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

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

3. 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 live births (2000)
Life expectancy at birth: 73,3 (1999)
Adult literacy rate: 98.2 (1999)
Per capita GNP: 4,625.1 $ (2002)

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

6. Modes of transmission
Source: Croatian HIV/AIDS Register

7. 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

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

9. *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

10. 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 had the first sexual intercourse when they were under 16. (A.Stulhofer 2001)
-not published in peer reviewed journal

11. 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)

12. 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

13. Patterns of IV Drug Use
Life time sharing of needles equipment varies from % 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

14. 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 ( )
Successful global fund application (2002-3)

15. 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

16. 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?

17. 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

18. 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 (information, education, condoms)
To increase access to voluntary counseling, testing and referral services
To improve surveillance of HIVAIDS in Croatia

19. 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

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

21. 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)

22. 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

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

24. 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

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

26. 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

27. 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