1. Essential package of targeted interventions for MARA Romania Experience

2. UNICEF Romania specific profile General population = 21.5 mill People living with HIV = 9 540 Low HIV prevalence – less than 0.1% - first HIV case: 1985 Aprox. 7 500 young people aged 15-19 years, infected during 1988-1991 via transfussions with infected blood; Efficient governmental and NGOs response (ARV treatment is covered from the National Program funds; National AIDS Commission, national strategy, social protection for PLHIV);

3. UNICEF Estimation of drug users/sex workers in Romania in relation with HIV/HCV/HVB IDU/SW estimation number: 2004 - Bucharest (aprox 2,5 mill. population): 24.000 IDUs (National Anti-drug Agency report); 2008 - Bucharest: 16 800 IDUs - (National Anti-drug Agency report); No statistics available (prostitution is criminalized) HIV cases among IDUs: 1985 – 2008: 3 HIV cases among IDUs (HIV M&E Department); 2008: 3 new HIV cases among IDUs (Public Heath Authority – study among 380 IDUs) HIV/HCV prevalence among IDU accessing Needle Exchange Programs andOpiate Substitution programs (National Antidrug Agency, 2008 – 327 IDUs questioned): 18-24 y. o. = 42% 1.5% HIV prevalence; 61.5% HCV prevalence;

4. UNICEF Project: Essential package of targeted interventions for MARA Goal: To prevent HIV/hepatitis/STIs and to reduce the related harm associated to risk behaviors among MARPs, including MARA Activities: Evaluation study of MARA risk behaviors Harm reduction (IEC, needle exchange, codom distribution, VCT) Referrals to medical and social services Develop and pilot a referral system on voucher basis; Capacity building for local and national counterparts; Networking among counterparts (regular consultation meetings & communication);

5. UNICEF Project: Essential package of targeted interventions for MARA (cont.) Key results achieved so far: 7 ongoing projects targeting MARA (IDU, SW) operating in 4 cities; Research finalized; More than 300 MARA reached out of 3 000 IDU and SW involved in harm reduction services (needle exchange programs, medical care, voluntary testing).

6. UNICEF Partners 7 NGOs providing harm reduction services (RHRN members): –Needle exchange (outreach and drop-in centers): ALIAT, ARAS, Integration, PARADA, Sastipen, Samu Social; –Opiate substitution treatment (ARAS – National Infectious Diseases Institute partnership); –HIV/HCV/HBV counseling and testing (Public Health Authorities and ARAS). Local partners: Child Protection Authorities; Medical Units (National Infectious Diseases Institute; hospitals, clinics, etc). National partners: National Antidrug Agency (NAA); MoH (National Commission against AIDS); Ministry of Labor, Social Protection and Family; National Authority for Child Rights Protection; Romanian Angel Appeal Foundation – GFATM PR for Round II; UNODC (technical and financial assistance – training on MARA and M&E; prevention equipment – condoms, lubricants, injection kit) UNAIDS (technical assistance)

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8. Programme data collection sources National AIDS Authority statistics; MARA data base (data collected at NGOs implementing MARA projects); Voucher collection and analysis; Project records; Service providers interviews; Meeting with partners; Site visits; Routine quality monitoring (supplies, facilities check lists, code system in use).

9. UNICEF Policy, legal barriers and advocacy efforts – voucher system – Medical staff working in NGOs offers the voucher to clients depending on the health problem; The clients access the medical service on voucher basis and informal partnership with ARAS; The vouchers are collected and data interpreted by ARAS coordinator; Preliminary aspects: –Clients, especially FSW, accessed the medical service (HIV, HVB, HCV tests, STI) in an increased number in relation with other vulnerable groups (IDUs); –Increased number of clients accessing medical services, including HIV/HCV, HBV counseling and testing;

10. UNICEF Policy, legal barriers and advocacy efforts – health services – Barriers in accessing health services for MARPs: health insurance; ID papers; parental or child protection consent for under-aged clients; ethical bias of medical staff; limited knowledge in toxicology. Advocacy efforts: Increasing access to medical and social care: partnerships with medical units (the voucher system pilot); cooperation with Population Registration Service – the right to identity; cooperation with child protection services.

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12. Policy, legal barriers and advocacy efforts (cont.) - social protection and ethical concerns - Policy and legal barriers Limited specialized child protection services and professionals (outreach units/detoxification services/low threshold clinics accessible to MARA aged 16 – 25 years old); Parents consent for treatment; Confidentiality. Advocacy efforts Conduct capacity assessment exercise in order to evaluate specific needs of medical care units and child protection departments; Advocate towards local authorities in order to put on their agenda the issue of MARA; Include the MARA problem on National Authority for Child Rights Protection agenda (specialize existing services for MARA under 18 years old)

13. Other challenges due to emerging situations Financial crisis: Cuts in governamental expenditures; Reorganization of central and local authorities: National Antidrug Agency was restructured and reorganized under the Police Inspectorate – its current situation is uncertain; NAA OST services should be taken over by MoH UNICEF

14. Next steps - governmental sector Meetings with MoH – put on MoH agenda the issue of IDU and SW, including MARA; Adopt a minimum medical - social package for uninsured clients; Specialize child protection services for working with MARA under 18 years old; Increase the capacity of local public authorities to work with IDUs and SWs, including MARA through trainings and establishing networks; Conduct impact research on pharmacies and level of syringes access for IDUs.

15. UNICEF Next steps - NGO sector Conduct a capacity assessment of service providers in order to evaluate their needs and develop strategic plans to work with MARA; Increase the capacity of harm reduction NGOs to work with MARA (trainings, standards and protocols of working with MARA); Identify possible solutions for unifying the code system data base on MARA from implementing NGOs in order to avoid overlapping in intervention and have a common data base available at the level of RHRN. RHRN coordination meetings

16. UNICEF Next steps - NGO sector Continue NGOs MARA interventions for 18 months; Conduct internal evaluation of the projects; Conduct MARA study at the end of the project to document changes of risk behaviours due to project implementation or due to other emegeing situation (unemployment rate, poverty, financial crisis).

17. UNICEF Thank you for your attention! Questions or comments? ebadiu@unicef.org valentin_simionov@yahoo.com www.rhrn.ro