1. SAULIUS ČAPLINSKAS MD, PhD Director, Centre for Communicable Diseases and AIDS Assoc. Prof., Mykolas Romeris University Lithuania The impact of the HELP program on the former Lithuanian AIDS Centre activity Lithuanian experience in organizing intersectoral response and HIV case management www.ulac.lt saulius@ulac.lt

2. Major characteristics of HIV epidemic in Lithuania Concentrated epidemic: – Predominant mode of transmission – men (84%), IDU (73%); average age – 32; F/M = 1/6 – Prevalence in IDUs: 8,5% HIV; 94-98% HCV; 7-10% HBS Ag 64% at least one time have been incarcerated in prison Mainly concentrated in seaport Klaipeda and capital Vilnius 4 % diagnosed at late stage of infection, 6% unknown mode of transmission Increasing number of HIV positive women (54% IDU, 35 % hetero) – 1 case of perinatal transmission Source: Center for Communicable Diseases and AIDS, www.ulac.lt.

3. New HIV/AIDS cases diagnosed in Lithuania Source: Center for Communicable Diseases and AIDS, www.ulac.lt. 2010 01 01 (Population 3,4 mln.)

4. Two essential issues in HIV topic 1.People with complex problems need inter-disciplinary support 2.Passive information on what a patient has to do and how is not effective - A need for informed consent to engage the patient into decision taking process about own health and further actions (since we talk about his behaviour change and medication use for the entire life)

5. The Emerging Role of the HIV Case Management Psychological and Social support Secondary HIV Prevention and Adherence Counselling Social worker, police, nurse, doctor, addiction specialist, peer group etc...

6. HELP training 2006-2008 Total number of participants: 218 including general practitioners, nurses, public health specialists, other medical and social workers New approach in HIV response – The Lithuanian AIDS Centre has introduced HIV case management system including integrated health care, medical, social and psychological services

7. HIV case management in LAC Information and education on HIV/AIDS related issues; Gender-specific services; Harm reduction and needles/syringes exchange ; Psychological-social rehabilitation of drug users; HIV testing and counselling; Motivation and consultation on dependency treatment.

8. HIV case management in LAC Prevention of mother–to-child transmission; Clinical, laboratory and epidemiological surveillance, treatment; Post-exposure prophylaxis; Addressing the social and psychological problems; Testing on and treatment of STI; Referrals to the TB institutions.

9. Principles Underlying the Policy of Lithuanian AIDS Centre for Working With Target Groups Accept them as equals; Treatment on equal basis; Openness in discussing drug use and sexual relations issues; Availability and acceptability of health care and social services; Peer education; Double prevention.

10. Low-threshold site (LTS) for SW and IDUs of the Lithuanian AIDS Centre (LAC) First contacts and needle exchange for IDUs started in 1991; LTS was established in 1998 with the aim to improve services to IDUs and to reduce HIV/STI spread among IDUs and their sexual partners; The staff is also involved in motivation of behavioural change and/or promotion of abstinence from drugs (preparation for detoxification and psychological social rehabilitation), in HIV and other blood-born infection prevention, and in promotion of safer sex.

11. LTS for IDUs of the LAC Other activities of the site staff: – monitoring of HIV, HBV, HCV and behavior, – improvement of patients’ adaptation to the changing environment, – assessment of individual needs of the clients, – information and consultations on available social support, – assistance in resocialisation, stimulation of their social functioning, – evaluation of their social situation, and assistance in problem overcome, etc. Free tests on HIV, hepatitis, other STIs are available on site

12. Clients in Lithuanian AIDS Centre LTHSC for IDUs 20052006200720082009Total Total visits5 8488 8279 7063 4922 895 Permanent clients 210522796401511 New clients13422722578145 Total clients3467 Source: Center for Communicable Diseases and AIDS, www.ulac.lt.

13. Objective: – to evaluate prevalence of HIV, virus Hepatitis B /C and tuberculosis and related risk behaviour in injection drug users in Vilnius LatviaEstoniaLithuania Number of participants (IDUs)407 (Riga) 350 (Tallinn) 400 (Vilnius)

14. Accessibility of HIV prevention services Visits in LTC (syringe/needle exchange) at least once 43 %Riga 82 %Tallinn 98 %Vilnius (comparison among Baltic countries) Source: ENCAP project data

15. Accessibility of HIV prevention services (percent) TallinnRigaVilnius HIV test at least once in a lifetime84,671,794,8 HIV test in last 12 months56,944,272,5 Last test results HIV positive (self - reporting) 40,715,16,3 HIV (+) cases identified 95% PI 55,3 (50-60) 22,6 (19-27) 8 (5-11) HIV+HBV+HCV47,415,66,8 Source: ENCAP project data

16. Awareness of HIV status (comparison among Baltic countries) Research results: Confirmed HIV positive test result, though, not aware of own positive HIV status 25 % (10-40) Vilnius (95% PI) 35 % (28-42) Tallinn (95% PI) 43 % (33-53) Riga (95% PI) Source: ENCAP project data

17. Vilnius injecting drug use characteristics Duration of injection career (years) N%HCV+ (n/%) Crude OR 95% CI Fisher exact test p-value 0,0901 Adjusted OR 95% CI** <=214412 85.7 11 3-5471243 91,5 1.8 (0.1-14.2) 2.0 (0.3-12.3) >533985324 95,6 3.6 (0.4-18.5) 3.4 (0.7-16.7) Source: ENCAP project data

18. Commercial sex workers (female) in Vilnius IDU among CSW: in 1998 - 23% in 2001 - 65% in 2004 - 80% in 2006 - 90 % in 2008 - 96 % Source: Lithuanian AIDS centre, end of 2008 Source: Center for Communicable Diseases and AIDS, www.ulac.lt.

19. Major changes in the structures of the response to HIV in Lithuania, 2009

20. The Centre for Communicable Diseases and AIDS ulac@ulac.lt  Was established on 1 st October 2009 by merging two institutions:  the Centre for Prevention and Control of Communicable Diseases  and the Lithuanian AIDS Centre  The goal of the new institution is coordination of the national response to all communicable diseases  Objectives of the Centre include epidemiological surveillance of communicable diseases, organisation and implementation of vaccination in Lithuanian population, administration of governmental system on communicable diseases and their agents, etc.

21. More circumscribed role focused on HIV-related public health issues of the new institution The Centre for Communicable Diseases and AIDS no longer provides treatment and care for individual PLWHA and high risk groups.

22. Objectives of the Centre for Communicable Diseases and AIDS: Coordination of the national response to all communicable diseases.

23. Objectives of the Centre for Communicable Diseases and AIDS: Implement the Governmental policy on prevention and management of communicable diseases, launch and implement epidemiological surveillance of communicable diseases; Organise and coordinate vaccination of Lithuanian population; Administer the governmental system of communicable diseases and their agents; Provide individual (laboratory diagnostics and immunoprophylaxis) and public health care services.

24. LTHSC for IDUs clients coverage in Lithuania (max 14 centers; - 2 in 2008; - 1 in 2009) LTHSC for IDUs clients / years 20052006200720082009 Total visits48 00245 61543 85656 54847 375 Permanent clients2 5823 4383 3995 9426 047 New clients7944337749771 209 Source: Drug Control Department, www.nkd.lt.

25. LAC Psychosocial rehabilitation department for drug addicted First and innovative establishment in Lithuania (founded 24 March 1992) which gave start for long term rehabilitation programs in Lithuania; In 1999 AIDS centre's professionals developed practice manual for drug user's psychosocial rehabilitation; 1999-2002 more than 18 rehabilitation centres were established all over Lithuania. Up to date 17 rehabilitation centres are functioning; AIDS centre provide educational and methodological support for specialists working with drug addicted people.

26. Drug users rehabilitation communities in Lithuania and impact of AIDS centre Source: Center for Communicable Diseases and AIDS, www.ulac.lt.

27. Results of LAC Psychosocial rehabilitation department's activity 1993 – 2008 People entered the program194 Successfully finished the program 98 (50,5%) In program14 (7,2%) Dropped out but ceased using drugs26 (13,4%) Total not using drugs 138 (71,1%) follow up 1 year Source: Center for Communicable Diseases and AIDS, www.ulac.lt.

28. One year remission rate related to drug treatment stage 1-5% 15-17%25-28% 30-40% Mental disorder treatment Detoxification after drug abstinence Psychotherapy Rehabilitation IV III II I 70% LAC San Patriano

29. The first and only complex service provision model in Lithuania The Lithuanian AIDS Centre has formed the network of NGOs, GOs and private institutions, launched a complex system of dependency prevention, treatment, outreach, harm reduction (LTHSC), rehabilitation and social services.

30. Feedback from HELP trainees Generally, they report to have: Received lot of information; Improved their knowledge on case management and skills on project development and implementation; Improved their communication skills with people with HIV/AIDS and their families; Changed their attitudes towards people with HIV/AIDS and risk groups; Spread their knowledge among colleagues.

31. CONCLUSIONS Intersectorial collaboration improved; Improved awareness of medical workers on principles of HIV case management; Social workers engaged into communication on HIV issues; Services for drug users improved; Low threshold centres in Kaunas and Klaipeda were supported by project implementation; Networking with prison system, LAC and Mykolas Romeris University established.

32. CONCLUSIONS HELP was an impetus to put on agenda the HIV case management issue, to systemize the whole previous information, knowledge and response; HELP could be continued – either as deeper knowledge improvement for the same participants, or/and involving the new ones; HELP could be easily adopted for other countryes HELP in Lithuania could further evolve through expanding into training on communicable diseases case management network.

33. It is important to have similar sheet music and sing one song – in one or several voices Thank You!