TOR_programming_MSM

Terms of Reference for consultancy

Technical assistance for enhanced programming for HIV prevention among MSM





I – Background





In the Republic of Moldova the first case of HIV infection has been attested in year 1987. Since then the

country embarked on building its national response to the HIV epidemic. The initial period included

sporadic cases until mid 1990s and in year 1995 an HIV outbreak has hit among injecting drug users.

Starting with year 2000, the proportion of heterosexual transmission was increasing gradually and in year

2005 heterosexual mode prevailed over transmission through injecting drug use. Yet, as of the end of year

2008, IDU mode of HIV transmission still accounted for 50% of cumulative cases, sexual mode for

47.3%, perinatal mode for 1.3% and undetermined mode for 1.3%. Some subpopulations become

increasingly affected, such as migrants and youth, but increase in HIV prevalence has also been registered

in pregnant women and blood donors. The data available, i.e. annual rise in HIV incidence, the

geographic spread of the epidemic, with new cases of HIV spreading into the general population,

including rural population (41.64 per cent of all new cases diagnosed in 2008 was in rural population

versus 38.7 per cent reported in 2007), is pointing at the generalization trends of the HIV epidemic.

However, the epidemic is still considered to be concentrated in most-at-risk populations (IDUs, FSWs,

MSMs, inmates). Significantly higher percentages are HIV-positive in these groups compared to the

general population and according to sero-surveillance studies the HIV prevalence does not show signs of

decrease in MARPs. According to the results of the HIV prevalence survey in 2007, an increase of the

HIV prevalence was registered among MARPs that are clients of harm reduction and prevention services:

the HIV prevalence among IDUs reached 22% in year 2007 compared to 17% in year 2004, among

Female Sex Workers (FSWs) 11% in year 2007 compared to 8.5% in year 2004 and among MSM of

4.8% in year 2007 compared to 2.5% in year 20041. Although the first study on risk behaviors in most-at-

risk adolescents (MARA) was conducted in 2007-2008, there are no data estimates on the size of this

group. The mandatory consent of parents / custodians when doing any medical procedure in underage

groups is a major barrier in enrolling MARA in HIV prevalence studies conducted in the most-at-risk

populations (MARP).



The national response has also passed through several stages. Initially, the main response was mass HIV

screening and increasing the HIV testing, diagnosis and surveillance capacity. Starting with the outbreak

in IDUs, the country has started mandatory HIV testing for drug users, but also has started implementing

Harm Reduction projects to contain the epidemic in the most affected areas. Two National AIDS

Programs have been implemented so far and the third is undergoing at present. The National Programme

on Prevention and Control of HIV/AIDS and STIs for 2006–2010 (National AIDS Programme – NAP)

determines national strategies of priority for prevention, epidemiological surveillance and treatment and is

currently in its last year of implementation.



The current NAP underwent a mid-term-review (MTR) process. This process represented a huge task

involving many players and required a good coordination mechanism. The evaluation process was

facilitated and overseen by a coordination team mandated by the CCM and took place from July to

December 2008. The focus of the review was forward looking and focused on developing consensus

around the future priorities for the delivery of the NAP and the National Monitoring and Evaluation plan.

It provided an opportunity for partners to jointly review progress, identify achievements, constraints and

gaps to be addressed. In addition to MTR, the country is currently undergoing situation analysis and

response analysis processes.







1

Scutelniciuc O, Bivol S. Behavioral and Sentinel HIV Surveillance Moldova 2007. Chisinau, 2008. In print

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There is also a concept endorsed by the government for building one comprehensive national M&E

system. The National Monitoring and Evaluation System is Government-based and Government-led. The

Department for M&E of National Health Programs (M & E Unit), as a subdivision of the National Center

of Health Management of the Ministry of Health of the Republic of Moldova, represents the only

monitoring and evaluation mechanism at the country level.



Credible estimations of sizes of key populations at risk are lacking in Moldova, the ranges listed in

different sources lacking the evidence-base and varying greatly based on source and methodology.

Moldova is currently in process of developing credible estimations of sizes of MARPs, which shall be

instrumental in determining coverage rates.



II – Context for Consultancy



Taking into consideration that the HIV epidemic in the Republic of Moldova is concentrated in MARPs,

particularly in IDUs, one of the strategies of the National Programme of Prevention and Control of

HIV/AIDS and Sexually Transmitted Infections is the Harm Reduction Strategy among the high risk and

vulnerable groups (IDUs, LGBT, CSWs, truck drivers and migrants).



The MTR of the NAP has determined that programmes targeting MSM have been limited and have lacked

sound evidence-base in their design. Due to their inherent vulnerability with respect to health and human

rights, associated with stigmatization and to limited coverage of this hidden population, stronger focus on

data availability and use related to HIV prevalence and risk behaviours are imperative.



HIV prevalence in MSM (blood samples, “take all” sampling), Republic of Moldova, 2003 - 2007

Data collection 2003 2004 2007

site Sample HIV prev Sample HIV prev Sample HIV prev

Chisinau, 118 1.7 % 121 2.5% 83 4.8 %

capital city



About 90% of Harm Reduction activities are provided by NGOs. The first Harm Reduction project

targeting LGBT community was open in 2004, and provided for:

• Information/education on HIV transmission and prevention in the framework of high risk behaviur and

outreach with distribution of information materials, condoms and seminars,

• Referral to medical institutions and social assistance (medical consultations, as a common practice for

STIs, consultations for psychological rehabilitation, pre and post‐test counselling).



Starting with 2006, some limited harm reduction activities targeting the LGBT community have been

implemented in Transnistria (left bank of Nistru river, separatist enclave) targeting the local LGBT

community. An outreach worker was hired to distribute condoms and informational materials on the left

bank, especially in Tiraspol city. Seminars were provided on the left bank by the NGO working on the

right bank. Among key stakeholders, the activity of Genderdoc-M ought to be mentioned, this being a

NGO working with LGBT and also a strong advocate for nondiscrimination provisions in the national

legislation. The NGO has raised funds and has implemented a variety of projects targeting the LGBT,

including condom and lubricants provision, Safer Sex Parties within gay discos; informational materials

provision; online counseling and counseling; informative seminars separately for younger gays and for

those over 35. The outreach activities organized by the same NGO include commodities and information

materials provision, complemented by peer education (talks with beneficiaries about the necessity of

using condoms and being protected). Currently, Genderdoc-M reports having 5 volunteers involved in

outreach work.









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Key indicators, MSM, Republic of Moldova, 2003 - 2007



2003 2004 2005 2006 2007

Number of MSM, ever reached by n/a 612 638 735 751

Harm Reduction Programmes,

cumulative number

HIV knowledge, % UNGASS 30.5 38.3 46.8

indicator2

Condom Use at last anal intercourse 59.0% 63.0 48.1

%3







In early 2010, HIV Sentinel surveillance shall be conducted in MSM through a quantitative study with

linked anonymous testing to HIV, VHC and VHB, to provide the strategic information on trends and

current behaviors and risks needed to guide planning. The BSS among MSM shall complete the cycle of

2009 BSS, also carried out among IDU and FSW. Among MSM, there are difficulties to enroll

respondents in a survey, as the group remains hidden and hard to reach due to associated stigma and fear

of discrimination. Consequently, access to specifically-tailored health services is limited. In this context,

provision of health services specifically targeted to meet the needs of the MSM in the framework of the

BSS is both an incentive for MSM to enroll in the survey as well as a service delivery entry point. STI

counseling and diagnosis, lab tests, and psychosocial counseling shall be provided in the framework of

the BSS.



The equivocal Governmental commitment to provide resources, support and services for sex workers and

MSM and to address the existing legal, financial and administrative barriers to service access for MARA

indicates a lot more needs to be done on the part of the Government of Moldova to address the HIV

epidemic in those most vulnerable populations. The Government’s financial contribution to and

involvement in prevention efforts among MARPs is barely adequate. Coordination of service delivery by

Governmental and non-governmental service providers needs to be strengthened to contribute to the

sustainability of the entire prevention programme.



Regardless of the worrisome trends in knowledge indicators, concerns where coverage of harm reduction

programmes are concerned, and projected increase of HIV prevalence among MSM if current trends

persist, the programme interventions targeting MSM are somewhat sporadic. The 2007 HIV Law does not

refer explicitly to MSM or other members of the LGBT community nor to sex workers, the articles

providing for enhanced prevention efforts among these groups being excluded before the Parliament has

adopted the draft. There is strong opposition in the society and government for recognition of rights for

LGBT persons and communities, a draft law on nondiscrimination being struck down by the Parliament

and raising vocal opposition of certain segments of the society, because it was perceived as a tool for

more rights for LGBT.



The Concluding observations of the Human Rights Committee4 noted with concern that discrimination

based on sexual orientation appears to be widespread at all levels of society, and called for measures to

combat discrimination based on sexual orientation, including training programmes for police officers and





2

All BSS until 2009 targeted the beneficiaries of Harm Reduction Programmes. This fact explains the high values of

core behavioural indicators registered overtime.

3

The condom use at last anal intercourse in MSM declined in the last data point comparing with the

previous ones. The data collection for the last data point was poor quality and this could bias the

results

4

HUMAN RIGHTS COMMITTEE. Ninety-seventh session. CCPR/C/MDA/CO/2, 29 October 2009

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health-care professionals, as well as campaigns aimed at raising awareness, among potential victims, of

their rights and of the existing mechanisms for redress.



Moldova has embarked on developing a new cycle of the National Programme for prevention and control

of HIV/AIDS 2011-2015, this representing a window of opportunity for designing evidence-based

focused interventions targeting HIV prevention and promoting healthy behaviours among MSM.

However, technical expertise at country level is limited, and the context is not extremely rights-based or

LGBT-friendly.





III - Consultancy Objectives and Expected Results



 Overall Objective:

Analyze the country context and the data and trends documented in the existing strategic information base

and formulate recommendations for further programming,



 Specific Objectives:



 Assist the national M&E unit in developing the qualitative interview/focus group guidelines for

the qualitative research in MSM (data collection planned for April)

 Assist the national M&E unit in analyzing data obtained from the 2010 BSS among MSM (RDS

method) and qualitative data obtained through focus groups in the framework of the 2010 BSS

(available as of end of April)

 Compare the data obtained from the 3 rounds of BSS, the programme data held by NGO

implementing harm reduction programmes, and the qualitative inputs obtained through interviews

with key stakeholders and assist in analyzing trends

 Formulate recommendations for programming targeting MARPs in the framework of the new

NAP, based on human rights standards, existing policy framework and guidelines, including the

Global Fund Strategy in Relation to Sexual Orientation and Gender Identities, GF/B19/4, May

2009.

 Document recommendations and support them with best practices examples in similar country

contexts

 Facilitate consensus among key stakeholders by holding a briefing with the preliminary mission

findings



Deliverables

 Analytic Report documenting data and trends of HIV incidence, prevalence and risky

behaviours among MSM

 Set of recommendations for addressing the rights and specific needs of MARPs, aprticulalry

MSM, in the new NAP

 Briefing for key national stakeholders





III – Conditions for consultancy



Duration of work:

Desk review/preparations for the mission: 2 working days

In country mission: June 15 - 17, 2010 (travel dates not included)

Post-mission TA and report writing: 5 working days



Management of consultancy: the consultants will work in cooperation with the Department of M & E of

National Health Programmes (with National Centre of Health Management) and the UNAIDS M & E

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Advisor. Consultations with the national TWGs on MARPs, Prevention, and M & E and the UN JT on

HIV/AIDS shall be undertaken.



Profile of the consultant



 Competencies:

o Behavioral and biological surveillance studies

o Monitoring and Evaluation of AIDS programmes

o Programme design targeting hidden/most-at-risk populations

o Human-rights based approach to programming





 Experience:

o relevant educational background in sociology, epidemiology or related field

o minimum 5 years experience in evidence-based programming for MARPs

o experience in data analysis

o Strong team work leadership

o Analytical and report writing skills



 Languages: English writing and presentation skills. Knowledge of Russian and/or Romanian

would be an asset









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