South-Eastern Europe

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

EHRN's sub-region of South East Europe (SEE) includes Albania, Bosnia-Herzegovina, Bulgaria, Croatia, Kosovo, Macedonia, Montenegro, Romania and Serbia. EHRN country-profiles exist for  Albania, Bulgaria, Macedonia, Montenegro, Romania and Serbia; Slovenia - from EHRN's Central European (CE) sub-region - has also been included as the only CE country for which there is currently an EHRN country profile and the many similarities between the harm reduction situation in Slovenia and the SEE region.

Issues covered in this overview include the economic development of the countries of SEE analysed by EHRN, the low prevalence of HIV among the general population but high prevalence among people who inject drugs (PWID)[i] together with poor service coverage through the lack of domestic funding following the end of Global Fund support. The existence of PWID activist groups, and their direct actions, is also covered.

The seven countries of SEE analysed by EHRN have experienced increasing economic development over the past decade with an average Gross National Income (GNI) per capita in 2014 of $17.084 and a combined population of 43.2 million, of which 0.2%, or 82,070 people, are estimated to be PWID. With the exception of Slovenia, all six countries analysed by EHRN are classified as 'Upper Middle Income' and, consequently, are either transitioning out of Global Fund support or have no access to such funding at all. All of the countries of SEE analysed by EHRN are either members of the European Union (EU) or are 'candidate countries', thereby making them eligible for EU financial and technical support, such as the 'Instrument for Pre-accession Assistance (IPA) II' of €11.7 billion for the period 2014-2020.

[i] The definition of a PWID various across countries of the region but, in general, refers to a person who has injected an illicit drug one or more times over the previous six months.

Drug Use and Infectious Diseases

Adult HIV prevalence in the seven countries of SEE analysed by EHRN is low at 0.03% but is particularly high among PWID, averaging 5.3%. Adult HIV cases totalled 20,518 in the same seven countries of the SEE region, or 0.05% of the adult population. Of five countries with data available (Albania, Macedonia, Montenegro, Serbia and Slovenia), access by people living with HIV/AIDS (PLHA) to antiretroviral therapy (ART) is good at an overall average of 84.6%, although no data is available for ART access by PWID-living with HIV/AIDS. Hepatitis C prevalence among PWID is a major issue at an average of 56.7% but treatment is only 'partially' available in Montenegro and in Bulgaria; PWID in Albania either have to be on opioid substitution therapy (OST) or to have ceased drug use; and no such treatment is available at all in Serbia. Tuberculosis (TB) prevalence averages 29.8 people per 100,000 population across the SEE countries analysed by EHRN. None of the five countries analysed in SEE for which information is available has an integrated approach to the provision of ART, TB and OST for PWID.

Epidemiological data

Country

HIV prevalence among adults (15–49 years old)

HIV prevalence among PWID

Hepatitis C prevalence among PWID

Hepatitis B prevalence among PWID

Albania

< 0.1%

0.50%

28.8%

11.5%

Bulgaria

   -

10.65%

78.6%

9.84%

Macedonia

   -

0.12%

64.5%

   -

Montenegro

<0.02%

1.10%

53%

1.4%

Romania

   -

21.4%

79%

5%

Serbia

<0.1%

1.50%

61%

5%

Slovenia

   -

1.40%

32.1%

   -

Policies

Drug policies are easing in Montenegro and Slovenia and no major changes are reported in Bulgaria and Romania. Penalties imposed for the use of drugs continue to be criminalized in five of the six countries with penalties ranging from a fine to forced treatment, although consumption in Bulgaria and Romania is not a criminal act but possession is. Only three countries of the region have information available on the existence of PWID activist groups, with one group in Montenegro undertaking direct activities, no such groups reported in Serbia, and a coalition group of harm reduction NGOs advocating for change in Romania.

Programs

Consequently, the lack of funding, together with widespread stigma and discrimination against PWID, is impacting upon the coverage of harm reduction interventions. For example, as of 2015, both NSP and OST coverage averages 23.3% through 39 NSP and 110 OST sites (in all 7 countries analysed in SEE), far below the 60% coverage levels recommended by WHO, UNODC and UNAIDS to stop the further transmission of HIV and to reduce the incidence of new cases. Furthermore, the number of NSP and OST sites has dropped following the end of Global Fund assistance to countries of SEE, although NSP services has suffered greater cutbacks than OST. Also, NSP is not available in prisons of SEE but OST is, mostly for those who continie OST in prison, although no information is available for Macedonia. Furthermore, overdose prevention is only available in Bulgaria and none of the five countries in the SEE with data available have naloxone.

NSP Coverage*

OST 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.

Funding

Harm reduction is mentioned in the drug policies of Macedonia, Montenegro and Romania but not in the other countries of SEE analysed by EHRN, and is referred to in the health programs of all of the countries of the SEE although no information is available for Slovenia. However, governments in SEE lack the political will to fund harm reduction interventions from domestic sources. For example, in Montenegro, Romania and Serbia, harm reduction services have either ceased or have been severely curtailed due to the lack of Government funding following the end of Global Fund support. In addition, rather than using state budgets to fund harm reduction services through NGOs, Governments are seeking access to EU structural funds. NSP is funded by the Government in Slovenia and partially supported in Macedonia and Montenegro, but the other four countries analysed in SEE provide no assistance whatsoever. For OST, funding from domestic resources is available in Macedonia, Montenegro, Serbia and Slovenia and is partly funded in Albania, Bulgaria and Romania.

Global Fund 2016 Eligibility List

Country

Income category

Disease Component

Disease Burden

Eligibility

Bulgaria

UMI

HIV

TB

​High

Moderate

Not eligible

Transition (2016)

Montenegro

UMI

​HIV

TB

​High

Low

Not eligible

Not eligible

Romania

UMI

​HIV

TB

​High

High

Not eligible

Yes

Serbia

UMI

​HIV

TB

 

​High

Moderate

Yes

Not eligible

Albania

UMI

​HIV

TB

​Low

Low

Transition

Transition

 

EHRN Members