HIV INFECTION IN ROMANIA Current Strategies Odette Chirila, clinical psychologist The Institute of Infectious Diseases “

1. HIV INFECTION IN ROMANIA Current Strategies Odette Chirila, clinical psychologist The Institute of Infectious Diseases “Prof. Dr. Matei Bals” Bucharest, ROMANIA

3. Romania

4. General Data Romania’s population = 22,000,000 Total cumulative cases of HIV/AIDS=14 385

5. Overview • Cumulative HIV + AIDS = 14 385 • Living with HIV + AIDS = 10 278 • Children living with HIV / AIDS = 7 797 • Under treatment = 5 547

6. Trends for Romania • maintenance of a high number of new pediatric cases (born between 1987 – 1990), with the disappearance of non-vertical transmission after 1994 and an increase in vertical transmission; • a rapid increase of the number of new adult cases (especially in young adults), involving heterosexual transmission;

7. Trends for Romania • an overall increase of the number of HIV positive persons who seek medical care and ARV therapy, that means increasing life expectancy, decreasing mortality, improving the quality of life in HIV / AIDS patients, increasing adherence and compliance to therapy; • Romania has a Surveillance and Monitoring Program, developed through 9 Regional Centers;

8. Trends for Romania cont. • Each center has a Day Clinic for children and adults; • In our Day Clinic for HIV Children we have registered 985 cases; 610 of them being active cases; mean age is12 – 14 years old; • 198 children benefit by psychological services:psychotherapy – specific interventions to factors causing behavioral disturbances,family counseling throughout the entire disease process,preparing the family and the infected child / adolescent for disclosure,supportive counseling in the terminal stage, continued after the child’s death / loss and grieving.

9. National HIV / AIDS strategy • The last one adopted: 2002 / Low no. 584 • Partners: • Government (MNAC): MOH, Education, Defense, Interior, Justice, Youth and Sports, Labour, Finance; • National Helath Insurance System • NGO,s • UN system • World Bank / Global Fund / PHARE • Drug Companies: MSD, GSK , BMS, Roche, Abbott, BI

10. National HIV / AIDS strategy (cont.) • Priority areas: • youth • vulnerable and disadvantaged groups (sexworkers, homosexuals, IDUs, rroma population, prisoners) • nosocomial infection control • health care • social support • epidemilogy: testing policies and surveillance • education

11. Challenges • increasing number of IDU,s • tuberculosis and HIV / AIDS interaction • increasing number of STI,s • the children cohort  adolescents • human rights issues (eg. discrimination, confidentiality)

12. The National Program for the Prevention of HIV Infection • Sexual Education Programs for General Population • leaflets; • condoms; • TV and Radio broadcasts; • health education in schools. • Sexual Education Programs for High Risk Groups • sex workers; • homosexuals; • street children; • IDU,s.

13. The National Program for the Prevention of HIV Infection (cont.) Prevention of Vertical Transmission • HIV screening in areas with a high incidence of HIV infection. • HIV testing is strongly recommended for pregnant women, but it is not mandatory. • ARV treatment for HIV pregnant woman • ARV profilaxis for the new-born • Avoiding breastfeeding / Milk formula for the new-born

14. Methodology of pregnant woman testing Prevention of HIV MTCT PSYCHOLOGIST SOCIAL WORKER INFECTIONIST GINECOLOGYST 8 9 10 7 PREGNANT WOMAN FAMILY DOCTOR 1 2 6 COUNSELOR 3 5 4 TEST ACCEPTED ACREDITATED LAB HIV TEST RESULT

15. Vertical transmission by year of diagnosis Total: 477

16. The National Program for the Prevention of HIV Infection (cont.) • Increasing number of IDU,s; • Estimated number: 33 000 persons; • HIV infected IDU,s: 5; • Harm reduction programs: - Romanian Harm Reduction Network - decreasing of at-risk behaviors associated to drugs use; - prevention of HIV, HBV, HCV transmission among IDU,s (needle exchange, testing, vaccination, treatment, psychological counseling) - Romanian Anti- Drug Agency (strategies and policies)

17. The National Program for the Prevention of HIV Infection (cont.) Blood donors • Since 1990 all donated blood is mandatory tested for: HIV, HBV, HCV, syphilis; • All donors for transplantation are tested, too.

18. Blood donors

19. The National Program for the Prevention of HIV Infection (cont.) TB patients • Since 1995 MOH ordered HIV testing with counseling for all TB persons; • All HIV persons are investigated for TB.

20. TB patients

21. The incidence of syphilis

22. STI,s patients

23. Medical Care and Monitoring • Generally, in hospitals for infectious diseases; • The associated conditions to HIV infection are treated in clinics of infectious diseases, TB, STI’s and other specialized clinics;

24. ARV Treatment in Romania • ARV therapy was introduced in 1995 (ZDV); • In 1996, double therapy with ZDV+ddC was introduced; • Followed by ZDV+3TC in 1997; • Since late 1997, triple therapy (2 NRTI+1IP) became operational (HAART); • 1998 - the first edition of the“Guide to HIV/AIDS Therapy”.

25. Principles of ARV Therapy • non-discrimination, • solidarity, • cost-effectiveness, • optimum quality ARV Therapy Goals • Increasing life expectancy; • Decreasing mortality; • Decreasing morbidity through AIDS-related diseases; • Improving the quality of life in HIV/AIDS patients; • Increasing adherence to therapy; • Increasing compliance to therapy; • Facilitating access to ARV therapy for eligible patients.

26. ARV Therapy Initiation Criteria • Since May 1999, the MOH National AIDS Commission recommends that ARV therapy be initiated according to the following criteria: • Clinical: symptomatic HIV infection non-symptomatic HIV infection + immunological criteria non-symptomatic HIV infection + virological criteria. • Immunological: CD4 count<350 cells/mm3. • Virological: HIV-RNA> 50,000 copies/ml.

27. Factors Ensuring Access to ARV Therapy • The political commitment, stated in the program of the current government, to increase access to ARV therapy for the HIV persons; • Reinforcement of the national capacity to provide preventive and therapeutic strategies; • Involvement of all social segments (government, non-governmental organizations, pharmaceutical industry, local administration, etc.).

28. Psychological perspective on priorities and needs in HIV / AIDS • pre-testing counseling • post-testing counseling • psychotherapy – specific interventions to factors causing behavioural disturbances • family counseling throughout the entire disease process • preparing the family and the infected child for disclosure • supportive counseling in the terminal stage, continued after the child’s death / loss and grieving

29. Disclosure the diagnosis / Assumptions the child handles the disease in a more appropriate manner if: - he is part of the clinical process - understands what is happening to him develops trust towards the adults protect him and learns to adjust; so the child’s life expectancy improves: *the imminent death concept has disappeared, * letting the child know about the diagnosis provides him with new capabilities to face the difficulties associated with HIV infection, * representations are changing;

30. Disclosure the diagnosis / Assumptions The children cohort  adolescents • 7 797 children living with HIV / AIDS • 75 % of them are coming to become adolescents, with their specific problems, especially sexual experiences; • These data are representing the basis for establishing the future prevention strategy, these persons being or becoming sexually active; • Disclosure of HIV status is necessary in the process of their education in preventing the spread of infection; • Disclosure of diagnosis and psychological counseling is one of the most important goals of the National Program for the Prevention of HIV Infection, which has to face with stigma, discrimination and isolation.

31. “ After disclosure I found out what does it means HIV. In my opinion is hope, decision to face destiny and to prouve that I can be someone, although I am infected. At least, I am a human being…”