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Hiv prevention and care in serbia where are we after 12 years of gfatm funding - katarina mitić

  1. HIV Prevention and Care in Serbia – WHERE ARE WE after 12 years of GFATM funding Katarina Mitic Maja Aleksic Ramadan MoH of Serbia
  2. HIV Prevention projects implemented by the MoH of Serbia GFATM Approved two five-year projects for Serbia to the Ministry of Health as a Principal Recipient: • Round 6 project in the amount of 9,186,190 EUR (implemented from 1 June 2007 to 31 May 2012). • Round 8 project in the amount of 5,783,639 EUR (implemented from 1 July 2009 to 30 September 2014),  Total value of grants is 14,968,929 EUR
  3. Goal: To stop the spread of HIV infection among particularly vulnerable groups and to provide care, support and treatment to people living with HIV Specific objectives: 1. Providing universal access to prevention, care, support and treatment of especially vulnerable groups 2. Enhancing the quality of care , treatment and support for people living with HIV 3. Creating environment that provides support to HIV prevention efforts 4. Strengthening the capacity of health systems to develop effective , affordable and sustainable services for people living with HIV Implementers: • MoH/Project Implementation Unit • Non-governmental organizations • Health authorities : o Clinics for Infectious Diseases o Psychiatric clinics/ centers for substitution therapy o Institutes for Public Health • Ministry of Justice/Penitentiary institutions • Ministry of Labour and Social Policy/Institutions for children and youth deprived of parental care the
  4. Activities  Field activities in the community in order to change behavior among IDUs , SWs, MSM, prisoners, young Roma, children and youth in institutions of social care  Counseling and testing for HIV  Condom distribution Monitoring Performance of ARV therapy Care and support to chronically ill  Strengthening civil society in response to HIV infection  Reducing stigma and discrimination associated with HIV at all levels  Strengthening the national system for monitoring and surveillance of HIV infection and targeted research
  5. The project focused on the following vulnerable groups : • Injecting drug users ( IDUs ) • Sex worker ( SWs) • Men who have sex with men ( MSM ) • Young Roma and other marginalized youth • Prisoners • Children and youth placed in social welfare institutions (juvenile delinquents, children in foster families) , and • People living with HIV ( PLHIV )
  6. Where do we work?  More than 40 towns in Serbia  More than 60 institutions and organizations  More than 70 projects
  7. Harm Reduction - NSPs The exchange of sterile injecting equipment 4 Regional centers / NGOs (Belgrade, Novi Sad , Kragujevac, Nis) Since June 2007, a total of 3,887 new clients reached Training on HIV prevention for NGO activists ( peer educators , outreach workers ) , police officers working in health and social care Expansion of the program and the formation of so-called . mobile field teams working with IDUs Fieldwork : exchange of sterile equipment , distribution of condoms and IEC materials, education on HIV / AIDS, referral to VCT and treatment of sexually transmitted infections Strengthening the capacity and functional connectivity of all relevant actors in the NGO sector and institutions of the system
  8. Needle Syringe Programs Achievement  367,000 sets of sterile injecting equipment and 14,000 boxes for disposal of used accessories distributed  Acquired 4 field vehicles (medical mobile units)  Educated NGO activists for field work and VCT , established cooperation between the IPHs and NGOs  Health care and social workers , police officers and pharmacists, sensitized to work with IDUs  IEC materials (developed in accordance with IDUs’ particular needs), and condoms distributed Challenges  Insufficient knowledge and lack of understanding of the general population for the program  Difficulties in promotion/ extension of programs, and attracting of beneficiaries/IDUs  Treatment of injecting drug related problems  Reducing stigma and discrimination  The problem of contamination in the local community  Implementation of programs in the penitentiary institutions  Problems in cooperation between institutions and NGOs/ private sector
  9. Substitution treatment The overall objective of this program was to improve existing services and to introduce additional, as to include 3,000 IDUs in substitution treatment 26 centers for substitution treatment in 20 cities (in health institutions , covering three levels of care ) Since June 2007 , a total of 2,719 new clients reached Specific objectives:  Develop a stable network of institutions working with IDUs involved in substitution program  Decentralize services of the methadone therapy at primary health care level  Initiate positive changes in the behavior of IDUs , supporting their social rehabilitation and inclusion into the health system  Encourage change in attitudes and behavior towards IDUs  Promote respect for human rights of IDUs
  10. Substitution Treatment Achievement  Improved legislation  Adopted “National guidelines for substitution treatment”  Health workers trained  Centers’ premises refurbished  Increased number of health institutions that provide treatment  Introduced buprenorphine  Organized supervision  Established cooperation between centers and IPHs (VCT centers) Challenges  One coordinating body, continuous support ( budget and policy) for the prevention of HIV / AIDS, care and treatment of IDUs  Republic Expert Committee / MoH (consensus of profession, communication )  Further sensitization and training of health professionals to work with drug addicts  Defining the place and role of the program in primary health care/ expansion of the program  Enhancing cooperation with the penitentiary institutions , police, centers for social work, labor market
  11. HIV prevention among sex workers 5 NGOs - Kikinda , Novi Sad , Beočin , Novi Sad, Belgrade , Kragujevac, Nis, Zajecar ... Since June 2007, a total of 2,711 new clients reached • Developed standardized protocol / guide for field work • Organized trainings for field workers and magistrate judges • IEC material developed and distributed • 3 vehicles for field work procured, specially adapted to the needs of SWs • Engaged professionals to perform examinations, provide advice (psychological, social , legal ) in mobile units • Provided counseling on HIV and STIs , IEC materials , condoms and lubricants , and instructions for VCT/ testing with rapid tests
  12. HIV Prevention among sex workers - challenges  Incorporation of services into the system/ sustainable funding of services provided in the field  Increasing the availability of HIV prevention services for SWs as multiple vulnerable clients  The inability to make decisions, low income , limited “mobility ", auto- stigma  Stigma, discrimination, violence (from insults to physical violence and economic exploitation)  Further sensitization of health care/ social workers, police officers , improving mutual communication  Changes in legislation and policies
  13. HIV Prevention among man having sex with men  4 NGO - Belgrade , Novi Sad, Sabac , Valjevo , Loznica , Sremska Mitrovica , Kragujevac, Nis , Uzice, Cacak  Since June 2007, a total of 47,367 new beneficiaries reached  Provided counseling about HIV and STIs, IEC materials , condoms, lubricants, and referral for VCT/ rapid tests  Procured one vehicle for field work  Developed standardized protocol/ guide for field work  Conducted trainings for field workers, health care workers, police officers, journalists, in order to reduce stigma and discrimination against the LGBT population  Provided online counseling  Provided fees for project coordinators and administrators, field workers, and consultants in mobile teams
  14. HIV Prevention among MSM Population - challenges  Increase in HIV prevalence among MSM population  Decentralization of health services for MSM  Bridging the gap between health care and other state institutions whose clients are MSM  The sustainable funding of services provided on the ground ( NGOs)/networking in the local community  Homophobia  Stigma and discrimination (status of HIV-positive MSM )
  15. HIV Prevention among Prisoners  The program is implemented in 12 prisons (as of June 2007, a total of 6,214 inmates reached)  Developed a “National guideline for Health in Prisons” (HIV prevention, treatment of drug addiction)  Conducted trainings on substitution treatment for medical workers and associates, and established cooperation between penitentiary institutions and substitution centers  Penitentiary staff trained on HIV, hepatitis and other STIs prevention, and their knowledge transferred to inmates through workshops  Conducted training on VCT for health workers and associates  Established cooperation with VCT centers in the community, as well as with NGOs that perform rapid HIV testing in mobile units •Multiple ways of HIV and STIs transmission (injecting drugs, sexual route of transmission, tattoos, violence) • Standardization of services for substitution treatment among prisons •Establishing better communication between penitentiary and health institutions in order to improve monitoring, reintegration , and resocialization •Empower NSP, expand condoms and lubricants distribution
  16. HIV Prevention among Roma  3 NGOs - 10 cities ( Subotica, Novi Sad, Subotica, Sombor , Smederevo , Kraljevo , Kragujevac, Nis , Vranje , Bor, Obrenovac ) Since June 2007 , a total of 25,698 new Roma reached Achievement  Organized and conducted training sessions for peer educators and outreach workers IEC material developed  Health mediators who provide counseling for behavioral change and risk reduction included in a field work  Provided referrals for VCT, treatment of STIs and screening for tuberculosis Challenges  Further improvement of health care of Roma population, by providing information  Changing attitudes towards reproductive health ( rights and obligations )  Increased access to health and social institutions through peer support, support of Roma mediators  Legal representation in cases of violations of the rights of patients
  17. HIV prevention among children and Youth deprived of parental care/placed in institutions  Center for Protection of Infants , Children and Youth , Belgrade, Zvečanska 7 ( 10 cities )  Education of staff and children/ youth using a “Guide for Life Skills Based Education” Since June 2007 , a total of 1,733 beneficiaries reached  The training program based on life skills ( LSBE ) takes place in cooperation with the homes for children deprived of parental care centers, foster care (foster families ) and social welfare centers in Serbia  Education of staff/teachers and other professional workers, and children /youth ( as peer educators )  Manual accredited at the Ministry of Education  The program covers children and young people in 10 institutions and foster families  Distributed IEC materials , condoms VCT testing, and referrals for VCT/STIs centers
  18. Enhancing the quality of care , treatment and support for people living with HIV Treatment Literacy The standardized curriculum that should encircle the topic of use and life with ARV therapy : • Immunology and virology • Antiretroviral therapy • Side effects , opportunistic infections • Resistance and interactions with other medications • Adherence • Proper nutrition • Reproductive health • The long-term life managing with ARV therapy 740 people living with HIV trained Other activities  7 PLHIV organizations reached 1,006 people in six towns in Serbia  Strengthening regional centers and support the formation of new organizations to support PLHIV  Rent and refurbishment of premises, honoraria for coordinators, administrators, consultants  Trainings for the improvement of knowledge and skills/ courses that can expand chances for employment (computer, languages, driving)  Legal and administrative counseling  Reference to professional services to obtain/ maintain rights to social and health care  Psychosocial support for PLHIV and families  Trainings in the local community (informing, networking, advocating)
  19. Voluntary Confidential Counseling and Testing VCCT  16.340 counseled and tested in 36 health care institutions, institutions for execution of penal sanctions and CSOs  23 institutes of public health in Serbia connected through regular quarterly meetings, joint participation in promotions, campaigns, marking significant dates  Services in penitentiary institutions  Trainings on principles of VCCT conducted  Established the system of referral and reporting between institutions and NGOs  Developed VCT national data-base  Participation of employees of IPHs in the work of mobile teams (vehicles), enabling hard to reach populations to receive the services in a place that suits them and where they will not feel threatened, stigmatized and discriminated against  Strengthening Capacities (research of second generation surveillance of HIV infection)
  20. Health systems strengthening to develop effective, affordable and sustainable services for people living with HIV / AIDS  Bio-behavioral research (4)  Research on the quality of life of people living with HIV  The survey on knowledge, attitudes and behavior of health workers (KAB) related to HIV infection  Survey in general population  PLHIV Stigma Index survey  Strengthening the National M&E System
  21. Creating an environment that supports the HIV prevention efforts Trainings 123 training, trained 2,540 participants • Trainings on HIV prevention for NGOs Strategic planning • Project design and fundraising in the local community • Training for journalists, priests and decision-makers • Training on the principles of bio- behavioral research Health communication :  Establishing a structure for transmitting messages tailored to the unique needs of target groups  Improving communication skills of those who should pass the messages  The implementation of activities based on evidence  IEC material  Campaigns
  22. Conclusions • Existing HIV prevention services are enriched and expanded, new ones introduced, standardized, and set number of members of the populations at risk is reached • Improved knowledge and skills for the protection not only of HIV infection but also from hepatitis and other sexually transmitted infections  Improved knowledge about HIV project target groups and the general population  The number of people counseled and tested for HIV increased  Improved conditions for treatment and the implementation of substitution treatment in health care and in the penitentiary institutions  Provided the continuous monitoring, better planning and timely detection of new infections, and therefore the quality of treatment of PLHIV   Enhanced cooperation among governmental and non-governmental sector in the field of HIV prevention, defined common objectives, cooperation mechanisms and activities  It enables the delivery of health services outside the health system  The status of NGO activists promoted  4 bio-behavioral surveys completed the picture of HIV infection in Serbia , pointed out the problems and pave the way towards the development of programs to meet the needs
  23. Sustainable Services Out of numerous services partially/fully financed by GFATM the following became sustainable (funded from the national budget): - HIV preventive program in 12 prisons - LSBE in institutions for children deprived of parental care - Harm Reduction Programmes for drug users/substitution treatment (methadone and buprenorphine) in 26 health centers and prisons - HIV prevention among Roma (included in curricula with STIs, performed by health mediators, and funded from the budget/other donors) Besides that, the following services are available: - HAART for registered HIV positive patients in four AIDS clinics - Testing for HIV positive patients (needs improvement) - VCCT in 23 institutes of public health (need to be improved)
  24. HIV PROGRAMME GAP - 1 - Outreach Voluntary and Confidential Counselling and Testing on HIV In newly registered cases in 2014. every forth patient discovered his/her status in the terminal clinical stage of HIV infection. It is important to enable counsellors to “leave” their institutions and work in partnership with the civil sector organizations in the field/ medical mobile units. It is desirable to increase use of rapid tests, to provide (simultaneous) testing on Hepatitis B and C, and to make VCCT accessible on the primary healthcare level - Harm Reduction Programmes among drug users Outreach work in drop-in centres is not performed within the health and/or social systems. From 2004 to 2014 the programmes existed in continuity and they were complementary with substitution therapy, which maintained HIV prevalence on a low level (up to 1.5% in 2013). With the end of the GFATM programme the majority of drug users not in treatment programmes, will be left with no support. There will be an increased use of non-sterile injection equipment and other forms of risk behaviour, increasing the prevalence of HIV and HCV infection among drug users.
  25. HIV PROGRAMME GAP - 2 - Outreach/Mobile Medical Unit and Drop-in centres for the most-at-risk populations (SWs, MSM, IDUs) Outreach work and drop-in centres are not a part of the official healthcare and/or social system, so that with the end of the GFATM programme the majority of vulnerable individuals will be left without any support. Outreach work and drop-in centres represent the most important prevention strategy in HIV response. The lack of these strategies also excludes the possibility of any kind of HIV monitoring, as well as the possibility to provide care for a number of health disorders to vulnerable individuals and the rest of the population, who have close ties with these individuals. - Care and support programmes for PLHIV Satisfaction with social relationships, provided support and inclusion in the society was expressed by 41.6% of responders, while quality of life and health was satisfactory for the 13.3% responders. Education, development of social support systems, strengthening the capacity of NGOs and continuing fight against discrimination are essential conditions for improving quality of life of people living with HIV.
  26. Partnerships The purpose of co-ordination and partnerships is : • to avoid duplication • to identify gaps and needs • to build upon one another’s abilities and skills • to maximize coverage There is little indication of well-functioning co-ordination structures in the communities  Most organizations co-operate with a few organizations that they have immediate and practical need to have contact with  Such contacts are usually not formalized and are sporadic rather than regular Partnerships between community organizations  Competition between community organizations working in the same field  Competition for clients and territory  CBOs are often driven by a leading individual and such individuals are identified with the organizations they start and support over the years
  27. PLHIV associations  The fact that people involved in community organizations are often directly affected by HIV/AIDS places considerable pressure on them to respond  In this context opportunism and self-enrichment are regarded with suspicion and tension emerges between the ‘opportunities’ offered by HIV/AIDS funding and the humanitarian, community-motivated and philanthropic motives for response  Such a backdrop provides a poor context for partnerships
  28. Partnerships between CSOs and government  60% of GFATM budget was disbursed to CBOs/NGOs. 40% to institutions  Little formal involvement of relevant community-based organizations in planning new developments at local government level  No existing blueprint or published strategy for municipal-level HIV/AIDS responses and the official Integrated Development Plans of the respective municipalities are inadequate in their HIV/AIDS components.  Lack of involvement of community organizations in working within government programmes is most notable in the case of the anti-retroviral programmes which are largely hospital-based and which community organizations have not as yet been formally drawn into, although they often supply much-needed background support in an informal and unrecognized way  There are also often insufficient linkages between public sector institutions, such as IPHs that provide VCT, and community organizations such as support groups, which provide on-going support to infected individuals in the community itself
  29. What do we have Health Insurance Fund Ministry of Health  HIV treatment  Diagnostics  Surveillance in a small part  Not transparent system of contracting and slow procurement procedure Health-care institutions (their own sources)  „Programmes of general interest“ covering prevention and control, surveillance and part of diagnostics  Provided by public health institutes  Small grant for non-profit organization
  30. What do we have Ministry of Youth and Sports Autonomous Province of Vojvodina  Small grant for preventative programmes targeted young people  Provided by non-profit organizations  Often do not fit the National strategy for HIV Infection and AIDS Other ministries, agencies and institutions at national level don’t participate in financing of national HIV response  Financing of small non-profit organization projects through Secretariat for health, youth and education Local Self Governments • Only a few local self governments financing HIV response identified • Usually small grants for projects for young people • City of Novi Sad continuously supports VCT and support for PLHIV
  31. Scenarios  Full integration – 2,620,000 EUR  Integration of only effective and efficient programs – 1,020,000 EUR  Integration of only effective and efficient programmes, but to reach universal access – 2,160,000  Significant role of local self government  Example of City of Novi Sad: in 2011 spending for HIV programmes 0.052 EUR per capita  Integrated approach – participation of different ministries in financing of national HIV response  Besides MoH and MoY also participation of ministries of interior, defense, labor and social policy, science and education, regional development, justice, culture and information  For the national level it would make 370,275 EUR yearly  In the case of 0.1 EUR spending of local self-government for HIV programmes, it would make 712.067 EUR