings, sets of recommended actions were developed and validated through participatory process and consensus-building, national consultation workshops held in February-March, 2017 in Pristina. These recommendations have been incorporated into the current HIV NSP to ensure smooth transitioning from the external support to uninterrupted and adequate domestic funding of full-scale HIV national response in Kosovo.
The HIV NSP is in line with the country’s strategic vision outlined in the recently endorsed Health Sector Strategy 2017-2021 which aims at “improving the quality of services, responding to the requests for health services and efficiency of the delivery of these services, improving of financing while also improving the access to services for vulnerable groups facing various barriers in access to services.”1Even though that currently Health Sector Strategy includes the section on HIV/AIDS, the priority areas for HIV prevention, treatment and care services are scarcely described. However, there is a declared political commitment from the Government of Kosovo that the vision and strategic objectives outlined in the HIV NSP 2018-2022 will be adequately reflected in the Health Sector Strategy which is reviewed “each year based on new priorities in order to serve in drafting the Medium-Term Expenditure Framework.”2
Current National HIV Strategic Plan for 2018-2022 is a result of joint efforts and contributions of professionals from the Ministry of Health and medical institutions; representatives from other national organizations, civil society organizations and key constituencies. The Ministry of Health believes that the current NSP reflects the dedication and hard work of every individual engaged in the NSP preparation process.
Special thanks should be extended to the MoH staff, CCM and Community Development Fund (CDF) - the GF grants principal recipient,for facilitating theNSP development process. Exceptional gratitude should be expressed to the GF Portfolio Manager in Kosovo, as well asDr. Edona Deva,Head of TGF HIV
1Health Care Sector Strategy 2017-2021. November 2016 Ministry of Health. Kosovo 2Health Care Sector Strategy 2017-2021. November 2016 Ministry of Health. Kosovo, p.10 programme, Dr. ilirHoxha – the local consultant, and Curatio International Foundation for their valuable contribution to the NSP development.
Kosovo – Country Context Demographic Characteristics: The Republic of Kosovo has an area of 10,908 km2 and 1,804,944 inhabitants.1The population growth (annual %) has remained positive though under 1% from 2002 till 2014. It started declining over the last three years reaching its lowest in 2015 when the population annual growth reduced to (-0.09.%). The average life expectancy in Kosovo in 2011 was estimated to be 76.7 years (for males - 74.1 years and for females - 79.4 years)3.Morbidity data, including maternal and infant mortality data is not available on the WB database. Human Development Index increased incrementally from 0.68 in 2007 to 0.74 in 2016 but still remains the lowest in Europe.
Economic indicators:Kosovo is one of the poorest countries in Europe with Gross Domestic Product (GDP) of € 3,084 per capita, or 257 euro per month.1 Real growth rate of GDP for 2013 compared to 2012 was 3.2%, according to estimates of Macroeconomics Unit of the Ministry of Finance of Kosovo. Poverty headcount ratio at national poverty lines (% of population) has been declining – from 45.1% in 2005 to 29.7% in 2011 (the latest available data). According to the World Bank Report on Poverty Assessment in Kosovo in 2011, 29.7% of the population lived below the poverty line of € 1.72 per day for adults and 10.2% lived below the extreme poverty line of € 1.2 per day for adults4. Unemployment stands at 40.7% for men, and 56.4% for women.Error! Bookmark not defined.While Kosovo’s economy faces many fundamental challenges, the energy and potential of Kosovo’s young work-ready population are significant economic assets.5
Overview of Health Care system: Health services in Kosovo are provided through a network of public and privatehealth institutions organized into three levels: primary (PHC), secondary (SHC) and tertiary (THC). Strengthening the Primary Health Care infrastructure has been one of the major focuses on health care reform in Kosovo. PHC plays key role in health promotion, prevention, diagnosis and early detection. PHC also provides treatment and rehabilitation services, dental care and minor surgeries based on the concept of family medicine. Public network of PHC consists of a total of 429 institutions6 with the Main Family Medicine Centre in each municipality with its constituent units of Family Health Centres, and Family Health Ambulances.7
Secondary and tertiary health care is provided through the institutions established under the Law on Health, within which are included hospital, outpatient, diagnostic, therapeutic, rehabilitation services, emergency transportation, dental care and regionalized public health services. Tertiary Health Care includes advanced health care, hospital, outpatient and public health services and counselling teams of tertiary health care level.6
3Statistical Yearbook of the Republic of Kosovo 2016, Statistical Agency of Kosovo, Prishtina 2016 4Consumption Poverty in the Republic of Kosovo 2011, WB 5http://www.ks.undp.org/content/kosovo/en/home/countryinfo.html 6Health care sector strategy 2017-2021. November 2016 Ministry of Health. Kosovo 7Centre for Development of Family Medicine of Kosovo/MoH 2013 Health Care Financing: The health sector in Kosovo is financed from income tax, taxes and co-payments; out-of-pocket paymentconstitutes to about 40% of the medical costs. The state budget allocated to health sector has been on rise over the last five years reaching its maximum -€ 163,760,703 in 2015 which accounted for 2.8% of the GDP. Despite increasing trend, the Government spending on health per citizen per year does not exceed €91. PHC is funded through transfers from the central budget to municipalities in the form of specific health grant, in the amount of€42,085,036 which includes 28% of the total budget allocated to health. SHC and THC are funded by the Ministry and includes over 72% of the budget allocated to health.6
Available data from the Ministry of Finance of Kosovo about the Government expenditure on health shows increasing trend: 8 the Government spending on health out of the total Government spending increased from 4.9% in 2011 to 10.6% in 2014 and 2015. The percentage of GDP for health including private expenditures has been stable over the last few years ranging from its lowest 3.9% in 2009 and 2011 to its highest 4.5% in 2015. 9
Figure 1: Government expenditure on Health
Health Sector Strategy 2017-2021 in Kosovo identifies the problem of insufficient financial resources for health in Kosovo.10 Even though, the Government of Kosovo makes efforts to increase its investment in health, limited financial resources for health care may pose a substantial risk on HIV programme sustainability as HIV/AIDS is not one of the top priorities for health sector due to low HIV prevalence among population.
HIV/AIDS: Background and situation analysis Kosovo is among the countries with one of the lowest HIV prevalence among general population and low prevalence among key populations at risk: MSM, PWIDs, FSWs. In total, 111 HIV cases were registered from 1986 through 2016. Of them, 69 persons have already developed AIDS, and 46 died from AIDS related diseases. Only single new cases are found on an annual basis. During 2016, 11 new HIV cases were detected. Majority of HIV registered cases (70%) are among male.11The recent 2014 IBBS
8 The GF Concept Note for HIV grant. 2015. Kosovo 9 Kosovo Ministry of Finance data 10Health Care Sector Strategy 2017-2021. November 2016 Ministry of Health. Kosovo 11DrLuljetaGashi, Chief of Unit for HIV/AIDS/STI; Department of Epidemiology; National Institute of Public Health of Kosova. Email communication of March 9, 2017 studies12 confirmed low prevalence of HIV in all the keypopulations: no HIV positive cases were found among PWIDs and FSWs tested during the survey; HIV prevalence among MSM respondents was 2.3% (0.5% - RDSAT).
Figure 2: Modes of HIV transmission, cumulative 1986-201611
Modes of transmission 1986-2016 2% 2%
18%
52% 26%
Heterosexual Unknown MSM PWID Vertical transmission
Kosovo stakeholders acknowledge that HIV testing sites are limited in the country and testing uptake among general population as well as among key affected populations should be scaled up. The Multiple Indicators Cluster Survey (MICS) in 2013-2014 found that only15.5% of women and 31% of men aged 15 to 49 know where they could get testedfor HIV. Only0.7% of women and 1.4% of men have been tested for HIV in the last12 months and know their HIV status.13The annual number of HIV testing performed in the country is not available. HIV testing uptake among key populations is suboptimal: latest IBBS from 2014 shows that only 12% of PWIDs, and 34% of MSM were tested on HIV during last 12 months. Only 52% of surveyed FSW in Ferizaj had ever tested for HIV; and out of them only 28% were tested during last 12 months (only 14% of all respondents).14
The 2014 IBBSs demonstrate that risk behaviors are widespread among key populations: slightly more than one-third of FSWs (38%) reported not using condom at last sex with clients. MSM are a highly mobile population with 55% reporting traveling outside of Kosovo,and of them 27% reported having anal sex without a condom while being abroad. Anal sex without a condom is even more common during in-country travel - 38% of those who travelled outside of Pristina reported unprotected anal sex during their travel.15This is particularly important risk factor given that higher HIV prevalence of HIV is observed in all neighboring countries.
All these factors may indicate that HIV cases are under-detected and the number of people who are infected but do not know their HIV status might be higher. The situation is exacerbated by the fact that HIV estimations using standard software (such as SPECRTUM) are not available for the country.
12 IBBS among PWID, MSM and SWs in Kosovo, 2014. Community Development Funds. TGF HIV grant 13Kosovo HIV Country Profile. Ministry of Health. Kosovo 14 IBBS among PWID, MSM and SWs in Kosovo, 2014. Community Development Funds. TGF HIV grant 15Standard Concept Note for HIV grant. Kosovo, 2015 Low HIV testing among KAPs and other underserved vulnerable populations, such as migrants, ethnic minorities, at-risk youth, including vulnerable young girls, combined with unfavorable socio-economic factors – high stigma attached to HIV and certain behavioral groups, high migration, low education level, high unemployment rate, and high poverty level may result in a rapid spread of HIV epidemic if HIV infection becomes more prevalent among populations at risk.
By the end of 2016, 25 patients were enrolled in ART. In 2012-2014 ARV patients could not continue treatment due to frequent stock outs of ARV drugs as a result of problems in procurement system led by the Government of Kosovo. Since 2015, ARV drugs have been procured through UNICEF and no stock- outs and/or emergency procurement was reported during the last three years.
Table 1: ARV Treatment and AIDS Related deaths in Kosovo (by years)
ARV treatment and AIDS related deaths (by years) 2010 2011 2012 2013 2014 2015 2016 # of PLHIV receiving ARV treatment (as 10 14 14 15 14 24 25 of end of the reporting year) # of PLHIV on treatment who died in 0 3 2 0 0 0 3 the reporting year Laboratory monitoring of CD4 cell count and Viral Load for all PLHIV in a systematic way has not been ensured, and the treatment cascade or treatment outcome (survival rates and viral suppression) data is limited in the country. Organizational structure of the National HIV response
The Ministry of Health: The MoH is the main agency that sets the vision and mission of the health care sector in Kosovo. Department of Health Service of the MoH monitors the management quality of healthinstitutions of all levels, provides support in the coordination of health institutions and ensures the optimal integration of public and private health services provided by the government and non – government organizations. The Department of Health Service provides assistance and advice in drafting policies /strategies and the legislation in health sector. Within this Department, a Division of Special Health Care Services is operational that is the key agency dealing with specific diseases, including HIV/AIDS and TB.
To improve coordination and leadership of HIV national response within the MoH, an HIV/AIDS Coordination Office was established in 2002. The Office is composed of two staff members: the Head of Division, an HIV Officer (1); and the Monitoring and Evaluation Officer (2). Major responsibilities of the HIV/AIDS Coordination Office at the MoH include the following: ➢ Assist in drafting document of policies /strategies and legislation in HIV prevention and treatment, etc. ➢ Coordinate and support the Country Coordination Mechanism for HIV&TB prevention, treatment and care services; ➢ Monitor HIV service delivery; ➢ Monitor the quality of the management of health institutions in HIV prevention and treatment; ➢ Monitor implementation of relevant policies, strategies and legislation; ➢ Prepare periodic reports about the national response to HIV.
Country Coordination Mechanism: To expand multi-sectoral coordination of HIV national response and ensure participation of civil society organizations and HIV constituencies in HIV coordination, a Country Coordination Mechanism was established that underwent substantial restructuringin 2016. Currently, the CCM has 30 members: 15 permanent members and 15 alternative members.The CCM is represented by the Ministry of Health, Ministry of Finance, Ministry of Labour and Social Welfare, Ministry of Youth, Culture and Sport, Ministry of Internal Affairs, Ministry of European Integration, Infectious Disease and Pulmonology clinics, National Institute of Public Health , Faculty of Sociology, Committee on Health, Committee on Human Rights and Gender equality, Ministry of Education, Science and Technology, ombudsperson, people living with disease (HIV &TB), andhuman-rights NGO.16
AIDS committee: Since 2011, the AIDS Committee has been functional within the MoH which consists of 20 members from the Ministry of Health; National Institute of Public Health; Ministry of Justice; Ministry of Culture, Youth and Sport; Ministry of Education Science and Technology; clinics for infectious diseases, dermatology and gynecology; , Blood Transfusion, WHO,UNICEF, UNFPA, and representatives of civil society, artistic community.16
HIV surveillance and service delivery: AIDS treatment services as well as treatment for opportunistic diseases are provided by the Infectious Diseases Clinic in Prishtina. HIV National surveillance system is led by the Unit for HIV/AIDS &STIs of the National Institute of Public Health / Department of Epidemiology. Laboratory capacity for HIV clinical management and monitoring has significantly improved over the last few years through coordinated efforts from the MOH and financial support from the GF. Currently, all major testing methods are available in the country: HIV serology, Western Blot, CD4 count, and viral load. In 2014 the MOH decided to establish HIV Reference Laboratory at the NIPH (adopted on 16.01.2014) and efforts were taken to strengthen its capacity. HIV genotypic resistance tests are performed in external laboratory, at Pasteur Institute in Paris, France.
HIV prevention services targeting KAPs – MSM, PWIDs, FSWs, and social and support services for PLHIV are provided by civil society organizations. CSO landscape/engagement in HIV response The Community Development Fund (CDF) is a non-governmental organization in Kosovo that commenced its activities in November 1999, when it was established in partnership with the Soros Foundation/Open Society Institute. Since October 2000, the CDF is registered as a local, non-profit NGO with Public Benefit Status to carry out a community development project through small-scale community investments through World Bank program. As of October 2011 CDF is the Principal Recipient to the Global Fund Grants for HIV and TB Programs in Kosovo. The GF Grant is managed by CDF on behalf of Kosovo Country Coordinating Mechanism for HIV/AIDS and TB, and the Program is implemented through specific modules by respective Sub- recipients of the Grant. Labyrinth is a unique NGO in the country working on HIV prevention among PWID. Labyrinth has been a Sub-recipient to the Global Fund HIV funded program since 2009 covering People Who Inject Drugs in three locations: Prishtina, Prizren and Gjilan. The services provided are: Needle and Syringe Exchange Program (Including Outreach), Voluntarily Counseling and Testing
16HIV Coordination Office, MoH of Kosovo for HIV, Hep B and C, Methadone Maintenance Therapy, Self-Help groups, Psychosocial Counseling, Medical and Psychiatric Services. Center for Social Group Development – CSGD is a local non-governmental organization working with LGBT communities. Since April 2009 CSGDbecame a Sub-recipient the Global Fund HIV funded program, working in the field of HIV prevention among MSM. CSGD work in the field geographically covers 6 regions in Kosovo: Pristina, Mitrovica, Peja, Gjakova, Prizren and Ferizaj. CSGD provides different HIV prevention services: HIV counseling and testing, provision of prevention packages (5 condoms, 5 lubricants and one IEC material), referral to VCT and other STI diagnostic and treatment services, peer education. Kosovo Association of People living with HIV and AIDS – KAPHA is the only non-governmental organization in Kosovo working with People Living with HIV and their partners and families, living in Kosovo. KAPHA is a Sub-recipient to the Global Fund HIV funded program, and implements the interventions for care and support to PLHIV.The services KAPHA provides are: Psychological and Medical Counseling, Care coordination and follow up of ARV treatment, and provision of Hygienic Packages. Kosovo Population Foundation – KOPF, is an NGO that works in HIV prevention among Female Sex Workers in Kosovo. Since July 2009 KOPF is a Sub-recipient to the Global Fund HIV funded program targeting Female Sex Workers, currently covering two regions: Ferizaj are and Prizren. KOPF provides following services: Outreach,Condom and lubricant distribution, IEC materials distribution, HIV testing and counseling, Gynecologic controls and STI treatment.
Integra is an organization formed by a group of people committed to contributing to the recovery and development of Kosovo and the region. Integra’s work is guided by the principles of good governance and full enjoyment of human rights, regardless of ethnicity, race, religion, gender, sexual orientation and political belonging, which are essential to building a democratic Kosovo, fully integrated in the European community.Integra is one of the SRs of GF HIV Kosovo Program from the beginning, working firstly with hard to reach youth, and in last couple of years working on human rights and advocacy.
Funding sources for HIV national response
HIV national response is financed by two major funding sources: from the Government of Kosovo, and the Global Fund.Public expenditure during 2014-2015 for HIV/AIDS was on rise: from €476,896 in 2013; increasing to €680,082 in 2014; and reaching its pick in 2015 - €705.886.17
17 TGF HIV CN for Kosovo. Funding Gap Analysis
The share of public funding for HIV out of the total HIV financing has been changing from 36% in 2013, to 44% in 2014 that decreased to 38% in 2015.18 The decrease partially might be explained by sharp increase in HIV financing from the GF in 2015 (60% increase from 2014 to 2015).
The Global Fund started supporting the Kosovo HIV national response in 2008 and since then a total amount committed by the GF has reached USD 9,310,337 (grants # KOS-711-G04-H; QNA-708-G02-H; &QNA-H-CDF). Total budget of current active grant “Scaling up HIV prevention in Kosovo” is up to €1,180,766 for the 18-month implementation period (from July 2016 – through Dec 2017).
Figure 3: HIV/AIDS financing by financial sources
Data on public spending by categories - programmatic areas and key affected populations is not available. However, IDIs with stakeholders and analysis of GF program budget proves that public spending on HIV prevention targeting KAPs is minimal. HIV case detection among KAPs is fully covered by the GF program. Low threshold services targeting MSM and transgender populations and sex workers are available under the GF funding. Harm reduction services include Needle and Syringe Exchange programs, as well as OST (MMT) are provided through the financial support from the Global Fund.
While the Government fully covers the ARV costs to treat AIDS Patients, community-based care and support services to PLHIV are provided through the GF funded grant. The Government provides funds to test all blood units on various infections, including HIV. Universal testing of pregnant women for PMTCT is not in place.
Apart from the Government of Kosovo and TGF, there were UN agencies that have offered modest contribution to the national HIV response. After the GF, the largest financial assistance to HIV program has been provided by UNFPA which supports peer education on sexual and reproductive health, including HIV, social marketing, condom procurement and other public awareness and media campaigns.19In previous years WHO allocated some funds for HIV programme review, and to support development of HIV-related policies, and participation of local staff at international conferences. However, in 2015-2017 the WHO has not planned any budget to support HIV program in Kosovo.
18 Updated data about TGF financing was provided by the GF HIV Gant top management team; CDF 19Standard Concept Note for HIV grant. Kosovo, 2015
HIV/AIDS National Strategic Plan (NSP) for 2018-2022
Overarching Goal of the HIV/AIDS NSP The major goal of the HIV/AIDS NSP in Kosovo is to maintain low prevalence of HIV among general population and key populations and improve the quality of life of people affected by AIDS in Kosovo.
Ending the AIDS epidemic has become a new goal for many countries over the globe as the UNAIDS set new, ambitious, but achievable targets20:
➢ By 2020, 90% of all people living with HIV will know their HIV status. ➢ By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy. ➢ By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression.
The government of Kosovo is also committed to end AIDS epidemic in the country and within the next five-year period, in 2018-2022 will strive to contain one of the lowest HIV prevalence among general population (<0.1%)and maintain low HIV prevalence among key populations (under 1%). Kosovo will embrace the “Test and Treat” strategy to ensure universal access to quality treatment and support services and improve the quality of life of people affected by HIV in Kosovo.
The Kosovo HIV NSP 2018-2022 is structured around the five Specific Objectives (SOs):
SPECIFIC OBJECTIVE 1. Reduce the impact of HIV in general population and key populations by strengthening HIV prevention interventions and improve access to services
SPECIFIC OBJECTIVE 2. Improve the health status and quality of life of people living with HIV by providing universal access to treatment, health care and other support services.
SPECIFIC OBJECTIVE 3. Ensure sustainable response to HIV through strengthening coordination, leadership and financial and political commitment of the Government.
SPECIFIC OBJECTIVE 4. Ensure sustainable response to HIV through resilient health systems strengthening interventions.
SPECIFIC OBJECTIVE 5. Empowerment and engagement of CSO in HIV policy, programming, advocacy and HIV services in the community through CSS
SPECIFIC OBJECTIVE 1. Reduce the impact of HIV in general population and key populations by strengthening HIV prevention interventions and improve access to services Equitable access to high quality HIV prevention and harm reduction services for key populations with the focus of MSM, PWIDs, FSWs, prisoners, and at-risk youth: To achieve this objective, activities that have been supported by the GF will be scaled up through intensified community services and outreach to KAPs. User-friendly drop-in centers run by civil society organizations will continue providing HIV
20 UNAIDS 90-90-90 http://www.unaids.org/sites/default/files/media_asset/90-90-90_en_0.pdf prevention package that,as a standard, includes counseling and testing for HIV in drop-in centers; peer- education and psychological supportand legal assistance services to those in need. Free condoms and IEC materials will be distributed among KAPs. In addition, mobile units will be operational to reach those who do not seek health services offering HIV prevention and harm reduction interventions. Biannual campaigns to promote HIV testing –“HIV-testing week” will be organized to increase the share of KPs who are tested and know their HIV status.
In addition to standard HIV prevention package, each key affected population will have equitable access to targeted interventions and specific services based on the needs of respective communities. These services for each key affected population are briefly described below:
PWIDs will have access to sterile needles and syringes and safe injection paraphernalia as well as to free testing for Hepatitis B and C. The methadone-maintenance treatment will be available and will strive to attract new beneficiaries through better outreach and awareness raising. The quality of MMT services will improve through addressing the operational challenges identified during the MMT program assessment in 2016. Self-groups will continue providing community-based care to PWIDs. Following the WHO recommendations issued in 2015 after the review of the HIV national strategic Plan21, PWIDs and other people who may witness an opioid overdose will also have access to naloxone and will be instructed in its use in emergency situation.
MSM-friendly drop-in centers will provide HIV testing and counseling services, peer education, as well as access to safe sex kits – condoms, lubricants. HIV national program will start policy dialogue and start exploring possibilities, including fundraising, to ensure that MSM have an access to pre-exposure prophylaxis (PrEP) as an additional HIV prevention choice within a comprehensive HIV prevention package.
Sex workers - in addition to comprehensive HIV prevention package, female sex workers will be offered gynecological check-ups and access to free STI testing and treatment services. Special focus will be placed to introduce innovative approaches and re-design the interventions targeting FSWs given the limited capacity of the program to expand service coverage.
Prisoners: The HIV NSP for 2018-2022 focuses to scale up HIV prevention services for prisoners through expanding VCT capacity in detention centers and providing training to prison medical staff and social workers in risk reduction counseling. Prisoners will have access to condoms and IEC materials. Prisoners will also have access to MMT services in prisons.
At-risk vulnerable youth: Despite low HIV prevalence among general population, young people and especially young girls are vulnerable to HIV: the MICS from 201422 states that only approximately 17% of young people correctly identify ways of preventing the sexual transmission of HIV and reject major misconceptions about HIV prevention (16.8% among women; 17.4% among men). The percentage of young people aged 15-24 who reported condom use during the last sex with a non-marital, non- cohabitating sex partner in the last 12 months was substantially lower among young women (37.3%) than among young men (67.6%). Furthermore, percentage of sexually active young people who have
21Review of the HIV Strategic Plan in Kosovo (in accordance with United Nations Security Council Resolution 1244/1999) -WHO Technical Assistance for concept note development under Cooperative Agreement with the Global Fund. WHO 2015 22Multiple Indicator Cluster Survey 2014-2015 Kosovo. Oct 2014; revised May 201 had sex in the last 12 months, and who have been tested for HIV in the last year and know their results is extremely low among women (1.3%) and men (1.1%).
Low HIV awareness, risky sex behavior, and low HIV testing uptake – altogether put young people at elevated risk of HIV infection. Considering above mentioned factors, the Government of Kosovo will start focusing on youth and initiate non-formal health education interventions among youth (15-24) through disbursing small-grants to youth-friendly centers. For this purpose, existing potentials of the Kosovo Youth Center’s Network (KYCN)23 will be explored through the assessment and consultation meetings. The KYCN was established in December 2013, and unites 20 youth centers from different cities of the country. Suitable models for integrating health education component into the KYCN work will be designed in partnership with Youth Centers and formative researches among youth. Capacity building interventions will be warranted to enable the Youth Network to deliver health education to youth; train peer educators; establish referral system to HIV prevention and other health services as appropriate; and to manage social mobilization among youth and organize public events. Special focus will be placed to outreach to most vulnerable youth from ethnic minorities (Roma, Ashkali, and Egyptian). The Youth Network will collaborate with the Ministry of Justice to target youth in conflict with laws, and pilot a small scale diversion program for delinquent youth.
In addition, HIV VCT capacity will be established at the Students’ Center-policlinic to increase the access to youth-friendly HIV counseling and testing services. Implementation of youth prevention interventions will be closely monitored and based on the observations, the strategy will be refined during the HIB national program mid-term review planned in 2020.
Improving HIV case detection and HIV surveillance through initiation of Provider Initiated Counseling and Testing (PIT) at selected sentinel sites: Kosovo stakeholders acknowledge that HIV testing sites are limited in the country and testing uptake among general population needs to be scaled up. Initiation of PIT was recommended by the WHO mission during the HIV program review in 2014, as well as by the experts’ of TPA experts’ team in early 2017. The MICS in 2013-2014 found that only15.5% of women and 31% of men aged 15-49 know where they could get testedfor HIV. Only0.7% of women and 1.4% of men have been tested for HIV in the last12 months and know their results.24
Strengthening VCT capacity in the country, expanding testing availability and scaling up HIV testing to various population groups at least for few years will help the country generate stronger epidemiological data about the HIV burden in Kosovo, based on which future HIV/AIDS strategies can be adjusted.
Provider Initiated testing will complement other HIV testing strategies among KAPs, such as, client initiated testing, VCT in drop-in centers and mobile units. To ensure optimization of PIT strategy, a guideline and protocol will be developed that will define clinical settings and selection criteria for clients who will be offered pre-test counseling and testing for HIV.
PIT will be recommended in health facilities for:
➢ Patients who present in clinical settings with signs and symptoms or medical conditions that may indicate HIV infection or TB; ➢ Patients infected with hepatitis C and B;
23Kosovo Youth Centers’ Network; http://orgs.tigweb.org/kosovo-youth-centers-network 24Kosovo HIV Country Profile. Ministry of Health. Kosovo ➢ Patients receiving treatment or rehabilitation services for drug addiction disorders; ➢ Patients with STI diagnoses; ➢ Key populations (MSM, TG, PWIDs, SWs) accessing health institutions and disclosing (voluntarily) their behaviors with medical personnel.
Prevention mother-to-child HIV transmission: HIV testing of pregnant women is voluntary and only two HIV positive cases of MTCT/verticaltransmission were registered in Kosovo since 1986. However, pregnant women undergoing caesarean section are requested HIV status disclosure and compulsory HIV testing, which does not necessarily intend to have known patient’s HIV status for providing most appropriate treatment to patients.25The 2014 WHO mission for HIV program review in Kosovo, states that: “The last detected paediatric HIV positive case was diagnosed just before the death of patientwhich indicates lack of access to HIV testing for pregnant women and missed opportunity toprovide PMTCT interventions.26”
The MICS 2014 in Kosovo found that only 3.6% of women who had a live birth in the last 2 years and received antenatal care during the pregnancy of their most recent birth, received counseling on HIV; and only 2.1% of women reported having HIV tests and receiving test results. The survey also found low awareness of PMTCT among women: only 44.7% of women could correctly identify all three means of preventing mother-to-child HIV prevention.27
Although the PMTCT Guideline and Protocol was officially adopted in 2011 in Kosovo, it was not followed by capacity building activities to enforce proper implementation of the PMTCT strategy.28 Based on the WHO (2014) and TPA (2017) recommendations, PMTCT protocol will be revised and activities to implement PMTCT strategy will be carried out starting from 2018 year. At the initial phase, anHIV counseling and testing will be offered to pregnant women attending antenatal clinics in three municipalities with relatively higher number of HIV cases: Prishtina, Prizren, and Peje. PMTCT data will be integrated into the overall HIV health information system. Antenatal sites offering testing to pregnant women will establish consequent linkages to PMTCT treatment and care services for those who test positive for HIV infection.
Blood Safety:
The Blood Safety in Kosovo is regulated under the Law No: 02/L-101 For Blood Transfusion, Blood Control and its Products.29The National Center for Blood Transfusion of Kosovo (NCBTK), is a Tertiary- level Public Health Institution where the blood testing is performed, blood units for transfusion are processed and distributed to all public or private clinics based on the needs. The NCBTK also implements educational and scientific activities. In case of positive results on any blood-borne infections, the NCBTK
25Kosovo HIV/AIDS and Tuberculosis Programme Transition from Donor Support. Transition Preparedness Assessment. The Global Fund programme in Kosovo. Curatio International Foundation. March 2017 26Review of the HIV Programme in Kosovo (in accordance with United Nations Security Council Resolution 1244 (1999)) WHO Technical Assistance for concept note development under Cooperative Agreement with the Global Fund 27Multiple Indicator Cluster Survey 2014-2015 Kosovo. Oct 2014; revised May 2015 28Review of the HIV Programme in Kosovo (in accordance with United Nations Security Council Resolution 1244 (1999)) WHO Technical Assistance for concept note development under Cooperative Agreement with the Global Fund 29Law No: 02/L-101 For Blood Transfusion, Blood Control and its Products available at http://www.unmikonline.org/regulations/unmikgazette/02english/E2008regs/RE2008_07_ALE02_L101.pdf is obliged to immediately report the case to the National Institute of Public Health. The number of tested blood donors on an annual basis ranges from approximately 20,000-25,000 units. The majority of blood units are collected through volunteer donors. No HIV positive cases were found among the donors tested. During 2018-2022, the Government of Kosovo will continue screening of all blood units on HIV, syphilis, and hepatitis B&C. Taking into account the TPA recommendation, an internal and external quality assurance mechanism will be developed and institutionalized to ensure that all, 100% of blood units are tested in a quality assured manner producing accurate test results and guaranteeing the safety of blood and its products. SPECIFIC OBJECTIVE 2. Improve the health status and quality of life of people living with HIV by providing universal access to treatment, health care and other support services
ARVtreatment has become accessible in Kosovo since 2005. ARV drugsare on theessential drug list and the cost of ARV is covered from the PharmaceuticalDepartment (MoH); the treatment cost for all patients is financed by theMoH.ARV treatment is provided by University Clinical Centre (UCC)Department for Infectious Diseases in Pristina. There were consistent delays in implementation of necessary immunological and virology tests forassessment of HIV patients at initial and subsequent visits.26 The delays were caused by stock outs of test kits and reagents, and by implementing testing outside of Kosovo. Before 2015, frequent stock-outs of ARV drugs were also observed that might also explain high treatment drop-outs and suboptimal treatment outcome.
Since 2014, substantial efforts have been taken in Kosovo to improve HIV treatment, patientsmonitoring and care services: after the Kosovo UNICEF office started assisting the MoH in drugs procurement, uninterrupted supply of ARV has been ensured. Standardized clinical protocol was developed and laboratory capacity for treatment monitoring has been built. In 2018-2022, more focus will be placed on enhancing treatment services through development and approval of clinical protocols including that for pediatric cases. To improve HIV diagnostics and treatment monitoring, new laboratory technologies will be rolled out and continuous supply of laboratory reagents will be ensured.
Capacity building training for medical personnel on adopted clinical protocols will be provided; trainings of laboratory staff on modern technologies for HIV testing are also envisioned. CD4 count and Viral Load testing will be performed according to the European Guidelines for HIV treatment and patients tracking system will be strengthened to observe treatment outcome and achieve favorable HIV care continuum/treatment cascade. In addition, all PLHIV will receive counseling and testing for TB and, TB preventive treatment will be ensured.
HIV National Strategic Plan for 2018-2022 draws attention to every step of HIV care continuum which is a progression from testing to enrollment in HIV care, in ARV treatment, treatment adherence and retention, and, ultimately, viral suppression. The Infectious Disease Clinic will strengthen the linkages with the medical institutions, antenatal sites and civil society organizations engaged in more aggressive HIV case finding strategies. Collaboration with the Kosovo Association of PLHIV (KAPFA) with treatment clinic will be enhanced to ensure enrollment in HIV care and improve treatment adherence and retention. The KAPHA will continue providing social support services and benefit packages to PLHIV. It will also conduct key informant interviews and/or group discussions among beneficiaries to explore what are the reasons for treatment drop-outs and will assess the behavioral, structural and/or psychosocial barriers affecting treatment adherence to prescribed regimens. After the findings are analyzed, KAPHA will use its network of social workers, community members, and peer-supporters to employ innovative and targeted approaches (e.g., social accompanying to clinics, setting SMS reminders, adherence counseling, etc.).
The WHO program review mission has challenges the reliability of existing data showing NO co- infections/co-morbidities among PLHIV enrolled in care in Kosovo. This may indicate that there is a lack of systematized approach to investigate and manage co-infections among PLHIV. Thus, the NSP envisions addressing this weakness through standardized protocols on management of opportunistic infections, co-infections and co-morbidities (such as HIV/viral hepatitis, HIV/TB), and through ensuring free treatment for OIs & comorbidities per the approved national guidelines. Patients’ tracking/clinical database will collect information aboutthe prevalence and treatment of OIs, co-infections, co- morbidities, which will be routinely analyzed as a part of HIV surveillance system.
Per the WHO recommendation, sero-discordant couples, whenever identified, will be offered counseling and daily oral PrEP as an additional prevention measure for uninfected partner. While revising the clinical guideline, medical professionals may consider tenofovir or the combination of tenofovir and emtricitabine30 for PrEP.
SPECIFIC OBJECTIVE 3. Ensure sustainable response to HIV through strengthening coordination, leadership and financial and political commitment of the Government. Political Commitment of the Government: There is a visible, strong commitment from the Government of Kosovo to ensure multi-sectoral participation and engage civil society organizations in development of national HIV/AIDS strategic plan. Prior to 2017, Kosovo has developed several action plans for HIV national response (HIV Action Plan for 2004-2008; Action Plan for 2009-2013; Action Plan for 2015- 2019); however none of the previous NSPs were either costed or formally approved by the Government. Current HIV NSP for 2018-2022 is the most comprehensive policy document that consists of the core strategic plan, costed operational plan, as well as M&E framework.
Strengthening HIV coordination: To improve the coordination and leadership of HIV national response within the MoH, an HIV/AIDS Coordination Office was established in 2002. However, the capacity of the MoH to perform the coordinating role needs to be strengthened in terms of organizational development, leadership, management, andgovernance.31
There are two parallel systems for HIV and TB programme coordination in Kosovo. While the CCM is seen as the major coordinating body for TGF-funded HIV and TB programme, the AIDS committee within the MoH is considered to oversee and coordinate the overall HIV national response in the country. However, most HIV stakeholders are not familiar with the AIDS Committee and there is no evidence that
30World Health Organization: Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. www.who.int/hiv/pub/guidelines/keypopulations/en/ March 2017 31Review of the HIV Strategic Plan in Kosovo (in accordance with United Nations Security Council Resolution 1244/1999) -WHO Technical Assistance for concept note development under Cooperative Agreement with the Global Fund. WHO 2015 the AC is functional and active.32The TPA report states that “CCM may not be sustained beyond the GF funding in the country, and instead, the AIDS Committee may assume full responsibility for coordination. There are no clear plans how this transition will take place, and whether the engagement of civil society organizations and people affected by diseases in the AIDS Committee will be sustained or not.”32
Following the TPA recommendation, the NSP envisages to conduct a study to explore alternatives for evolution of HIV coordinating mechanism. The study will assess strengths, weaknesses, opportunities and threats (SWOT) for each alternative (sustained CCM vs functional AIDS Committee), and develop most appropriate mechanism for strengthening HIV programme coordination. The assessment processwill involve interviews with stakeholders, program beneficiaries and review of legal basis and formal documentationsfor both coordination structures (charters, mission statement, composition, existence of legally determined seats for CSOs/constituencies; job descriptions, availability of meeting minutes, etc.). The model proposed based on the Assessment findings should ensure that Coordinating Body is placed adequately high within the Government hierarchy to have legal power for inter-sectoral coordination. National consensus-building workshops will be organized to validate assessment findings and discuss the alternatives proposed by the assessment team.
During 2018-2022, capacity building activities will be implemented to address the weaknesses in coordination and leadership. Training in leadership, program management, HIV M&E, and evidence- based policy making will be organized. In addition, other professional development opportunities will be supported for the MoH staff as well as newly elected CCM members.
Coordination amongdonor communities active in Kosovo and other implementing partners from the field of HIV and adjacent areas will be strengthened. Regular Donors’ Coordination meetings will be organized at least on a quarterly basis to avoid overlapping and duplication of efforts, on the one hand, and achieve complementarity and synergies between various initiatives, on the other hand.
Enhancing HIV Program accountability: Effective system of accountability is a powerful tool to improve the quality and ensure equitable access to HIV-related services. Well-functioning system of accountability requires systematic assessment of program financial and other inputs, evaluation of program impact and outcomes, and provides the voice to civil society and HIV-affected communities. Based on the TPA recommendation, HIV programme will develop an outcome dissemination and communication strategy to define reporting standards for involved institutions; to ensure the transparency and access to HIV programmatic and financial data. The MOH will establish a website for HIV program (under the MoH domain) that will serve as a national resource hub for HIV. It will regularly publish and make accessible the programmatic and financial reports on HIV/AIDS program implementation to all interested parties, including the CSOs, beneficiaries and wider public.
Conduct HIV program Evaluation study: In 2018, HIV national program evaluation study will be conducted toinform stakeholders how to improve program effectiveness, program management and administration. The evaluation study will identify program strengths and operational bottlenecksthat can help stakeholders to maximize program outcomes and optimize program spending. This is particularly important during the transition period as itwill serve as a practical tool for the Government
32Kosovo HIV/AIDS and Tuberculosis Programme Transition from Donor Support. Transition Preparedness Assessment. The Global Fund programme in Kosovo. Curatio International Foundation. March 2017 of Kosovo and decision makers to prioritize the interventions with the potential to achieve greater returns on the Government’s investment.
Refining HIV national response through program evaluation and periodic reviews: The NSP envisions resources to conduct HIV program mid-term review and annual review of the HIV national strategic plan. The Government of Kosovo will ensure the review process be participatory involving stakeholders from state institutions, civil society organizations, private sector and community members.
Enhancing Legal and policy framework for the National HIV Program: In general, legal environment in Kosovo safeguards equal fundamental rights and freedoms of every citizen regardless their age, gender, ethnicity, social status, health conditions, etc. The Article 24 of the Constitution bans discrimination on a number of grounds, including sexual orientation, which makes the country one of the few states in Europe with a constitutional ban on discrimination on the basis of sexual orientation.33 The Anti- discrimination Law was also adopted in 2004 that bans discrimination on the basis of sexual orientation in a variety of fields, including employment, education, receiving public goods and services, social security, access to housing, etc. However, enforcement of the Antidiscrimination Law remains weak, and HIV vulnerable populations – PLHIV, PWIDs, MSM/TG, and sex workers face strong stigmatizing attitudes from the society driving these groups underground. The MICS34 found that only 6.2% of women and 8% of men 15-49 years old expressed accepting attitudes towards people living with HIV. Attitudes of general population and/or health care workers towards other vulnerable, marginalized populations have not been studied, but there are evidences that S&D is prevalent in health care settings.
To realize the Goals and objectives of the HIV NSP 2018-2022, emphasis will be placed to reduce HIV- associated stigma and discrimination and generate non-judgmental attitudes towards key population groups to ensure that they seek services from targeted HIV prevention programs and enroll in HIV care.
Despite overall conducive legal environment, during the TPA study through the desk review and in- depth interviews with representatives of CSOs, several specific articles in the legislation were found that may create barrier to HIV prevention services.35 Namely:
➢ Prostitution is foreseen as a minor criminal offense. Condoms are used as an evidence of criminal behaviors. Therefore, SWs sometimes refuse to accept condoms from HIV prevention program.36;37 ➢ By criminal code (Kosovo Criminal Code, Article 274 paragraph 4) possession of narcotic drug paraphernalia is punishable (1-10 years) only in cases without authorization. The term "authorization" has been ambigous to stakeholders and requires clear definition. ➢ HIV transmission is criminalized in Kosovo. The Criminal Code of the Republic of Kosovo defines that anyone knowing to be infected with HIV, and does not reveal this fact and transmits HIV to another person, shall be punished with imprisonment of two (2) to twelve(12) years. According to stakeholders, the provision does not differentiate non-disclosure from transmitting HIV deliberately to another person, which creates ambiguity around the article.
33 Constitution of the Republic of Kosovo, Fundamental Rights and Freedoms 34Multiple Indicator Cluster Survey 2014-2015 Kosovo. Oct 2014; revised May 2015 35Preparedness Assessment. The Global Fund programme in Kosovo. Curatio International Foundation. March 2017 36HIV/AIDS Related Rights in Kosovo: Review of Existing Legal Barriers. April 2016 Prepared by EdonaAhmetaj. TGF 37 In-depth Interviews with civil society To tackle legal barriers, the NSP plans to initiate policy dialogue about the legal challenges identified through the legal mapping exercise in 2016. Legislation will be reviewed and appropriate amendment will be proposed to harmonize legal framework, and corresponding Administrative Instructions regulating HIV testing and MMT services.
Create a sustainable legal mechanism for CSO Contracting:There are no legal barriers for the Government to contract civil society to deliver HIV-related services to key affected populations. Various ministries, including by the Ministry of Health as well as municipalities have practiced contracting non- government organizations using public funds. In most cases, Government funds CSOs, predominantly, professional associations for short-term projects, e.g., for organization of public events dedicated to World AIDS Day; World TB Day, conferences, etc. Currently the CSOs in the field of HIV are solely funded by the GF, and none of them have ever received state funding for HIV service delivery.
Even though that the MoH and municipalities have been practicing to fund CSOs, there are no detailed rules and procedures for contracting CSOs for health service delivery. Considering the TPA recommendation, Kosovo will initiate a study to assess existing CSO contracting mechanisms and established practices in Kosovo, and to identify potential barriers for civil society organizations to deliver HIV and TB services under the state funding. To achieve complementarity and avoid duplication of efforts, the assessment study will coordinate with the EU project that intends to assess legal environment for CSO contracting in different sectors. Based on the assessment, detailed regulations and operational manual for CSO contracting for HIV services will be developed. The document should describe the rules and procedures for CSO contracting, such as: tendering procedures, technical specifications, qualification & past experience requirement for potential applicants, proposals’ review committee composition, selection process, transparency & conflict of interest requirements, etc.
After the regulations and procedures are defined and formally approved by the Government resolution, technical assistance and training will be provided to local civil society organizations to increase their capacity for fundraising, proposal development, and resource mobilization including that from the Government.
The Government of Kosovo acknowledges the role and potential of civil society organizations in providing HIV prevention and care services to key affected populations. To ensure smooth transition and sustainable engagement of CSOs in HIV service provision, the Government of Kosovo will incrementally increase its funding for services delivered by CSOs to KAPs. To facilitate the CSO contracting process, an assessment of CSO landscape in HIV field will be conducted. CSO mapping may serve as a practical instrument helping the Government to select most capable CSOs after the Government initiates grants program for HIV prevention interventions targeting KAPs.
Strengthening Government financial commitment: The Government continues increasing state investments in HIV national response to meet the Counterpart financing requirement for lower lower- middle income countries as set in the Global Fund Eligibility and Counterpart Financing Policy. During 2018-2022, further increases in the share of Government spending out of the total AIDS spending is planned. However, Kosovo lacks the capacity to accurately track the spending and produce spending data disaggregated by program areas and by funding sources. Based on the TPA recommendations, Kosovo will initiate work to establish a System of Health Accounts (SHA) with disease-specific sub- accounts. This will help the country regularly monitor overall health expenditures, including HIV spending. Starting from 2019 year, Kosovo will conduct National AIDS Spending Assessment (NASA) on an annual basis, and produce expenditure reports that will become publicly available on the MoH website. After the SHA system, and/or HIV sub-account is established, the capacity building activities for relevant staff will be implemented on reporting spending data, as well as data analysis and NASA report preparation.
Financial Transition Plan: Within the HIV NSP 2018-2022, further steps will be taken by the Government to start gradually absorbing costs of activities that have been fully and largely supported by the Global Fund grants since 2008. A Financial Transition Plan to absorb the HIV HR-related cost will be developed, and monitoring of its fulfillment will be done every year. In addition, the NSP sets targets that the Government of Kosovo will allocate commensurate funding for HIV prevention programs targeting KAPs. The state will also demonstrate its commitment to sustainability of HIV surveillance and HIV-related researches and will start covering certain portion of the IBBS/PSE costs previously covered by the GF. SPECIFIC OBJECTIVE 4. Ensure sustainable response to HIV through resilient health systems strengthening interventions.
Strengthening Health Information System for HIV:
One of the strategic Objectives of the MoH Health Sector strategy from 2010-201438 was development of an integrated Health information system (HIS) with clearly defined managerial and organizational structures. This initiative is being supported by Lux Development.3940 The National HIS outputs are expected to meet WHO and Eurostat standards.40 However, a phased approach that was designed for implementation of HIS nationwide, has been taking considerable time. Despite this challenge, HIV stakeholders are planning to initiate and coordinate dialogue for integrating HIV module within the national HIS to make sure that HIV information system meets established reporting requirements.
HIV routine surveillance:Under the current GF HIV grant, work to develop and operationalize integrated HIV database is underway. The database will help service delivery organizations to track program coverage, minimize double-counting of beneficiaries and will facilitate routine HIV surveillance and reporting. The electronic integrated HIV prevention and clinical database will collect information from all sources, including the medical institutions providing VCT and ARV treatment, the clinics testing blood units for infection, antenatal clinics, NGOs, prisons, and private clinics. Currently, anonymous HIV testing is available at several private laboratories, but testing data is not reported to the national HIV surveillance system. Dialogue with private clinics/laboratories will be held, and a clear mandate for HIV reporting will be institutionalized. During 2018, HIV recording and reporting national standards will be created; structural and data flow arrangements will be defined and Standard Operational Procedures (SOPs) to support effective functioning of HIV HIS nationwide will be developed and formally approved.
Relevant staff will be trained or re-trained on routine reporting and second generation HIV surveillance in order to increase their capacity for providing up-to-data epidemiological and patients’ data that will become a trustworthy instrument for program M&E, as well as for evidence-based programming and strategic decisions.
38 Health Sector Strategy 2010-2014. Ministry of Health. Kosovo 39IDIs with stakeholders and Lux Development 40Corruption Risk Assessment in Health. UNDP December 2014 Second generation surveillance: Several rounds of Integrated Bio-BSS (IBBSs) have been conducted in Kosovo in 2006, 2011 and 2014 years among key affected populations: MSN, PWIDs and FSWs. However, findings of surveys are not comparable due to different settings for survey sites41. That limits the country’s ability to assess HIV program impacts, observe trends in service coverage or behavioral changes among KAPs. One of the major purposes of having population-based sample surveys is to produce reliable data about KAPs and evaluate progress achieved towards HIV program objectives. In 2020, next round of IBBSs/PSEs is planned. More focus will be placed to ensure systematic sampling that are repeatable and the changes in behaviors and service coverage are observable with minimal bias.
The TPA identifies a high risk of sustainability of second generation surveillance studies in Kosovo given that all previous surveys have become possible through external financial and technical support from the GF. To address this challenge, in 2020, the Government will start investing in procurement of test- kits, data processing and data dissemination.
Two rounds of KAP survey among youth (in 2018&2022) are planned. A study to assess knowledge, attitude and practice among prisoners in correctional setting will be conducted. Study findings will enable policy makers and program implementing partners to design tailored interventions targeting youth and prisoners, respectively.
Procurement and Supply chain management system:
Law on Public Procurement in Kosovo No 04/L-042 establishes the Public Procurement Regulatory Commission (PPRC) as having primary responsibility for overall functioning of public procurement rules and system in Kosovo. The WHO mission42 in 2014 indicated that the procurement and logistics management system was not adequate enough to prevent ARV stock-outs. The lack of coordination of overall procurement processes and inadequate buffer stock was also identified as challenging. At present, these issues have been resolved: a Memorandum of Understanding between the MoH and UNICEF was signed and currently ARV drugs are procured through UNICEF that has ensured uninterrupted supply of ARV drugs over the last three years. A Buffer stock for 6 months has been created.
In early 2017, under the GF TB grant, a thorough assessment of PSM system was initiated to identify persisting problems and improve the overall capacity of the MOH procurement department. In addition to ongoing efforts, the HIV NSP envisions additional activities to develop PSM plan for ARV drugs and other HIV-related laboratory reagents, medical supplies and non-medical commodities. Respective SOPs will be also developed and corresponding training to relevant staff will be conducted.
Strengthening Human Resources for effective HIV response: The number of physicians per 1,000 population in Kosovo was 1.2 in 2012 that remainsfar below that in EU (27) - 3.2 physician per 1,000 population. Despite that, the staff shortage in HIV/AIDS field has not been observed partly due to the low number of patients in HIV care. However the absence of qualified medical doctor for pediatric AIDS management is documented, which will be addressed soon after the treatment protocol is approved and training of relevant medical personnel is provided.
41Country Report, GARP 2015 42Review of the HIV Programme in Kosovo (in accordance with United Nations Security Council Resolution 1244 (1999)) WHO Technical Assistance for concept note development under Cooperative Agreement with the Global Fund The TPA in Kosovo43 identified several challenges in terms of HR in health sector, and in the field of HIV: absence of HR policy in health; lack of integration of HIV-related trainings into formal education system; inadequate government investments for HR salaries, and continuous professional development in program management, HIV surveillance and M&E, new technologies for laboratory diagnostics, etc.
Integration of HIV-related trainings into formal education system: Within the HIV NSP, a set of interventions will be implemented to address the challenges that may pose risks to HIV program sustainability after external support for Kosovo ends. Special emphasis will be placed to integrate HIV training modules into formal education system at the undergraduate and postgraduate level. For this purpose, a inventory list of existing training modules or guidelines and service protocols that have been developed through the GF funding will be created. A dialogue with the Ministry of Education, and MoH will be initiated to define relevant faculties/specialties where training modules can be incorporated. The process will involve close cooperation among HIV program trainers and academia staff to adapt training modules to the standards for formal education curriculum. To facilitate the integration process, training of trainers (ToT) for future lecturers will be organized.
Staff performance Assessment system: Even though that the staff performance assessment is practiced by the MoH and some medical institutions in Kosovo, the system is weak and not well institutionalized. TA will be needed to assess existing staff appraisal mechanism; promote best practices; review completeness and accuracies of staff job descriptions; revise self-evaluation and supervisor’s assessment form, and explore possibilities of introducing performance-based rewarding system in health sector.
HR financing transition plan: To avoid staff turnover, and sustain all critical HIV program management positions, the Government of Kosovo will develop an HR financing transition plan, and start gradually absorbing the HR-related costs for the staff currently fully or partially supported through the donor funding. In addition, the Government of Kosovo will allocate state funds in amount of €5,000 every year to offer continuous professional development courses to HIV personnel.
Improve the quality of HIV service delivery: Considerable efforts will be devoted to development of national standards for quality HIV care in Kosovo. Numbers of national guidelines and protocols are expected to be prepared based on WHO consolidated guidelines, and other international standards:HIV treatment protocols for adults and pediatric cases will be translated and adapted; the protocol will include management of opportunistic infections and other comorbidities and co-infections, including HIV/TB co-infection; the PMTCT guideline and protocol will be updated; a protocol for provider initiated testing will be developed; the MMT protocol will be reviewed. All standards will be formally approved by the Government resolution, and institutional monitoring mechanisms will be created to assess if service providers follow the national guidelines on HIV prevention, treatment and care services.
SPECIFIC OBJECTIVE 5. Empowerment and engagement of CSO in HIV policy, programming, advocacy and HIV services in the community through Community Systems Strengthening
43Kosovo HIV/AIDS and Tuberculosis Programme Transition from Donor Support. Transition Preparedness Assessment. The Global Fund programme in Kosovo. Curatio International Foundation. March 2017 The national strategy aims at involving key populations (PWID, SW and MSM) in Kosovo in quality HIV prevention and care. The initial phase will include strengthening the current services in the existing intervention sites. Strategic outreach and the delivery of essential combination of HIV prevention and care services will be eventually provided in all areas of high concentration of KP.
The offered essential combination of services for KP will include:
1. Supply of appropriate types of injecting equipment for needle; 2. Behaviour change communication work with clients through structured verbal interaction and distribution of quality printed IEC materials developed with participation of clients; 3. Opioid substitution maintenance treatment to prevent HIV transmission by reducing injection frequency and to improve the quality of life of PWID; 4. Referrals to STI testing and condom distribution to prevent sexual transmission; 5. Ensuring access to and support of ART; 6. HIV testing and counselling (HTC); 7. Distribution of condoms and lubricants; 8. Referrals or delivery of gynecological services.
Complementary services will be also provided in order to attract and retain clients and address their essential needs. These may include: basic health care, testing for viral hepatitis and treatment referrals, screening clients for tuberculosis with subsequent referrals for diagnostics, reproductive health services, legal support, livelihood development, and humanitarian aid.
The National HIV Program realizes the importance of building resilient system for health in which HIV prevention, treatment and care services are provided to key populations. Therefore, the new Community Systems Strengthening (CSS) strategic orientation of the national program will focus on the issues that ensure better quality of services, better geographical coverage and more frequent reach of KPs through strengthening community systems and ensuring greater engagement of community groups in national response.
Strong emphasis will be given to social mobilization, advocacy, strengthening of CSO capacities and establishing linkages between government (incl. local government) and civil society, as well as creating an enabling environment for contracting CSOs under the state funding. Also, to enable a supportive environment for implementation of KP activities, the program will support amendment of existing legal framework and national guidelines and protocols. This will facilitate the readiness for transition of the Global Fund financed program to NAP financed program.
A number of advocacy activities will be realized, such as round tables and open discussions in support to advocacy/sensitization activities of the public and media – about human rights aspects around key populations, through use of testimonials and success stories, and support trainings about standards for behaviour towards KPs (rights based, welcoming, trustworthy and supportive) – for NGOs, medical staff, police, judiciary system, etc.
Costing HIV/AIDS NSP
The costing was based on budget format and costing items that were developed by Ministry of Health during development of Health Sector Strategy 2017-2022. In such forms Ministry,havs developed a format to describe and derive number of cost units and there was a detailed sheet for many costing items including their price. This information was pre-requisite for development of costing for HIV/AIDS NSP. Additional costing items, that were needed, were introduced and costed based on estimates received from Ministry of Health, Global Fund project recipients and CDF.
The process of development of costing consisted of consultation with key stakeholders and final review of costing with key Ministry of Health (in decision making capacity) and CDF representative (in technical/advisory capacity). Key stakeholders including staff of Ministry, recipient organizations and CDF were consulted for each costing unit, price and allocation time. In the end, all costing items were verified with representative from Ministry of Health. Final form of HIV/AIDS NSP is an excel sheet designed to allow easy adjustment and automatic calculation of costing items in case Ministry needed to change any detail of costing items for any activity line.
Monitoring and Evaluation Monitoring and Evaluation system for HIV national response is underdeveloped. Previous Strategic Plans did not include M&E and national indicators measuring HIV program impact were not defined. Till present, the M&E of HIV response fully relies on the GF project support, and the capacity of CDF, the GF principal recipient that performs monitoring and evaluation of the GF funded-activities, and also produces most national level indicators for KAPs. Through the support of the GF and with cooperation with the MoH of Kosovo, an M&E officer position was established within the HIV Coordination Unit at the MoH; but significant capacity building will be required to ensure effective functioning of the M&E system within the MoH.
The M&E framework of the HIV NSP 2018-2022 identifies a set of SMART indicators of different levels: impact, outcome and process indicators. The Framework displays baseline value and sources when applicable/available, and sets annual targets. Targets were defined through the participatory process involving key stakeholders and based on existing epidemiological and programmatic data. The M&E framework also suggests potential sources for data verification for each indicator.
Appendices Excel file – NSP
Budget sheet
HIV M&E
Bibliography
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