Response to HIV/AIDS in Croatia Josip Begovac University Hospital of Infectious Diseases, Zagreb, Croatia Budapest, October 2003

HIV/AIDS in Croatia: an overview Basic indicators Cases of HIV/AIDS Testing/behavior data Response

Croatia – Basic Indicators Total Population: 4,400,000 (2001) Rural/Urban:43/57 (1999) Infant mortality rate: 8 per 1000 live births (2001) Maternal mortality rate: 11 per 100.000 live births (2000) Life expectancy at birth: 73,3 (1999) Adult literacy rate: 98.2 (1999) Per capita GNP: 4,625.1 $ (2002)

HIV/AIDS in Croatia (1986-2002) AIDS=200; HIV/AIDS=386 Deaths:111

Modes of transmission Source: Croatian HIV/AIDS Register

Status of the epidemic merchant marines female male males imported females female 22,5 male males 77,5 male imported imported labor migrants New HIV/AIDS cases among MSM are not imported Source: Croatian HIV/AIDS Register

Number of patients treated at the UHID in in Zagreb, per year in the period 1997-2002 Increasing treatment Increasing prevalence of HIV/AIDS

*duplicates not sorted out Population 1998 Pos*/tested 1999 2000 2001 2002 IVDU 9/761 6/984 5/1047 5/724 10/785 VTC & Clinical settings 46/15891 37/15620 47/22810 44/23043 73/28532 *duplicates not sorted out

Behavioral surveillance Today both men and women have the first sexual intercourse at almost the same age. In the past it was the age of 18 and now it is around 17. (according to dr A. Stulhofer, 2001) Age at first sexual intercourse lower in selected populations of young people (16 years, RAR 2002) Up to 25% of young men and 8,6% of young women aged 16 - 19 had the first sexual intercourse when they were under 16. (A.Stulhofer 2001) -not published in peer reviewed journal

Condom use among youth School based surveys indicate 40-50% of regular condom use by young people (High school and University students) 9,3% of girls and 13% of boys are using condoms regularly (RAR 2002, conducted among vulnerable youth)

Patterns of IV Drug Use Behavior favoring the spread of HIV/AIDS “Shooting galleries” (places where IDUs can rent injection equipment) “Dealer‘s works” (injection equipment kept by a drug seller, which can be lent to successive drug purchases) Protective behavior “Serial monogamy” (e.x. each person changes sharing partners once a year)– new infections occur at a low rate

Patterns of IV Drug Use Life time sharing of needles equipment varies from 40- 70% in various researches Variations among cities, depending on availability of Harm Reduction services Fewer sharing noted in Needle Exchange Programs source: RAR 2002 RAR(UNDCP) 1998

Response-past Educational campaign including sex education in schools (1987-) Testing of blood and blood products (1987-) Availability (purchase) of syringes from the pharmacy for IDUs (1987-) Establishment of confirmatory HIV-testing sites (1986) Establishment of treatment Centers on a national level (1986) National HIV/AIDS Prevention Committee (1992) National HIV/AIDS Prevention Program (1993) First needle exchange program (Help, Split, 1996/97) Introduction of HAART thru National Insurance (1998) Extension of needle exchange programs (1998-2003) Successful global fund application (2002-3)

Country Response - Present National HIVAIDS Committee, -multisectorial- Health Education Justice System Media Social Sector HCK-Harm Reduction Iskorak (G&L) HUHIV – PLWHA Association Children’s Hospital

Response present: HIVAIDS – National Action plan 2003-2005 Main goal: To scale up the national response to HIVAIDS epidemic in Croatia, in order to maintain low level of epidemic and to reduce the risks of increased transmission in the future To maintain a yearly incidence of new HIV infections below 10 per million However: How do I prevent a single case of HIV infection in Croatia?

What do we need more? Evidence-based interventions More research, particularly into human behavior Constantly collect analyze and disseminate health-related information Monitoring and evaluation More investment into prevention

Strategic goals To ensure continuity of care and constantly provide counseling for PLWHA To decrease HIVAIDS risks among people involved in risk behaviors (harm reduction, needle exchange, condoms) To increase the level of protective behaviors among young people aged 14-18 (information, education, condoms) To increase access to voluntary counseling, testing and referral services To improve surveillance of HIVAIDS in Croatia

Strategic goals General public educational efforts (stigma, fear, discrimination) – health care, school and, social sectors Prevention of mother to child transmission Aim for elimination - 100% (zero or close to zero prevalence) Secure blood supply and universal precautions STI prevention and treatment

Continuity of care for PLWHA Comprehensive health care Treatment of HIV (HAART) Treatment of opportunistic diseases Psycho-social counseling and long term case management

To decrease HIVAIDS risks among people involved in risk behaviors-IDU Outreach (peer), needle/syringes/condoms, treatment (methadone) Current outreach 5-50% depending on the location Drug users: to reach out at least 60% of actively injecting IDUs Increase outreach capacity through: Increase the capacity of current HR centers Provide training and capacity building for NGOs and local authorities, where no services are currently available, through training study tours exchange visits Provide regional mobile outreach services out of large urban settings Maintenance of the methadone program (primary care physicians)

To decrease HIVAIDS risks among people involved in risk behaviors- other vulnerable groups Goal: to empower people involved in risk behaviors, to adopt and maintain safe sex practices (NGO) MSM – peer based prevention, counseling and referral services Migrant workers: risk assessment, information, education, referral Sex workers – outreach services, condom programming To increase the level of protective behaviors among young people aged 14-18 peer education

To increase access to voluntary counseling, testing and referral services Current number of tests performed < 25.000 (5 per 1000 inhabitants) Diversification of testing centers Testing of “hard to reach populations” Confidentiality Introduction of rapid tests

Improving surveillance of HIV/AIDS in Croatia in the period 2003-2005 Improving surveillance system including behavior and sentinel HIV surveillance The major research gaps exist among sex workers, and MSM, both behavior surveillance and sentinel

HIVAIDS Expenditures – 2002 The need to increase prevention and research expenditures Total expenditures: 2.6 millinos USD care: 2.3 millions USD

IMPLEMENTING INSTITUTIONS Objective Implementing organizations   Peer Education Children's Hospital, Zagreb Andrija Stampar School of Public Health VCT     Croatian Youth Council, UHID, HUHIV, CPHI   Targeted interventions NGOs (Help, Red Cross, Terra, Iskorak), CPHI   Conitnuity of care UHID, HUHIV   Surveillance CPHI Abbreviations: UHID= University Hospital of Infectious Diseases HUHIV= Croatian association of people living with HIV CPHI= Croatian Public Health Institute  

WHAT IS NEEDED FOR HIV/AIDS PREVENTION (a common sense approach) Political good will Good sex education Condom distribution Needle exchange Good general education Good peer education Good care and treatment Access to information technology Healthy economy