An investigation into how a funding crisis for NGOs carrying out direct care on the street for heroin addicts could provoke a rise in new cases of HIV In Bucharest, Romania. Since this article appeared, its predictions have sadly come true. In 2012 there was a 200 per cent increase in the the number of new HIV cases among drug users. This feature was published in ‘The Diplomat – Bucharest’ magazine in May 201o – http://www.thediplomat.ro/print2.php?id=1122
Romania NGO funding crisis risks rise in HIV infections
For two decades Romania has contained a mass spread of the HIV virus – but this success is under threat as funding for critical NGOs stops Report by Michael Bird
At 4:30 pm on a Tuesday afternoon in Bucharest’s Sector 5, our van turns the corner from a street of suburban houses into a dirt track, scattered with scavenged and burnt out cars. The streets and pavements are clogged with rubbish, where gangs of kids wander through the trash without socks, in filthy t-shirts and wearing trainers with burst seams. There are new vehicles – a BMW and a Mazda – outside bruised and crumbling four-storey flats, where satellite dishes hang under broken windows.
Once a week at the same time the van parks at this location and slides opens its doors. A forty-year old unshaven man with blackened fingers walks up to the vehicle with his wife – both are wearing stained tracksuits.
“It’s her first time,” he says, pointing to his wife.
Inside the van, a man in his 30s with a pony-tail – Costin – asks to see traces of needle pricks on the woman’s body. She shows black dots along her ankles, shins and her forearm. Costin writes down her name and that of her parents.
Then he hands her a package of 50 injectable needles – the minimum number a heroin addict needs for a week to prevent her from sharing needles.
More addicts – from their late teens to their 50s – emerge from the streets and gather around the van.
One 20 year-old takes his quota of needles, runs away to hide the stash and then returns to the van, soliciting for more. He has been a user for eight years – and injects around five times a day. “The heroin is not good enough and the effects only last for twenty minutes,” he complains. Recently users have been mixing the poor quality heroin – which is only around 15 per cent pure in Romania – with legal high Mephadrone, which trades under brands such as ‘Special Gold’.
Now the Government has criminalised Mephadrone, but the user says he is now taking another legal high NRG, to give his heroin cocktail an extra boost.
Another boy of 19 brings a bucket of used needles to swap for fresh ones – he wants 300. There is a debate between him and Costin – a compromise which angers the addict, but he settles for what he can get. “If we give them more needles than they can use, they can sell them on for drugs,” says Costin.
Three teenage girls huddle up to the van, holding out their naked arms and slapping their forearms in mockery.
“We are heroin addicts, we want needles,” one says. They all laugh. Costin shakes his head.
“No needles for you,” he says.
“How about condoms?” another insists. “Do you have condoms?”
He gives each girls a condom. They dance into the streets shouting at the passers-by, brandishing the prophylactics in the air.
“We have condoms! We have condoms!”
Outreach programmes aim to ensure addicts do not share needles, helping to limit a spread in HIV or Hepatitis C – a rate which has been contained among Bucharest’s addicts since 2007.
This van, run by NGO Integration, also acts as a link between civil society and addicts, who are a hidden, suspicious and vulnerable community. The organisation provides counselling, viral testing and keeps in contact with addicts unwilling to go to the hospital’s drop-in centres.
But due to a financing crisis many of these programmes are under threat. The UN’s Global Fund Against AIDS ends its funding for NGOs this June because Romania no longer qualifies as a developing country which can benefit from its grants.
Romania’s Ministry of Health will spend its entire budget for 2010 by June and hospitals now face a crisis in drug availability. Corporations are scaling back sponsorship and private donors are scarce. The only hope for civil society is EU structural funds, but the EU does not fund healthcare services.
Around one to 1.5 per cent of Bucharest’s heroin addicts are HIV positive, while up to 80 per cent carry Hepatitis C. In Romania since 2006, HIV mostly spread through sex and the number of new cases has been going down. “The spread of HIV among heroin users is low compared to some other countries in the region,” says Eduard Petrescu, regional consultant for HIV/AIDS.
The situation has stabilised and new users on the market are less likely to become infected. “Those who have fewer than ten years’ history of drug use are not testing positive for Hepatitis C,” says Integration’s director Costin Militaru.
These experts argue that if needle exchange programmes end, Romania’s success rate of keeping its HIV+ numbers low is in danger, while a rise in Hepatitis C is almost certain.
“The big risk is if addicts do not have access to syringes,” adds Bogdan Glodeanu, executive director of NGO ALIAT. “Some users will even share a syringe with someone they know to be an HIV+, rather than to go without the heroin.”
Specialists argue that 1.5 per cent of HIV sufferers is the tipping point and if a larger proportion of addicts do not have access to clean syringes, the numbers could increase.
Integration works with 100 addicts per month and reaches 600 in total. The NGO is running out of syringes and also needs to pay its personnel and have cash for gas, electricity and rent.
A target for Integration’s financing is EU structural funds, which are administered by the Romanian Government. NGOs have to apply to the Ministry for Work and Labour, because no money is available through the Ministry of Health. Integration is on a waiting list for this EU Social Fund project with fellow NGO ARAS.
The project, which has been approved on paper, is for a substitution centre and needle exchange programme, but under the framework of the benefits this brings to job creation. “The idea is to take a drug user from the streets, put him in treatment, re-educate him and reinsert him on the work market,” says Militaru.
This indirect form of financing needle exchange is a career development solution for a public health problem. But the contract was still not signed by the time we went to press and the money was not due to arrive. “By 30 June it is possible we will close our doors,” says Militaru.
Meanwhile ALIAT’s three-year outreach project in Bucharest’s Sector 4 serves around 400 addicts weekly and is running out of needles. Neither the Health Ministry nor local Government will fund such a project. “It is difficult now because there is no money for medicine in hospitals,” says ALIAT’s Bogdan Glodeanu.
But there is a business case for these programmes. Every year the needle exchange programme costs between 100 and 250 Euro per person, while the annual treatment for a HIV sufferer on anti-retroviral therapy is 24,000 Euro for the drugs alone.
Around 40 per cent of Bucharest’s 20,000 heroin addicts are now covered by needle exchange programmes. Users are mostly poor, half are under 30 and they tend to start using at 14, while the oldest reported user is 67 years old. Around 70 per cent are unemployed, but most have a home. In Sector 5, the youngest user Costin Militaru has seen is six years of age. Her father and mother were drug users. “Her parents injected her at lunchtime – she was complaining that she was hungry and received heroin as a meal,” he says.
If funding vanishes, the mobile units will not supply condoms to users, many of whom work in the sex trade. If the services stop, users will also have to buy syringes and other products, which means they will resort to crime to raise the cash. “Probably sex work will increase dramatically,” says Militaru. “I do not think there is a female heroin user I know who doesn’t sell herself for sex.”
Another problem is that outreach NGOs have formed a bond of trust with the community over the last ten years. When such a programme has stopped for two months in the past, it has lost contact with users, who have fallen deeper into the underground. “The risk is that users will become a hidden population again,” says Glodeanu.
Cracks in the relationship between the NGOs and users are already appearing. Users are starting to blame NGOs for the reduction in the frequency of their trips in providing syringes. “They say we encouraged their behaviour of coming to collect the syringes and taught them how not to share and why and told them to spread the word,” Glodeanu says. “Now that we are are running out of needles, the addicts argue – ‘We did not know the risks before you came and now you leave us without the needles, but with the knowledge that we are at risk’.”
Breakdown in anti-HIV therapy equals death sentence
In Romania in the last year, HIV positive carriers have been suffering gaps in the availability of crucial drugs which suppress the virus.
Over 1,000 have seen interruptions of over a month in this crucial treatment, which prevents the carrier developing full-blown AIDS.
“When the treatment stops for more than two weeks, there are very high chances the HIV virus can become resistant to the patient’s treatment scheme,” says the National Union of HIV/AIDS organisations UNOPA’s executive director Iulian Petre.
The excuse is that the Health Ministry’s purse – the National Health Insurance House – did not receive money for the drugs from the Ministry of Finance at the right time.
At present those who could spread HIV are two at-risk categories – injectable drug users and around 7,000 who were children in social institutions between 1986 and 1992 and were infected by blood transfusions.
Under a 2002 law, every carrier has the legal right to free anti-retroviral therapy (AVTs).
But the Ministry of Health is failing to deliver these drugs consistently, at a time when most carriers are in their early twenties – their most sexually active period.
The AVTs suppress the virus, but cannot cure the carrier. “If funding breaks down for free treatment, this could develop into full-blown AIDS,” says Edmond McLoughney, UNICEF country manager and coordinator for UNAIDS in Romania.
If there is an interruption in treatment, the body can develop resistance to the treatment. This means – at best – the carrier may need a new form of treatment, which means stronger and more expensive drugs. But Iulian Petre says that if doctors have finished the most efficient treatment solutions for the patient, the person is sentenced to death.
A breakdown in treatment also means the carrier is more infectious, so the spread of further cases of HIV becomes more likely.
The number of those with HIV in Romania is estimated at between 12,000 and 16,000, while 10,000 are officially diagnosed. Currently 8,500 are in treatment – every HIV carrier who wants treatment should, theoretically, have access to care.
At present UNOPA does not have assurances from the Romanian Ministry of Health that the HIV/AIDS treatment will be consistent.
Collapse in cash hits most vulnerable
Charities and NGOs in Romania in sectors such as education, health, home care, mental care and the environment are suffering massive drops in funding.
With a social care system in disarray in Romania, many NGOS are currently the only groups giving at-home care to the disabled and semi-paralysed.
There are also NGOs which drive kids who live 20 km from the nearest school to their place of education, and others which offer after-school facilities and career guidance.
These services fill a gap in the state sector and save the nation money in the long-term by integrating vulnerable communities in wider society.
“Some NGOs are heading for bankruptcy,” says Ionut Sibian, director of the national resource centre for NGOs FDSC. “The lack of cash flow is killing them.”
Annually NGO costs in Romania are between 800 million Euro and one billion Euro. Between 90 and 95 per cent of this cash comes from external sources and the rest from central and local Government.
Now the European Social Fund is the main target for NGOs. These are EU funds administered by the Ministry of Work and Labour. But many NGOs who have received the go-ahead for financing from this fund have been waiting around one year to receive the cash reimbursement. “If the Social Fund is not working, a lot of NGOs will disappear,” says Sibian.
Organisations including FDSC have met with Prime Minister Emil Boc in an attempt to increase advance payment to NGOs. This includes the Government creating a guarantee fund – similar to that for small businesses and public administration. This would allow NGOs to take a bridge loan from a bank, until it could be reimbursed with EU funds. The Government has agreed to this project in principle.
NGOs are also asking the Government to increase to 35 per cent the advance it pays to NGOs who have funding from the EU. The Government then receives this money back from the EU. Now the EU only grants seven per cent up-front. The pre-accession PHARE funding system worked better that the post-accession funding, argues Sibian, because 80 per cent of PHARE’s money was paid in advance.
Another source of cash is the two per cent of income tax which all wage-earners can donate to charities or NGOs. However this brings in about 25 million Euro to the system – only 2.5 per cent of the annual funds necessary.
Meanwhile the number of private and corporate donations is falling. Individuals and businesses tend to prefer to fund projects which are more PR-friendly – such as helping kids with cancer or planting trees. But even these charities are facing a tough time. “Local fund-raising and corporate social responsibility budgets have really shrunk, even from multinationals and even for UNICEF,” says UNICEF Romania’s Edmond McLoughney.
There are unique mechanisms for corporate charity financing in Romania, such as the United Way, where companies pool their funds and then give them to projects as a collective unit.
But for HIV sufferers – especially among the drug community – there is little corporate interest in funding, because of the disease’s association with heroin use and homosexuality. “Many NGOs active in the HIV/AIDS sector financed from the Global Fund will close down or will orient their activity towards other sectors,” says the National Union of HIV/AIDS organisations UNOPA’s Iulian Petre. “Romania’s Government had not allotted funds for this purpose and the EU funds do not finance prevention activities and treatment for HIV/AIDS.”
It is also tough to attract cash for justice and home affairs issues – such as ‘watchdog’ NGOs encouraging democracy and the rule of law. Without these there will be few bodies probing worrying legal decisions, such as the Constitutional Court’s recent declaration that Romania’s EU-sanctioned National Integrity Agency is illegal.
It is hard for the Government to finance these civil society organisations, argues Sibian, as the executive does not want to pay to be criticised.
However one strategy under discussion is for the Prime Minister’s Department of Governmental Strategies to fund projects where NGOs can use their expertise to compile independent reports on issues such as administrative reform or the conditions of the Roma. These can criticise Government policy and practice but, because they are not financed by individual Ministries, there is less pressure to publish a report which whitewashes major problems.