Global Fund Round 10 Country Application
Effective Response to HIV with Focus on Most At Risk Population Groups in the Republic of Moldova
4.4.1 Interventions
Describe the objectives, service delivery areas (SDA), and activities of the proposal. The description must be organized in that exact order and the numbering system must match the Performance Framework, detailed budget and work plan.The description must reference:
(a)who will implement each area of activity (e.g. Principal Recipient, Sub-recipient or other implementer); and
(b)the targeted population(s).
Currently, the HIV epidemic in the Republic of Moldova is considered to be concentrated among most-at-risk populations (mainly IDUs in civilian and prison sectors, SWs, MSMs). At the end of year 2009, IDU mode of HIV transmission still accounted for 50% of cumulative cases since 1987 (Source: NationalAIDSCenter). The epidemic is IDU-driven and according to the projections, will continue to be IDU-driven at least 5 years (Source: EPP Report 2010). The HIV prevalence among IDUs, SWs and MSMs is significantly higher (5% and above) compared to other sub-populations (migrants, young people, blood donors, pregnant women) in the Republic of Moldova; according to sero-surveillance studies, the HIV prevalence does not show signs of decrease in MARPs. Therefore, the overall goal of the proposal is to curtail the spread of HIV among most at risk population groups in Moldova through effective and evidence-based response. The goal is set in accordance with the international recommendations stipulated in the United Nations General Assembly Declaration onScaling Up HIV Prevention, Treatment, Care and Support and other WHO and UNAIDS guiding documents calling for the ensuring of universal access for HIV prevention, treatment, care, and support.
The design of current prevention programme for MARPs is largely consistent with needs of the populations they serve, but requires some significant revisions and improvements. Despite the concentration of HIV cases among MARPs and continued efforts of harm reduction provision supported by the Round 6 proposal, there is uneven geographic distribution of needle-syringe programs and other harm reduction activities, with low coverage rates in the most affected parts of the country. The majority of current prevention services do not reach those most hidden and vulnerable populations, and are not well-suited to address emerging sub-groups,such as members of the social and sexual network of MARPs. In addition, the harm reduction services thus far have not addressed effectively needs of specific populations in MARPs, such as most-at-risk adolescents or women, where surveys have shown worse biological and behavioral indicators compared to the overall group of people who inject drugs. While sterile syringe use has become consistent, safer sexual behaviors have not been adopted fully by IDUs and this is probably responsible for the prevalence of heterosexual HIV transmission starting with year 2005. Currently, harm reduction services supported by Round 6 program offer a minimal set of syringe, condom and IEC provision, insufficient to address effectively all drivers of the epidemic and all needs associated to effective HIV prevention, such as access of MARPs to counseling and testing services, STI diagnosis and treatment, hepatitis prevention and treatment, opioid substitution therapy, because of either unavailability of services (insufficient low threshold STI and hepatitis management, opioid substitution treatment services) or convenience (lack of community VCT services or rapid testing, lack of integrated services at point of care).At the same time, the ongoing Round 8 program is exclusively addressed to PLWH needs and does not cover preventionand care services specifically focused on MARPs.
The Government is committed to fight the epidemic and increasingly allocates financial, human and infrastructural resources for this purpose. However, substantial financial and programmatic gaps exist, especially in regard to the complex and costly interventions in HIV/AIDS treatment and prevention activities among most-at-risk population groups. The CCM has therefore decided to solicit support from the Global Fund in Round 10 in bridging the gap in the field and ensure continuation, consolidation and scaling up of activities initiated within the Round 6 project (ending in December 2012).
The results of the 2007 Sentinel Surveillance Survey show that the HIV burden is high among the most-at-risk population groups: HIV prevalence among IDUs was 16.4% in capital city (39.0% in Balti and 12.6% in Tiraspol), prisoners who have used drugs in their lifetime – 12%, SWs 6.1% in capital city (23.5% in Balti), MSM – 5%.Therefore the key target group is represented by the injecting drug users in civilian and prison sectors, with documented HIV prevalence of more than 10%, and SWs and MSMs with documented prevalence of 5% and more.
The anticipated impact of this project is that 60% of IDUs and sex workers, 80% of MSMs and 80% of prisoners will have access to integrated harm reduction and other appropriate prevention services, community VCT services, hepatitis B and C testing and vaccination, STI diagnosis and treatment, OST and ART. It is expected that the provision of necessary services to these most-at-risk groups will contribute to greatly reducing not only HIV transmission, but also of Hepatitis B and C and STIs, thus bringing a society-wide benefit.
In total, the project will support access to services of about 15,700 injecting drug users, some 12,000 prisoners, 3,600 SWs, 2,000 MSMs of the Republic of Moldova, including Transnistrian region over the five years. The peer driven initiative will extra-boost the coverage of injecting drug users by 20% with easy accessible harm reduction services, bringing some 3,000 additional beneficiaries to existing and new service provision sites. The project aims at providing some 30,000 rapid tests for HIV, Hepatitis and STIs in MARPs, vaccinate 10,000 people for Hepatitis B, provide 18,000 STI counseling sessions and exams and syndromic treatment to 9,000 patients, provide ARV treatment to 1,600 patients and get 2,900 patients in OST over the project life. In addition, the project targets largely community organizations and service providers, high level officials, managers and general health service institutions: during five years, over 400 people will be covered by different training and capacity building activities with the project support. For the first time, harm reduction activities address effectively and comprehensively all four groups of MARPs in the Transnistrian region as well.
The Global Fund resources will be additional to domestic resources that will be allocated to cover substantial costs of the staff, medical interventions and facility expenses. The GFATM funds are complementary to the public funds allocated to the National AIDS Programme; the Round 10 project aims at ensuring continuation of the activities partially covered under the Round 6 project and will be implemented in a coordinated manner with the support provided by other external partners in the area of HIV/AIDS control.
The proposal aims at both sustaining the existing interventions (such as scaling up harm reduction services initiated with the GFATM Round 1 and 6 projects support) and initiating new activities such as peer driven initiatives, set up of integrated approach to prevention and treatment services. Operational research will be conducted to develop evidence and inform further actions, with special emphasis on most at risk population groups.
The Principal Recipient (Project Implementation Unit) will be responsible for the overall implementation of the project and will channel the funds to the Sub-Recipients in line with their mandate and specialization: 3sub-recipients from civil society sector: Soros Foundation Moldova, National Harm Reduction Association and NGO Gender-Doc and public institution National Center of Health Management. Also, a particular attention is oriented to public and civil society partnership.
Indicators and targets
Indicators for the programme performance and annual targets over the proposal term are presented in the Performance Framework (Attachment A to the Proposal Form). Interventions to be supported by this project will contribute to improving the key impact indicators of reducing HIV prevalence among high risk groups to less than 16% in IDUs, less than 6% in SWs and less than 5% in MSMs. Outcome indicators included in the Performance Framework are in line with WHO and UNAIDS recommendations, target maintaining safe injecting behavior at more than 95% for IDUs, increasing safer sexual behavior to 55% in IDUs, 65% in MSMs, 90% in SWs and HIV correct knowledge in more than 50% of prisoners.The SDA reporting indicators are designed to monitor the progress in coverage by essential interventions and correspond to the project workplan. Please refer to the Performance Framework for details.
Objectives
This proposal has 5 objectives as outlined below.The program will support evidence-based interventions aimed at ensuring that the most at risk population groups have access to HIV prevention, treatment, care and support in the Republic of Moldova. This includes the“comprehensive package for the prevention, treatment and care of HIV among people whoinject drugs” as defined by WHO, UNODC and UNAIDSin Technical Guide for Countries to Set Targets for Universal Access to HIV, Prevention, Treatment and Care for Injecting Drug Users, 2009.
Objective 1. Enhance HIV prevention services in most at risk populations
Activity 1.1. Build service provision capacity and ensure sustainability
[SDA: Community based activities and services - delivery, use and quality]
The country has identified a need in improving the quality of harm reduction services and their standardization through development of quality standards, training of service providers and ensuring sustainability of the program. Initially, local consultants in collaboration with a working group will develop a training package on basic harm reduction, mandatory for all service providers. The developed curriculum will be integrated in the school of public health as an optional course, to ensure its sustainable use beyond project needs.A national team of 15 trainers will receive training on harm reduction and adult teaching methods from two external trainers selected in Year 1.Theywouldthen provide basic harm reduction trainings for a total 150 existing and new staff hired by the projects and from other public institutions involved in service delivery, to ensure quality service provision and minimal standards of services.
In order to ensure institutionalization of the comprehensive package of harm reduction services to MARPs, nine local consultants (one per each of the service areas) will develop and prepare for approval guidelines and standards. They will revise the documents on a biannual basis. Four workshops (for North, Center, South and Transnistrian regions) with 20 participants each will be organized to introduce guidelines and minimum standards during Year 3.
To address the problem of low coverage of IDUs with services in the three main cities of Moldova (Chisinau, Balti and Tiraspol) the project will introduce a new approach in boosting access of MARPs through peer-driven interventions (PDI) and will hire external technical assistance from similar projects in neighboring countries in starting PDI program in Moldova. A follow-up visit to monitor and evaluate the first year pilot will be conducted in the second year. The external consultants will provide a 3-day training to introduce 5 workers each from three sites (Chisinau, Balti and Tiraspol) to PDI approach in Year 1, and an additional workshop in Year 2, linked to monitoring visit. In parallel, two local consultants will be selected on a competitive basis to develop the guidelines, set of training materials and M&E forms for PDI.
To address the problem of lack of sustainability of harm reduction activities in the absence of external donor funding, the project will continue the work initiated under Round 6 and develop the mechanism of contracting NGO services by the national health insurance fund. A grant will be provided on a competitive basis to perform costing of HR services, advocacy for take-over, develop quality standards, certification requirements and accreditation mechanism.
Activity 1.2. Increase quality and expand needle and syringe programs
[SDA: Community based activities and services - delivery, use and quality]
In order to improve quality of services of NSPs the project will expand range of services, build local capacities and facilitate community involvement. The project will start 3 new programs in uncovered geographic areas (Transnistrian and Southern region of Moldova) and will decentralize 6 current projects to 13 projects. It is planned to provide operational support to 2 new programs in Year 1 and full funding of 16 NGOs starting from Year 2 beyond finalization of Round 6 support. The projects will expand their current range of services to provide NSP, condom distribution, targeted IEC for IDUs and their sexual partners, overdose prevention, specific services for females and adolescent IDUs, counseling and referral to VCT, STI, Hepatitis B testing and vaccination, OST, legal advice and in three sites PDI and provision of on-site integrated services.
The project will procure and distribute syringes, condoms, alcohol swabs, containers for syringe utilization, based on the client needs and assumptions of 210 syringes and alcohol swabs, 110 condoms and 0.5 disposal containers per client per year. Client estimates have been calculated based on latest size estimations and will target some 800 new clients in Year 1, 8,000 existing and new clients in Year 2, 10,000 in Year 3, 14,000 in Year 4 and 15,600 in Year 5 (60% of the estimated IDU population of 26,000).
A new strategy to boost coverage, PDI, will be implemented in three main cities (Chisinau, Balti and Tiraspol), to increase community participation in maximizing coverage and access to most vulnerable IDU populations (rural, young and other subpopulations of IDUs). The PDI seeds will be selected initially from the most active and enthusiastic clients and will be trained by project staff in peer-to-peer provision of the intervention, and they in turn will recruit other new clients, by providing them peer-to-peer educational session on HIV and referring them to NSP site for passing an exam and access to services. After successfully passing exam, the recruiter gets an equivalent of US$ 15 in goods for each newly brought client. It is envisaged to bring 500 new clients in Year 1, 700 in Year 2, 1,300 in Year 3, 2,000 in Year 4 and 3,000 in Year 5 (extra 19% of the expected number of IDUs to be covered).
Activity 1.3. Ensure comprehensive approach: provide additional services
[SDA: Community based activities and services - delivery, use and quality]
In order to address the perpetuation of unsafe sexual behaviors in IDUs, the project will conduct informational campaigns and behavior change activities among MARPs to increase condom acceptability and promote safer sex behavior. Activities will include production of new informational materials to be used in motivational activities and will focus on developing new skills in service providers and outreach work in counseling for behavior change in MARPs. For IEC activities, new informational materials to address expansion of services will be developed, designed, consulted with representatives of the beneficiaries and printed. These materials will be used in outreach activities in all harm reduction projects implemented by local NGOs.
In order to identify specific service needs and barriers in access of IDUs younger than 25 years and women who use drugs, the project will provide support to research company or local consultants on a competitive basis to conduct a needs assessment among female and adolescent IDUs in Year 1. The results of the assessment will feed into recommending a range of services to increase access of adolescents and female IDUs to existing programs. Additional targeted grant allocations will be provided to NGOs to add specific targeting of female and young IDUs to their current range of activities.
And finally, overdose prevention is seen as a major unmet need by most drug users. The project will provide earmarked funds to the 16 organizations to add informational and educational activities regarding overdose prevention to their current range of activities.The project will procure Naloxone and based on the agreements with the public institutions, the Naloxone doses will be distributed to IDUs upon completion of overdose prevention module. The project plans to distribute Naloxone to 400 IDUs in Year 1, 2,000 in Year 2, 6,000 in Year 4 and 8,000 in Year 5.
Activity 1.4. Scale-up HIV prevention among SWs and MSMs
[SDA: Community based activities and services - delivery, use and quality]
The project will support continuation of service provision to MSMs in Chisinau (partial support in Year 1 and full support starting with Year 2).starting with Year 1,and will provide support to expansion of services through set up of new grants in the North (Balti) in Year 1 and Transnistrian region (Tiraspol) in Year 2. Grants will be provided on a competitive basis to local NGOs. Service provision includes outreach work in cruising areas and discos, provision of IEC, condoms and lubricants, counseling services and peer support. Condoms with increased resistance and lubricant will be procured and distributed by outreach workers (150 condoms and two tubes of lubricant per client per year).Size estimations of population to be covered are based on the latest size estimations conducted in the country: 300 in Year 1, 500 in Year 2, 1,000 Year 3, 1,500 Year 4 and 2,000 in Year 5 (1,750 on the Right Bank and 250 in the Transnistrian Region).