Eve of an Epidemic in Romania

Sometime past 10 p.m., on a dimly lit street north of Bucharest’s Gara de Nord train station, a dozen prostitutes stake their ground in front of an abandoned building. When a van pulls up to the curb, a Roma teenager quickly puts out her cigarette, straightens her miniskirt, steps inside the vehicle and slams the door behind her. Ten minutes later, she emerges with a cheeky grin and shouts at the driver: “Merci, boss.” But she doesn’t walk away with a wad of cash. Instead, she’s holding a bag of clean syringes.

Outreach workers from the Romanian Association Against AIDS (ARAS) make runs like this twice daily, distributing clean needles to Bucharest’s most vulnerable residents: sex workers, street children and homeless adults, most of them Roma, and most of them heroin addicts. It’s a vital service to help prevent the city’s 17,000 addicts from sharing needles and spreading HIV. “Even the pimps know us now,” says Alexandra Luca, a health educator in charge of this evening’s run. “They see the women as money machines, so we explain that it’s in their best interest to keep them healthy, clean and informed.”

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With the global community focused on AIDS in Africa, Romania isn’t an obvious front line in the fight against HIV. But across Eastern Europe and Central Asia, injecting drug use is driving the world’s fastest-growing HIV epidemic. According to UNAIDS, since 2001, HIV prevalence in the region has risen by 66% to include 1.5 million people. In Russia, 160 people contract HIV every day and the average age of death from AIDS-related causes is just 32. An estimated 70% of Ukraine’s injecting drug users (IDUs) now have HIV.

The problem, experts say, is lack of funding for HIV prevention and of political will to work with stigmatized groups. Despite the explosive growth of HIV rates in parts of Europe, UNICEF reports that combined international investment in HIV in the entire region of Eastern Europe and Central Asia “does not come close” to investments in a single country like Ethiopia, which records a similar number of HIV cases as Russia or Ukraine. “Donors and politicians see our region’s epidemic as a lower priority,” says Shona Schonning, an activist with the Eurasian Harm Reduction Network based in Vilnius, Lithuania. “They see the countries as a little richer and the epidemic as a little smaller, and therefore something that can be ignored. But the only difference between Eastern Europe and Africa is time.”

Until now, Romania had been the exception. Romanian NGOs were the first in the region to gear up AIDS-prevention programs targeting vulnerable groups a decade ago, and together they have helped keep the HIV rate among the nation’s IDUs at just 1% — the lowest in Eastern Europe. That result is in big part thanks to needle-exchange programs run by ARAS and five other NGOs, who together gave out more than 1.6 million syringes last year to 7,500 addicts. Now a funding crisis could see all that good work undone. The NGOs have long relied exclusively on international donors. But nearly four years after Romania joined the European Union, the World Bank no longer classifies Romania as a developing country, making it ineligible for a number of international grants. Since June, UNICEF, the Open Society Institute and the Global Fund to Fight AIDS, Tuberculosis and Malaria have all withdrawn funding for the country’s HIV programs.

Without money going into prevention, some experts say, Romania’s HIV problem could get very serious, very fast. “Where you don’t provide interventions for drug injectors, there’s a potential for the epidemic to rage out of control,” says Martin Christopher Donoghoe, the World Health Organization project manager for HIV/AIDS in Europe. That has consequences for the rest of Europe too. Freedom of movement within the E.U. makes it easier for disease to spread; what’s more, in 2008 Romania surpassed Russia to become the largest supplier of migrant sex workers to the E.U. “The bulk of HIV infections are in the east, but HIV doesn’t respect national boundaries,” says Donoghoe.

Romania’s NGOs can’t turn to their cash-strapped government for help. Last year its total contributions to ARAS allowed for the purchase of 7,000 syringes — enough for just one day. Now, with Romania mired in recession — its economy shrank by 7% last year — the chances of the government throwing organizations like ARAS a lifeline are slim.

Uncertain Future
Romania’s unique history with HIV partly explains its success in fighting the spread of the disease. Unlike in the rest of Eastern Europe, the majority of people living with HIV in Romania did not become infected as adult drug users or sex workers, but as children living in orphanages. In 1987, nurses hoping to cure Romania’s orphans of their anemia started injecting them with whole-blood transfusions daily, reusing syringes on multiple children. Some of the blood turned out to be contaminated and at least 10,000 orphans contracted HIV. By 2000, Romania claimed 60% of all the pediatric HIV infections registered in Europe.

International pressure, coupled with a burgeoning activist movement inside the country, compelled the government to act. The infected children began receiving state-provided antiretroviral (ARV) treatment, which still keeps 7,000 of them alive today. In 2001, the government closed a deal with pharmaceutical companies to lower drug prices, paving the way for Romania to become the first country in Eastern Europe — and one of the few in the world — to provide universal coverage to HIV-positive patients. Besides improving the quality of patients’ lives, the drugs also reduce their viral load, making them less likely to transmit the disease to others. “At that time, Romania was the model for the region,” says Eduard Petrescu, the Romania country coordinator for UNAIDS. “I hope in two or three years it will be seen as a model of how to deal with HIV/AIDS during an economic crisis.”

It’s not off to a good start. The Ministry of Health used up all of this year’s budget to pay for ARVs in August and must now wait for more funding to arrive through bureaucratic channels. The delay could take up to 180 days. ARV shortages have already interrupted treatment for up to 1,000 patients, and forced patients from rural areas to line up outside Bucharest hospitals to receive treatment. “The government has given us no guarantees, and we are scared what will happen in September,” says Iulian Petre, the executive director of the National Union of People Living with HIV/AIDS.

With funding in limbo, ARAS worker Luca continues to steer her van into an uncertain future. At yet another squatter complex, a 13-year-old girl stands in line. Bright-eyed and surprisingly cheerful for someone surrounded by homeless men and sex workers, she visits every week to get basic medical care and a dose of attention. Her father is an addict and at home used syringes are scattered around the floor. She stepped on one recently, so wants to get an HIV and hepatitis test. “She’s still in school and she’s trying to stay clean,” Luca says. “Miracles happen everywhere.” But if support for Romania’s outreach programs disappears, there may not be many left.

(See pictures inside a Romanian drug house.)