Evaluation of HIV Prevention Programmes in the Republic of
Moldova 2010
DRAFT
February 2011
1
Contributions
Data collection team
Ecaterina Busuioc, Prevention and Communication Specialist, Coordination Department, National AIDS
Center
Silvia Stratulat, VCT Specialist, Coordination Department, National AIDS Center
Lilia Toderascu, M&E consultant, VCT, M&E Unit, National Center for Health Management
Tatiana Cotelnic, M&E consultant, SIME-HIV, M&E Unit, National Center for Health Management
Coordination and assistance
Otilia Scutelniciuc, Chief of M&E Unit, National Center for Health Management
Stefan Gheorghita, Deputy Director, National Center for Public Health, AIDS Center)
Lilian Gutu, Chief of Prevention Unit, Tiraspol AIDS Center
Alexandrina Iovita, M&E Adviser, UNAIDS
Authors
Stela Bivol, independent consultant
Natalia Vladicescu, Director, "Iligaciu" SRL
Larisa Lazarescu, independent consultant
Angela Dumitrasco, independent consultant
Olga Osadcii, independent consultant
2
Acronyms
AIDS
ARV
BCC
BSS
FSW
GF
GFATM
HIV
HR
IBBS
IEC
IDU
KAP
LGBT
MARA
MARP
MoH
MSM
M&E
NAP
NCHM
NCC
NGO
NHIF
OST
PLWH
PMTCT
RND
SFM
STI
TB
TWG
UN
UNAIDS
UNDP
UNFPA
UNGASS
UNICEF
WHO
VCT
YFHC
YFHS
Acquired Immunodeficiency Syndrome
Antiretroviral
Behavior Change Communication
Behavioral Surveillance Survey
Female Sex Workers
the Global Fund
the Global Fund to Fight AIDS, Tuberculosis and Malaria
Human Immunodeficiency Virus
Harm Reduction
Integrated Bio-Behavioral Survey
Information, Education and Communication
Injecting Drug User
Knowledge, Attitudes and Practice
Lesbian Gay Bisexual Transgender
Most-At-Risk Adolescents
Most-At-Risk Population
Ministry of Health
Men Having Sex with Men
Monitoring and Evaluation
National AIDS Programme
National Center of Health Management
National Coordination Council
Non-governmental Organization
National Health Insurance Fund
Opioid Substitution Therapy
People Living with HIV
Prevention of Mother-to-Child Transmission
Republican Narcology Dispensary
Soros Foundation Moldova
Sexually Transmitted Infections
Tuberculosis
Technical Working Group
United Nations
United Nations Joint Programme for HIV/AIDS
United Nations Development Programme
United Nations Population Fund
United Nations General Assembly Special Session
United Nations Children’s Fund
World Health Organization
Voluntary Counseling and Testing
Youth Friendly Health Clinics
Youth Friendly Health Services
3
Contents
Background ................................................................................................................................................... 5
Evaluation Purpose and Methodology .......................................................................................................... 6
Goal of prevention evaluation .................................................................................................................. 6
Methods .................................................................................................................................................... 6
Results ........................................................................................................................................................... 8
Legislation, policies and recommended strategies in HIV prevention ..... Error! Bookmark not defined.
Prevention Programs Targeted to Most-at-Risk Populations .................................................................10
Injecting Drug Users – Needle and Syringe Programs ........................................................................10
Injecting Drug Users – Opioid Substitution Therapy ..........................................................................14
Female Sex Workers ...........................................................................................................................17
Men having sex with men ..................................................................................................................19
Prevention Programs Targeted to General Population ..........................................................................22
Young people ......................................................................................................................................22
Other key populations perceived as higher risk in the general population .......................................28
Supporting HIV Prevention Activities and Services.................................................................................30
HIV Voluntary Counseling and Testing ...............................................................................................30
Behavioral Interventions to Reduce Sexual Transmission of HIV.......................................................34
Positive Prevention .............................................................................................................................34
4
Background
Currently, the HIV epidemic in the Republic of Moldova is considered to be concentrated among mostat-risk populations (MARPs) mostly Injecting Drug Users (IDUs) in civilian and prison sectors, female sex
workers (FSWs) and men who have sex with men (MSMs)) and their sexual partners. The HIV prevalence
among IDUs and FSWs is significantly higher (5% and above) compared to other screened subpopulations (migrants, young people, blood donors, pregnant women) in the Republic of Moldova. The
HIV prevalence in IDUs and FSWs shows signs of decrease in the city of Balti and shows fluctuating
results in Chisinau. The official HIV/AIDS statistics allow for breakdown of HIV cases by mode of
transmission and not by MARP category, so at the end of year 2010, the IDU mode of HIV transmission
accounted for 43% of cumulative cases, sexual mode for 55%, vertical transmission for 1.5% and
undetermined mode for 1.2%1. There are signs of spread into sexual partners of MARPs. The
estimations based on the Modes of Transmission Modeling show that in 2010 sexual partners of IDUs
would have accounted for 30% of the heterosexual transmission of HIV, the single highest category
compared to other subpopulations. 2 The official statistics show for the year 2010 some 8.1% of HIV
cases transmitted through injecting drug use, heterosexual transmission was responsible for 85.9%,
homosexual for 0.85%, mother to child for 1.42% and undetermined for 3.7%.3
Since year 2002, the HIV epidemic process is characterized by an increase in heterosexual mode of
transmission, feminization of the epidemic and geographical spread in all administrative units of the
country, including rural areas. As of January 2011, the HIV cumulative incidence of registered cases
constituted 120.11 on the Right Bank and 378.6 on the Left Bank (Transnistrian region), with an average
total cumulative incidence of 155.9 per 100,000 population. The hardest hit regions are the cities of Balti
with HIV cumulative incidence of 861.0, Chisinau, capital city (146.4) and on the Left bank, Rybnitsa
(609.6) and Tiraspol city (579.5). As of January 1, 2011, a cumulative number of 6,404 HIV cases were
registered, including 2,127 on the Left Bank. The annual incidence of registered cases has increased
more than two-fold to 17.12 in year 2010 compared to 8.4 in year 2004.4 In the past six years the
majority of newly registered HIV cases in the Republic of Moldova report heterosexual transmission as
probable route (85.9% in 2010). Although still bellow 1%, some screened subpopulations in the general
population become increasingly affected (migrants, youth, pregnant women, blood donors). The
number of newly registered HIV cases among blood donors has been constant in the past years (60.6
newly registered HIV cases per 100,000 blood donations in 2007 compared to 59.9 in 2010) and among
pregnant women has registered on a stab le trend (83 newly registered HIV cases in 2008 compared to
69 in 2009 and 87 in 2010).5 HIV affects mostly young adults, as 85% of total HIV cases have been
registered in the age group 15-39 years (including 29.7% among those aged 15-24 years).6 The gender
ratio has significantly changed towards an increase of the share of HIV-infected women in the number of
new HIV cases from 26.5% in year 2001 to 39.2% in year 2010.7
The Government is committed to fight the epidemic and allocates financial, human and infrastructural
resources for this purpose. However, substantial financial and programmatic gaps exist, especially in
regard to the complex interventions in HIV/AIDS prevention activities among most-at-risk population
groups. HIV Prevention in MARPs has been implemented with substantial Global Fund Rounds 1 and 6
support through community-based organizations.
1
National AIDS Center Epidemiological Bulletin 2010. Unpublished draft, February 2011
UNAIDS. Modes of Transmission modelling spreadsheet. Unpublished draft, November 2010.
3
National AIDS Center Epidemiological Bulletin 2010. Unpublished draft, February 2011
4
National AIDS Center Epidemiological Bulletin 2010. Unpublished draft, February 2011
5
National Coordination Council. Republic of Moldova UNGASS Report 2008-2009. Chisinau 2010.
6
Government of the Republic of Moldova. National Program to Prevent and Control HIV/AIDS and STIs for the
years 2011-2015. Accessed online: www.aids.md/aids/index.php?cmd=item&id=250&lang=ro
7
National AIDS Center Epidemiological Bulletin 2010 Draft February 2011
2
5
Evaluation Purpose and Methodology
Goal of prevention evaluation


Determine the effectiveness of an HIV prevention project in changing the risk behaviour among IDUs
in the NAP implementation period 2006 – 2010, on the right bank of Nistru. Determine the key
factors contributing to or impeding project results. The findings of the evaluation will be used to
inform government and NGO partners of the viability of scaling up the harm reduction programme
to rural areas.
Assess the effectiveness of HIV prevention interventions focusing on behavior change in the general
population, with a particular focus on young people, in the NAP implementation period 2006 –
2010, on the right bank of Nistru. Determine the key factors contributing to or impeding results. The
findings of the evaluation will be used to inform government and NGO partners in planning Behavior
Change Communication in the framework of the NAP 2011 – 2015.
Methods
A working group consisting of 12 national experts and stakeholders conducted an internal evaluation of
the HIV prevention efforts. The assessment was conducted in the period September 2010 - February
2011. The evaluation team conducted the following activities:
Desk Review and Secondary Data Analysis
The main quantitative information sources were HIV national statistics, studies on size estimations of atrisk groups, and IBBS, Youth KAPs and General Population Surveys, as well as other evaluation studies,
prevention program reports and program reviews. The most recent reports, databases and preliminary
results of the most recent studies have been used, thus many sources are still in draft version and
unpublished and include preliminary data.
Focus groups and in-depth interviews
With the intent to complement quantitative data with ethnographic understanding of underlying
behaviors related to HIV transmission, the prevention evaluation team developed interview guides for
evaluation of behaviors and coverage and access to HIV prevention services for IDUs (male and female),
FSWs, MSMs (Chisinau and Balti), young people in the age groups 15-19 years and 20-24 years (rural and
urban) and PLWH. Professional investigators conducted focus groups and in-depth interviews in the
period October 2010 - February 2011. The detailed list of focus-groups schedules and the number of
people who participated is included in the table below.
Table 1. Distribution of focus groups and in-depth interviews by categories
Category
a. General population
Young people (15 – 19) rural, male
Young people (15 – 19) rural, female
Young people (20 – 24) rural
Young people (20 – 24) rural
Young people (15 – 19) urban
Young people (20 – 24) urban
b. MARPs
IDUs, men
IDUs, women
FSW
MSM
MSM
MSM
c. People living with HIV
Men living with HIV
Women living with HIV
Date
# participants
7.11.2010
31.10.2010
24.10.2010
14.11.2010
23.10.2010
30.10.2010
7
7
9
11
7
7
16.11.2010
17.11.2010
10.02.2011
10.11.2010
11.11.2010
19.11.2010
11
9
5
11
11
9
28.12.2010
29.12.2010
11
12
6
In addition, in order to evaluate the quality of VCT services, 6 VCT counselors and 20 VCT clients who
underwent either pre-test or post-test counseling were interviewed in 5 different locations, of which
three cities, Chisinau, Balti and Bender and two rayon centers, Soroca and Cantemir.
Table 2 Distribution of qualitative interviews with VCT clients
Location
Date
Female
Male
Selfreferral
Providerinitiated
Chisinau, AIDS Center
Chisinau, District Center
of Family Medicine
Balti city
Cantemir
(Sourthern region)
Soroca
(Northern Region)
Bender
(Left Bank)
Total
Dec 21, 28, 2010
28-Jan-11
3
6
5
4
0
2
0
2
2
1
0
3
0
2
0
2
0
2
1
1
1
1
1
1
6
14
7
13
10-Feb-11
4-Feb-11
3-Feb-11
21-Jan-11
20 clients
Analysis
Information/data from document reviews and qualitative interviews was aggregated according to the
evaluation questions to ensure that team conclusions would be based on data derived from several
sources. Qualitative research findings were used to interpret quantitative indicators and to formulate
realistic conclusions and recommendations. The team presented preliminary findings and
recommendations to the National AIDS Center, TWG on Communication and HIV prevention and
UNAIDS Moldova.
7
Results
Legislation, policies and recommended strategies in HIV prevention
Likewise other countries, the Government of Moldova signed the Declaration of Commitment on
HIV/AIDS approved by the General Assembly Resolution S-26/2 of 27 June 2001. Also, the Government
committed in achieving the MDGs targets8 by 2015, including the MDG 6: Combating HIV/AIDS,
tuberculosis, malaria, and other diseases. After an assessment on the progress achieved in reaching the
MDG targets carried out in 2009 revealed an increase in the HIV incidence and mortality associated with
tuberculosis , the Government decided to revise the MDG 6 targets along with the others, having also a
special target focusing on youth sub-population, age 15-24 group. However, the political instability and
economic and financial crisis which deepened in the last years hinder the poverty reduction and
questions the realistic achievement of the MDGs targets.
Many social policies and legal framework that demonstrate country’s political commitment in
responding to the HIV epidemic have been developed in recent years, including those related to general
health policy and HIV/AIDS issues. HIV prevention is an integral part of a number of broader national
initiatives, including the National Development Strategy (NDS) for 2008-2011 that foresees
accomplishment of MDG 6 Fight HIV/AIDS and Tuberculosis; National Health Policy approved in 2007,
part of National Development Strategy for 2008-2011, National Strategy for Health System Development
for 2008-2017, which foresees consolidation of actions in area to stop the increase in HIV incidence. The
legislative tools include a set of laws which have been adopted to ensure sustainability of actions: Law
on Health Protection (1995), Law on Reproductive Health and Family Planning (2001), Law on Migration
(2003), Law on Equal Opportunities (2006), Law on AIDS Prevention and Control (2007), Law on
Combating Domestic Violence (2008), Law on Social Assistance (2008), Law on donors and blood
transfusions (2009).
The Moldovan Government developed and approved the Law on Prophylaxis of HIV/AIDS (Law Nr. 23XVI dated 16.02.2007) which is considered to be one among the few laws developed in compliance with
the human rights-based approach. Under the circumstances of non-approval of Anti-Discrimination Bill9
by the Parliament, the given Law on Prophylaxis of HIV/AIDS is currently the only biding document
which provides the legal basis for interdiction of discrimination of people leaving with HIV at the work
places, provision of medical treatment and services, education, travel and choosing the place of
residence. It also contains provisions ensuring the right on confidentiality of people leaving with HIV,
voluntary counselling and testing. The Law also targets the prevention measures for several subpopulations, which include children and youth, women, including pregnant women, IDUs,
representatives of armed forces/uniformed services, prisoners, as well as mobile groups (immigrants,
emigrants, refugees and asylum seekers. However, the Law in its final adopted version has excluded
specific provisions on prevention measures for other vulnerable subpopulations like MSM and sex
workers. Also, the Art. 24 of the present Law and other related ones had some discriminatory and
restrictive provisions related to the entry and stay of the foreign persons with HIV positive status on the
8
Millenium Development Goals Report: New Challenges-New Objectives, page 23
http://www.un.md/key_doc_pub/doc/Raport_preliminar_ODM_en_mod.pdf
9
A draft Law on Anti-Discrimination has been under development for over the last two years. The Law was
withdrawn from the Parliament and returned to the Ministry of Justice for further work. The Law is also publicly
available for further comments. Major concerns were raised by some representatives from Parliament, Church and
certain
NGOs on provisions related to sexual minorities. For more details, please see
http://justice.gov.md/ro/acte-coordonare/
8
territory of Moldova. With the support and advocacy of specialized NGOs (namely, NGO “IDOM”) and in
accordance with the Ministry of Health Order Nr. 347 dated 26.05.2010, the Ministry of Health initiated
a working group to revise a series of Laws, including the Law on Prophylaxis of HIV/AIDS, the Law on
Migration, the Law on the Legal Regime of foreigners, etc., as well as subordinated normative
documents (i.e. Instruction on HIV Testing of Young People before Registration of Marriage, Instruction
on HIV Testing of Pregnant Women etc.). In accordance with the Ministry of Health Order Nr. 36 dated
17.01.2011, a series of amendments containing discriminatory elements were operated to the
aforementioned legal documents. While most of them were approved by the Government, still, the
amendments to the Laws which require the endorsement of other line ministries, including the Law on
Prophylaxis of HIV/AIDS is still under examinations by the related line ministries and awaiting approval.
Significant efforts were invested to develop harmonized national standards and instructions related to
the prevention and prophylaxis of HIV/AIDS. These include a series of national standards and guidelines
related to HIV services (VCT, PMTCT, HIV surveillance, Infection Control, HIV Care and Treatment etc).
However, in practice, the enforcement of these normative documents is still not perfect and there are
discriminatory episodes in provision of medical treatment and services.
The exposure to or transmission of HIV is still prosecuted under the Criminal Code (amended by Law Nr.
985-XV dated 18.04.2002) with specific provisions under articles 211 and 212. While the move towards
criminalising HIV transmission has often been prompted by governments’ attempts to respond to the
rising numbers of HIV infections in their countries and prevent the deliberate contamination with HIV,
yet, human rights campaigners have expressed concerns that these laws lead to a violation of the rights
of people living with HIV, exacerbating their marginalization. Hepatitis and TB are also considered to be
diseases of a same level of threat for public health, still, their transmission is not prosecuted. However,
it is worthwhile mentioning that Moldovan legal framework does not contain an offence for a man to
have sex with another man (MSM). Moldova has one the most progressive legal environments around
harm reduction and decriminalising drug possession. Since 2004 there has been a marked shift in drug
enforcement strategy towards prioritising the prosecution of drug dealers alongside the detection of
drug trafficking networks and drug producers, rather than criminalisation of drug use In addition, in
2008, personal drug use was decriminalised. Major amendments to the Penal Code and Administrative
Offences Code reformed criminal punishment, including by promoting alternative punishments to
imprisonment, and by excluding the application of arrest for personal drug use, now constituted an
administrative rather than criminal offence. The illegal purchase or possession of narcotic drugs or
psychotropic substances in small quantities without the intention to distribute them, as well as their
consumption without a medical prescription, is sanctioned by a fine or community service.
Due to some political and administrative limitations, this report does not contain a thorough analysis of
the legal framework on HIV/AIDS present in the Transnistrian region. However, it is worthwhile
mentioning that, de jure, the so-called Transnistrian authorities put in place the legal framework on
HIV/AIDS which, in principle, can be considered developed in accordance with the basic international
standards. HIV prevention and combating is regulated by the so-called Law Nr. 32-3 on HIV Prevention in
Trasnistria dated 7.02.1997, Law Nr. 29-3 on Fundamentals on Public Health, so-called Criminal Code
(art. 119 and art. 134) and other subordinated normative documents. While Transnistrian Law on HIV
Prevention and other related legal documents contain non-discriminatory provisions (i.e. HIV testing is
not compulsory for young people who want to register their marriage), de facto, there are many
inconsistencies between these laws and the subordinated normative documents and mechanism of
their implementations is ineffective. Records on the discrimination and infringements of the rights of
the people leaving with HIV/AIDS, including HIV testing of migrants, from this region are highly
observed.
National AIDS Programme: at the national level, the state policy in the area of HIV/AIDS in Moldova is
implemented through the National Programme on Prevention and Control of HIV/AIDS and STIs for
2011–2015 (National AIDS Programme – NAP), just approved by the Government of the Republic of
Moldova on December 16, 2010. The current NAP follows the previous three programs implemented in
9
years 1996-2000, 2001-2005 and 2006-2010. The last NAP has been primarily funded by international
donor assistance, with the Moldovan government contributing about 20% overall.
The NAP has the following main expected outcomes by 2015:
1. HIV incidence will not be more than 20 cases per 100,000 population of age 0-39 years.
2. Mortality of PLWH will be reduced by 10%
It has also prioritized HIV control strategies in the following 10 objectives to be achieved by 2015:
1. Ensuring access of at least 10% of general population to HIV/STI prevention services
2. Ensuring access of 60% of the estimated size of MARPs (IDUs, SWs, MSMs) to prevention services
3. Ensuring access of 10% of general population to condoms
4. Ensuring access to STI treatment of 80% of diagnosed STI cases
5. Ensuring access of 95% of pregnant women to PMTCT services
6. Ensuring 100% blood safety
7. Ensuring access of 100% persons exposed to HIV transmission risk to post-contact prophylaxis
8. Ensuring access to ARV treatment of 80% of the estimated number of PLWH in need of ART
9. Ensuring access to care and support services of 10% of the estimated number of PLWH
10. Development of an effective program management system
In conclusion, it is recommended to conclude and approve the amendments to the Law on HIV and
subordinated normative documents from human rights and discrimination lens.
Prevention Programs Targeted to Most-at-Risk Populations
Injecting Drug Users – Needle and Syringe Programs
Situation analysis
According to national estimates, Republic of Moldova (Right Bank only) has some 25,000 people who
inject drugs;10 this represents an overall IDU prevalence of 0.8% in the population aged 15 years and
more. This is the most numerous at-risk group with the highest HIV prevalence. Official statistics indicate
a decreasing trend of HIV incidence among IDUs at fluctuating levels of HIV testing of IDUs (34 new
cases on the Right Bank in 201011 compared to 111 new cases in 200512). According to the most recent
IBBS, the prevalence of HIV among IDUs was 16% in Chisinau, capital city, 39.0% in Balti (Northern
region) and 12.6% in Tiraspol (Transnistrian region) in 2009.13 Compared to previous HIV prevalence
surveys in the same locations, HIV seroprevalence attests a rather stable trend in IDUs, although
comparability of studies is limited (in years 2001-2007 sampling included clients of harm reduction
projects, in year 2009 respondent-driven sampling was used).
Table 3 HIV prevalence in IDUs, IBBS 2001, 2004, 2007 and 2009, Republic of Moldova
City
Chisinau
Balti
Tiraspol
Years
2001
15.8%
60.3%
N/A
2004
14.4%
36.5%
N/A
2007
17.5%
44.8%
20.7%
2009
16.4%
39.0%
12.6%
10
Preliminary Results Size Estimations, unpublished draft 2010.
National AIDS Center Epidemiological Bulletin 2010 Unpublished draft, February 2011.
12
National Coordination Council. Republic of Moldova UNGASS Report 2008-2009. Chisinau 2010.
13
National Coordination Council. Republic of Moldova UNGASS Report 2008-2009. Chisinau 2010.
11
10
The behavioral survey shows that sustained safer injecting practices have been mostly adopted (over
99.2% IDUs in Chisinau and 97.9% in Balti used a clean syringe at last injection). At the same time, the
majority of IDUs, 74.8% IDUs in Chisinau (45.8% <25 years and 81.8% in 25+ years) and 66.9% IDUs in
Balti (36.7% <25 years and 73.8% in 25+ years) have antibodies to Hepatitis C, a marker of history of
unsafe injecting behavior. Thus, a significant difference in Hepatitis C prevalence is noticed in younger
and older IDUs, probably pointing to a recent adoption of safer injecting practices, yet even in the
younger IDUs in Chisinau, every second has Hepatitis C. The contribution of indirect sharing to a high
prevalence of Hepatitis C (front- and back-loading, using preloaded syringes, taking drug solution from
the same recipient) needs to be taken into account, as these practices are still high.
Progress in adopting safer sexual behaviors has been less promising: condom use at last sex averaged
35.6% in Chisinau and 50.8% in Balti. The sexual activity patterns show that 47.4% IDUs in Chisinau and
45.4% IDUs in Balti had more than one sexual partner in the past year (average number of sexual
partners/year is 3.1 in Chisinau and 2.6 in Balti), some 43.4% IDUS in Chisinau and 48.4% in Balti had
casual partners, and 5.1% in Chisinau and 5.4% in Balti had commercial sexual partners. Only 20.7%
IDUs in Chisinau and 22% in Balti reported consistent condom use with their permanent partner in the
past month and 48.8% of IDUs in Chisinau and 59.2% of IDU reported consistent condom use with their
casual sexual partners in the past month. The HIV knowledge composite indicator14 reached 64.9% in
Chisinau and 81% in Balti 2009. Some 33.3% IDUs in Chisinau (72.7% females and 26.7% males) and
45.6% IDUs in Balti (83.7% of females and 28.8% males) had a partner who also injected drugs. Syphilis
prevalence appears to be low, as 2.2% male and 3.9% female IDUs in Balti and 2.3% male and 2.5%
female IDUs in Chisinau have antibodies to syphilis.15
Focus groups discussions with both male and female IDUs confirmed a much higher focus on safer
injecting behaviors and an overall inconsistent condom use with all types of sexual partners and a lack of
risk perception related to unsafe sex. The majority of FG participants take the risk of unprotected sex,
especially if they “know well” their sexual partner. Although IDUs perceive the condom as the most
effective means of protection of sexual transmission of HIV infection, the majority have had unsafe
sexual encounters, with reasons varying from not having condoms with them at that moment to
diminished pleasure when using a condom or because they feel confident in their partner. Many men
have acknowledged sex under alcohol influence as most likely to be unprotected.
A friend of mine came over, he brought lots of vodka and she should have been with him and not with
me, with condoms, as it should be. I fell asleep and when I wake up this crazy woman was riding me, I
threw her off. After three days I started having eliminations (male IDU)
“When one is drunk, then is 50/50, you don’t think if you get infected, only you can ask her is she’s
“clean”, and then if she is, then…” (male IDU)
There are significant behavioral and HIV prevalence differences by sex and age of IDUs. Women IDUs
reported lower condom use at last sex in all sites and lower level of HIV testing compared to men. In
terms of age differences, IDUs younger than 25 years reported much lower coverage with harm
reduction services in all sites compared to their older peers (8.5% in those with age of 25 years or older
compared to 2.6% in those younger than 25 years) (Table 2).
Table 4 Main outcome and behavior indicators in IDUs, breakdown by gender and age, cities of Chisinau and Balti and
Tiraspol, IBBS 2009
Chisinau, capital city
Males
Females
<25 years
> 25 years
Total
14
The UNAIDS-recommended HIV knowledge composite indicator includes the correct answers to five questions as
the nominator with the total number of people who answered the five questions as denominator: a) the risk of HIV
transmission can be reduced by consistently using condoms at each sexual encounter; b) the risk of HIV
transmission can be reduced by having sex with only one faithful uninfected partner; c) a healthy looking person
could be HIV-infected, d) HIV cannot be transmitted by sharing food, and e) HIV cannot be transmitted through
toilet seat
15
National Center of Health Management. Integrated Bio-Behavioral Survey 2009. Unpublished draft, 2011.
11
HIV
Hepatitis B
Hepatitis C
Syphilis
Sterile syringe use at last injection
Condom use, last sex
Aggregate HIV knowledge
HIV test in the past 12 months
Coverage with interventions
14.2
10.3
64.5
2.0
99.1
40.5
64.6
49.4
7.4
29.8
1.0
10.3
0.3
100.0
12.2
66.7
41.2
7.6
10.0
13.6
45.8
0.0
99.0
35.1
66.4
48.2
2.6
18.2
10.7
81.8
2.9
98.9
31.6
64.1
48.6
8.5
16.4
11.3
74.8
2.3
99.3
35.6
64.9
48.4
7.4
Balti city
HIV
Hepatitis B
Hepatitis C
Syphilis
Sterile syringe use at last injection
Condom use, last sex
Aggregate HIV knowledge
HIV test in the past 12 months
Coverage with interventions
Males
39.2
12.4
71.0
2.1
97.2
53.2
83.0
32.8
26.6
Females
38.3
7.6
60.8
3.8
100.0
34.1
71.8
28.3
38.3
<25 years
13.5
6.1
36.7
0.0
85.2
64.3
59.6
12.0
10.0
> 25 years
42.0
12.1
73.8
2.9
94.4
47.7
83.6
35.7
32.2
Total
39.0
11.3
68.6
2.5
97.6
50.0
81.0
32.4
29.2
Tiraspol city
HIV
Hepatitis B
Hepatitis C
Syphilis
Sterile syringe use at last injection
Condom use, last sex
Aggregate HIV knowledge
HIV test in the past 12 months
Coverage with interventions
Males
10.1
10.0
35.2
1.9
93.3
37.7
37.2
24.3
15.2
Females
17.7
5.6
14.1
0.0
84.8
34.6
29.6
21.1
21.1
<25 years
7.8
8.3
18.1
2.8
85.4
44.6
27.0
23.4
8.0
> 25 years
14.9
9.1
34.0
1.0
93.8
31.6
38.7
23.6
18.5
Total
12.6
8.9
29.9
1.4
91.2
36.9
36.8
23.6
16.7
FG discussions with female IDUs confirmed that women are the ones to persist in suggesting condom
use and when they feel they cannot do it, and then most likely they agree to unprotected sex.
What usually was the case for me, I would insist on using condoms with my husband. I was working from
time to time in Moscow. When he was asking for sex I’d say it would be with condom or we go to the
doctor. I knew he was injecting and perhaps having affairs and he had high chances to get infected. He
could have then claimed that I had infected him. I did not trust my husband whom I lived with for 15
years (female IDU).
If a man and a woman inject drugs together and one is HIV-infected, when they have sex together she
suggests using a condom. He says that with condom it feels like wrapped chewing gum. And if they are
under influence of drugs, let it be, once without condom won’t do much, I have strong immunity and
nothing will happen (female IDU).
Another study on most-at-risk adolescents (MARA) has shown that only half of young injecting drug
users stated always using sterile syringes during the last month. All respondents in the age group 12 – 14
reported indirect sharing of the injection equipment during the last month before the interview. IDUs
aged 12 to 14 years reported extremely poor access to services, which makes them even more
vulnerable to HIV. None of the respondents from this age group resorted to harm reduction
12
programmes for sterile syringes during the last 12 months. A very small number of MARA is reached by
outreach services.16
Prisoners: Approximately 7,000 people are incarcerated in Moldova. The 2010 IBBS reported that HIV
prevalence among prisoners in 2010 was 3.5%, compared to 4.7% in 2004 and 4.2% in year 2007. Each
fourth prisoner (25%) admitted to have a history of drug use, while fewer admitted to injecting drug use
(8.9%). Much lower proportion admitted to drug use in the past year (3%), which is probably
underreported due to the illegal nature of using drugs in prison. Of the sample, 30.0% of respondents
admitted to having sex within the last year, the majority (69.8%) reporting a single partner. Very few
(9.8%) reported condom use with their spouse or permanent partner at last sex and in case of a casual
partner 9 respondents out of 21 (42.9%) used condoms at last sex. Some 4.9% admitted having
homosexual partners in their lifetime, but only 5 respondents admitted to homosexual sex in the past 12
months. The HIV integrated knowledge indicator value was 43.4%.17
Activities
Among all areas of HIV prevention, HIV Prevention among IDUs has seen the most progress and included
early on adoption of harm reduction and NSP as the national strategy of HIV Prevention in IDUs (since
year 2000), initial NSP in the most affected areas (Balti and Chisinau and other 4 most affected rayons)
in years 2000-2002 and rapid program scale-up under Global Fund Round 1 (years 2003-2006). Due to
early start and rapid scale-up of Harm Reduction Programmes among MARPs, both in the civil sector
(IDUs, SWs, MSM) and in penitentiaries (IDUs), the Republic of Moldova is known as being an example of
best practice. Global Fund Round 6-8-supported NSP is provided by both public and community-based
points of care and they provide sterile needles, syringes, alcohol swabs, informational brochures, and
condoms and offer collection and safe disposal of injection equipment. The distribution is made through
a network of 12 geographic sites that include stationary NSP points and outreach to apartments. In
addition, social and outreach workers provide referrals to other HIV prevention services, VCT,
gynecological consultations, STI diagnosis. NSPs also provide a point of entry to substitution therapy.
NSP is currently provided in 9 prisons and pretrial detention centers and an estimated number of 800900 prisoners who use drugs access NSP services while in detention on a monthly basis. Starting with
October 2010, three prisons on the Left Bank have also started NSP.
As of January 2011, a cumulative number of 12,644 IDUs on the Right Bank, including 2,337 IDUs in
penitentiaries and an additional 1,088 IDUs on the Left Bank have ever reached by NSP, constituting a
coverage level of 50.5% of the estimated 25,000 IDU population on the Right Bank. 18 However, it is not
possible to estimate accurately annual coverage with prevention services based on current paper-based
client registration system. With the introduction of the unique identifier software and client reregistration, it will become possible to provide more accurate data starting with year 2011. The IBBS
2009 has shown limited coverage with three main interventions (awareness about HIV test, receiving
free condom and free syringe) in IDUs in Chisinau city (7.4%) and Balti city (29.2%). At the same time,
free syringes are not an attractive service for many IDUs, as 99.4% respondents in Chisinau and 98.9%
have mentioned that they can easily obtain syringes when needed. Because syringes are very cheap and
do not need a prescription, the main source for urban IDUs are the pharmacies (88.6% for IDUs in
Chisinau and 59.3% in Balti) and only 31.4% in Balti and 8.5% in Chisinau get free syringes from NSPs.
Gaps
16
Scutelniciuc O, Iliinschi E. Surveillance of Risk Behavior associated to HIV. Assessment of Risks to HIV infection
among young Injecting Drug Users, Men having Sex with Men, Commercial Sex Workers and Juveniles in
Detention. Chisinau 2010
17
National Center of Health Management. Integrated Bio-Behavioral Survey 2009. Unpublished draft, 2011.
18
GFATM Round 6-8 Progress Report for trimester IV, 2010.
13
The biggest shortcoming of the current HIV prevention strategy in IDUs is the lack of focus on evidencebased behavior change towards safer sex practices. There is insufficient human capacity in both facilitybased and community-based services able to provide behavior change counseling to MARPs and their
sexual partners and current programs are mostly oriented at provision of syringes, condoms and IEC and
increasing coverage. While sterile syringe use has become consistent, safer sexual behaviours have not
been adopted fully by IDUs and this is probably responsible for the prevalence of heterosexual HIV
transmission from IDUs to their sexual partners starting with year 2005.
There is uneven geographic distribution of needle-syringe programs and other harm reduction activities,
with still low coverage rates in the most affected cities, especially Chisinau. Currently, harm reduction
services offer a minimal set of syringe, condom and IEC provision, and do not provide the internationally
recommended comprehensive package of the nine services necessary for eeffective HIV prevention,
especially access to community-based counselling and rapid testing services, free STI diagnosis and
treatment, hepatitis prevention and treatment, lack of integrated services at point of care.
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 sexual network of IDUs. In
addition, the harm reduction services thus far have not addressed effectively needs of specific IDU
populations, such as most-at-risk adolescents or women, where surveys have shown worse biological
and behavioural indicators compared to the overall group of people who inject drugs.
Currently HIV prevention in IDUs relies mostly on GFATM Round 6-8 funds and committed funds for NSP
in the next NAP 2011-2015 are limited. State ownership is underdeveloped, particularly since
coordination of HR implementation is largely left to umbrella NGO.
Implications for Programming
 In order to timely address current HIV transmission patterns, develop and fund specific
strategies to address safe sexual behaviour of IDUs and programmes to focus on sexual partners
of IDUs.

In large cities where coverage remains insufficient, expand the package of services that target
IDU, using a variety of strategies (pharmacy-based syringe exchange, mobile outreach and
access to community-based integrated services, peer driven interventions (PDI)).

Conduct a detailed inventory of Governmental policies, regulations and practices that
undermine or inhibit HIV prevention programmes among MARPs (e.g. legal barriers hindering
service provision to MARA), and systematically revise them to eliminate or at least minimize
their negative impact.

Develop a minimum package of prevention services for IDUs and standards of quality for all
prevention programmes.

Develop a normative framework for the financing of harm reduction programs from national
sources (local public authorities, the National Medical Insurance Company, the Ministry of
Health, and the Ministry of Social protection, Family, and Child) and ensure that the National
AIDS Programme allocates and earmarks proportionate funding for prevention programmes
among MARPs.
Injecting Drug Users – Opioid Substitution Therapy
Situation analysis
OST is currently provided to IDUs through four OST sites located in the cities of Chisinau and Balti and
seven sites in the penitentiary sector. By the end of 2010, there were a total of 345 patients enrolled in
14
OST in three sites (233 patients in Chisinau, 70 in Balti and 49 in the prisons). The cumulative number of
clients on OST has increased more than 10-fold over five years from a cumulative number of 73 clients
who have started OST in 2006 to 880 clients in 2010. At the same time, the uptake of new patients has
slightly declined starting with 2007 from 222 new patients in that year to 189 new patients in 2010. 19
In the civilian sector four OST sites are open in the cities of Chisinau and Balti and they have had a
cumulative number of 621 patients on OST, of which 303 patients were still enrolled in OST at the end of
2010. (Figure 1)
Figure 1 Number of patients enrolled in OST in the cities of Chisinau and Balti, years 2006-2010
The first OST site was opened in a prison in July 2005 and currently there are seven OST sites in the
penitentiary sector, including two in pretrial detention jails starting with 2010. A cumulative total of 259
patients were enrolled in OST in prisons and 49 patients were still enrolled at the end of 2010.20(Figure
2)
Figure 2 Number of patients enrolled in OST in penitentiary sector, years 2006-2010
In order to assess client feedback to OST program in Balti, a small survey of 41 clients who entered OST
was conducted in late 2009. Its results have shown that most clients entered the OST program in order
to come off drugs (65.8%) and avoid withdrawal (17%). The majority of OST clients (78%) considered
that the program allowed them to avoid problems with police and made them able to find a job, 19.5%
thought they felt better. The shortcomings of the program, based on the opinions of 39% of
respondents, were lack of flexibility of the program (short work hours, impossibility to leave town, no
take-home doses) and some 15% clients considered they had a worse dependence from methadone.
Some 34% of OST patients admitted to still using other drugs in addition to OST and thought more than
half of their friends on OST (58.5%) were still using other drugs. The vast majority (95%) had good or
excellent relationship with medical staff. As barriers for higher uptake of OST in Balti were mentioned
19
20
Soros Foundation Moldova. Activity report, 2010. Unpublished report.
Soros Foundation Moldova. Activity report, 2010. Unpublished report.
15
lack of information about OST (39%), the requirement to be on narcology registry (22%) and negative
attitudes towards methadone (12%) in the community of IDUs.21
According to program reports, the average daily dose for OST clients in Chisinau is 42 mg, in Balti 47.4
mg and in prison hospital 64.4 mg22, well below the WHO daily recommended dose of 80 to 120 mg of
methadone, necessary to avoid any withdrawal symptoms. The under dosing might be the reason for
parallel use of street drugs as a way to self-medicate withdrawal symptoms in patients on OST.
It appears that IDU community has biased attitudes towards OST. A survey to investigate attitudes of
IDUs towards entering OST program in Balti showed that of 152 IDUs clients of harm reduction program
that were not in OST, only 23% would want to enter OST, 13% were not sure, while 64% did not want to
enter OST, the main reasons being the belief that methadone is worse than street drugs (36%), the
intention to come off drugs using another method (30%) and various inconveniences related to
methadone program (8%). This might be one of important barriers in scaling up the program.
Activities
The first attempts to initiate OST in the country started in 2003 and the first batch of Methadone was
procured in 2004. In 2005 the Government endorsed the OST strategy as a national strategy to prevent
HIV transmission. The first OST site opened in prison in July 2005. Initially slow progress was registered
until year 2006, when only 16 patients were in OST in the civilian sector and 27 in the prison sector, the
eligibility criteria were highly restrictive and the clinical practices were not in line with the international
recommendations. In 2007, after an external evaluation, a rapid scale-up of program has occurred, with
scaling-up the number of patients at the Republican Narcology Dispensary and in prison, as well as
opening a new OST site in Balti.
The enabling environment has been developed as well and is currently supportive of OST. The HIV Law
stipulates provision of methadone substitution treatment to IDUs as an HIV prevention strategy.23
Moldova is one of the very few countries in the region to have introduced OST in the prison sector
starting with 2005. In 2008 the MoH has approved a protocol on OST that has brought the national
guidelines in line with the WHO guidelines that involved revision of eligibility criteria, increased capacity
of initiation of OST on an outpatient basis without mandatory initial hospitalization.
The continuity of care between prison and civilian OST services have improved the capacity of
outpatient services in enrolling OST has been allowed, and currently there is a better cooperation
between penitentiary and civil sector.24 Currently both HIV infected and uninfected patients can receive
services at narcology (substance abuse) clinics in both civilian and prison sectors.
Gaps
Remaining issues in OST relate to coverage and quality. Nationally, OST coverage is low and is not yet at
levels necessary to impact HIV incidence at population levels. The estimated coverage is less than 1% at
the moment. Geographical availability of the OST in the country is still low, with OST programmes
available only in Chisinau and Balti. OST in health care facilities still lacks full multidisciplinary approach
to address multiple social needs of patients and the complete package of services does not always
include wraparound services, such as employment support or the provision of OST to pregnant women
who are active IDUs. There is a sizeable attrition rate of clients in OST programs. The verticality of the
health care system undermines the provision of integrated services and reduces the effectiveness of
21
NGO The Youth for Right To Live. Rapid assessment of OST patients opinions about the OST program in Balti,
2009. Unpublished report
22
Republican Narcology Dispensary. Annual activity report 2009. Unpublished report
23
Parliament of the Republic of Moldova . Law no. 23 from 16 February 2007 Regarding HIV/AIDS Prevention.
Chapter III, article 7, point 4. Monitorul Oficial no. 54-56, from 20.04.2007, art. 250
24
Subata E. Final Report on the Evaluation of Opioia Substitution Therapy in the Republic of Moldova 2009.
Unpublished work
16
individual medical interventions. Currently HIV prevention in IDUs relies 100% on GFATM Round 6-8
funds and there are no committed funds for OST in the next NAP 2011-2015.
Implications for Programming
 To develop a better data collection system that tracks quality and outcomes of OST programs

There is a need to address technical and programmatic gaps in OST, such as OST service
continuity across health care service points, and strategies to increase program retention
 To increase volume of OST services to achieve a higher coverage of IDUs

Pilot service integration projects, such integrated HIV/TB/OST services at point of service
Female Sex Workers
Situation analysis
The estimated population size of FSWs is 6,000 on the Right Bank25, with an estimated prevalence of
FSW of 0.4% in the female population aged 15 years or more. The official HIV statistics do not label new
cases by commercial sex work. Based on the 2010 IBBS, the national HIV prevalence among FSWs totals
6.0% in Chisinau and 23.8% in Balti. Hepatitis C prevalence reached 19.0% in Chisinau and 25.8% in
Balti, pointing a high proportion of FSWs injecting drugs. Syphilis prevalence is 5.7% in Chisinau and
5.3% in Balti (2.1% in FSWs under 24 years and 7.0% in 25+ years in Chisinau). (Table 5) Based on the
2010 IBBS, intervention coverage (provision of free condoms, information, education, and
communications, needle and syringe programs (NSP)) reached 53% in 2009. The HIV knowledge
composite indicator was 32.2% in Chisinau and 53.5% in Balti.26
Table 5 Prevalence of HIV, HCV, HBV, and syphilis in FSWs, breakdown by age and city, Republic of Moldova, IBBS 2010, in %
Age
Chisinau
25 years and older
25 years old and
younger
Total
Balti
25 years and older
25 years old and
younger
Total
HIV
HCV
HBV
Syphilis
8.5
24.6
10.6
7.0
3.2
8.4
6.3
2.1
6.0
19.0
9.3
5.7
32.5
39.2
11.3
7.2
13.5
9.8
7.4
3.1
23.8
25.8
9.5
5.3
Compared to earlier IBBS conducted in 2003, 2004 and 2007 among FSWs beneficiaries of harm
reduction projects, a smaller prevalence is observed among FSWs recruited through RDS in Balti (23.5%
in 2010 compared to 32.8% in 2007), while in Chisinau the HIV prevalence in 2010 was higher (6.0% in
2010 compared to 2.9% in 2007). (Table 6)
Table 6 HIV prevalence trends in FSWs, seroprevalence surveys 2003-2010, cities of Chisinau and Balti
Site
Years
2003
2004
2007
2010
25
Ministry of Health of the Republic of Moldova, National Center for Health Management. Universal Access Report
2010. Preliminary Results Size Estimations. Unpublished Report
26
National Center of Health Management. Integrated Bio-Behavioral Survey 2010. Unpublished draft, 2011.
17
Balti
Chisinau
N/A
4.6%
N/A
8.5%
32.8%
2.9%
23.5%
6.0%
Only 3.3% of the sampled FSWs in both Chisinau and Balti reported being current injecting drug users,
with 11.0% of them in Chisinau and 12.8% in Balti reporting an injecting drug history, while a total 34.6%
of FSWs in Chisinau and 27.6% in Balti reported a history of any drug use. FSWs that used drugs appear
to be older (mean age 30.0 years in Chisinau and 33.2 years in Balti); they have a higher HIV prevalence
(21.9% in Chisinau and 52.2% in Balti) and HCV prevalence (62.5% in Chisinau and 73.9% in Balti),
indicative of unsafe syringe practices. Most FSWs (88.4% in Chisinau 93.3% in Balti) reported consuming
alcohol before having contact with their clients.
Data indicate moderate commercial sex activity within Moldova, with the average number of clients per
sex worker per week at 5.9 clients in Chisinau and 1.7 clients in Balti; however, commercial sex activities
remain unsafe in a high proportion of cases. While the majority of FSWs (90.3% in Chisinau and 91.4%)
reported condom use at last vaginal sex, a lower proportion (72.9% in Chisinau and 80.9% in Balti)
reported always using a condom for vaginal sex in the past 30 days. Condom use at anal sex was lower,
as 68.8% of FSWs in Chisinau and 65.5% in Balti reported consistent condom use during anal sex in the
past 30 days. Condom use with regular partners is even lower: only 29.3% of FSWs in Chisinau and
43.6% of FSWs in Balti always used condoms in the past 30 days with their regular partners.
The in-depth interviews have shown that in reality consistent condom use might be lower than
estimated by the quantitative survey for several reasons. First, there are financial incentives for
engaging in unsafe sex, as many commercial clients insist on not using condoms and many FSWs
reported that commercial sex without condom use pays much more.
“Most clients want sex without condom. He has a really good car, a jeep, he has a family and everything
else and he stills wants to have sex without a condom…” street-based SW, 45 years, Chisinau
„Many offer to pay more for sex without condom but I do not do this, sometimes I provide oral sex
[without condom], you are paid double, but sex like this, no. Categorically not...(after 5 min)... If the
client pays my requested amount, I would have sex [vaginal without condom], if I see the client is older
and cleaner.... (after another 1 min)... With a youngster I wouldn’t [without a condom], but it happens,
once a week or even twice a week, if they come and are clean and give me the money I ask for, then yes,
I have sex without condom... usually I charge 150 MDL, if he gives me 300-350 MDL, I would have sex
without a condom” street-based FSW, 27 years, Chisinau
Second, street-based sex work is a higly unsafe environment and violence and highly unsafe sex occurs
frequently:
„It happened to me that 28 persons have taken advantage of me, have threatened me with a knife,
made me smoke pot, drink wine, they took me from the center of the city and got me to a village. They
would take me to a house where there were 4-5 guys, then to another house... half a village... and they
were all young, this is why I fear most the younger clients. When I got back to the car he showed me the
knife again: are you going to do something? Better not do anything”, street-based SW, 27 years,
Chisinau.
Third, alcohol consumption is high among street-based FSWs, which significantly increases risk of
violence and low condom use.
“… we lose our health working here. A girl has problems with her liver and her legs, they drink lots of
vodka, I did, too, 3-4 liters of home-brewed liquor and vodka a day… There are many problems when the
girl is drunk, they can take advantage of her, can avoid paying her money, can beat her”, street-based
SW, 45 years, Chisinau
18
A similar qualitative research was conducted in MARA FSWs with ages comprised between 15-19 years.
Compared to adult sex workers, younger FSWs appeared to have higher number of sexual partners
ranging from 1 up to 11 clients and one respondent reported between 10 clients and 20 clients in a busy
day. Almost all respondents offered all types of sex: oral, vaginal, and anal sex and fewer included the
group and sadomasochistic sex. Most young FSWs reported that they faced difficulties in negotiating
condom use with clients.27
Activities
HIV prevention interventions for FSWs includes the following services: condom distribution, IEC
distribution and referral to facility-based STI and VCT services. The primary method of service delivery is
via outreach to apartment- and street- based venues. There are currently five program sites that provide
outreach services to SWs. Based on the activity reports, by the end of 2010 some 1,215 FSWs have been
cumulatively reached with HIV prevention services.28 Based on IBBS 2010, some 30.9% of FSWs in
Chisinau and 17.3% in Balti have received condoms for free, while most buy them in pharmacies (58.8%
in Chisinau and 45.8% in Balti).29
Gaps
Overall, HIV prevention programs targeted to FSWs focus on condom distribution and referral to facilitybased VCT and STI management; not all elements within a state of the art package of HIV prevention
services targeted to FSWs are provided. Condom distribution does not seem to be accompanied with a
strong behavior change communication (BCC) component, since qualitative interviews show low level of
consistent condom use. Implementers tend to deliver a standard package of services to all FSWs.
Providers do not segment the FSW by prevalence of risk behaviors, despite the fact that needs vary
greatly depending on context and situation (e.g., economic status, apartment-, street-, and highwaybased; static or migratory status; injecting drug use). The nature and extent of referrals and supporting
follow up to Positive Prevention and other services is unclear. HIV prevention activities are not targeting
clients of FSWs’, as well as regular and casual partners.
Implications for Programming
 Expand provision of a comprehensive HIV prevention package of services (especially outreach
HIV and STI rapid testing, on-site STI management) tailored to sub-populations of FSWs and
increased emphasis on behavioral interventions with FSWs and their commercial and noncommercial partners.

Better target and tailor approaches to specific segments within commercial sex work to achieve
better HIV prevention outcomes.

Increase coverage of FSWs with HIV prevention services to closer to 60%

Improve FSW client registration method, to be able to evaluate annual coverage
Men having sex with men
Situation analysis
27
Scutelniciuc O, Iliinschi E. Surveillance of Risk Behavior associated to HIV. Assessment of Risks to HIV infection
among young Injecting Drug Users, Men having Sex with Men, Commercial Sex Workers and Juveniles in
Detention. Chisinau 2010
28
Soros Foundation Moldova. Activity report, 2010. Unpublished report.
29
National Center of Health Management. Integrated Bio-Behavioral Survey 2010. Unpublished draft, 2011.
19
The estimated size of MSM in Moldova, Right Bank only, based on network scale-up method was 2,200
people in 2009.30 This number is considered to be underreported because of high stigmatization of this
group. Based on an expert group opinion process that took into account MSM population estimates
from neighboring countries, a number of 2% of adult male population has been used to estimate modes
of HIV transmission for 2010.31 The size of MSM population in Moldova is thus considered to be in the
range of 2,200 to 19,700 people. The cumulative number of officially registered cases of HIV infection
among MSM is 32 for the Right Bank and 3 for the Left Bank. Based on the 2010 IBBS using RDS, the
prevalence of HIV among MSM is 1.7% in Chisinau city and 0.2% in Balti city, Hepatitis C prevalence is
3.6% in Chisinau and 1.2% in Balti and Syphilis prevalence is 12.7% in Chisinau and 0.4% in Balti.32
Compared to previous IBBS surveys, the HIV prevalence in the sample recruited through RDS in 2010 is
lower compared to samples of project beneficiaries. (Table 7)
Table 7 HIV prevalence in MSMs, BSS 2003, 2004, IBBS 2007, 2010, Chisinau, Republic of Moldova
Site
Chisinau
Years
2003
1.7%
2004
2.5%
2007
4.8%
2010
1.7%
Chisinau city: approximately 43% of MSMs reported having sex with women in the past year with an
average number of 3.2 female partners in the past year and only 19.5% of MSMs reported using
consistent condom use with a woman in the past month. MSM report an average number of 5.6
homosexual partners in the past year and 3.3 partners in the past six months, with less than half (47.3%)
reporting only one male sexual partner in the past 6 months. Older MSMs reported higher number of
partners compared to MSMs younger than 25 years, (8.2 partners compared to 3.3 partners). Condom
use with a regular partner at last anal sex was 58.1% and with casual partners at 69.2%, whereas
consistent condom use with regular partners was 40.7% and 44.4% with casual partners. For oral sex,
condom use is significantly lower: 16.4% reported consistent condom use with casual partners. Some
23.4% have admitted to a history of any drug use and 2.1% admitted to a history of injecting drug use.
The HIV knowledge composite indicator was 40.4%.33
Compared to previous IBBS conducted in MSMs who benefited from HIV prevention services, the survey
in 2010 conducted by RDS method has shown lower indicators regarding HIV composite knowledge
indicator (40.4% in 2010 compared to 46.8% in 2007) and lower HIV testing indicator (19.1% in 2010
compared to 38.3% in 2007). (Table 8)
Table 8 HIV Knowledge and Behavior Indicators, MSM, BSS 2004, IBBS 2007, 2010, Chisinau city, Republic of Moldova
Knowledge and behavior indicators
Condom use, last anal sex
Aggregate HIV knowledge
HIV test in the past 12 months
2004
59.0%
60.0%
38.3%
2007
48.1%
46.8%
38.3%
2010
57.9%
40.4%
19.1%
Focus-groups discussions with MSMs who are covered by HIIV prevention efforts have provided more
understanding about perceptions about risk of HIV transmission and safer behaviors. Compared to other
MARPs, the level of correct knowledge about HIV and about safer sex is highest and the perception of
increased risk of getting HIV through sex is also high. Many participants mention high number of
partners, multiple concurrent partnerships, a high number bisexual men having regular female partners
and a high number of male casual partners picked up in cruising areas or through internet and this is
coupled with low levels of faithfulness and low rates of condom use.
30
Preliminary Results Size Estimations, unpublished draft 2010.
UNAIDS Moldova. Estimating modes of HIV transmission, 2010. Draft, December 2010. Unpublished report.
32
Ministry of Health, National Center of Health Management. Information Letter no. 01-16/479 from 15.09.2010.
Preliminary results in need of validation by the UNAIDS ECA Regional office.
33
National Center of Health Management. Integrated Bio-Behavioral Survey 2010. Unpublished draft, 2011.
31
20
„In our case, no matter how much love is involved between two partners, they cheat anyways.” (FG 1)
„I thought he was a married faithful partner who had homosexual sex only with me, but one time I saw
him at the lake he was in WC and had sex with six people, then he got out and I had a fight with him and
it has been a year since I haven’t talked to him” (FG 2)
MSM engage in unprotected anal and oral sex fully aware about risks, prioritizing pleasure rather than
risks. Oral sex is unprotected as a rule.
„Let’s be honest, in our community the oral sex is unprotected.” (FG 2)
„I have noticed that people who are afraid to get infected use condoms for anal sex, but the majority do
not use condoms for oral sex, I saw that a French guy who came to visit did the same, used condoms for
anal sex and not for oral sex” (FG2)
For anal sex, although most participants understand that it is higher risk, they often rely on chance
rather than protection, especially if there was high alcohol consumption.
„At that moment you do not think because you are sexually aroused and afterwards you think several
days before you take an HIV test and you ask yourself: God, what did I do for five minutes of pleasure”
(FG2)
„If you are drunk you do not remember your name, not about condoms” (FG 1)
„If I don’t have a condom, I take the risk and do not use one, I just take a leap of faith” (FG 3)
„You cannot impose condom use, he has been informed about risks, the social institutions have made
their best, but you cannot go and actually put the condom on” (FG 3)
Another qualitative study was conducted in adolescent MSM with ages between 15 and 21 years and it
concluded that the level of knowledge varied from well informed to total lack of information on sexual
health, risky behavior and HIV/AIDS/STIs. The interviewed youth had a strong feeling of invulnerability
of their sexual health. Many respondents mentioned a larger number of sexual partners compared to
adult MSM (up to 6 - 8 partners during the last 12 months). Transactional sex was offered by adolescent
MSM to older MSM in quite a few instances. Respondents have positive attitude about condoms, but as
in adult MSM population, condoms were not used in oral sex and were used inconsistently during anal
intercourses.34
Activities
HIV prevention interventions targeted to MSM are provided primarily by community-based
organizations (Gender-Doc and Center ATIS) in the two main cities (Chisinau and Balti). GenderDoc-M
has started outreach activities within the Health Program in 2005. Services include condom and
lubricant distribution, distribution of information leaflets, organization of seminars, safer sex promotion
parties for the LGBT community, providing individual counseling services, and developing referral
system to medical specialists, referral to facility-based VCT. Programs reach MSM through outreach to
venues where MSM congregate, such as bars and cruising areas, and through support groups held at
community centers. By the end of 2010, a cumulative number of 886 MSMs have been reached by HIV
prevention services.35
34
Scutelniciuc O, Iliinschi E. Surveillance of Risk Behavior associated to HIV. Assessment of Risks to HIV infection
among young Injecting Drug Users, Men having Sex with Men, Commercial Sex Workers and Juveniles in
Detention. Chisinau 2010
35
Soros Foundation Moldova. Activity report, 2010. Unpublished report.
21
Gaps
Overall coverage of MSM with HIV prevention programs is low, particularly among non-gay identified
MSM, “hidden” MSM, MSM with overlapping risk behaviors (e.g. injecting drug use), and among the
female partners of MSM. Programs implement a partial package of HIV prevention services as per
international standards for MSM. There are gaps in delivering interventions outside of familiar venues to
underserved or most-at-risk MSMs (e.g. male sex workers). There are few MSM-friendly health
providers which decreases access to specialized services. Compared to other categories, the enabling
environment is the least developed and puts significant barriers in accessing HIV prevention services.
Unlike many countries, homosexuality and sodomy are not illegal in Moldova, so there is no legal basis
for deterring HIV prevention services to MSM. Despite the absence of legal sanctions against
homosexuality, there is a strong cultural and religious bias against MSM. MSM experience stigma and
harassment, especially by informal hate groups and some elements within law enforcement.
Implications for programming
 Increase emphasis on behavioral interventions towards safer sex with MSMs.

Strengthen the technical quality of MSM programs, including the expanded provision of a
comprehensive HIV prevention package of services, with increased focus on addressing
overlapping risk behaviors.

Programs should scale up HIV prevention interventions to increase condom use and VCT among
female partners of MSMs.
Prevention Programs Targeted to General Population
Young people
Situation analysis
Adolescents and young people in Moldova make up over one quarter (26%) of the total population of
3.38 million (excluding the Transnistrian region). The rapid political and social changes that have
characterized Moldovan society in the last decade have brought new opportunities, but also risks for
youth. Many of those factors that are contributing to risky behavior among youth are rooted in the
social environment they live in, characterized by poverty, unemployment and reduced access to
information and quality services.
Sexually Transmitted Infections (STIs) and HIV: the incidence of STIs in Moldova is high, compared to
other European countries in the region and the knowledge and awareness about them is low within
youth aged 15-24 years. Moldova remains one of the three countries in the Commonwealth of
Independent States (CIS) with the most rapid spread of HIV infection. HIV incidence reached 19 per
100,000 people in 2008, creating serious challenges to achieve the MDG 6 on HIV/AIDS. In 2010, a total
24 new HIV cases were registered among adolescents aged 15 to 19 years accounting for 5.3% of new
cases36. The preliminary data of Youth KAP 2010 has shown a decrease in the number of young people
aged 15-24 years being able to mention at least one STI symptom in women from 48% in 2006 and
47.8% in 2008 to 34.9% in 2010.37
Sexual Behaviors The mean age at first sexual contact among adolescents aged 15-24 years in 2008 was
16.6 years old. While the proportion of those entering prematurely into sexual relations is relatively
small, the sexual practices are not always safe. Every fifth single young person had two or more sexual
36
National AIDS Center Epidemiological Bulletin 2010 Unpublished draft, February 2011
National Center of Health Management. Youth’s Knowledge, Attitudes and Practices regarding HIV/AIDS 2010.
Preliminary data extracted from survey database. Unpublished work.
37
22
partners in the past year and only half of youth of 15-24 years reported condom use at last intercourse.
Around 5% of youth aged 15-24 years have reported sex initiation through forced sex. The high number
of unwanted pregnancies indicates a lack of knowledge on and usage of contraception. Some 5% of
young people aged 10-24 years experienced pregnancy in 2008, usually an unwanted one, with only 7%
of them ending with birth.38,39
HIV knowledge and testing: Efforts of informing about HIV show an unstable trend, as the proportion of
youth (15-24 years old) having correct knowledge about HIV transmission increased from 26% in 2006
to 41% in 2008 and then decreased to 36.2% in 2010. Tolerant attitudes towards people leaving with
HIV/AIDS (PLWH) remain at an alarmingly low level of 10.7% on the Right Bank. (Figure 3)
Figure 3 Main indicators of knowledge and sexual behaviors in youth aged 15-24 years, comparison years 2006, 2008, 2010
Most-at-Risk-Adolescents (MARA) constitute the group of young people with the highest risk to acquire
HIV and their specific situation analysis has been addressed in the sections dedicated to IDUs, FSWs and
MSMs.
Activities
MARA
First projects on outreach activities for MARA and especially vulnerable adolescents have been initiated
and implemented during 2008-2009 in Balti and Tiraspol. The focus of the pilot project in Balti was on
outreach activities for adolescents and young people living in the street, including mobile outreach,
social theatre (street theatre), and innovative social photo/social video activities. Altogether about
3,000 adolescents and young people have been reached or involved in specific activities, being provided
with comprehensive information on HIV/AIDS, STIs and substance abuse prevention and on available
services, among them 164 most-at-risk and especially vulnerable ones. The project in Tiraspol
implemented by the NGO Future Generation covered about 2,000 adolescents and young people with
IEC, among them 300 adolescents, aged 10-16 being street children and children in conflict with the law
and 150 adolescents being from the boarding school.
The adolescents and young PLWHIV CBO “Among us” has been consolidated, involving adolescents and
young people of different ages (10 to 29 years). This initiative group got a series of specific trainings,
including through a summer school, aiming to build capacities on medical aspects of HIV, leaving with
HIV, developing a PLWHIV community, civil society and management of NGOs, team building,
38
39
Scutelniciuc O, Condrat I, Gutu L. Youth’s Knowledge, Attitudes and Practices regarding HIV/AIDS 2008 Chisinau.
Scutelniciuc O, Gutu L,Lesco G. Youth’s Knowledge, Attitudes and Practices regarding HIV/AIDS 2006 Chisinau.
23
involvement and participation, etc. Two Clubs of adolescents and young PLHIV have started their
activities in Chisinau and Balti. Within the Club sessions adolescents and young PLWHA got the
opportunity to set up support groups, to receive individual and group counseling and up-dated info
materials.
Life-skills-based education
The Moldovan Government requested the development agencies’ supports to develop and implement
specific programmes addressing the young people needs for information and services. The United
Nations Agencies and GFATM supported the Government initiative of introducing Life-Skills Based
Education (LSBE) in the school curriculum in Moldova, by allocating USD 1.8M. During 2003-2004 the
joint team of international and local experts, worked out a full package of materials in order to
introduce LSBE in national curricula. The LSBE materials included the concept, curricula, teacher’s guides
and student’s books. National team of trainers (30 persons), regional team of trainers (105 persons),
local trainers (more than 3,000 persons, including teachers from all schools in Moldova) were trained by
international and local trainers to teach LSBE using the latest teaching interactive methodologies and
techniques. The introduction of Life Skills Based Education (LBSE) in the mandatory school curriculum
was piloted during 2004-2005 school year in 35 schools and lyceums and monitored by national trainers
and representatives of the MOE. Only positive feedback was received from teachers, children and
parents during the piloted year.
However, this initiative was met with hostility from some religious leaders and parents in September
2005 when the LSBE subject was introduced as mandatory subject in school curriculum. Most concerns
were raised by certain representatives of Orthodox Church regarding the exact content of the LSBE
materials, more particularly as they refer to sexual education and HIV/AIDS prevention and
transmission. A few surveys conducted by different civic organizations including youth NGOs indicates
that more than 80% of pupils express their wish to study LSBE and that such a demand increases as age
and grade progress. Nonetheless all debates limited LBSE to the status of an optional course for
students 12 years old and above.
A new course, Civic Education, have been proposed as an alternative to LSBE and implemented as a
mandatory course in the academic year 2008/2009 in order to exclude new debates and confrontations
in society. The curriculum of the latter was developed using modules of Life Skills, and some teachers
trained in Life Skills were used as resources for the Civic Education course. However the optional course
has been taught for a limited number of hours, excluding or limiting the number of hours for HIV
prevention and sexual education hours.
The first attempt to measure results of such decision was taken in 2010 while preparing UNGASS report
for 2008-2009. Data presented for this indicator were collected during a survey in 200 schools,
representative for schools on the right bank of Dniester River. The main finding of the survey confirm
that in Moldova the value of the indicator related to life-skills based HIV prevention education in the
academic year 2008/2009 equals to zero. Out of the 200 institutions included in the sample
representative for the school education system on the right bank of Dniester River, none of them had 30
or more hours of HIV prevention taught throughout the previous academic year for each grade. The
UNGASS 2008-2009 report mentioned that one of the commitment (indicator 11, Life Skills based
education in school was not fulfilled by the Government of Moldova.40
Peer education for HIV prevention
Starting with 2007, the National Youth Resource Centre (NYRC), in collaboration with the Ministry of
Education, supported by UNICEF, UNFPA and the GFATM launched Young People Preventing HIV/AIDS
Project. The project was focused on a new qualitative approach to the development of a network of
40
National Coordination Council. Republic of Moldova UNGASS Report 2008-2009. Chisinau 2010.
24
peer educators. Each group was made up of four peer educators and one adult coordinator in each
community (preuniversity education setting) from the districts involved in the project. Every year seven
new districts were taken in the project in order to increase geographical coverage.
The quality of peers educators work in the project was proved by the internal evaluation report on
young people-s knowledge and attitudes related to HIV and AIDS conducted every year at the beginning
and at the end of the project. A marked increase in correct HIV knowledge has been registered in all
three years (from 8.11% to 48.08% in 2008, from 12.04% to 43.02% in 2009 and from 9.13% to 21.38 in
2010). (Table 9)
Table 9 Main indicators of peer education program by school years
Indicators
No. district/municipalities
No. schools/communities involved
No. of peer educators
No of adult coordinators
No. of activities conducted by PE
No. of beneficiaries
Correct knowledge on HIV pre/ test
Correct knowledge on HIV after/test
2007/2008
7
241
1,089
241
4,408
36,499
8.11
48.08
2008/2009
7
266
1,117
218
6,548
43,093
12.04%
43.02%
2009/2010
7
249
948
361
5,166
37,464
9.13
21.38
Total
3 years
21
756
3,154
820
16,122
117,056
In addition to the above mentioned project, UNFPA supports a local network of peer educators on
Reproductive Health (Y-PEER), and HIV prevention is an important part of Y-PEER education programme.
In the circumstances LSBE course is not reached by majority of youth across the country, out of school
activities are of added value in preventing HIV in Moldova. In 2010, 165 Y-PEER network educators
informed more than 6000 young people about HIV, STI and other important health issues, including in
Transnistria region (1000 young people in Transnistria). The network distributed 24.000 informative
leaflets on Reproductive Health and HIV/AIDS among youth; advocated for the right to sexual
reproductive health education in schools and created 7 social theatre clubs in different regions of
Moldova, performing social theatre on health issues for young people. The network has a functional
website www.y-peer.md and a regular newsletter developed by young people themselves for their
peers “Without Tabu”. Currently, the network has the capacity to organize informative activities based
on peer to peer methodology about HIV prevention on a regular basis in Chisinau, Balti, Soroca, Orhei,
Glodeni, Drochia, Cahul, Tiraspol, Bender, Calarasi, Falesti, Soldanesti, Causeni, Nisporeni, Straseni
regions. As of March 2011, the Y-PEER network extended to 183 members.
Dance4Life
Dance4life was piloted by AFEW in 2007, providing to young people the opportunity: to learn more
information and useful facts about HIV and AIDS; change attitude towards personal health and inspire
them to become active leaders in HIV prevention activities. Following this structure, during the period
2007-2010, the Dance4life project worked in more than 165 schools in Chisinau, Chisinau suburbs, Balti,
Comrat, Floresti, Glodeni, Ialoveni, Riscani, Donduseni, Hincesti, Calarasi and five rayons of Transnistia.
At least 15 937 young people were reached by dance4life project within school settings and more than
190 000 people additional from general population were reached by act4life activities conducted by
4241 agents for change.
Pre and post training evaluation of agents for change attest to a medium 95% of knowledge retention.
More than 165 mass-media activities have been carried on to promote HIV prevention activities by the
dance4life project team. More then 200 000 informational materials on HIV and AIDS are distributed
directly throughout the general population, every year.
Youth Friendly Health Services
25
YFHS represent an important entry point for a comprehensive approach to adolescent health and
development, including HIV/STIs prevention. In the past ten years the Ministry of Health with donors
support have established the national network of YFHS, drawn from the best international and national
practices. For the time being, 12 Youth Friendly Health Centers (YFHC) are operational in the country,
providing reproductive health and HIV prevention related services to young people. Two more YFHC
were established in the Transnistria region with the Global Fund to fight HIV/AIDS grant following
already existing model and concept approved by the MOH.
In the first years, the number of beneficiaries increased from roughly 15,000 in 2004 to around 70,000 in
2007. Starting in 2008, the services of these clinics are reimbursed by the National Health Insurance
Fund (NHIF) therefore first half of 2008 and partially 2009 year was marked by an irregular/sporadic
activity for some centers and decrease in the number of beneficiaries. In 2008 around 54,000 youth
have accessed services, of which about 19,000 (35%) were clients that accessed medical, psychological
and social services and 32,000 (59%) were beneficiaries of informational activities and approximately
4,000 (6%) accessed phone hotlines. The proportion of first time visitors was 54% and the clients were
66% girls and 34% boys. In 2009 the number of beneficiaries was 43,108.
Quality of care: A group of national experts conducted a baseline assessment of the compliance of
existing YFHCs and selected WHCs and RHOs to the new quality standards. A total of 98 clients of YFHCs,
WHCs and RHOs, 179 young people from the communities covered with YFHS, 74 service providers and
20 managers from these centers were interviewed. In the sample have been included 12 YFHCs, 2 WHCs
(out of existing 3) and 6 RHOs (2 per geographic region, out of a total number of 47).
The results for YFHCs have shown that the highest compliance is to:
Standard 1: Young people know when and where to ask for health services (70.2%)
Standard 3: Services providers respect youth confidentiality and intimacy (67.8%)
Standard 2: Young people have ease of access to health services which they need and when they
need (67.0%)
The lowest compliance is for standard 5: Health service providers supply effective and comprehensive
services according to real needs of the youth (41.1%).
At this transitional phase from donors’ to the Governmental support the YFHS could not ensure
adequate staffing, equipment and supplies that would allow for comprehensiveness and equal access
for all young people. For the time being the limited budgets available cover in practical terms only
human resources costs, very little being earmarked for activities per se. The coverage with YFHS is
limited and the quality of services still needs improvement in order to extend the coverage of services
and reach the excluded adolescents.
RH cabinets that offer free of charge contraceptives, including condoms – young people up till the age
24 are eligible.
Reproductive Health Offices (RHO)
Young people’s sexual reproductive health is one of the main priorities of the National Reproductive
Health Strategy (2005-2015). The National Centre for Reproductive Health and Medical Genetics has
been delegated by the MOH to have overall oversight of the RH network, offering RH services including
distribution of contraceptives. The Centre also has the responsibility to receive, temporarily store, and
distribute donated contraceptives to all districts (including the Transnistrian region), as well as to
manage the monitoring system. Overall there are 47 (RHC) mostly located in rayon centres and 8 RHC
located in Transnistria region, which offer free of charge contraceptives, including condoms to young
people up till the age 24.
26
Current Government financial constraints mean no national budget is available for contraceptive
procurement for free of charge distribution. UNFPA remains the major donor of all contraceptives for
free of charge distribution (intended for the “vulnerable groups”). Some additional supplies of condoms
are available through the Global Fund and other development partners. According to the Ministry of
Health there is a continuing need for donated contraceptives, particularly for vulnerable groups
including for young people.
In the current situation, the purpose of the RHC network has to expand to embrace the needs of
vulnerable groups, including youth and HIV issues. Overall the network does not work to capacity, as
personnel are not fully trained and therefore are not fully on board. It is nevertheless a good model for
Moldova; it is necessary to maintain and support the RHC network because the family doctors / GPs
cannot deal with all the issues. 41
In 2010, the Government has undertaken a mid term evaluation of RH Strategy
Implications for programming

Revise decision and introduce LSBE as a compulsory component of the education curriculum in
Moldova as part of government commitment to HIV prevention strategy and develop and apply
monitoring and evaluation system to assess coverage, effectiveness and quality of the taught
courses related to personal, social and health development.

Maintain existing networks of peer educators and adult coordinators at local level and
encourage their participation and ensure ways to train and motivate adult coordinators
(teachers and nurses in schools) and pay teachers for extra curriculum activities. Motivate,
recruit and train peer educators from the risk group so that they can communicate effectively
with vulnerable groups of adolescents and deliver to young people many messages related to
youth health, sexuality, personal hygiene, prevention of illicit substance consumption, etc.

Also, support and extend the network of peer educators to new regions of Moldova, therefore
each region has a team of young people to organize extracurricular activities by youth and for
youth using peer education methodology. Therefore, the information gap about HIV, STI in
schools shall be covered by distribution of informative materials and organization on regular
activities during extra school hours. A sustainable development intervention would be
institutionalization of peer to peer education within local education departments.

Strengthen capacity of school health workers to inform young people about HIV prevention in
schools and/or during out of school activities in partnership with peer education programmes.
National Medical College should introduce a module on HIV prevention in the compulsory
training programme for school nurses with a focus on young people communication techniques.
Ministry of Health and Ministry of Education should support training costs for school health
workers. Currently, there is a module on Reproductive Health developed for school health
workers, which includes HIV prevention information, but it is not part of compulsory education
curricula.

Develop and establish a proper financing and accreditation mechanisms to achieve the full
implementation of quality standards and extend geographical coverage with YFHS and build
capacities of staff for the early identification of potential risk behaviors among adolescents and
referral to appropriate services, provide outreach services for vulnerable youth groups.
41
Dr. Katy Shroff, Republic of Moldova Rapid Review of the Reproductive Health Commodity Security Status,
Unpublished report, June 2010
27

Train and motivate health workers at all levels family doctors, nurses, specialized health services
staff, Reproductive Health Offices, VCT staff to adopt youth friendly approach while working
with adolescents.

Integration of HIV prevention services into national existing Reproductive Health services,
therefore coverage with IEC and HIV testing shall increase for general population.

To improve intersectoral cooperation between health education and social protection sectors
for a better identification of vulnerable and at risk adolescents, needs assessment and
referral/access to integrated social services.

Include MARA-specific plan of Action in the National Programme on HIV prevention and control
for 2011-2015 and in the current HIV prevention services provided to MARPs, to meet the needs
of younger groups.
Other key populations perceived as higher risk in the general population
Situation analysis
Starting with 2002, the current tendencies of HIV epidemics in Moldova point to a prevailing sexual
mode of transmission and a feminization of the epidemic. Although there is a shift of transmission mode
from injecting drug use to sexual mode of transmission, the HIV epidemic is still concentrated among
MARPs, including, most significantly IDUs, sex workers, MSM, and and their sexual partners. The country
underwent through Modes of Transmission Modeling and the preliminary results showed that in 2010
MARPs and their sexual partners would have been responsible for 61.6% of new infections, while other
populations entering casual heterosexual sex and their partners would have contributed with 38.4%.42
(Figure 4)
Figure 4 Estimated distribution of HIV new cases for the year 2010, based on Modes of Transmission Model, in %
Migrants are one group that is considered at highest risk of acquiring HIV/AIDS among the general adult
population. National AIDS Center reports that out of a cumulative number of 194,618 migrants that
have done the tests before leaving the country, in the period of 2003-2009, 166 were HIV-positive, the
42
UNAIDS. Modes of Transmission modelling spreadsheet. Unpublished draft, November 2010.
28
prevalence being of 0.09%43. In 2009 only 1%, or 11 out of 1,151 the total number of returning migrants
who stayed more than 3 months outside Moldova proved to be HIV-positive, a higher percentage than
in the general population. Migrants reported higher risk sexual behaviors: a total of 40.3% reported two
or more sexual partners and a consistent condom use with these partners of an average 44%. Some
11.2% of men and 1.1% of women reported to have commercial sex while abroad. The proportion of
migrants who always used condom with non-regular partners was only 12.6%44.
Several other subpopulation groups are thought to be at higher risk of acquiring HIV in the general
population: sexual partners of people engaging in high-risk sexual encounters (multiple partners and
unprotected sex), female partners of clients of FSWs, but few prevalence studies have been conducted
thus far to document the actual transmission rates in these subpopulations. In the general population,
while only 10.6% admitted to have had non-regular partners during the last 12 months, some 68.0%
used condom at last sexual intercourse in 2009.45
Activities
HIV/AIDS awareness and HIV prevention activities among the general population have improved in
recent years, but key groups still remain only partially in the reach of current programmes. These
activities are funded and largely implemented by international organizations and NGOs (UNICEF, AFEW,
UNDP, UNFPA, IOM, SFM, etc.). Generally, the specific population groups targeted in this programmatic
area are young people, school children, students in universities and vocational schools, out-of-school
children, uniformed services personnel and recruits, mobile populations, and the general population.
The number of prevention programmes and activities for the general population and young people
increased in recent years. Over the period 2005-2007, two nationwide Behavior Change Communication
(BCC) campaigns to increase awareness and decrease stigma in the general population and youth were
conducted.
Migrant prevention activities include awareness raising and prevention activities by IEC material
distribution at customs checkpoints, railway stations and airport. A total of 1,053,542 IEC materials and
269,548 condoms were distributed during the period of 2006-2009.46 This group becomes a very
important one in the context of HIV epidemic and it needs more attention to detailed research,
programming and funding is needed for them.
In the period 2005-2009 a project on HIV prevention in uniformed services was implemented by UNDP
as the donor and national counterparts (Department of Boarder Guards, Ministry of Defence, Ministry of
Health and Social Protection, Ministry of Internal Affairs) and other partners. The main interventions of
the project were focused on IEC, VCT, provision of medical equipment and educational materials, as
well as establishing partnerships between instructors in uniforms from different regions. The final target
set by the project was the achievement of safer sexual behavior among young people in uniform. The
evaluation of the results showed an increase of HIV knowledge 6.4% in 2006 to 18.7% in 2007 and 20.9%
in 2009. HIV awareness increased some risk reduction behaviours: 69.8% respondents stated to use
condoms, 46.0% to reduce the number of sexual partners, 44.2% to remain faithful to one partner, to
13.2% abstain from sex and 11.5% to postpone the beginning of sexual intercourses.
43
National AIDS Center. Informative note on the HIV prevention activities among migrants in year 2009.
Unpublished work.
44
Stefan E., Sokolowski S., “The Health Risks of Migration: The Link between Health and Migration with Particular
Consideration of Knowledge and Attitudes towards HIV/STIs and the Sexual Practices of Moldovan Migrants”. Final
report. Unpublished work.
45
UNAIDS Moldova. “Women’s Vulnerability to HIV/AIDS in the Republic of Moldova”, 2009. Draft Report.
Unpublished work.
46
National AIDS Center. Informative note on the HIV prevention activities among migrants in year 2009.
Unpublished work.
29
As one of the biggest opponents of wider HIV prevention that includes public discussion about sexual
behaviors is the Orthodox Church, activities focusing on engaging the religious community discussions
regarding the HIV/AIDS epidemic and in HIV/AIDS control activities were also implemented. Several
trainings for this group, with support from the Moldavian Christian Aid (MCA), are considered to have
contributed to a more tolerant and constructive attitude towards the epidemic. In addition, a number of
public events, including concerts, were organized with the purpose of increasing awareness of HIV/AIDS
and reducing stigma with regard to HIV-infected/affected persons.
Gaps
The major failure of all prevention activities for various subpopulations is failure to openly promote
behavior change to safer sex, given the resistance from various social groups, from educational system,
parent groups and religious groups and overreliance on IEC as a strategy .
Although the existence of IEC and BCC activities for migrants represent a progress, they are
implemented by a small number of organizations. These activities should be intensified and made more
efficient, with an increased collaboration from customs personnel and government support.
Importantly, there is a lack of reliable information regarding HIV prevention efforts targeting mobile
populations in Transnistria.
Overall, prevention efforts have focused so far on increasing HIV knowledge and have focused less on
attitude and behavior change of specific higher-risk subpopulations. The efforts to decrease stigma and
discrimination towards PLWH proved little effectiveness, thus far, According to recent studies conducted
on issues of stigma and discrimination related to HIV/AIDS in Moldova, almost 70% of the population
showed a high degree of intolerance towards PLWH.47
Implications for programming
 All designed IEC/BCC activities have to be targeted based on gender, age and subpopulation,
have a clear behavioral focus, need to be evidence based and properly evaluated for further
planning and decision making.

Expand the HIV prevention efforts and BCC activities in migrants, by encouraging safer sexual
behaviors and access to VCT services upon return home and by piloting innovative and more
effective HIV prevention strategies, e.g., referrals to VCT or mobile VCT units at the points of
entry to the country.

Ensure gradual increase of government support and funding for national HIV awareness
campaigns, promote legislation for free-of-charge social advertisement and broadcasting of HIV
prevention messages.
Supporting HIV Prevention Activities and Services
HIV Voluntary Counseling and Testing
Situation analysis
On average, some 350 thousand tests are performed annually, including the screening of 120 thousand
blood donors and recipients, 100 thousand tests for pregnant women twice during pregnancy, 20
thousand migrants, 18 thousand other types of medical categories, 7.7 thousand persons with STI
symptoms, anonymous testing of 5 thousand persons, 4 thousand tests among TB patients, and 50
47
National Coordination Council, UNAIDS Moldova. Midterm Review of the National Programme on Prevention
and Control of HIV/AIDS/STIs 2006-2010, March 2009. Unpublished work.
30
thousand for other categories, while about 10 thousand MARPs (IDUs, MSM, CSWs and sexual partners
of PLWH) are tested on an annual basis.48
The testing levels in MARPs are the highest in Chisinau compared to other sites and the highest in IDUs,
compared to other groups. Based on IBBS 2009-2010, some 74.1% IDUs in Chisinau 65.7% in Balti and
50.4% in Tiraspol have been tested for HIV and 46.6% IDUs in Chisinau 31.9% in Balti and 23.5% in
Tiraspol took an HIV test in the past 12 months and knew their result. A little over half FSWs (53.5%)
have previously been tested and 27.9% took an HIV test in the past 12 months in Chisinau, and less than
half of FSWs in Balti (46.8%) have been tested and 22.8% in the past 12 months. The lowest testing level
has been reported in MSM in Chisinau, where only 35.1% have taken an HIV test in their lifetime and
18.1% in the past 12 months. (Figure 5)
Figure 5 Lifetime HIV testing indicator and in the past 12 months in IDUs, FSWs and MSMs in the cities of Chisinau (capital),
Balti (North) and Tiraspol (Left Bank), IBBS 2009-2010, in %
HIV testing among the general population stands at 2.7% in 2010. According to official statistics, the
testing of pregnant women in the last five years varies between 95-98% on the Right Bank.
A total of 19,423 people received pre-test counseling from a VCT counselor in 2008 and 56,432 people in
2009, an almost triple increase. The rate of return for post-test counseling was lower than anticipated:
only 78.5% in 2008 and 74.9% in 2009 of those who received pre-test have returned to receive post-test
counseling. Yet, when broken down by groups, only 0.5% (114 people) in 2008 and 0.7% (396 people) in
2009 were MARPs, which indicates an underutilization of VCT services by at-risk populations and
possibly underreporting of at-risk categories because of fear of stigma. Pregnant women counted 30%
(16,959 tested women) in 2009, and only 64% (10,901) of them came back for counseling for the second
test.49
As for the quality of VCT, a survey of women in maternity post-delivery wards conducted in 2008
showed that most women (93.5%) knew they have been tested for HIV during their last pregnancy. Most
of them (65.8%) knew the test was done twice, but only 71.3% mentioned that medical staff has
discussed with them about HIV, and in only 25.6% of cases this was a VCT counselor. In addition, only a
half of the sample (49.8%) has discussed the test result with their physician and only 16.9% received it in
a VCT Center. Almost a third (31.9%) have received the result on paper, without discussing it with
anyone and only three quarters (73.2%) felt they have received enough information, about two thirds
48
National Center for Public Health. Informational Bulleting on the Epidemic HIV/AIDS Situation, the Review of the
National Program and the Tasks for year 2010.
49
National Center of Management in Health. National monitoring data of the activity of VCT centers in years 2008
and 2009. Data extracted from national VCT data base.
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(63.5%) have discussed about condom use and only every sixth (15.5%) have assessed their behaviors
during counseling session.50
For the purpose of evaluating the quality of VCT service, a qualitative research was conducted with VCT
clients and VCT counselors.
Accessibility was considered increased by the urban clients and somewhat difficult by rural VCT clients.
Geographically, the VCT service is well-located, and easy to find, while the working hours seemed to be
convenient for most clients. The VCT clients have mentioned short waiting time and easiness to find the
VCT office.
Self-referrals: based on both clients’ and service providers’ opinions, very few come to the VCT center
willingly. Many have mentioned low awareness about the VCT service and usually the health service
providers are those referring clients to the VCT centers. Yet, by far the most frequently reason was
stigma attached to HIV from the clients’ perspective. Many associate AIDS with shame, fear, disease, so
based on their own opinions, if there weren’t referred, they would not have come on their own.
“Not everyone has internet, not everyone has information and people are afraid. For example, I have
asked for directions the maxi taxi driver and he looked at me in such a way… and continued staring at
me all the way up here, as if I already have the disease” male, 32, years, self-referral, Chisinau
“I don’t like this place, because people that come here have the chance to get out with their legs first
[dead]”, male, 35 years, provider-referred, Cantemir
Even those that are in a higher risk situation prefer not to know and delay testing, as FG discussions with
MSMs revealed both because of fear but also being afraid about breech in confidentiality.
“People are afraid to get tested not to learn that they are HIV-infected, it is just easier to not know the
truth. They think they would live as long as God gave them and should not get tested, because if they
learn they are infected, people around them will know, too”. FG MSM Balti
A promising development is an increasing number self-referred young clients who thought they were in
at-risk situation and came to check their HIV status.
„My friends told me about this VCT center. In the summer I had unprotected sex with a woman at sea
side, I do not know her status, who she is or how to get in touch with her, so I got tested half a year ago
and to be sure, now again. As for my permanent parnter, I am her first man, since I came from seaside
we did not have sex, because I was away from Moldova, I have just returned and I came first to take an
HIV test and then I will go to see her.” male, 22 years, self-referral, Chisinau
„A year ago I had a relationship with a man who died, I do not know the reason. He got wasted really
quickly and then died, so I decided to take an HIV test, I have already been tested twice, at 3 months and
6 months.”, female, 24 years, self-referral, Chisinau
Client satisfaction: all VCT clients were happy about their interaction with the VCT counselor, mentioned
that the VCT counselors introduced themselves, were friendly, neutraly discussed intimate details and
provided a lot of information related to HIV. Most VCT counselors felt comfortable discussing details
about sexual lives of clients and VCT cilents appreciated tactfullness, still many did not feel comfortable
discussing their sexual life with strangers.
50
Bivol S. Scutelniciuc O., Parkhomenko J., “Evaluation of services of Prevention of HIV Mother to Child
Transmission in the Republic of Moldova”. Report 2009. Chisinau 2010. In print.
32
„The counselor is a physician, I had to answer those questions, but I felt OK, I did not have issues”, male,
35 years, Cantemir
„One always feels uncomfortable discussing with anyone, especially stranger, about sex life” female, 35
years, Bender
Quality of counseling: apparently, the VCT counselors provide correct information and check
understanding of the clients, as most VCT clients were able to correctly name the modes of HIV
transmission and especially how HIV is not transmitted, prevention methods, and seronegative window.
The overall perception is that the VCT service is high quality and the VCT clients have mentioned
excellent attitudes of the counselors and easiness to discuss intimate details, they thought they have
provided suficient information to help them reduce their risky behaviors. However, most clients who are
referred by service proivers feel this is a formality, as they do not perceive themselves at risk, thus do
not feel they need to change behaviors. It is promising that self-referrals have started to occur,
especially among young people, who come to be tested after some risky situations and in this case the
behavior change moment is most.
Activities
Currently VCT services were provided nationwide in 74 VCT sites (6 of them located on the Left Bank).
The national Law on HIV/AIDS specifies that all HIV testing must be done on a voluntary basis, and must
be accompanied by pre- and post-test counseling, except for mandatory testing of donations of blood,
liquids, tissues, and organ samples and when a person is charged with the crime of willful transmission
of HIV or rape. Specific policies that regulate VCT services in the country have also been endorsed by
the Ministry of Health. There is a coordinated VCT referral system and a designated authority at the
local level, the VCT services are reimbursed by the National Health Insurance Fund. VCT counselors have
been received several trainings and receive ongoing technical support through Global Fund Round 6-8
grant and Japanese Social Development Fund grant. A strong VCT M&E framework and supervision
system has been set up. Thus, significant progress has been made in recent years in scaling up access to
VCT. National protocols for blood and saliva rapid testing for HIV/AIDS have also been developed. The
use of rapid testing has been only recently introduced in Moldova, with particular focus on the use of
rapid tests in maternity hospitals for pregnant women presenting for delivery without a previous
antenatal HIV test. As many as 5,000 rapid tests (blood based) are purchased annually.
Gaps
VCT services focus more on provider-initiated referrals of low-risk patients (general population and
pregnant women) and have not been able to attract high-risk clients from MARPs, despite efforts of VCT
counselors to establish referrals from community-based organizations providing services to MARPs.
In the area of rapid testing progress has been made in making available to pregnant women, but these
benefits are limited to expanding testing among a small population of pregnant women who did not
receive antenatal care. Community-based HIV rapid testing for most at-risk populations is still not
available in the country.
Implications for programming
 HIV prevention programs should focus on increasing VCT among the sexual partners of MARPs
and encourage more partner referral and offer help with partner notification.
 Promote and strengthen partnerships for NGOs and build their capacity in the area of VCT, in
order to increase VCT reach to vulnerable populations; develop capacity to provide mobile VCT
services in outreach programmes.

Increase accessibility and use of rapid tests in point of care and community settings, especially
for MSM and FSWs and in service points outside Chisinau.
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Behavioral Interventions to Reduce Sexual Transmission of HIV
Behavioral interventions aim to reduce the sexual transmission of HIV by motivating behavior change in
individuals, couples, peer groups, networks, institutions, and entire communities. Currently there are
some elements of behavioral approaches, yet there is an overall lack of capacity in both community and
facility-based services to talk about sex behaviors and programming for effective HIV prevention
through changing sexual behaviors.
Implications for Programming
Significant technical assistance is needed to revise and strengthen interventions based on up to date
theories and models. Additionally, donors should support piloting and dissemination of innovative
behavioral interventions among MARPs, with a priority on sexual transmission among male and female
IDU and their partners, FSW and their regular partners, and MSM and their female partners.
Positive Prevention
In 2009, some 512 people were tested by code 101 ‘sexual contacts with a known HIV-infected person’ and 93 or
18% received an HIV-positive test51.
„eu trăiesc acum cu un bărbat care are hepatita C şi SIDA. Eu ştiu ca merg la risc, dar el insistă tot timpul cu
prezervativ. Eu i-am spus că dacă să murim, atunci să murim împreună. O dată s-a rupt prezervativul şi acum
probabil trebuie să merg la medic. Dar eu nu învinuiesc pe nimeni, eu ştiam la ce merg.” (F)
Positive Prevention services are a routine standard of care in HIV prevention, care, and treatment
settings, and are critical for reducing the risk of ongoing HIV transmission. A Positive Prevention package
of services includes behavioral counseling to reduce high-risk behaviors and increase adherence,
condom distribution, STI screening and treatment, OI management, ARV, PMTCT, reproductive health
and family planning services, and harm reduction/MAT. Although HIV-infected people are referred to
and registered in AIDS Centers, there is no apparent formalized, evidence-based intervention for
Positive Prevention services; interventions focus on ARV, TB and STI treatment, and adherence,
supported by some counseling. For example, it is unclear if the promotion of safer sexual behavior
among discordant couples, including condom use, is an integral part of the package of services.
Implications for Programming
Positive Prevention services should be formalized through the piloting, evaluation, and dissemination of
evidence-based Positive Prevention models. Service models should include community- and facilitybased approaches, with a focus on MARPs-friendly services and decentralized delivery
51
National AIDS Center Epidemiological Bulletin 2009. Unpublished draft, 2010.
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