Response to HIV/AIDS in Croatia

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 • Croatia • 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 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)

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 females 22,5 female male 77,5 males 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

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 16 - 19 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 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

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 (1998-2003) • 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 14-18 (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 < 25.000 (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 – 2002The 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