Response to HIV/AIDS in Croatia

Josip BegovacJosip Begovac

University Hospital of Infectious Diseases, University Hospital of Infectious Diseases, Zagreb, CroatiaZagreb, Croatia

Budapest, October 2003

HIV/AIDS in Croatia: an overview

CroatiaCroatia Basic Basic indicatorsindicators Cases of HIV/AIDS Cases of HIV/AIDS TestingTesting//behavior databehavior data ResponseResponse

Croatia – Basic IndicatorsTotal Population: 4,Total Population: 4,4400,00000,000 (200(20011))Rural/Urban:43/57 (1999)Rural/Urban:43/57 (1999)Infant mortality rate: 8 per 1000 live births (2001)Infant mortality rate: 8 per 1000 live births (2001)Maternal mortality rate: 11 per 100.000 live births Maternal mortality rate: 11 per 100.000 live births (2000)(2000)Life expectancy at birth: 73,3 (1999)Life expectancy at birth: 73,3 (1999)Adult literacy rate: 98.2 (1999)Adult literacy rate: 98.2 (1999)Per capita GNP: 4,625.1 $ (2002)Per capita GNP: 4,625.1 $ (2002)

http://wolf.hr/album/index.htm

HIV/AIDS in Croatia (1986-2002)

AIDS=200; HIV/AIDS=386 Deaths:111

0

5

10

15

20

25

30

35

40

45

nu

mb

er o

f pa

tien

ts

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

years

deaths

AIDS

HIV/AIDS

Modes of transmission

Source: Croatian HIV/AIDS Register

HIV/AIDS according to risk groups

2% 4%

37%

41%

11%

5%

perinatal

haemophyliacs

homo-bi

hetero

IVDU

Unknown

Status of the epidemic

female

malemale

females

merchant marines

labor migrants

New HIV/AIDS cases among MSM are not imported

imported

22,5

77,5

males

37

63

imported

Source: Croatian HIV/AIDS Register

Number of patients treated at the UHID in in Zagreb, per year in the period 1997-2002

Increasing treatment Increasing prevalence of HIV/AIDS

75

13 8

97

10

43

120

3

70

147

9

108

172

3

126

205

4

155

0

50

100

150

200

250

1997 1998 1999 2000 2001 2002

Number of treated

Deaths

HAART

Percentage of HIV positive tests in IDU and in VTC & Clinical settings in the period from 1998 to 2002

0,00

0,50

1,00

1,50

1998 1999 2000 2001 2002

Years

Pe

rce

nta

ge

s

IVDU (% positive) VTC & Clinical

Population Population 19981998Pos*/testedPos*/tested

19991999Pos*/testedPos*/tested

20002000Pos*/testedPos*/tested

20012001Pos*/testedPos*/tested

20022002Pos*/testedPos*/tested

IVDUIVDU 9/7619/761 6/9846/984 5/10475/1047 5/7245/724 10/78510/785

VTC & Clinical settingsVTC & Clinical settings 46/1589146/15891 37/1562037/15620 47/2281047/22810 44/2304344/23043 73/2853273/28532

*duplicates not sorted out

Behavioral surveillance

Today both men and women have the first Today both men and women have the first sexual intercourse at almost the same age. In sexual intercourse at almost the same age. In the past it was the age of 18 and now it is the past it was the age of 18 and now it is around 17. (around 17. (according to dr Aaccording to dr A.. Stulhofer Stulhofer, 2001, 2001))

Age at first sexual intercourse lower in selected Age at first sexual intercourse lower in selected populations of young people (16 years, RAR populations of young people (16 years, RAR 2002)2002)

Up to 25% of young men and 8,6% of young Up to 25% of young men and 8,6% of young women aged 16 - 19 had the first sexual women aged 16 - 19 had the first sexual intercourse when they were under 16.intercourse when they were under 16. (A.Stulhofer (A.Stulhofer 2001)2001)

-not published in peer reviewed journal

Condom use among youth

School based surveys indicate 40-50% of School based surveys indicate 40-50% of regular condom use by young people regular condom use by young people (High school and University(High school and University students students))

9,3% of girls and 13% of boys are using 9,3% of girls and 13% of boys are using condoms regularlycondoms regularly ( (RAR 2002RAR 2002, , conducted conducted

among vulnerable youthamong vulnerable youth))

Patterns of IV Drug Use

Behavior Behavior favoringfavoring the spread of HIV/AIDS the spread of HIV/AIDS ““Shooting galleries” (places where IDUs can rent Shooting galleries” (places where IDUs can rent

injection equipment)injection equipment) ““DealerDealer‘‘s works” (injection equipment kept by a s works” (injection equipment kept by a

drug seller, which can be lent to successive drug drug seller, which can be lent to successive drug purchases)purchases)

Protective behavior Protective behavior ““Serial monogamy” (e.x. each person changes Serial monogamy” (e.x. each person changes

sharing partners once a year)– sharing partners once a year)– new infections occur new infections occur at a low rateat a low rate

Patterns of IV Drug Use

Life time sharing of needles Life time sharing of needles equipmentequipment varies varies from 40- 70% in various researchesfrom 40- 70% in various researches

Variations among cities, depending on Variations among cities, depending on availability of Harm Reduction servicesavailability of Harm Reduction services

Fewer sharing noted in Needle Exchange Fewer sharing noted in Needle Exchange PProgramsrograms

source: RAR 2002source: RAR 2002

RAR(UNDCP)RAR(UNDCP) 19981998

Response-past Educational campaign including sex education in schools (1987-)Educational campaign including sex education in schools (1987-) Testing of blood and blood products (1987-)Testing of blood and blood products (1987-) Availability (purchase) of syringes from the pharmacy for IDUs Availability (purchase) of syringes from the pharmacy for IDUs

(1987-)(1987-) Establishment of confirmatory HIV-testing sitesEstablishment of confirmatory HIV-testing sites (1986) (1986) Establishment of treatment Centers on a national levelEstablishment of treatment Centers on a national level (1986) (1986) National HIV/AIDS Prevention Committee (199National HIV/AIDS Prevention Committee (19922)) National HIV/AIDS Prevention Program (1993)National HIV/AIDS Prevention Program (1993) First needle exchange program (Help, Split, 1996/97)First needle exchange program (Help, Split, 1996/97) Introduction of HAART thru National InsuranceIntroduction of HAART thru National Insurance (1998) (1998) Extension of needle exchange programs (1998-200Extension of needle exchange programs (1998-20033)) Successful global fund applicationSuccessful global fund application (2002-3) (2002-3)

Country Response - Present

National HIVAIDS Committee, National HIVAIDS Committee,

-multisectorial--multisectorial-

Health Justice SystemEducation

Children’s Hospital

HCK-Harm Reduction

HUHIV – PLWHA Association

Iskorak (G&L)

Media Social Sector

Response present: HIVAIDS – National Action plan 2003-2005

MainMain goal: goal: To scale up the national response to HIVAIDS To scale up the national response to HIVAIDS

epidemic in Croatia, in order to maintain low epidemic in Croatia, in order to maintain low level of epidemic and to reduce the risks of level of epidemic and to reduce the risks of increased transmission in the futureincreased transmission in the future

To maintain a yearly incidence of new HIV To maintain a yearly incidence of new HIV infections infections below 10 per millionbelow 10 per million

However:However: How do I prevent a single case of HIV infection How do I prevent a single case of HIV infection

in Croatia?in Croatia?

What do we need more?

Evidence-based interventionsEvidence-based interventions More research, particularly into human More research, particularly into human

behaviorbehavior Constantly collect analyze and Constantly collect analyze and

disseminate disseminate health-related information health-related information Monitoring and evaluationMonitoring and evaluation More investment into preventionMore investment into prevention

Strategic goals

To ensure continuity of care and constantly To ensure continuity of care and constantly provide counseling for PLWHAprovide counseling for PLWHA

To decrease HIVAIDS risks among people To decrease HIVAIDS risks among people involved in risk behaviors (harm reduction, needle involved in risk behaviors (harm reduction, needle exchange, condoms)exchange, condoms)

To increase the level of protective behaviors To increase the level of protective behaviors among young people aged 14-18 (information, among young people aged 14-18 (information, education, condoms)education, condoms)

To increase access to voluntary counseling, testing To increase access to voluntary counseling, testing and referral servicesand referral services

To improve surveillance of HIVAIDS in CroatiaTo improve surveillance of HIVAIDS in Croatia

Strategic goals

General public educational efforts (stigma, General public educational efforts (stigma, fear, discrimination) – health care, school fear, discrimination) – health care, school and, social sectorsand, social sectors

Prevention of mother to child transmissionPrevention of mother to child transmission Aim for elimination - 100% (zero or Aim for elimination - 100% (zero or

close to zero prevalence)close to zero prevalence) Secure blood supply and universal Secure blood supply and universal

precautionsprecautions STI prevention and treatmentSTI prevention and treatment

Continuity of care for PLWHA

Comprehensive health care Comprehensive health care Treatment of HIV (HAART)Treatment of HIV (HAART) Treatment of opportunistic diseasesTreatment of opportunistic diseases Psycho-social counseling and long term case Psycho-social counseling and long term case

management management

To decrease HIVAIDS risks among people involved in risk behaviors-IDU OOutreach (peer), needle/syringes/condoms, treatment (methadone)utreach (peer), needle/syringes/condoms, treatment (methadone) Current outreach 5-50% depending on the locationCurrent outreach 5-50% depending on the location Drug users: to reach out at least 60% of actively injecting IDUs Drug users: to reach out at least 60% of actively injecting IDUs Increase outreach capacity through:Increase outreach capacity through:

Increase the capacity of current HR centersIncrease the capacity of current HR centers Provide training and capacity building for NGOs and local Provide training and capacity building for NGOs and local

authorities, where no services are currently available, through authorities, where no services are currently available, through training study tours exchange visitstraining study tours exchange visits

Provide regional mobile outreach services out of large urban Provide regional mobile outreach services out of large urban settings settings

Maintenance of the methadone program (primary care physicians)Maintenance of the methadone program (primary care physicians)

To decrease HIVAIDS risks among people involved in risk behaviors- other vulnerable groups

Goal: to empower people involved in risk behaviors, to Goal: to empower people involved in risk behaviors, to adopt and maintain safe sex practices (NGO)adopt and maintain safe sex practices (NGO)

MSM – peer based prevention, counseling and referral MSM – peer based prevention, counseling and referral servicesservices

Migrant workers: risk assessment, information,Migrant workers: risk assessment, information, education,education, referral referral

Sex workers – outreach services, condom programmingSex workers – outreach services, condom programming To increase the level of protective behaviors among To increase the level of protective behaviors among

young people aged 14-18young people aged 14-18 peer educationpeer education

To increase access to voluntary counseling, testing and referral services

Current number of tests performed < 25.000 Current number of tests performed < 25.000 (5 per 1000 inhabitants)(5 per 1000 inhabitants)

Diversification of testing centers Diversification of testing centers Testing of “hard to reach populations”Testing of “hard to reach populations” ConfidentialityConfidentiality Introduction of rapid testsIntroduction of rapid tests

Improving surveillance of HIV/AIDS in Croatia in the period 2003-2005

Improving surveillance system including behavior Improving surveillance system including behavior and sentinel and sentinel HIV HIV surveillancesurveillance

The major research gaps exist among sex workers, The major research gaps exist among sex workers, and MSM, both behavior surveillance and sentineland MSM, both behavior surveillance and sentinel

HIVAIDS Expenditures – 2002The need to increase prevention and research expenditures

•Total expenditures: 2.6 millinos USD

•care: 2.3 millions USD

90%

9% 1%

care

prevention

research

Objective Implementing organizations

 

Peer Education

Children's Hospital, ZagrebAndrija 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

 

IMPLEMENTING INSTITUTIONS

WHAT IS NEEDED FOR HIV/AIDS PREVENTION(a common sense approach)

Political good willPolitical good will Good sex educationGood sex education Condom distributionCondom distribution Needle exchangeNeedle exchange Good general educationGood general education Good peer educationGood peer education Good care and treatmentGood care and treatment Access to information technologyAccess to information technology Healthy economyHealthy economy