The HIV story in Romania has been marked by several dramatic episodes. The first was in the late 1980s, when thousands of children became infected with HIV through a dramatic nosocomial HIV epidemic, predominantly among orphans and hospitalized children. The voices of parents and many supporters then led to the introduction of the country’s large treatment programs – early on with donor support – to provide HIV treatment to all in need. Today, the country spends about 70 million euros for HIV treatment, care and support towards reaching universal access, covering 12,247 people with HIV out of 15,212 as of 2017.

However, “the Romanian authorities invest practically no money in HIV prevention”, says Nicoleta Dascalu, project manager from the Romanian Association Against AIDS. That is why becoming ineligible for the Global Fund’s support of HIV became yet another dramatic episode in Romania’s HIV history.

Consequence of improperly planned transition from donor support

At the beginning of 2010, the country, then newly a member of the European Union, was praised for reaching out to people who inject drugs and even starting a pilot programme for opioid substitution therapy and needle exchange in prisons. This work was supported by the Global Fund as well as by the Dutch government through UNODC.

However, both funding streams stopped in 2010-2011 and the government did not take over funding for NGOs. At the same time, the drug scene also changed, with the emergence of new psychoactive substances that were legal but could mean receiving up to 10 injections a day.

While the legislative and policy environment in Romania did provide for harm reduction and other services targeted to key populations to be maintained, the Government had shown little commitment to funding such interventions, especially needle and syringe programs. “Most NGOs that had implemented harm-reduction services just closed them down, because of lack of funding,” remembers Nicoleta Dascalu. “The only funding still available was from European Union structural funds projects, dedicated to the social and professional reintegration of drug users.”

HIV prevalence among people who inject drugs (PWID) started growing rapidly: from 3.3% in 2009 to 27.5% in 2013, according to the European Monitoring Centre for Drugs and Drug Addiction. It was noted in a January 2016 article in the International Journal of Drug Policy that “a specific HIV outbreak among drug users (around 2011) has been directly linked to the significant decline in harm reduction services following the Global Fund transition out of the country”.

Another part of the Romanian HIV story is that HIV prevalence among men who have sex with men also rose to high levels. In the EU-funded study SIALON II, Bucharest recorded the highest HIV prevalence among the 13 cities in the study, at 18%. Nevertheless, as the country’s official report on the progress of the implementation of UN political commitments on HIV acknowledges, there were no real programs remaining among MSM as of 2016.

Reasons for ineligibility of Romanian HIV component for Global Fund support

Since 2007, there has been a requirement in the Global Fund’s Eligibility Policy that in order for UMICs to be eligible for HIV funding, they must have a high HIV disease burden and also be on the Organisation for Economic Co-operation and Development’s (OECD) Development Assistance Committee (DAC) List of Official Development Assistance (ODA) recipients. This list doesn’t include European Union member countries, making them ineligible to receive ODA. This requirement is the reason for Romania’s loss of eligibility to receive funding from the Global Fund, and why it has not regained eligibility since 2010, when its last Global Fund HIV grant came to an end.

Theoretically, Romania could become eligible if it met the requirements of the so-called ‘NGO rule’ – another provision of the Global Fund’s Eligibility Policy that allows for potential eligibility for UMICs that meet the disease-burden thresholds for HIV but are not on the OECD DAC List of ODA Recipients. Eligibility under this rule till recently was linked to the existence in-country of “political barriers,” which preclude the provision of evidence-informed interventions for key populations. Funding provided under this rule must be channelled through civil society and cannot directly fund governments.

In practice, the “NGO rule” to date has allowed only one country to be funded – the Russian Federation – in the 2014-2016 allocation period (see article in this issue). Romania could have been eligible for the 2014-2016 and 2017-2019 allocation periods, but according to the Global Fund “was not deemed to have substantive political barriers that would preclude providing services to key populations”.

Attempts to influence the situation

Romanian NGOs have tried at least three times to prove to the Global Fund their right to receive an allocation for the country’s HIV component in accordance with the ‘NGO rule’. In 2013, a targeted application for an HIV grant was developed and submitted by Romanian NGOs to the Global Fund within the ‘NGO rule’ but was not supported because the Global Fund Secretariat has considered the situation in Romania to be a result of “lack of funding or political will rather than political barriers”, per se, said the Eurasian Harm Reduction Network.

Another attempt was made in 2016 – a joint statement by Romanian civil society organizations was sent to the Global Fund’s Executive Director and Board in advance of its Thirty Sixth Meeting, urging the Board to prevent no allocation for Romania’s HIV component for the next three years. But their voices went unheeded and Romania was allocated zero funding for 2017-2019.

The last attempt was made this year, when more than 40 international, regional and national organizations addressed the members of the Global Fund Board on eligibility-related issues in advance of its 39th Meeting in May 2018. In their statement, among other issues raised, civil society organizations called on the Global Fund Board not to restrict access to funding for HIV for countries not on the OECD DAC List of ODA, with specific reference to the case of Romania.

In the opinion of the subscribers of the statement, “by continuously preserving this requirement, the Global Fund itself creates a political barrier that precludes the provision of evidence-informed interventions for key populations in these countries”.

Revised Policy – the same eligibility status

The Global Fund’s Revised Eligibility Policy was approved at the 39th Board Meeting. In the revised version, the OECD DAC ODA requirement unfortunately was left as it was – but the term “political barriers” in the same provision was replaced with just “barriers,” with a note that eligibility for funding under this provision will be assessed by the Secretariat as part of the decision-making process for allocations. In addition, the Secretariat will look specifically at whether there are laws or policies that influence practices and seriously limit and/or restrict the provision of evidence-informed interventions for key populations.

It is not clear yet if the replacement of the term “political barriers” with just “barriers” – prompted by many organizations’ call for the revision of this language due to a lack of definition of “political barriers” – will somehow influence Romania’s chance to receive an allocation for its HIV component within the next allocation period; speculation suggests probably not.

As before, it will be up to the Global Fund Secretariat to decide if there are demonstrated barriers in-country to providing funding for interventions for key populations. And it is clear from the clarification note that as before, when considering eligibility under this provision, the Global Fund Secretariat will probably not look at whether representatives of key affected populations actually have access to the HIV prevention services they need, but rather will consider the existence of the laws and policies that restrict the provision of such services by the government.

The only chance for the Romanian HIV component to become eligible again for Global Fund funding is the elimination of the relevant requirement in the Eligibility Policy, says Dragos Rosca, the Executive Director of the Romanian Harm Reduction Network. “By keeping the OECD DAC Requirement for HIV/AIDS components the Global Fund continues to restrict access for Romanian NGOs to vitally-needed funding, which could ensure an appropriate HIV response among key affected populations.“