HIV Prevention and Care in Serbia –
WHERE ARE WE after 12 years of GFATM
funding
Katarina Mitic
Maja Aleksic Ramadan
MoH of Serbia

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

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

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

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 )

Where do we work?
 More than 40 towns in
Serbia
 More than 60 institutions
and organizations
 More than 70 projects

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

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

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

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

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

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

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

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 )

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

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

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

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)

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)

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

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

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

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)

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.

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.

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

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

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

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

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

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