Unless otherwise referenced, data included in the following overview has been taken from EHRN country profiles and case studies, all of which are available from the Knowledge hub


Republic of Macedonia, a middle income, low HIV prevalence country in the Balkan region, is one of the countries impacted by the reduction of funding of the Global Fund to fight AIDS, Tuberculosis and Malaria. Macedonia has benefited significantly from Global Fund support for its national HIV strategic plans since 2004. Thanks to these prolonged efforts, Macedonia has maintained its low HIV prevalence, most evident by achieving control of the HIV epidemic among people who inject drugs.

The Global Fund support has helped build a wide network of harm reduction programs, including opioid substitution treatment (OST) and needle and syringe exchange programs (NSP), with Government implementation of OST interventions having already begun by 2009.

As the current and final Global Fund HIV grant is ending on 31 December 2016, Macedonia is now intensively undergoing a transition process to domestic funding primarily for its HIV prevention programs for key affected populations.

Drug Use and Infectious Diseases

Macedonia has a low level HIV epidemic concentrated among certain key affected populations. The total cumulative number of HIV cases between 1987 and the end of 2015 was 275, whereas the cumulative number of registered AIDS related deaths was 80. A recently conducted allocative efficiency analysis (Optima) by the World Bank estimated HIV prevalence among PWID at 0.12% in 2014 based on data from a bio-behavioral study (BBS), as well as from NGO testing data – a decline from the estimated 0.42% in 2006. The 2014 BBS also showed a decrease in viral hepatitis C (HCV) prevalence among PWID from an estimated 70.1% in 2009 to 64.5% in 2014. These numbers, along with increased rates of using sterile equipment during the last injection and during the last month, suggest that harm reduction programs in Macedonia have had a positive impact. The Optima analysis further concluded that the HIV epidemic among PWID in Macedonia is under control due to significant and prolonged efforts targeting this key group, but warns that there is still a risk of rising HIV infection that may happen as a result of changes in behavior or interactions with HIV-positive PWID in neighboring countries.

Epidemiological data



Year of estimate

Total number of HIV cases registered in the country




HIV prevalence among PWID




Hepatitis C prevalence among PWID



Hepatitis B prevalence among PWID




NSPs as a key component in the harm reduction program have been part of three national HIV strategic plans since 2003 and of even earlier Government policy documents. Moreover, harm reduction is recognized in the Law on the control of opioids and psychotropic substances as part of a range of activities including ‘exchange of sterile equipment’ and ‘working with a hidden population’. While there seems to be no legal barriers to its implementation, some services of the expanded package, such as treatment of wounds as well as HIV testing, are considered ‘medical services’ and CSOs are not recognized in the Law on Health Protection as providers of such services, which poses a potential barrier for the future. 


Macedonia has a relatively long history of harm reduction programs, including OST and NSP services, both of which predate the Global Fund grants. Between the 1980’s–early 1990‘s and the first Global Fund grant in 2004, methadone had become available at the Psychiatric Hospital in the capital, Skopje, and at three major penal institutions. Between 2005 and 2011, due to Global Fund support, substitution treatment was scaled-up and several OST centers were opened across the country.

Today opioid substitution treatment (OST) is available primarily within the developed national network of public health institutions. The majority of related costs, including the procurement of methadone and buprenorphine, are not covered by the national Health Insurance Fund but through a separate treatment program of the Ministry of Health. Since 2009, OST has been funded exclusively from the state budget and this was one of the first components of the HIV program that transitioned from Global Fund to domestic funding. A total of 16 sites are now delivering OST in 10 cities across the country. Of those, 12 have the official status of centers for treatment of addictions, one is the University Clinic of Toxicology and three are located in prisons. In addition to the government program, several private psychiatric clinics are also offering OST.

OST Coverage*

Needle and syringe programs (NSP) were first introduced in 1996 by the NGO, Mask, and soonafter continued by the NGO, HOPS. Starting from 2004, Global Fund support helped to expand NSP across the country so that there are now 16 NSPs in 13 cities. Unlike OST, these are almost exclusively funded through the Global Fund grant, which raises major concern as to their sustainability after the Global Fund transitions out of Macedonia. The minimum package of services includes one syringe, two needles, a condom and IEC material. However, all programs offer a wider range of services that vary between NGOs, but, as a minimum, include basic medical services and social support, while six NSPs also offer legal support37. Voluntary HIV counseling and testing (VCT) has been available through outreach mobile units for all key populations since 2007. In 2015, the Ministry of Health also allowed community-based VCT to be performed in drop-in centers through an NGO-led program with medical professionals engaged on-site only to perform the test. Overdose prevention in Macedonia is not readily available in NGO drop-in centres nor through outreach services. Naloxone can only be accessed through OST centers across the country as well as through the emergency medical service in some cities, and can be applied only by a medical professional. In the last few years, there has been civil society advocacy towards making naloxone accessible more easily to people when needed39. The total number of clients in all NGO-based harm reduction programs has been increasing in recent years (from 3,236 in 2012 to 3,885 in September 201440), as well as the number of clients who use NSP services (the minimum package): 3,217 in 2013, rising to 3,949 clients in 2015. As of 2015, the coverage rate for NSP is 36% of the officially estimated 10,900 PWID42, far below the level recommended by WHO, UNODC and UNAIDS.

NSP Coverage*

*In order to reverse an HIV epidemic, WHO/UNODC/UNAIDS (2014) guidance recommends that 60% of all PWID should be reached regularly by NSP, while 40% of all opiate users should be enrolled in OST.


OST has been fully covered with domestic funding since 2009 (staff costs, medication and psycho-social support) and the allocated budget for 2015 and 2016 was approximately €1.27 million annually. CSOs delivering NSP have performed an analysis of related budgets and a costing exercise that recommended a ‘minimum’ and an ‘optimum’ financial envelope in order to sustain programs in the current format, which is a good evidence base for allocating funds to NSP by the Government. The optimum estimated amount was calculated at €561,078 per year. Following early civil society advocacy, the Ministry of Health took proactive steps towards establishing a financing mechanism for CSOs in 2014. This was reflected in the annual National HIV Program for 2015 which specifies CSOs as implementers of ‘activities for prevention of HIV among MSM, SW and PWID and activities for support of people living with HIV’, included under national funding sources in the Program budget. Allocated amounts were only symbolic and they were meant to set a precedent and provide a framework for establishing and testing the financing mechanism as there is still major funding available from the Global Fund for prevention activities among key affected groups. Unfortunately, these targets were not met in 2015 with only an official consultative process around the financing mechanism having been started during the year. In the National HIV Program for 2016, which received a major increase from the budget of the Ministry of Health, the activities for key populations were included again, along with VCT, with an increased - although still symbolic - budget (approximately €29,000 for all NGO activities compared with the €508,227 from the Global Fund currently allocated for NGOs delivering only NSP). According to meetings held between CSOs and the Ministry, the envisaged social contracting mechanism is meant to include a registry of organizations that qualify to be implementers of the National HIV Program on the basis of their experience and expertise in working on HIV prevention programs and reaching out to key affected populations. OST and ART have already fully transitioned to government funding and national procurement procedures. In most other cases with using Global Fund support to procure commodities, the national law on public procurement has, in general, been followed both by the Ministry of Health and by sub-recipient CSOs. In terms of needles and syringes, the regular procurement mechanisms ensure reasonable price standards. Currently, the National HIV Program includes procurement of condoms under the domestic budget but still hasn’t taken over the remaining commodities, in particular needles and syringes.

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readiness to sustain harm reduction interventions