Romania

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

Overview

Romania is a European Union (EU) Member State located in Southeast Europe. The total population of Romania in 2015 was 19.77 million people.

The country does not have national-level estimates of the size of the number of people who inject drugs (PWID). In 2014, there were estimated to be 6,288 PWID (range 4,703-8,492) in Bucharest.

Drug-related offences in Romania are criminally prosecuted. Growing, production, manufacture, experimentation, extraction, preparation, processing, purchase or possession of drugs for one’s own consumption, without the legal right, is punishable by imprisonment and/or fines depending on the substance group. In the case of ‘risk’ drugs a person is punished by imprisonment for between three months and two years or a fine. In the case of ‘high-risk’ drugs a person can be sentenced to imprisonment for between six months and three years. ‘High-risk’ drugs include: desomorphine, codeine, heroin, cocaine, and amphetamine. 

There appears to be no policy barriers to the provision of harm reduction services in Romania, except the lack of political will to support them. Although harm reduction services are mentioned in key political documents, there is no clear commitment from the Government to sustain OST and NSP services at the necessary scale using domestic resources.

Harm reduction services in the country are supported by international donors and provided by NGOs. NSP services are not supported by the government. There is confirmed limited support from government agencies with syringes and municipal funding for NSP services. The government provides only OST medication for limited number of patients.

NSP services are provided only in the capital city of the country, Bucharest. There is limited access to OST services in Romania due to the lack of finance, thus, some clinics and to some degree NGOs provide OST at fee.

There is only one initiative group of people who use drugs (PWUD) in Romania, but it has not been actively involved in advocacy yet. At the same time, Romanian non-governmental organizations (NGO) involved in harm reduction are actively engaged in advocacy for resources and for improved access to services for PWID.

Drug Use and Infectious Diseases

The country does not have national-level estimates of the number of people who inject drugs (PWID). In 2014, there were estimated to be 6,288 PWID (range 4,703–8,492) in the capital city, Bucharest, based on the number of those accessing drug treatment services and using a multiplier method.

Of the 6,288 PWID in 2014, 52.5% used heroin, and 28% consumed new psychoactive substances, mainly injecting synthetic cathinones (a form of stimulant) and piperazines (new forms of synthetic psychoactive stimulants, also known as ‘party pills’ in some countries). 

Romania has a low — at under 1% — but steadily increasing HIV epidemic among the adult population, with the disease concentrated in key populations. There were 13,766 people living with HIV/AIDS in the country as of the end of 2015 (see Table 1). First diagnosed in Romania in 1985, there has been a cumulative total of 21,263 cases of HIV diagnosed since then, of which 343 have been PWID (81% male). The number of PWID living with HIV may be significantly underestimated because of the limited access to low-threshold rapid testing services — which are only available in Bucharest — and the unwillingness of PWID to self-report injecting drug use for fear of arrest by the police or stigmatization and discrimination from health care workers.

HIV prevalence among PWID in Romania was estimated to be 6.9% in 2012. It then shot up to an estimated 53% in 2013 — likely as a consequence of the end of the Global Fund’s support to NSPs — before falling back somewhat to 21.4% in 2014. However, NGOs believe this figure to be higher.  

Hepatitis C appears to be rampant throughout the PWID community in Romania. Its prevalence among PWID was reported in 2011 to be 79%, compared to 3.2% among the general population, the highest rate in Europe. Hepatitis B prevalence among PWID was reported as 5% in 2011. It indirectly indicates that risky behavior among PWID (e.g. sharing injecting equipment) is rather common.  

Indicator

Data

Year of estimate

Total number of HIV cases registered in the country

 

21,263

 

1985–2015

Cases of HIV transmission due to injecting drug use

 343

1985–2015

HIV prevalence among adults (15–49 years old)

24.3 per 100,000

2014

HIV prevalence among PWID

21.4%

2014

Hepatitis C prevalence among PWID

79%

2011

Hepatitis B prevalence among PWID

5% 

 

2011

Policies

Drug-related offences in Romania are criminally prosecuted. Growing, production, manufacture, experimentation, extraction, preparation, processing, purchase or possession of drugs for one’s own consumption, without the legal right, is punishable by imprisonment and/or fines depending on the substance group. In the case of ‘risk’ drugs a person is punished by imprisonment for between three months and two years or a fine. In the case of ‘high-risk’ drugs a person can be sentenced to imprisonment for between six months and three years. ‘High-risk’ drugs include: desomorphine, codeine, heroin, cocaine, and amphetamine.  

Since 2012, the number of prison sentences for drug possession with the intention of using drugs for one’s own consumption has plummeted, and there has been an increase in the number of court decisions ordering suspension on probation in such cases. This trend has been noticeable for a few years now.

Harm reduction in Romania is mentioned in a number of political documents: the Program of National Interest on Prevention and Medical, Psychological and Social Care for Drug Users in 2015–2018; the National Program of Prevention and Medical, Psychological and Social Care for Drug Users in 2015–2018; the National Public Health Strategy 2014–2020; and the National Anti-Drug Strategy 2013–2020. Unfortunately, they do not assume budget allocations from domestic sources.

The National Anti-Drug Strategy 2013–2020 is the main document describing in detail the harm reduction and HIV prevention objectives targeting PWID in Romania. Under this strategy, the demand reduction component, which addresses treatment of drug users, specifically indicates objectives of diversifying relevant programs (needle and syringe programs — NSPs — and opioid substitution therapy — OST) in the community and in prisons; increasing the level of information, education and awareness among PWID to prevent negative consequences of drug use; and improving access to prevention, testing and relevant medical services for PWID in the community and in prisons.  

It is possible to conclude that there are no policy barriers to the provision of harm reduction services in Romania, except the lack of political will to support them financially.  

There is only one initiative group of people who use drugs (PWUD) in Romania, but it has not been actively involved in advocacy yet. At the same time, Romanian non-governmental organizations (NGO) involved in harm reduction are actively engaged in advocacy for resources and for improved access to services for PWID. The sustainability of funding for harm reduction is a high priority for NGOs, as harm reduction services in Romania are highly dependent on international financial support. 

Programs

Global Fund support for HIV services in Romania ended in June 2010 due to the relatively low burden of the disease and the economic growth of the country, but with no transition plan in place for domestic and other resources to sustain interventions, resulting in a collapse of services, especially the availability of NSPs for PWID. This lack of funding coincided with a dramatic increase in HIV among PWID, especially in the capital, Bucharest (53% in 2013). Due primarily to the response of NGOs and funding from the EU (structural funds), Norway and various private foundations, some NSP services were reestablished after the withdrawal of the Global Fund, but not at the scale needed to address the needs of the Romanian PWID community.

After the end of the Global Fund’s support in 2010, NSP services survived only in Bucharest. In 2014, the number of NSP sites dropped from seven to three, and OST sites from 13 in 2013 to eight in 2014. A slight improvement came in 2015–2016. NGOs remained the sole implementers of NSP services, with increased focus on secondary exchange and outreach work. There are also other services such as distribution of condoms, information and education materials, HIV testing and counseling, hepatitis B and C testing, referrals for PWID etc. In 2016 there are four NGOs engaged in NSP service provision (Asociatia Romana Anti-SIDA (ARAS), Aliat, Carusel, and Parada). They run two drop-in centers, two specialized mobile units, and one mobile unit that occasionally provides NSP. NSP services are implemented from five fixed locations and via 114 outreach sites by street workers and mobile teams. NSP coverage in 2015 was 3,238 PWIDs, while 5,148 PWIDs were served in 2013. The total coverage of NSP services was 51.5% in 2015, but 99% of the clients were served in Bucharest, where the NSPs remained.

 

OST was introduced in Romania in 1998. At the end of 2014 there were eight OST sites in the community and an additional two sites in prisons. OST is conducted with methadone and buprenorphine/naloxone combination. It can be provided by either state institutions or NGOs. There is inconsistent data on OST coverage in Romania. In 2014, the local NGO ARAS reported 556 OST clients (coverage of 8.8%), whereas the National Anti-Drug Agency (NADA) stated that the total number of OST clients in 2014 was about 1,219 (representing 19.4% coverage). There is no information on the number of clients getting methadone or another kind of OST. In 2016, the NGO-run service had 500 clients, among whom only 20% were covered by the State — largely HIV-positive pregnant women. With the state funding available OST coverage is not sufficient, and some clinics — and to some degree, NGOs — provide OST for a fee.

Officially NSP is available in the penitentiary system. It has been piloted with UNODC support, but in 2013 the prison administration reported that there were no requests for needles from prisons. Thus, in practice the program is not operating. OST and antiretroviral therapy (ART) services are available in prisons. However, condoms for the prison population are bought only by NGOs and donated to prison authorities.  

There is no specific overdose prevention and management program in Romania. Naloxone is available only to medical/ambulance personnel and is used accordingly.

*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.

Funding

There is no recent holistic data on funding for harm reduction in Romania, as there has been no analysis of the current financial landscape.

The most complete financial data on harm reduction and HIV expenditures is available for 2011. According to this data, total harm reduction spending for PWID in 2011 was USD1,649,849. Only 7% of this amount was provided from domestic sources, while 93% came from international donor funding. Spending on harm reduction for PWID accounted for only 6% of the total HIV/AIDS prevention spending from domestic sources, and 29.3% of the total HIV/AIDS prevention spending from international sources, in 2011. The amount spent on harm reduction for PWID per capita was 0.08% of the total spent on HIV/AIDS prevention.

In 2013, the Romanian State spent around USD70 million to ensure access to AIDS treatment and care for all the people living with HIV who are eligible according to the national therapeutic guidelines, but only about USD0.5 million for prevention activities.

These financial statistics explain further the sustainability crisis that has affected harm reduction projects in Romania: the amount of international funding decreased significantly, while at the same time the government’s attitude to domestic funding did not change and focused on medical services.  

As the Global Fund grant and support from UNODC — the main sources of funding for harm reduction in Romania — ended in 2010–2011, the government did not take on the responsibility for funding harm reduction services to ensure they continued. As already mentioned above, this led to a marked decline in harm reduction services and the outbreak of an HIV epidemic in the community in 2013. No transition plan, needs assessment or costing process has been undertaken to inform a plan to ensure the sustainability of HIV/AIDS services, including harm reduction, in Romania. Moreover, at the state level there are still no cost estimates for harm reduction services; no financial gap analysis for the HIV/AIDS sector and the current financial landscape; and no sustainability plan for harm reduction.

The situation as regards funding harm reduction services has been changing over the last few years, closing and opening opportunities for Romania. Fortunately, local harm reduction NGOs and international donors have managed to mitigate the epidemiological consequences of the withdrawal of Global Fund support for HIV. Harm reduction was included in the Global Fund grant for tuberculosis (TB) in Romania (until 31 March 2018). The actual budget for harm reduction in 2015–2019 is EUR545,291. Those funds are provided by the Global Fund TB grant, the National Health Insurance House (NHIH), the Norwegian Financial Mechanism, and SIDACTION (France). The programs are implemented by Romanian NGOs.

Although no information on the total amount of financial support from domestic sources (the NHIH and municipal governments) is available, it is known that between 2015 and 2018 the NHIH will be supporting free OST courses for 130 vulnerable people. In 2013, 2014 and 2015 the General Council of Bucharest approved financial support for harm reduction and reintegration services and channeled that support through NGOs.  

Unfortunately, it seems that international financial support is merely delaying the next collapse of harm reduction services, rather than solving the issue of their financial sustainability in Romania, given that the government is not taking responsibility to provide sufficient support to harm reduction to meet the country’s needs. The very existence of harm reduction services remains dependent on international funding, the amount of which is constantly changing.  

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readiness to sustain harm reduction interventions