When it became known that Ludmila U, an obstetrician for 17 years, was HIV positive, she lost her job, social network and hope for a 'normal' life. Yet, seven years on, she has a second chance. Free antiretroviral (ARV) treatment has changed everything about living with HIV, rapidly improving her own health and that of her friends. 'Future' has returned to her vocabulary. When asked what life would be like without ARVs, Ludmila gives a sad smile and replies: "There would be no life."

The HIV/AIDS epidemic among Moldova’s four million people was late to start but quick to take hold. While many infections were not reported until after the mid–90s, prevalence escalated by nearly 10 percent in 2001–2003 alone, reaching 0.2 percent among adults. As for tuberculosis, 2002 saw some 98.1 notified cases and 15.6 mortality per 100,000 people.

Providing free ARV treatment, the first nation-wide initiative of its kind in a nation of the former Soviet Union, is central to the country’s integrated response to the two diseases, led by the National Programs for the Prevention and Control of HIV/AIDS/Sexually Transmitted Infections and Tuberculosis. The work is enhanced by a Round One grant from the Global Fund, signed in March 2003. With the Ministry of Health’s Project Coordination, Implementation and Monitoring Unit (PCIMU) as the Principal Recipient, nearly US$ 5.03 ($5,026,861 as of March 2005) million of the two-year budget of US$ 5.3 million has been disbursed to date.

By the end of 2004, ARVs had been provided to 115 people (109 adults and 6 children), with two health facilities supported to provide needed services. While the numbers may seem low in absolute terms, they represent an important start to scaling up comprehensive care and support to the nearly 2,000 people reported to be living with HIV by the end of 2003. Direct procurement and government negotiation of drug prices have resulted in reductions in both overall treatment acquisition costs and per patient ARV costs.

As well as increasing access to treatment, the National Program and its partners have also developed prevention strategies targeting groups that are particularly vulnerable to infection. These include young people, prisoners, truck drivers, commercial sex workers, men who have sex with men and injecting drug users (IDUs).

Evidence is already beginning to emerge that this targeted approach is slowing the epidemic among some groups. With IDUs, for example, the sharing of infected syringes had contributed to HIV prevalence of 1.6 percent in 2002.However, data now show that the number of new cases among IDUs is stabilizing at a relatively low level, and the proportion of IDUs among the country’s new infections has dropped from over 80 percent in 2000 to under 55 percent in 2003.

Another first for a state-run initiative in a former country of the Soviet Union was the introduction of HIV and TB prevention and diagnosis, treatment and care for people in prisons. HIV prevalence among detainees was over 2 percent in 2002. Efforts supported by the Global Fund have brought comprehensive services to four sites.

Moldova’s Country Coordinating Mechanism (CCM) — by actively involving Ministries as varied as Justice, Labor and Education — has supported the government’s efforts to broaden its responses to HIV/AIDS, previously confined to the health sector. It is also, within a context of increasing external funds and an urgent need for coordination, helping to streamline planning among donors. This includes assuming oversight for other major initiatives in the country, including the World Bank’s AIDS program (US$ 5.5 million) and a USAID-funded TB project (US$ 4 million).

According to Dr.Oleg Barba, the Executive Secretary of the CCM, one of Moldova’s key lessons is that HIV/AIDS and TB are promoted by poverty, injustice and discrimination, and their successful control will require the involvement of a variety of sectors. In 2004, the CCM improved its links with all constituencies, appointed a Stakeholder Communication & Coordination Advisor and started work on revising its terms of reference and representation. This helped to strengthen coordination with NGOs, whose involvement as Global Fund grant sub-recipients is facilitated by the Soros Foundation. Currently, 28 sub-recipients support some 11,000 people, mostly from vulnerable populations.

Progress was also made in two other areas of HIV/AIDS work supported by the Global Fund: voluntary counseling and testing, with 408,738 people reached; and prevention of mother-to-child transmission of HIV, with 35 women and 35 children reached. While the start of planned activities targeting young people was delayed, plans were drawn up to take action in 2005, introducing a comprehensive, life-skills based curriculum as a mandatory subject in preuniversity education.