REPUBLIC OF ALBANIA MINISTRY OF HEALTH LETÿS KEEP ALBANIA A LOW HIV PREVALENCE COUNTRY The National Strategy of Prevention and Control of HIV/AIDS in Albania 2004 þ 2010 December 2003 UNAIDS INSTITUTE OF PUBLIC HEALTH The need for a Strategy of Prevention and Control of HIV/AIDS in Albania The need for a Strategy of Prevention and Control of HIV/AIDS in Albania became evident after 2000 due to the following factors: - Change of epidemiological situation, with an increase in the number of new cases every year. Out of 117 HIV/AIDS cases diagnosed and reported (as of end November 2003), 75 have been detected after 2000, with an average of 20 cases annually. - Change of behavioral patterns among the general population. Although, more in- depth studies are needed, existing data shows an increasing trend of risky behaviors. - The opportunities and the need to establish an active intersectorial and interagency collaboration and actions. - The need to plan in a long-term approach and avoid spontaneous responses in potential emergency situations that might emerge, if appropriate measures are not taken in time. - Building of necessary technical, scientific and management capacities able not only to develop strategic plans, but also to implement them. - Strengthening the efforts and commitment of the Albanian Government and International Organizations present in our country, to achieve Millennium Development Goals where prevention and control of HIV/AIDS is included in Objective Nr.6. Combination of these factors led to the development of a national project, implemented by the Ministry of Health and the Institute of Public Health within the framework of a regional project, which included 10 other countries of East and Central Europe funded by UNDP, UNAIDS and MoH. The goal of this project was the preparation of a Draft Strategy for Prevention and Control of the spread of HIV/AIDS in Albania, titled ÿLetþs keep Albania a low HIV prevalence countryý. 2 A National Strategic Advisory Group of Experts representing different sectors, governmental, nongovernmental and international agencies was established near the Ministry of Health. A long process of consultations and round tables was finalized by the approval of the draft strategic paper in October 2003. The Albanian HIV/AIDS National Inter-Ministerial Committee in its meeting in December 2003 adopted the proposed draft strategy with minor changes. Acknowledgments The Ministry of Health gratefully acknowledges the time, expertise and efforts of different governmental, nongovernmental and international agencies as well as of other consultants and internal Institute of Public Health staff that composed the working groups and participated in round tables leading to preparation of the draft strategy of prevention and control of HIV/AIDS in Albania. This document benefited from thoughtful recommendations and written comments as well as active participation of members of National Strategic Advisory Group of Experts listed in Appendix C. We recognize the guidance provided by Deputy Minister of Health Office especially Dr.Petrit Vasili and Dr.Eduart Hashorva. We acknowledge the contribute of UNDP country office and especially Mrs.Anna Stjarnerklint, Mrs Elzira Sagynbaeva, Mrs.Irena Dule, Mrs.Etleva Vertopi and Mrs. Maria Roura and Dr.Erion Dasho for helping to coordinate the process and as a catalyst for the development of this document. A special thank to country HIV/AIDS UN Theme Group chaired by Dr.Santino Severoni for their strong support during the strategy preparation process. We highly appreciate the contribute of USAID and Prof. James Chin as well as UNICEF for the support towards epidemiological and vulnerability evaluation of HIV/AIDS in Albania. Dr. Manuel Carballo and Dr.Rony Shtarkshall are very much appreciated for their continuous and invaluable insights provided for the refinement of such document. 3 Finally we recognize and acknowledge the work of drafting committee composed of Dr.Silva Bino, Dr,Erion Dasho, Dr.Arian Harxhi, Dr.Memo Boci, Dr.Roland Bani and Dr.Teuta Starova. 4 Contents 1. Guiding principles of the strategy 7 2. Situation analysis regarding HIV/AIDS in Albania 9 2.1. Introduction 9 2.1.1. The geographical position and the economical and social development 9 2.1.2. The important health indicators and organization of health system 11 2.2. The epidemiological situation of HIV infection in Albania 13 2.2.1. Past and current status of the HIV/AIDS in Albania 13 2. 2 .2. Vulnerability to HIV/AIDS of specific groups of population 15 2.2.2.1. The General Population 15 2.2.2.2. Young people 16 2.2.2.3 Women and gender related issues 16 2.2.2.4. Mobile population 17 2.2.2.5. Injecting drug users 18 2.2.2.6. Commercial sex workers 19 2.2.2.7. Men who have sex with man 21 2.2.2.8. Patients with Sexually Transmitted Infections 22 2.2.2.9. The prisoners 23 2.2.2.10. Roma community 23 2.2.3. Current Estimates of HIV/AIDS in Albania and Projections 25 3. Response analysis 27 3.1. Government 27 3.1.1. National HIV/AIDS/STI Program (Institute of Public Health) 27 3.1.2. Diagnostic capacities 28 3.1.3. Surveillance of HIV/AIDS 28 3.1.4. Blood safety and blood donors 30 5 3.1.5. Legal acts ensuring health and human rights 31 3.1.6. Activities in the area of prevention and care and support for PLWHA 31 3.1.6.1. Information, education, communication and training 31 3.1.6.2. Condom use and condom promotion 32 3.1.6.3. Confidential and voluntary counseling and testing 33 3.1.6.4. Care and support for people living with HIV/AIDS 33 3.1.2. Other government structures and country coordinating mechanism 35 3.2. NGOs 35 3.3. International organizations 36 4. Strategy goal, strategic components and objectives 39 5. Strategy implementation structures 54 Annex 1. Strategic Advisory Group of Experts 60 Annex 2. Acronyms 63 Annex 3. HIV/AIDS Figures 65 Annex 4. Implémentation Plan (separate document) 6 1. Guiding principles of the strategy The National Strategy of Prevention and Control of HIV/AIDS in Albania (NSPCHA) is designed based on the following principles: - NSPCHA will help in the management, coordination and orientation of the work of government, non-governmental and international organizations with activities in the area of prevention and control of HIV/AIDS in Albania. - NSPCHA is a comprehensive document using a multifaceted approach to HIV prevention addressing the individual, community, societal and structural level prevention and control needs. - The strategy will be reviewed and, eventually, modified bi-annually based on data provided from monitoring and evaluation process, changes in epidemiological situation, findings of research and scientific work, and possible organizational opportunities. - NSPCHA will ensure the continuity of the work of all organizations and structures involved in the area of prevention, care, and control of HIV/AIDS in Albania. It will reflect recommendations of international organizations (UNAIDS and WHO, in particular) as well as previous National HIV/AIDS Conferences. - NSPCHA creates a supportive environment and will guarantee the respect for human rights and places such value in the center of all HIV prevention, care and control activities. - NSPCHA will ensure that HIV prevention and control programs do the utmost to prevent and control HIV/AIDS based on available resources. - NSPCHA recognizes the importance of risky behaviors and the role of stigma and discrimination as a barrier to deliver highly effective programs of prevention, care and treatment. On the other hand, the NSPCHA views non-response to the specific needs of at-risk and vulnerable or marginalized groups as covert discrimination through neglect and will therefore focus on developing appropriate responses to their needs. 7 - NSPCH recognizes the importance of gender based HIV prevention and control programs stressing out gender equality and empowerment of women - NSPCHA addresses HIV/AIDS prevention and control as multidimensional problem related not only to health and in conjunction with all partners at all levels in the public, private and non profit sector and in coherence with other existing country strategies. 8 2. Situation Analysis regarding HIV/AIDS in Albania 2.1. Introduction 2.1.1. The geographical position and the economical and social development Albania is located in the Southeastern Europe (SEE) at western part of Balkan Peninsula. The country borders on UN Administered province of Kosova and Republic of Serbia and Montenegro to the north, the Former Yugoslav Republic of Macedonia to the east, Greece to the south and south east and Adriatic and Ionian Seas to the west. The terrain is mountainous except along the central coast. About 40% of the 3.1 million people of Albania live in urban areas. Approximately 20% of the population inhabits the capital of Tirana. Albania has the youngest population in Europe with an average age of 29 years old and 40% of the population is under 18 years old. Seventeen percent of the total population belongs to young people of 15-24 years old where 20% are thought to have been migrating abroad (INSTAT, 2002). Albania is a Parliamentary Republic, where the government is nominated by Albanian Parliament. The country is administratively divided into 36 districts and 12 prefectures, 309 communes, and 65 municipalities. Since the collapse of communism in 1991-1992 the transition from centralized government to a more developed free market economy brought social, political and economic changes to the country. During the years 1992-93 there was a huge wave of emigration mainly to Italy and Greece, which proximity to Albania makes them a natural destination of economic migrants. During the period 1990-95 it is estimated that the number of emigrants ranged from 300,000 to 600,000, representing the total population in 1995. During the past 12 years Albania has faced continuous political and social changes, and after a period of transition, interrupted many times by social crises such as those of the years 1991ü1992 and 1997 (the collapse of pyramid schemes) and the Kosovo crisis in 1999, Albania is now a country under profound economic and structural reforms. The economy of the country is changing from a central economic planning system to a free- market system; many questions related to privatization, property ownership claims, and the appropriate regulation of business still remain unresolved. 9 The country has experienced slow but steady economic progress; however, about 30% of the population of approximately 3.1 million lives below the poverty line, with poverty greater in rural areas (UNICEF-Albania, 2000a). The official unemployment rate is 16%, with two-thirds of all workers employed in agriculture, mostly at the subsistence level. Remittances from citizens working abroad remain extremely important, as does foreign assistance. Albania is a lower middle income country with a Gross National Income (GNI) per capita of US$ 1,380. Nonetheless, the country faces considerable challenges as it remains one of the poorest countries in Europe. The country has good potential for growth in agriculture, livestock, fisheries, forestry, tourism, mining, and light industry and the Albanian government has recently prepared a new strategy for poverty eradication, and economic and social development. Albania started negotiations with the European Union for a Stabilization and Association Agreement (SAA) in January 2003. Negotiations have so far focused on political issues. The policy of social welfare is highly conditioned from the economical situation. The programs of development and stimulation of the employment, social welfare, special social support of vulnerable groups are not sufficient. Also support on intervention programs for such groups of the population including health education, information and communication or behavioral change programs substantially lack funding although the attempts made by either governmental and non-governmental organizations or international agencies. The unemployment rate is higher among Roma group and it is the main cause of internal migration from rural areas to main cities or immigration outside the country. The National Strategy for the Economical and Social Development which aims poverty reduction and social and economical development of the country and placing an important role on HIV/AIDS prevention efforts has been recently adopted. The Albanian Government has signed the Millennium Declaration and hereby is committed to achieve the Millennium Development Goals. 10