Romania and other middle income countries – lost in transition and in lack of solidarity

14 November 2016

Last week, 20 Romanian NGOs addressed the board of the Global Fund to Fight AIDS, TB and Malaria in an open letter calling for support to rebuild the country’s HIV prevention programs for key populations. The donor left the country in 2010 and HIV rates have only increased since. This is just one of many calls for global solidarity among countries in Southern-Eastern Europe where so-called key populations, including people who inject drugs, men who have sex with men, trans* people, prisoners and sex workers—are being left behind by their governments and donors. Across the globe, middle-income countries like Romania face similar challenges.

Doing much for HIV treatment but not for prevention

Romania was the first country in Eastern Europe and Central Asia to start a large scale HIV treatment and today spends 70 million euros for HIV treatment, care and support—reaching universal access and covering 10,000 people living with HIV. That was a great achievement, especially given that the country makes several of the European Union’s lists of highest social inequalities, including only spending only 5.6 percent of its GDP on health, having the second highest poverty rate, and one of the highest income inequalities in the Union.

But when it comes to HIV prevention, however, there is much more to be done. The Romanian government spends less than 1 percent of its total AIDS budget on HIV prevention programs, while UNAIDS’ estimates recommend governments budget at least 25 percent for effective programs.

Becoming an ‘example’ of failed transition with untold story of MSM

In early 2010, the country—a new member of the European Union—was praised for starting a pilot opioid substitution therapy program and needle exchange in prisons. This work was supported by the Global Fund to Fight AIDS, TB and Malaria, and by the Dutch government through UN Office on Drugs and Crime. However, both those funding streams stopped by 2011 and the government did not take over the funding. NGO services started shrinking rapidly. At the same time, the drug injection scene also changed with emergence of new legal highs, and some people were injecting up to 10 times a day. People who inject drugs remained unable to access to health programs, and 88 percent were left without medical insurance.

Unsurprisingly, HIV prevalence among people who inject drugs started growing rapidly. And by 2013 it had grown from 3.3 percent in 2009 to 27.5 percent. This surge in HIV was extensively documented in 2013 by various European Union agencies and highlighted in numerous reports but there was no money or commitment from the government to invest in re-building the prevention services among people who inject drugs.

In 2014, civil society groups attempted to secure funding from the Global Fund to Fight AIDS, TB and Malaria through an “exceptional NGO rule” that allows HIV funds to go to NGOs from middle income countries, which should be supporting HIV prevention and treatment programs but don’t due to political barriers in spite of epidemiological imperative. The request, however, was denied.

In addition to increased HIV rates among populations of people who inject drugs, the prevalence among gay and other men who have sex with men has also increased. In the EU funded study SIALON II, Bucharest recorded the highest HIV prevalence among the 13 cities in study at 18 percent. The country’s official report to the United Nations on the progress of their AIDS response also acknowledges that there are no programs remaining that target men who have sex with men.

The European Union’s support

Romania receives one of the largest amount of the European Union structural support, including funding for reducing social inequalities among and within EU countries. From 2011 to 2014, NGOs applied and received some funds for running social reintegration and testing services for people who use drugs, but at high cost: Receiving funding requires programs to report personal data of all clients to a government agency.

Deja vu across Southern Eastern Europe and later in the East?

The Global Fund to Fight HIV, TB and Malaria has recently shifted its funding to focus on the world’s poorest nations with the highest burdens of disease. Countries like Bosnia-Herzegovina and Macedonia—upper middle-income countries where key populations managed to keep HIV below 5 percent—are no longer eligible for funding and will lose their main source of funding for HIV services for key populations. Bulgaria is another example. The country is finishing its final HIV grant this year and the funding of its HIV programs remains uncertain.

Two countries in the South-Eastern European region—Montenegro and Serbia—experienced an HIV increase among men who have sex with men after the Global Fund’s support for HIV programs ended in 2015 and 2014. Today, the HIV prevalence is high enough to make both countries eligible for funding again.

Being eligible for funding, however, does not guarantee you funding. Romania was allocated zero for HIV in the last allocation cycle of 2014-2016. While the exact allocations won’t be announced until December 15 this year, some are already forecasting that most Eastern Europe, South-Eastern European, and Central Asian countries should expect cuts by at least one third.

Way forward

Non-governmental groups in Romania are pointing to the major gaps in commitments from funders globally to the HIV response—especially the failed plans for transitioning from Global Fund support to national funding in middle-income countries. What Romanian groups expect from the Board of the Global Fund when it meets on 14-15 of November 2016, are answers to the following questions: What do UMICs and MICs do when they’re illegible for funding but there’s no political will to pick up the tab? What do HIV prevention and treatment services do when they are left behind by both donors and governments? How is the Global Fund planning to transition from these countries to ensure key populations don’t get left behind? How to ensure the real use of the NGO rule that was designed to address such exceptional cases likes their – being part of the rich countries but not for key populations, where NGO-run services are left behind by both donors and governments?

These questions and the global call to action is a call for more solidarity within and with the Global Fund, but also in our communities and regions. We need to look for solutions together, and not only for one group or one disease. This call is also to raise the alarm for the European Union and other donors to reconsider rapid transition but also to help facilitate a political dialogue with governments—like Romania—about how to do things right.