Progress and Barriers

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					A Review of HIV/AIDS Activities
for Youth in Moldova
A report to UNICEF Moldova




                                    Jeff Dodds
                             UNICEF Consultant
                                November 2004
Introduction
In September 2004, UNICEF Moldova undertook an interim review of HIV/AIDS
activities at the country level in order to determine the state of current strategies
addressing HIV/AIDS, and to make recommendations on future directions. Following a
review of existing global, regional and local literature about activities to address
HIV/AIDS in Moldova and Eastern Europe (Appendix A), a series of interviews with key
informants in Moldova (Appendix B) was undertaken to help determine the current
course of interventions at the country level.

This report is formatted to follow the regional goals for UNICEF Moldova as described
in the document UNICEF Regional Strategy on HIV/AIDS for Central and Eastern
Europe, the Commonwealth of Independent States and Baltic States.


Summary of Findings
In spite of developing a national response to HIV/AIDS only as recently as 2001,
Moldova has made significant progress over the past three years in mobilising against the
threat of an HIV epidemic. In the course of interviewing key informants for this report, it
became clear very early on that Moldova benefits from a core of community-based and
international donor organization workers who are well-versed in prevention, care and
support, and strongly committed to maintaining a relatively low rate of HIV infection in
their country.

The spread of HIV in Moldova has been slower than in most other countries, and official
statistics would suggest that the epidemic has, at least, stabilised for the time being. This
is due in no small part to the successes that Moldova has had in developing a cohesive,
multisectoral response to the epidemic that is evidence-based, and set out with time
bound goals and targets. In addition to a State sanctioned response, albeit often in
response to international pressure, the significant financial commitment from
international donor organizations has played a very substantial role in stemming the
higher rates of new HIV cases experienced in the late 1990s.

However, Moldova is not without challenges as it continues efforts to contain the HIV
epidemic. While much has been accomplished in creating interventions for vulnerable
populations, more needs to be done to ensure that these same vulnerabilities aren’t
perpetuated on upcoming generations. Issues such as economic decline, poverty, lack of
opportunities to fulfil human potential, and social exclusion will continue to create a
population more prone to succumbing to drug and alcohol addiction, becoming involved
in the commercial sex trade, falling victim to sexual exploitation and human trafficking;
all significant factors in increasing risk for HIV infection. Of greatest concern, is the
impact these social conditions have, and will continue to have if left unaddressed, on
Moldova’s population of children and youth. Being able to address HIV in the broader
context of existing social conditions will go a long way to containing the epidemic and
reducing its potential to adversely affect Moldova over the longer term.


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UNICEF Regional Strategy on HIV/AIDS for CEE/CIS & Baltics
Prior to undertaking the series of interviews with key stakeholders in Moldova, an outline
of themes to be analysed was created to help guide the questioning (Appendix C). These
themes were developed from various UNICEF documents in support of its missions to
address HIV/AIDS and promote the human rights of children. This report is not intended
to provide a verbatim reporting of those interviews. Rather, this report will reflect upon
each of the goals of the UNICEF Regional Strategy using information collected from
interviewee responses and reference documents to formulate an opinion on whether these
goals are being achieved, and whether more or different activities need to be undertaken.

The UNICEF Regional Strategy on HIV/AIDS is intended to provide a framework for all
member countries, including the Moldova Country Office, to draw upon based on its own
analysis of need. While the strategy acknowledges the need for individual flexibility in
how it is adapted for local use, there is an agreement that the following three tenets will
be respected:

    Prevention of HIV infection among young people and prevention of mother to child
     transmission work needs to be scaled up urgently

    Within the aforementioned priority populations, efforts will be undertaken to focus on
     the especially vulnerable taking an approach that combines the need for
     developmental work and emergency responses. UNICEF will assume the role of a
     facilitator and advocate for such change, but will not assume the role of a driect
     service provider

    Develop a response to care for children and families living with HIV/AIDS, and
     develop responses that protect, care, and support orphans, abandoned and other
     vulnerable children

This report will specifically examine the Moldova situation for the four priority areas
outlined in the UNICEF Regional Strategy, which are:

1.   Prevention of HIV infection among young people
2.   Prevention of Mother to Child Transmission of HIV
3.   Ensuring care for children and parents living with HIV
4.   Ensuring protection, care and support for orphans and children in families made
     vulnerable by HIV/AIDS




                                            -3-
Summary of Key Recommendations

The following are a range of observations following the review of HIV/AIDS services
and programs in Moldova. Some of the observations from the review of HIV/AIDS
activities in Moldova do not fall under the responsibility of UNICEF to address, however,
these issues can and will create particular impediments in addressing the regional
priorities and are therefore captured in this section.

      The response to HIV in Moldova has been remarkable both in its speed,
       coordination and scope. The limitation currently is that the response lacks depth –
       most programs and services are limited geographically. What has been
       accomplished so well, in such limited time, now needs to move out across the
       country to the benefit of all Moldovans.

      UNICEF Moldova should resist the temptation to develop and deliver harm
       reduction interventions that address the most vulnerable and most at-risk.
       Populations such as prisoners, commercial sex workers, and injections drug users
       are currently well served by government and non-governmental service providers.
       While the benefits are less immediate, UNICEF should instead continue to
       operate, and expand, programs that make investment in the future of Moldova by
       focusing on the development of youth as full and equal participants within
       Moldovan society.

      Training should be provided to the UNICEF project sites, and any other interested
       NGOs, so that Participatory Evaluation Models can be implemented to test the
       efficacy of interventions currently underway. While there were several indications
       that a national evaluation framework was developed and ready to be implemented
       in 2005/06, not one interviewee could actually articulate what the framework was
       intended to measure. It was clear that capacity within the government’s
       Evaluation and Monitoring Unit was limited and reliance on their evaluation
       framework could prove problematic.

      While the Government of Moldova has demonstrated progress in some areas of
       the national strategy, there seems to be reluctance on the part of the government
       to assume a leadership role. While there seems to be general agreement that
       organizations are working well together there is also a sense that the government
       needs to assume more of a leadership role and be less reliant on the Country
       Coordinating Mechanism. There are no assurances that ongoing funding will be
       secured from international donors beyond 2006, so it is critical that a
       sustainability plan (that emphasises more governmental leadership) be in place
       quickly. The government needs to consider that funding bodies are more likely to
       continue supporting activities when it is clear that governments are making use of
       the lessons learned and implementing previously funded services as part of their
       core government services and programs.




                                           -4-
      Most interviewees felt that HIV/AIDS was an issue that most Moldovans had
       heard of, suggesting that awareness about HIV exists, but few interviewees
       believed that the average person saw themselves as being at any risk for being
       infected or affected by HIV. Moldova must find the necessary resources to
       provide a nation-wide, repetitive campaign that provides clear and accurate
       messages about HIV. This campaign needs to be supported with companion
       resources that can provide more detailed information, such as a national, toll-free,
       information line, and sufficient print resources that are accessible throughout the
       country. Aside from the obvious benefits of encouraging behavioural change, a
       national campaign could also generate public interest, enough perhaps to
       encourage the government to do more to address this emerging epidemic.

Understanding that UNICEF Moldova can not assume primary responsibility for
legislative or legal reforms that would help in fighting the spread of HIV, UNICEF
Moldova could provide training and support to NGOs to improve their capacity around
advocacy that would compel the government to move more quickly in addressing
HIV/AIDS. Collectively, organizations need to advocate for:

      Improved Access to Voluntary and Confidential Testing
       There is a sense among government officials that access to testing and principles
       of confidentiality are in place and effective. However, there are indications that
       more could be done to improve access to testing, improve the provision of pre-and
       post-test counselling (not limiting responses to only a medical based approach),
       and some serious concerns about the lack of anonymous testing. In discussing the
       management of positive test results, it is clear that confidentiality, while
       promised, can not really be provided. The process of recording information about
       positive tests, and then the sharing of that information through insecure means
       such as the mail and by fax, fails to maintain the confidentiality and security of
       the individual as much as it should. Except in instances of individuals wishing to
       obtain treatment, the option of anonymous testing should always be available.
       Failing this, it will only be a matter of time before people choose not to seek
       testing and move the epidemic underground.

      Enhanced and Expanded Training
       Much progress has been made in the creation of standards of care, provision of
       therapies, introduction of curricula, etc., however, by most accounts, more needs
       to be done to ensure that the uptake of such new resources are utilized across the
       country. Health care practitioners, educators, counsellors and others need to have
       the opportunity to expand their knowledge of HIV/AIDS so that levels of service
       delivery are equitable across the country. Resources for training have often been
       provided by non-governmental agencies and have therefore been limited in scope
       due to funding limitations. Government departments must ensure that appropriate
       and ongoing training opportunities exist across Moldova.




                                           -5-
   Improved Access to Services for all Moldovans
    As can be expected, most programs and services have been piloted and
    established in Chisinau and, to a lesser degree in Balti. Emphasis must now be
    placed on moving these models across Moldova so that all communities may
    benefit from them. The government must take advantage of the investments made
    by international donor organizations and non-governmental organizations, and
    move existing service models throughout the country to the benefit of all
    Moldovans.

   Surveillance Improvements
    In spite of some very significant improvement to surveillance more needs to be
    done, particularly in the area of Second Generation Surveillance. Essentially, data
    collected about the HIV epidemic appears limited and not particularly useful in
    informing the development of programmatic responses. While sentinel
    surveillance is in place there are still significant limitations that may well inhibit
    an effective response to the epidemic. Capacity building to support the
    appropriate collection, analysis, and reporting of the data will be critical.

   A Shift in Attitude
    There is an over-riding sense in government that people will adhere to prescribed
    behaviours as outlined and expected by the State. The Government of Moldova
    needs to understand that any expectation of “mass fidelity”, “abstinence”, or
    “treatment compliance” will not serve to reduce the incidence of HIV. In fact,
    such approaches often only create a culture of shame among those who can’t or
    won’t conform to such rigid expectations, thus driving the epidemic further
    underground. Services, programs and information must always be provided in a
    non-judgemental atmosphere that respects the inherent dignity and rights of each
    and every individual. Without respect for individual rights, including the right to
    make informed choices, it will be difficult to encourage behaviours that will
    benefit the good of the collective population.

   Provision of Funding
    Understanding that governments can only do so much, recognition must be
    provided to the NGO sector for the considerable contribution they have made in
    worldwide efforts to slow the spread of HIV. Moldova enjoys NGOs who are
    clearly committed to the publics they serve, well educated in effective
    interventions, and well aware of potential barriers to effective prevention. The
    government must make efforts to better acknowledge the particular expertise of
    the NGO sector, and a good starting point would be through the provision of
    funding to support the work of the NGO sector and encourage the establishment
    of more NGOs throughout the entire country.




                                         -6-
Goal One:
Prevention of HIV Infection Among Young People
Context
The existence of an HIV epidemic within Moldova has been slower to arrive than in other
countries around the world, and Moldova still enjoys a relatively small population of
known HIV infected citizens (1,945 reported cases to March 2004). This reported reality,
however, does not reflect the number of hidden cases (estimated as high as 5,000) nor
negate the very real possibility that Moldova will become as seriously affected as other
countries around the world, including some of its very close neighbours. Complacency
about this epidemic can be the most significant contributor to a spread of HIV that
renders the epidemic completely unmanageable. With an already unstable economic
situation, Moldova’s leadership needs to understand that the impact of an unmanageable
HIV epidemic could well bring the country to the brink of economic disaster.

In addressing HIV prevention and the ongoing stability of its population, it is necessary
to focus significant attention to the population of children and youth, who represent the
future of Moldova, and, without intervention, could also represent the future of the HIV
epidemic. Currently, estimates indicate that the HIV epidemic in Moldova exists
primarily among the young (~70% of infections) although there are limitations in the
surveillance data.

With only very recent experience as an independent republic, much of the population is
not conversant in their rights and responsibilities as part of a democratic nation. As a
result, there still exists an attitude that the government will identify individual needs and
priorities as they relate to the health and wellness of the population. Additionally, the
population is also less likely to make demands of a government failing to see themselves
as having a role in the development of policy and legislation that will benefit them. With
a range of other very serious social, health, educational, and economic issues facing their
country, it is not likely that people would necessarily see HIV as one of their
government’s first orders of business.

It is not at all clear that Moldova society recognises children and youth as valuable assets;
high numbers of children are abandoned by their parents in pursuit of economic or
employment opportunities outside of the country. The state only provides institutional
care for these children in the absence of family-based supports (foster care, domestic and
international adoption). In interviews with key informants many expressed frustration
with parents, educators, and the society at large who they felt were significant barriers in
educating and informing children and youth about HIV prevention. Clearly the issue of
sexual health and sexuality plays some part in the hesitation to educate children, but
many interviewees felt that there was a more pervasive attitude that children and youth
were not equal societal partners in Moldova.

It is well accepted that the population of orphaned and abandoned children is unusually
high for a country of this size. It is also well known that there is a population of children


                                             -7-
who live outside of institutional care without the benefit of parents or biological families.
This population of children is highly vulnerable to entering the commercial sex trade;
highly vulnerable for addictions to alcohol and injection and non-injection drug use; more
likely to engage in risky sexual behaviour; and, more likely to fall victim to human
trafficking.

The key to successfully addressing HIV is two fold. There is the immediate need to
address the most at-risky activities associated with the spread of HIV – injection drug
use, unprotected sexual behaviour, mother to child transmission, and an unsafe blood
supply. However, as countries with longer experience addressing HIV have come to
understand, these efforts cannot occur in isolation of addressing the “upstream” reasons
why people are more likely to find themselves placed at risk for HIV. Programs and
policies that encourage children and youth to see themselves as being of value and having
an active role in their community will go a long way to reducing the numbers of children
who might otherwise go on to participate in the sex trade, develop addictions, and engage
in behaviours that negatively affect their health.

Progress
In many ways, Moldova is now well positioned to address the immediacy of the
epidemic. International donor organizations and non-governmental organizations have
responded to the highest-risk populations; injection drug users; prisoners; commercial sex
workers; and, men who have sex with men. The implementation of harm reduction
models is largely complete and being well utilised by the respective populations.
Successful programs and services have been developed to meet the needs of the most
vulnerable. But while the scope of responses to HIV has been good, there is a lack of
depth in that there are areas of Moldova that do not have any HIV/AIDS services at all.
While much has been done in some urban centres, many of the smaller centres, and
specifically the rural areas, remain underserved.

The issue for Moldova now is to address the underlying factors that contribute to a higher
likelihood that children and youth will go on to need harm reduction interventions. The
most effective means of reaching large numbers of children and youth is through the
school system. Based on a KAP (Knowledge, Attitudes, and Practices) study of youth,
the Ministries of Health and Education worked together with UNICEF and other
international donor organizations to develop a Life Skills-Based Education (LSBE)
program in schools for full piloting in September 2004; country-wide introduction in
September 2005. Training for teachers is also being provided. Ministry of Education,
UNICEF, UNESCO, and WHO assisted in the development of a teacher guide, although
indications from interviewees suggested that more needed to be done to provide even
more teachers with the necessary skills and abilities to fully implement the curriculum.

It would appear that the most appropriate organizations are addressing the most at-risk
populations and while it is likely that they would all benefit from additional resources,
none of the organizations expressed concern that they felt their current challenges are
more than they can manage. Overall, it seemed clear that the immediate interventions to




                                            -8-
prevent a spreading epidemic among the most efficient means of transmission were being
addressed, although, again, only in some areas of the country.

In addition to providing a voice for children and youth in the development of national
responses to HIV/AIDS, UNICEF Moldova has responded to the HIV epidemic by
choosing to focus efforts on the development of a mentally and physically healthier
population of youth.

Through the establishment of Youth Friendly Health Services (YFHS), UNICEF
Moldova is providing supportive environments where youth can obtain counselling and
medical information and treatment, while allowing them to develop the skills and abilities
in that will promote a greater sense of self-esteem and avoid the development of
behaviours that could put them at an increased risk for HIV/AIDS. There are currently
three centres in Moldova with an expectation that ten more will open in new locations
across the country.

Through its support of the Youth Media Centre, supporting radio broadcasting and
newspapers by and for youth, UNICEF is promoting the value of their voices and
encouraging greater participation in the democratic process, promoting social inclusion,
and enhancing good decision-making skills. These projects provide youth with an
opportunity to think critically about their country and their role within it, promoting a
stronger sense of social entitlement among the youth. Through these programs youth are
also able to consider what issues are of importance to them and their peers, and which
issues should be promoted through their radio broadcasts and newspapers. Both of these
mechanisms for reaching youth have included the promotion of good sexual health, the
provision of prevention education about STIs and HIV, and encouragement for improved
sensitivity towards people living with HIV/AIDS.

UNICEF Moldova has also supported the creation of a network of peer-educators in
HIV/STI prevention. This program has engaged youth in roles of leadership as educators
among their peers. The program has empowered youth to take more responsibility in the
protection of their health, which can only happen with the provision of accurate
information delivered in a meaningful way. Through the peer educators network,
HIV/AIDS has been demystified and factual information has been provided that assists
youth in seeing the threat as real and relevant to their own lives.

UNICEF Moldova also supports a Youth Resource Centre and Multi-Media Centre that
again encourages capacity and esteem building through innovative approaches. The
Multi-Media Centre provides training to youth around photography and animation as a
means of imparting information to them about HIV/AIDS prevention. Using the training,
youth are then able to create other tools and resources that go on to provide broader
education to the youth of Moldova.

All of these youth friendly programs and services take on a very important function in the
range of interventions designed to slow the HIV epidemic. As other countries have come
to understand, a failure to eliminate the root causes of at-risk behaviour means that the



                                           -9-
chances of mitigating the HIV epidemic are considerably reduced. By choosing to invest
in the capacity of youth, UNICEF is in fact making a substantial investment in reducing
the population of people who could go on to represent the most at risk in Moldova. As is
well understood, the opportunity to create good decision making skills and establish good
behavioural practises is much more effective and efficient than being in the position of
having to try to change behaviours later on.

Unfortunately, this investment in creating good behaviours is not always appreciated for
its real value, with the more tangible exercises of condom distribution and needle
exchanges seeming to be more effective, and certainly being less “expensive” in the short
term. However, it needs to be clear that until such time as the children and youth of
Moldova have the capacity to participate in their country, have the knowledge to make
good health choices, and feel a sense of entitlement to information that will help them
maintain good health, the pool of people that make up the highest risk populations will
only continue to increase in numbers. The efforts of UNICEF Moldova are helping to
create a population that will not come to need interventions at a later date. As such, this is
an investment in human capital, an investment whose benefits won’t completely be seen
immediately but an investment that is no less important than needle-exchanges and street
outreach services.

Gaps and Challenges
In spite of the evident successes witnessed among the youth at every youth-friendly
centre, it was clear that those youth who are currently engaged are in fact the more
confident and socially aware youth. The most vulnerable children of Moldova are not
being captured by such programs and consideration needs to given on how to best seek
out and engage the most disenfranchised children and youth as they are the population
who would most directly benefit from such services and programs.

There is a significant population of children who are under the care of the state because
their parents have died, or because they have been abandoned by parents seeking out
better economic possibilities outside of the country. More must be done to reduce this
population under state care and efforts that are underway to develop family-based
alternatives such as foster care and adoption must be increased. Without question, many
of these institutionalised children and youth run a much greater risk of becoming the
future generations of vulnerable young adults.

Specific Recommendations

During the course of site visits and interviews with key informants it became quite
evident that the projects supported by UNICEF were successful and highly rewarding for
the youth involved. The ability to move the projects throughout the country to benefit
even greater numbers of youth will be contingent on whether UNICEF can provide the
necessary evidence to compel the government and other funding bodies to support such
expansion. While the anecdotal evidence (and some statistics) is compelling, UNICEF
Moldova should move quickly to train their project sites on the development and
implementation of Participatory Evaluations Models so that clear and concise evidence



                                            - 10 -
can be gathered as to the efficacy of existing programs. Outside of the obvious benefits
for building a case for expansion, participatory evaluation also creates more buy-in from
planners and participants of particular projects, while providing useful information as to
the components of the project that are most meaningful, and those components that may
well require some modification.

Outreach efforts need to be undertaken so that the more marginalized youth of Moldova
have access to the excellent programs developed and funded through UNICEF. Without
question, these programs are proving highly successful, but they aren’t always benefiting
the most at need. The development of a strategy to create peer outreach workers (youth
led by adults) who can do outreach in their communities and engage other youth, will go
a long way to capturing this population at risk. Using key opinion leaders, or youth well
known among their peers, to encourage participation will also be effective. Finally, the
application requirements for the programs (submission of applications, etc.) should be
reviewed to see if there aren’t ways to make the program more accessible to those who
may find such processes prohibitive.

In spite of a strong NGO sector within Chisinau, there is a lack of NGOs throughout the
balance of Moldova. More must be done to encourage the expansion of an NGO sector
throughout Moldova; an NGO sector that is coordinated and funded by the Government
of Moldova. Additionally, capacity building could be provided to the existing
infrastructure of NGOs to improve their advocacy skills. While there are clear
opportunities and need for both a community and State response to HIV, there is little
sense that the community groups are holding the State accountable for their share of
responsibility. It is not acceptable to suggest that all reform must be the responsibility of
international donor organizations or NGOs, but NGOs must assume responsibility for
more proactive approaches to calling for an increased response from the State, including
the elimination of barriers created by the State.

Goal Two:
Prevention of Mother to Child Transmission of HIV
Context
As it became clear that the HIV infection was moving from male injection drug users to
their female partners, most of childbearing age, incidence of mother to child transmission
was beginning to appear. There was no formalised response to the prevention of mother
to child transmission until very recently, much like what was in place for Moldova’s
other populations vulnerable to the HIV epidemic.

Progress
Preventing vertical transmission of HIV has been embraced as a priority among
governments and non-governmental organizations with an equal sense of urgency. As a
result, rates of new cases of MTC transmission continue to drop through an aggressive
and well coordinated campaign of offering testing to all pregnant women who present to
health facilities while pregnant. Additionally, considerable progress has been made in the
development of guidelines in the counselling and testing of pregnant women, training for


                                            - 11 -
practitioners in the protocol of counselling, testing, the treatment of HIV in pregnant
women and newborn babies, and the provision of free alternatives to breast-feeding. With
a centralised birthing centre for all HIV+ pregnant women, a model of best-practise of
care can be delivered by skilled and experienced practitioners who have access to
appropriate treatments to prevent the transmission of HIV from mother to child. Like
most developed nations, Moldova will soon be able to eliminate the infection of children
through vertical transmission as a significant population of HIV infected people within its
country.

Gaps and Challenges
Centralised care for HIV+ patients often makes sense in small, densely populated regions
or countries that are under-resourced and unable to mobilize best standards of care across
larger geographic regions. Economies of scale can be best realised when limited
resources (funding, skilled workers) are pooled and offered through a single entry point.
There are, however, limitations inherent with such an approach. Firstly, the issue of
access becomes complicated and prohibitive for individuals who cannot afford to travel
to such services. Secondly, women are often the primary care giver within the family
setting, often having other children’s care to consider; leaving home can be a hardship for
more than just the mother. Finally, the issue of specific wards for the exclusive use of
HIV infected pregnant women raises the possibility that women will avoid care for fear
of being stigmatised and isolated by the very services that could improve her own health
and prevent the infection of her child. Individuals who may be, or have been involved in
such activities as illicit drug use or commercial sex trade may especially fear further
marginalization and avoid centres where their very presence indicates that they are HIV+.

Alternatively, women who are pregnant but unaware of their HIV status may not seek
antenatal treatment throughout their term fearing that HIV testing will be mandatory,
non-anonymous, or that the confidentiality of their results may be compromised. These
concerns are particularly serious for women who are already disenfranchised from
services, and more likely to be infected, or fearful of the authorities (e.g. commercial sex
workers, IDU). More must be done to educate women about the benefits of treatment to
prevent the transmission of HIV to their unborn child and provide more security to
women who may seek out testing. Governments must be willing to assume the best of
their population by providing anonymous and truly confidential services particularly if
they hope to prevent the infection of unborn children.

As is the case more generally with HIV+ people living in Moldova, the provision of
medical services for pregnant women far outweighs the available social and
psychological supports. While the medical model is clearly proving effective in slowing
the spread of HIV in Moldova, it is not the only approach that needs to be available.
More resources need to be applied to the emotional and psychological needs of women,
to ensure that they remain connected to the social fabric of Moldova, and feel able and
confident to continue to care appropriately for their child(ren).

Specifically with women who might still be using illicit drugs or alcohol at the point of
presenting as pregnant, more programs and services need to be established to support any



                                            - 12 -
decisions they might make to stop using. While the immediate intervention of testing and
treatment is laudable in terms of reducing harm to the baby, the health and well-being of
the mother remains at risk due to continued drug/alcohol use. Offering alternatives to
addictions will be critical to improving the overall health of Moldovans including
detoxification centres and drug and alcohol rehabilitative services. Access to methadone
needs to be made available more universally and offered as an alternative to opioid use
particularly through injection. Confronting the prospect of motherhood, and the need to
provide love and support to a child can often be a compelling factor in the decision to
stop using drugs. When such a breakthrough occurs, it is imperative that some options be
available to women who wish support to stop using. The lack of options can leave the
impression that the State or the care providers are only interested in the woman in so far
as her ability to bring a new life into the world is considered.

Specific Recommendations

Recognizing the limitations of current resources levels, consideration should be given to
moving beyond centralized care for HIV+ pregnant women so that the services are as
accessible as possible for as many women as possible.

Programs and services should include professional support and peer-based alternatives to
supporting women through what can be a difficult time in their lives. Moving beyond the
medical model and targeting resources at psychosocial needs will go a long way to an
improved sense of well-being among HIV+ women and encouraging greater social and
familial participation, not to mention an improved sense of personal health and well
being.

Treatment of HIV infected women needs to move beyond the immediacy of their roles as
mothers-to-be and look more holistically at their overall health, including the provision of
interventions and services that will reduce or eliminate illicit drug use. By looking
beyond the immediate medical needs of an individual, harm reduction through
empowerment can contribute to a decreased incidence of new infections. Providing
service and programs to positive women beyond the window of time that they are
pregnant and giving birth will indicate that their value to society goes beyond their ability
to give birth and will lead to a healthier, more productive community of women.

Immediate attention needs to be directed to the provision of services for those wishing to
break the cycle of drug addiction. The continuing and singular approach of
criminalization has been demonstrated around the world as an ineffective approach to
reducing the use of illicit drugs, and reducing the spread of infectious diseases. Programs
and services such as universal access to methadone, detox and rehab centres, need to be
immediately integrated into the primary health care services of Moldova in order to
reduce the harm associated with alcohol and drug addictions – both of which have strong
correlations to increases in new HIV infections.




                                            - 13 -
Goal Three:
Ensuring Care for Children and Parents Living with HIV
Context
Moldova has a history of HIV positive people being oppressed and treated as threats to
the safety of the State. There were many expressions of concern among interviewees that
HIV+ people always had to hide their condition for fear of retribution, including
termination from employment, eviction from homes, isolation from family and
community, and discrimination within the public health and social services systems.
Moreover, people who did test positive were often left without access to information
about their disease, treatment for HIV or opportunistic infections, or access to support.

Progress
Moldova now has antiretroviral therapies available for its HIV infected citizens, free of
charge. Provision of care for HIV infected individuals is centralized through the National
AIDS Centre and requires that patients attend the Centre for their HIV related care,
including treatment for opportunistic infections, and receipt of necessary HIV treatments.
Travel to the Centre in order to receive care and medication is the responsibility of the
individual.

Moldova has a non-governmental organization that was created by, and operated for,
people living with HIV/AIDS. Established in 1997 with a centre that opened in 2002,
“Credinta” is the only non-governmental organization in Moldova dedicated to providing
support to HIV+ people.

While public awareness of HIV does appear to be fairly high, little progress appears to
have been made in reducing the stigma associated with being HIV positive. Government
has been slow to undertake legislative and policy reforms that would provide protection
for HIV infected Moldovans; the voices of PHAs aren’t generally represented in planning
and program development in Moldova; and, most groups, aside from Credinta, do not
claim any responsibility for promoting the concerns of PHAs.

Gaps and Challenges
As stated previously, centralized care is not uncommon in many countries, but also not
without limitations in ensuring that people are actually able to access the available care.
While it is a very significant step that antiretroviral (ARV) therapies are now made
available to all patients without cost, there is clearly a significant divide between the
number of those taking the medications, and the number known to be infected. It is not
the opinion of the writer that beginning ARV therapies early on is necessarily beneficial
or recommended, but the comparatively low numbers of patients on treatment does
suggest that some consideration be given to why such a significant gap exists.

One possible reason may be the reluctance of people to come forward fearing some form
of retribution from the State, their community, health care providers, or worse, their
families. Parents living with HIV will be generally preoccupied with caring for their


                                            - 14 -
families and not likely to put themselves at risk for things like eviction or loss of
employment. While self-care should be a priority, HIV+ parents, especially women, often
have to balance that need against the needs of their children and spouse, which usually
takes precedent. It is the balance of ensuring that appropriate care be provided to a person
who themselves is a care giver; every effort must be made to ensure that parents can
competently maintain their own health while maintaining the security required for their
family to thrive.

As in other areas related to HIV, much of the government response to the epidemic so far
has been through the establishment of medical models. While important, the medical
approach now needs to be expanded in order to provide psychosocial supports as well.
This can take the form of specially trained social workers, counsellors, or even peer
outreach workers. Much of the stresses related to living with HIV have little to do with
physical health, in fact social isolation and fear of the future are often more significant
issues for the individual.

One of the key functions that Credinta appears to play is in the provision of additional
funds to help PHAs survive on their limited incomes. HIV infection often requires
additional resources for medical, nutritional, transportation needs, and so on. Again,
while the provision of treatment is a significant step forward, treatment compliance may
well be affected by how well a person is feeling emotionally, and poverty can be a
serious deterrent to good mental health.

Specific Recommendations
There is no doubt that there needs to be prevention education among the non-infected
population of Moldova, in order to prevent them from coming into harm’s way. However,
what is often overlooked is that in order to stop an epidemic you must first go to where it
exists and stop it at its source. This approach can often be misunderstood and needs to be
approached cautiously. The writer is not suggesting a mass quarantine or isolation as an
option, but rather, to consider how PHAs are included in efforts to slow the epidemic.

It is important that planning and coordination of any national response include the voices
and experiences of PHAs. Inclusion and consideration of their experiences will provide
valuable information about creating successful interventions, treatment programs, and
other useful resources.

Additionally, one needs also to consider the social conditions within which PHAs must
try to survive and whether these conditions give PHAs hope for the future and motivate a
sense of social responsibility. Punitive or discriminatory approaches to PHAs suggest
that, as individuals, they are of no value to the dominant culture. Such expressions can
lead to poor self-care, and may also lead to instances where unsafe behaviours are
continued without concern for others. To prevent such possibilities from occurring, more
must be done to ensure that PHAs are protected by the State through legislation and legal
reform. Additional financial resources must be made available from the State to assist
PHAs so that they can take all necessary measures to protect their health and the health of




                                           - 15 -
others. Finally, PHAs should be given a more active role in defining, implementing, and
evaluating the national AIDS strategy.

NGOs also have a significant role to play in this issue. Each NGO, regardless of their
mandate, must consider how they are representing the concerns of PHAs in the work they
do and the advocacy they undertake. While it is appropriate that separate NGOs provide
services to PHAs, all NGOs working in HIV must come together to advocate for better
social conditions for PHAs. As well, any prevention programming or public awareness
campaigns undertaken must always include elements that reduce stigma towards PHAs.
While we want to encourage people to stay HIV negative, we need to spread that message
without suggesting that those who are positive are flawed, irresponsible or a threat to
public safety.

Alternatives must be made available to PHAs who are seeking non-medical support. Peer
support groups and psychosocial support workers provided by the State would be a
helpful initial step. Consideration must also be given to respite alternatives, particularly
for parents with HIV, so that the burdens of self-care and childcare can be better
balanced. Respite centres for adults, or day care centres for children, are recommended
alternatives to hospital care and should be developed and managed by NGOs with
financial support from government.

In several interviews the issue of alternatives to dying in hospital was raised, both by
community-based organizations and by medical staff. Home-based care protocols,
including palliative home care, need to be developed along with the establishment of
hospices, operated by NGOs and funded by government as part of the health system.

Much progress has been made in improving the level of care available to adults and
children living with HIV in Moldova, including efforts to develop guidelines and training
programs to support health practitioners. As is the case though with other initiatives, such
activities need to be broadened to support more individuals in more communities. In
addition to providing more copies of guidelines and training tools, a central national
directory of practitioners trained and comfortable in working with HIV positive clients
needs to be established. This directory would be available to other health care workers
who may be encountering HIV for the first time and looking for other professionals to
consult with. This kind of an approach provides hands-on training to practitioners with
limited cost.

In many interviews, organizations were able to provide samples of literature dedicated to
the prevention of HIV across a range of topics and populations. More effort needs to be
placed on creating print resources for PHAs about their health, about their mental health,
and about the services and resources they can access and are entitled to. As is the case
with prevention resources, care and treatment information should be created with
attention to the specific needs of the populations affected. A host of exceptional tools
have been developed throughout the world that could be easily modified for Moldova.




                                            - 16 -
Goal Four:
Ensuring Protection, Care and Support for Orphans and Children in
Families made Vulnerable by HIV/AIDS
Context
Moldova has a very high population of children living in institutional care. Estimates
report as many as 30,000 children are currently wards of the state, with countless others
orphaned and living on the streets, or in tenuous care relationships with non-immediate
family members. Street involved children are particularly susceptible to sexual
exploitation and falling victim to human trafficking. Institutionalised children are also
known to be vulnerable when they become independent of the State at the age of
majority.

As the HIV epidemic grows in Moldova, more and more children born to HIV positive
parents will become orphaned over time. The protection of children and youth as a
priority does not seem to be a cultural norm within Moldova, with many children living
in institutional care simply due to abandonment by their parents, as opposed to the death
of their parents. Public attitude towards protecting children seems weak, and the realities
of institutional care, and subsequent social issues that will confront these children later in
life, appear not to be well understood by the public.

Progress
Unfortunately, in most interviews, the issue of orphaned children was seldom raised as a
concern. Whether there is a sense that the State is providing good levels of care, or
whether there has just been a lack of consideration for a largely invisible population is
not clear. For children vulnerable to the affects of HIV, (whose parents may be injection
drug users, involved in commercial sex, or engaging in other high-risk behaviours), there
also did not appear to be much consideration for their issues. This is most likely due to
the fact that most initiatives are currently targeting the person most at risk, the parent.

With limited resources in Moldova, competing priorities, and a relatively new response to
HIV, progress around addressing the issues of these children has been slow.

Gaps and Challenges
As noted previously, the concept of children and youth as having social value in Moldova
needs to be promoted more vigorously. In considering interventions, it appears that the
issues of children and youth remain ignored unless the children and youth happen to be
the specific beneficiary.

The large population of children and youth in institutional care represents what could
well be the future population of people-at-risk. All available documentation suggest that
when children leave the care of the State at the age of majority they are more likely to
become victims of exploitation, develop addictions, and engage in high-risk behaviours.
Some documentation went on to suggest that the level of care in the State-run institutions
was quite poor and that children in these institutions were commonly exposed to abuse



                                             - 17 -
and neglect. It is well understood that a past history of being victimised greatly increases
the odds of being susceptible to abuse later in life.

Specific Recommendations
Institutional care exists largely because there are few alternatives. The government needs
to undertake legislative reforms necessary to create more family-based alternatives to
institutional care such as foster care programs, and domestic and international adoption
programs. Currently, some policies are overly protective of the rights of the parent and do
not reflect the needs of the child. While it is admirable that these policies appear to be
couched in efforts to maintain the family unit, there are occasions where the government
needs to acknowledge that the rights of the child need to take precedence.

More training needs to be provided to people working with children in these institutions.
Reports and interviews suggest that there is a very inadequate level of care being
provided to HIV+ children, due mostly to fear and ignorance about the disease, but also
due to attitudes about the “types” of people who get infected. Additionally, more effort
needs to be taken to ensure that an institutionalised child is safe, secure and free from
abuse and neglect while in the care of the State.

New initiatives to train and employ social workers should establish institutionalised
children as one of the first priority populations to receive such care. Regardless of living
conditions or quality of care, institutionalised care, by its very nature, can have adverse
affects on the development of a child. Social work interventions can go a long way to
mitigating poor self-esteem and help develop stronger coping mechanisms for these
children as they reach the age of majority.

In concert with legislative reform, UNICEF’s efforts to provide alternatives to state-run
institutions need to be expanded throughout the country based on the existing model in
Chisinau. These facilities need to be supported by government with funding and
recognition within the existing infrastructure of social services to children.

More consideration must be given to the children of Moldova who are made vulnerable
by HIV. Programs and services for at-risk adults should also provide components that
will encourage better childcare, encourage stronger parental responsibility, and develop
interventions to reduce the level of potential neglect faced by these children.




                                            - 18 -
Appendix A
Reviewed Literature
Annual Report, 2002. Center for Information and Documentation in Child’s Rights from Moldova

Annual Report, 2003. Center for Information and Documentation in Child’s Rights from Moldova

Conference Report: Moving Harm Reductions Policy Forward, 2003. Soros Foundation Moldova

Declaration of Commitment on HIV/AIDS, Moldova Progress Report, 2003. UNGASS

Dublin Declaration on Partnership to fight HIV/AIDS in Europe and Central Asia, 2004. Representatives
of States and governments from Europe and Asia

Executive Summary; Report on the Global AIDS Epidemic, 2004. Joint United Nations Programme on
HIV/AIDS.

Fighting HIV/AIDS Strategies for Success 2002-2005, 2003. United Nations Children’s Fund

HIV/AIDS/STIs Infections in the Republic of Moldova; Situational Analyses, 2000. Ministry of Health of
the Republic of Moldova

HIV Prevention Among MSM in Moldova: Step Forward, 2004. Boris Balanetkii, GenderDoc-M

Mapping Report on Youth Friendly Services in Moldova; Draft, 2003. Interagency Groups on Young
People’s Health Development and Protection.

Master Plan of Operations; Country Programme of Cooperation; 2002-2006. United Nations Children’s
Fund and Government of the Republic of Moldova.

Regarding Measures on Prevention and Fighting of HIV/AIDS and STIs Infections; Decision of the
Government of Moldova Nr. 482, 2001. Government of Republic of Moldova

Review of the National Programms on Prevention and Control of HIV/AIDS and STIs for 2001-2005, 2004.
Dr. Andrew J Amato-Gauci, UNAIDS Consultant.

Resolution Adopted by the General Assembly; S-26/2. Declaration of Commitment on HIV/AIDS; 2001.
United Nations

Strategic Framework for the Prevention of HIV Infections in Infants in Europe - Draft, 2004.

The Situation of Children and Family in the Republic of Moldova; Assessment and Analysis, 2002. United
Nations Children’s Fund, Government of Republic of Moldova

The United Nations in Moldova; Together for a Better Life, 2004. United Nations in Moldova

Towards an Enabling Legal and Policy Environment; HIV Prevention Among Vulnerable Populations in
the Republic of Moldova: An Assessment of the Legislative Environment and Recommendations for Legal
Reform; 2003. Jean-Paul Grund, PhD, Consultant.

UNICEF Regional Strategy on HIV/AIDS for Central and Eastern Europe, the Commonwealth of
Independent States and Baltic States, 2002. UNICEF Regional Office CEE/CIS and Baltics.




                                                  - 19 -
Appendix B
Key Informants

Officials from the following departments, organizations and agencies were interviewed
for this report including participants from various projects and members of some of the
following organizations:


Centre for Information and Documentation on Child’s Rights
Centre of Placement for Children
“Credinta” – National Non-Governmental Organization for HIV positive people
“GenderDoc-M” – National Non-Governmental Organization for GLBT communities
Institute of Scientific Research in the field of Mother and Child Health Care
Ministry of Education of the Republic of Moldova
Ministry of Health of the Republic of Moldova
Moldova National AIDS Centre
National Centre for Public Health and Sanitary Management
National HIV/AIDS Clearing Houser, National Centre of Preventive Medicine
“Neovita” – Youth Friendly Clinic, Chisinau
Republican Dermato-Venerologic Dispensary, HIV/AIDS Department
Soros Foundation
UNAIDS Office of Country Coordinator
UNICEF Country Office
United Nations Development Programme
World Bank and Global Fund Projects Office
World Health Organization Country Office
Youth Media Centre
Youth Resource Centre




                                           - 20 -
Appendix C
Interview Questionnaire Themes


                               Interview Outline
This outline is based on the articulated priorities of UNICEF designed to reduce the
impact of HIV/AIDS among children and youth. This outline does not intend to collect
information that encompasses all five priorities of UNICEF’s Medium-Term Strategic
Plan for 2002-2005; this outline only presumes to collect information that would inform
UNICEF on progress toward protecting the rights of children by addressing the priority
of fighting HIV/AIDS in Moldova.

The following areas of investigation that are listed under each theme are cross-referenced
with stated goals from a range of sources, or UNICEF recommendations, in order to
create a benchmark for each of the issues from which the interview can gauge specific
progress that has been made in Moldova. The intent of this exercise is not to assume that
Moldova is necessarily moving towards, or in agreement with, the collected
goals/recommendations from the various sources. Rather, the exercise will provide
UNICEF with indications where efforts are currently underway, and where future efforts
might be best placed in order to reduce the risk for HIV/AIDS among children and youth
in Moldova. Sources for the collected goals include the UNGASS Declaration;
Convention on the Rights of the Child; UNICEF Regional Strategy, CEE/CIS & Baltics;
UNICEF Medium-Term Strategy, 2002-2005; etc. In the case where no progress has
occurred, or where no stated goals exist, a recommendation will emerge to address that
issue as an identified gap.

OUTLINE

The Outline is based on four main themes:

1. Efforts to prevent HIV infection among young people in Moldova in the broader
   context of young people’s health, development and protection;
2. Efforts to prevent mother to child transmission of HIV;
3. Efforts to ensure care for children and parents living with HIV including protection,
   care and support for orphans and children in families made vulnerable by HIV/AIDS;
   and,
4. Efforts to create an integrated, co-ordinated, multi-sectoral response to the HIV
   epidemic in Moldova with clear goals and targets.




                                            - 21 -
THEMES

Each theme is further broken down into “areas of investigation” that will make up the
body of the interview. Note that the following bullets are not framed in the form of a
question, but represent the information that the question will be designed to collect. The
bullets are also not in any particular order and will be selected based on the information
and expertise available from each respondent, as appropriate.


Theme One
Efforts to prevent HIV infection among young people in Moldova in the broader context
of young people’s health, development and protection.

      HIV/AIDS/STI prevention strategies targeted at children and youth, including the
       most vulnerable and high risk sub-populations, most specifically IDU and young
       women while promoting responsible male adolescent partnership and
       participation.
      Strategies targeted at children and youth to delay the onset of drug/alcohol use;
       reduce the harm associated with drug/alcohol use; and, to promote drug/alcohol
       cessation.
      Efforts to provide school-based sexual health promotion and education.
      Implementation of Life Skills-based Education strategies that support the
       aforementioned priorities as part of a LSBE framework developed in partnership
       with youth, parents, families, educators and health care providers.
      Existing policies and legislation that prevent the implementation of effective harm
       reduction strategies.
      Level of enhanced behavioural research on young Moldovan people, particularly
       vulnerable and high risk youth, that helps inform and contribute knowledge for
       effective prevention interventions.
      Availability of, access to, and demand for, youth friendly services that integrate
       HIV/AIDS/IDU/STI efforts into existing programs and services in an effort to
       reduce stigma and increase utilization (this will include community, health, social
       services, education and justice systems).
      Support for the development, implementation and support for peer education
       networks.
      Efforts to promote healthy protective behaviour through social marketing
       communications strategies targeted for the general youth population, and
       vulnerable and high risk youth.
      Existence of outreach services and programs that assist the most marginalized and
       vulnerable youth in Moldova, including IDU, sexually exploited youth and
       children who live or work on the streets.




                                           - 22 -
Theme Two
Efforts to prevent mother to child transmission of HIV (PMTCT)

   Integrated national strategy to address PMTCT encompassing the following five
    elements: primary prevention of HIV/STI in young women; prevention of unintended
    pregnancies in young women, particularly HIV+ women; prevention of vertical
    transmission; effective antenatal care and treatment including anti-retroviral therapies
    and infant feeding programs; and, integrated management of childhood illnesses
   Surveillance to better understand seroprevalence among pregnant women
   Access to, and demand for, voluntary and confidential counselling and testing.
   Integration of voluntary HIV and STI testing and vertical transmission prevention as
    part of prenatal, child birthing, and antenatal health services.
   Specific approaches for PMTCT within the IDU population that include: improved
    outreach and access to health services and neonatal care for pregnant IDU women;
    access and outreach to prevent unintended pregnancies among IDU women; improved
    access to anti-retroviral therapies for pregnant women.


Theme Three
Efforts to ensure care for children and parents living with HIV including protection, care
and support for orphans and children in families made vulnerable by HIV/AIDS.

   Adoption of rights-based approaches to policies and programs with strategies to
    develop capacity for those who have rights and for those with a duty to ensure that
    equal rights are fulfilled (e.g. Convention on the Rights of the Child).
   Improvements made to the social acceptance of persons infected and affected by
    HIV/AIDS. The degree to which leadership is undertaken on strategies to protect
    individuals from stigma and discrimination.
   Strategies to reduce the rates of child abandonment due to real or feared infection of
    the child, or due to the mother’s lack of capacity to care for the child, including
    programs to support mothers (particularly IDU) and strengthen their capacity to care
    for children, particularly those infected with HIV.
   Policies and legislation that improve the care and support services for mother and
    child with a particular emphasis on expanding non-medical services and programs.
   Degree to which childcare services are deinstitutionalized for orphans including
    legislation and policy changes, appropriate funding levels and monitoring to see a
    transition from institutional childcare programs to family-based care models such as
    fostering and adoption. Efforts to reunite parents and children and programs to
    provide support to ensure successful reunification, and, activities that reduce
    institutional isolation of orphans and improve their care through strategies that will
    reduce stigma and discrimination among care givers in institutional settings.




                                           - 23 -
   Degree to which programs exist for orphans to provide appropriate counselling and
    psycho-social supports; ensuring access to and participation in school and access to
    shelter, nutrition, health and social services.
   Programs are in place to protect orphans and vulnerable youth from all forms of
    abuse, violence, exploitation, discrimination, trafficking, and loss of inheritance and
    property rights.
   Improvements to the primary health care system (specifically primary care
    practitioner training) to diagnose, treat and care for HIV+ individuals and their
    families so that better integration of HIV services exist within the existing health
    system.
   Reductions in stigma and discrimination to create stronger community support for
    individuals and families affected by HIV/AIDS; support for community-based HIV
    prevention and awareness campaigns; promotion of universal precautions and harm
    reduction principles (particularly with IDU) and the integration of voluntary and
    confidential counselling and testing services into existing community health services
   Policies and legislation to reduce stigma and discrimination and to ensure that
    individuals and families have optimal access to health (including comprehensive care
    and anti-retroviral therapies), education, and social services.


Theme Four
Efforts to create an integrated, co-ordinated, multi-sectoral response to the HIV epidemic
in Moldova.

   Government leadership to demystify HIV/AIDS and provide evidence-based
    information to the general public.
   Government leadership in developing partnerships that involve government health,
    social services, education, and justice sectors, the civil society, faith-based
    institutions, Moldovan communities and affected individuals in creating a co-
    ordinated response to the HIV epidemic.
   Activities that help develop the capacity of communities to create their own responses
    to the HIV epidemic and participate fully in any activities that may be of benefit to
    them, with a particular emphasis on creating capacity in the most vulnerable and at-
    risk populations.
   Laws and policies that promote human rights and equality and reduce stigma and
    discrimination that may prevent full and equal access to health, education and social
    services for all citizens of Moldova.
   Support for routine and enhanced surveillance, behavioural research, monitoring and
    evaluation of efforts (particularly the mainstreaming of successful pilot interventions)
    in Moldova to guide programmatic responses.




                                           - 24 -
   Introduction of policies and legislation that would protect the rights of orphans and
    other vulnerable children and youth through standards of protection that would
    include fostering and adoption, birth registration, inheritance and property rights.
   Establishment of clearly articulated, State sanctioned, time bound goals and targets
    developed in consultation with key stakeholders including communities and affected
    individuals.




                                           - 25 -
duals.




                                           - 25 -

				
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