A. PROJECT INFORMATION
1. a. Project Name or Title:	Silvia Asandi
b. Project URL, if any:	http://www.raa.ro/projectView.do?id=11
a. Utilizes ICTs to promote women's economic empowerment
a.1 What types of ICT tools do you use?	When AIDS case surveillance started in Romania in 1990, 94% of the total reported AIDS cases were in children (Hersh BS, Popovici F, Apetrei RC, et al. Acquired immunodeficiency syndrome in Romania. Lancet 1991;338:645-9). Nosocomial outbreaks in orphanages and other institutions and contaminated blood transfusions or products were identified as the main routes of transmission and public health measures rapidly introduced. Starting with 1996, cases of mother-to-child transmission appeared, but, without prior studies to identify the prevalence of this route of transmission and no methodology of epidemiological surveillance, the risks remained unknown and no preventive action could be framed. Since thereafter, the potential for the HIV epidemic to develop in Romania has been indicated by the increases in other sexually transmitted infections and prostitution while AIDS surveillance data have shown dramatic increases in young people, particularly women. At the beginning of year 2000, Romanian Angel Appeal has decided to begin an integrated program of mother-to child transmission of HIV prevention in Constanta County, a local area with the highest rate of HIV/AIDS infection of children comparative with the national population of HIV/AIDS infected children. A prior pilot study among pregnant women in Constanta County aimed to asses the mother-to-child HIV transmission rate. The study findings indicated that the vertical transmission rate here was high compared to the 1-2% rate achievable in Western Europe and the USA. The program intended to be implemented has benefited, from its beginning, of Ministry of Health and Family support. A protocol of regularizations and appropriate methodology for mother-to-child HIV transmissions prevention has been drafted in a successful and satisfactory collaboration with the Ministry representatives. Therefore, legislative policies has been issued in order to make the protocol effectual for vertical transmission prevention at local levels (Order no. 889/1999), but logistical, financial and institutional gaps have determined irregularities and practical barriers for implementing the norms and recommendations issued. Although the Romanian Health and Family Ministry representatives have repeatedly shown that a national program of prevention the vertical transmission of HIV is necessary, both in the benefit of public health and in the individual benefit of the pregnant women themselves, also mandatory recommendations for antiretroviral prophylaxis to reduce mother-to-child transmission have been issued, the infrastructure for a successful prevention of vertical transmission strategy was not always in place as a result of the under-funded and overburdened health care system, with average annual health expenditure per capita of 48 USD for Romania, respectively 42 USD for Constanta County, at that time. A large pilot program for the prevention of mother-to-child transmission (PMTCT) in Constanta County, the first of its kind nationwide, has been therefore developed by the Romanian Angel Appeal Foundation, in partnership with a large number of stakeholders in area, between June 2000 and May 2002.
a.2 How does the application of these contribute to the promotion of women's economic empowerment and gender equality?	The organization has focused its program on three main directions: - assessment of prevalence of HIV infection in pregnant women in Constanta County and risks factors associated with mother-to-child HIV infection transmission - networking local authorities responsible with the pre- and post- pregnancy services with clinical and epidemiological HIV infection surveillance services and enhancing local authorities capacity for mother-to-child HIV transmission prevention; - developing and testing the local implementation of a prevention program of mother-to-child HIV infection transmission in Constanta County. The program’s objectives were: - to raise the local providers of pre- and post- pregnancy medical services awareness upon the specificity of services addressing HIV infected pregnant women - to design and test a specific methodology for vertical transmission of HIV prevention in Constanta County - to frame a partner collaboration protocol between the responsible institution in HIV management of pregnant women at Constanta County - to facilitate the implementation of a protocol of partners collaboration framework and of the specific methodology designed for vertical transmission of HIV prevention in Constanta County; - to educate pregnant women regarding the risks associated with the HIV infection and the vertical transmission of the HIV virus - to fight the discrimination of people living with HIV AIDS and to promote information exchange among professionals within the network of specialized medical services.
a.3 How was the achievement of women's economic empowerment and gender equality assessed/determined?	The program has been implemented in collaboration with the national and local institutional partners, representatives of public authorities as well as of non-governmental associations, including representatives of three local associations of HIV/AIDS infected people: - Department of Public Health in Constanta County – Epidemiological Center - County Hospital in Constanta – Obstetrics-Gynecology Departments - County Hospital in Medgidia – Obstetrics-Gynecology Departments - Municipal Hospital in Constanta – the “Sunflower Smile” day-clinic - Ministry Health and Family – National Commission to Fight against AIDS - Romanian Association Against AIDS (ARAS) – Constanta Branch - “Speranta” Association of AIDS Infected Patients in Constanta County - The Eforie local association “ProSanatatea 2000” (distribution of informative materials - women’s community) - The Medgidia local association “Guarding Angels” (distribution of informative materials - women’s community) Epidemiological specialists have contributed to the program implementation efforts under the next international partnerships: - The Institute for Children’s Health in London - University of Padova, Italy – Department of Pediatrics A total number of 410 medical specialists (family doctors, obstetricians, infectious diseases specialists and medical nurses) were active participants for program implementation. There were also beneficiaries of 4 training sessions covering topics such as notions of pre- and post- test counseling, pre- and post- natal assistance, obstetrical management, clinical and therapy management, post-exposure prophylaxis, universal precautions regarding the transmission of the HIV virus. A total number of 11,423 pregnant women in Constanta County participated at pre-test counseling sessions and thereafter tested regarding HIV infection status. The large number of tests effectuation has been made possible through the medical education sessions held in this respect and informative and educational activities addressing pregnant women, totaling a number of 12,000 brochures distribution covering topics such us “What every pregnant women must know”, ”Continue to live, brochure for sero-positive women”, “Manual for the care of HIV positive pregnant women”. Monitoring HIV prevalence among pregnant women gave an indication of the prevalence in the general heterosexual population and provided the first estimates of HIV sero-prevalence in pregnant women in Romania. Based on demographic data for Constanta County a wide distribution on demographic characteristics (age, rural and urban residence, temporary or permanent residence in local area, ethnicity, marital status), including a wide distribution according with the risk factors associated with acquisition of infection in this population (history of sexual partners, history of surgery and/or dental procedures, previous blood transfusions, history of illicit drug injection use, previous or current at time sexually transmitted infections, imprisonments, travels abroad, women having a sexual partner with potential risks for HIV infection) has been envisaged for the selection of the targeted group, in order to estimate HIV prevalence and risk factors for pregnant women at local level accordingly to the demographic data characterizing the local area. Therefore, the beneficiaries of the program were represented by the next demographic details describing status on age, rural/urban residence and ethnical origin: AGE distribution: - 684 women, representing 6% were aged between 13 and 17 years old; - 3427 women, representing 30% were aged between 18 and 22 years old; - 4043 women, representing 35% were aged between 23 and 27 years old; - 2344 women, representing 21% were aged between 28 and 32 years old; - 725 women, representing 6% were aged between 33 and 37 years old; - 179 women, representing 2% were aged between 38 and 42 years old; - 19 women, representing less than 1% were aged between 43 and 47 years old; - 2 women not knowing their age. RURAL/URBAN distribution: - 5169 women were coming from rural medium, representing 45% from total women targeted; - 6254 women were coming from urban medium, representing 55% from total women targeted. The county demographic segregation of population under urban/rural category was, at that time, corresponding with 73, respectively 27% in total county population (male and female). ETHNICAL distribution: - 369 women, representing 3.23% in total targeted population, - oriental ethnic group (e.g. Turks, Tartars); - 862 women, representing 7.55% in total targeted population, - Romany Muslims ethnic group; - 10.192 women, representing 89.22% in total targeted population, - Caucasian ethnic group.
a.4 Which cultural, traditional and religious gender-biased notions and beliefs were challenged, if any?	The program working methodology, based on the Ministry of Health and Family recommendations for health management of HIV/AIDS infected pregnant women, centered its efforts on integrating a collaborative and sustained model of preventing vertical HIV infection transmission, between relevant psychological, social and medical services. The next public health departments were identified and have been therefore active participants in program implementation: - epidemiological departments of public health management authority at local level, responsible in HIV testing and pre- also post- test counseling; - clinical HIV infection medical services, at county and municipality level; - obstetricians and family unit physicians addressing pregnancy services, also pre- and post- test counseling; - medical nurses and familial planning units’ personnel, who provide additional medical services to pregnant women. Networking the key institution responsible with pregnancy at local level contributed to the introduction of standardized pre-test counseling form, formal recording of positive confirmed cases and standardized post-test counseling and effective methods for referrals to clinical HIV infection medical services as well as to the epidemiological departments of public health management authority on HIV cases surveillance. The family unit physicians and obstetricians were responsible in pre-test counseling of pregnant women. The role of medical personal that have had professional contacts with a woman who wanted to become pregnant was to explain the pregnant women how important is for herself, her child and for sexual past, present or future sexual partners to know her HIV status. An emphasis was put on having access to HIV testing before the conception. The prevention measures have to be presented to the pregnant women that were at risk of infection during pregnancy, especially if their partners were HIV positive and the HIV testing was to be repeated every trimester. Test results were to be given, whenever possible, by the same health care professional who performed the pre-test counseling. Confidentially of the information had to be respected. The clinical HIV infection specialists were responsible in infectious disease medical assistance for HIV positive pregnant women and obstetrics and gynecology services in case of pregnancy termination or prophylaxis of HIV positive pregnancies that are to be delivered. Collaboration between infectious disease specialist and obstetrical and gynecological specialists during pregnancy period was to be procedurally facilitated. Referrals to familial planning cabinets were to be made toward all HIV positive pregnant women in case of fertility age, in order to ensure access to adequate contraceptive means. Standardization of HIV positive confirmed cases referrals to the public health local authorities’ representatives were to be enforced. Following deliveries, in case of HIV positive pregnancies, further referrals were to be made toward the neonate pediatric specialists, to adequately establish and ensure the HIV prophylaxes for neonates till children’s HIV status is confirmed or infirmed. The public health management representatives were responsible in pre- and post- test counseling for pregnant women referred to them. Educational services were to be supplementary provided. Cases management was to be ensured, in order to have a HIV infection epidemiological surveillance. Standardized procedures were to be enforced. Medical nurses and familial planning units’ personnel were responsible in providing HIV positive pregnant women with contraceptive counseling as well as with adequate contraceptive means. Informative educational materials were to be distributed emphasizing specific case of HIV-positive pregnancies. An important contribution was given by the women’s community organization involved in the project implementation. Facilitating the community approach, the organization became also active in raising awareness over the need to change the traditional gendered familial roles pattern toward empowering women to understand and benefit of all-related reproductive rights The international medical professional experts have given their expertise input over the medical care services addressing pregnancy and statistical interpretation of data and study findings in accord with international commonly used indicators for HIV/AIDS surveillance, facilitating Romanian statistics corroboration with international statistics.
a.5 In what ways is your project different from others in enabling women's economic empowerment and gender equality?	The management of program has focused on implementation of a working methodology for HIV infection prevention of mother-to-child HIV infection transmission, in accord with the Ministry of Health and Family protocol issued in this respect. The management structure of the prevention program involved a first training component addressing general pediatric HIV issues, for general practitioners, medical nurses, and specialists for pregnancy and infectious diseases, followed by a prevention component with antenatal counseling and testing activities provided for pregnant women alongside with the introduction of specific prophylactic measures for HIV positive pregnant women, such us the use of antiretroviral treatment during pregnancy and for the new-born baby, formula baby milk feeding versus breast feeding, caesarean operation for delivery. The program ended with the interpretation of overall program implementation results and study findings. Methodology of HIV maternal-foetal infection prevention program implementation included a networking component between local authorities responsible in management of pregnancy cases. During the pregnancy, both family doctors and obstetricians supplied the pregnant women with information on the HIV tests and referred them to the Epidemiological Centre run by the County Public Health Department where they were actually tested. The women were asked to give their written agreement after going through the pre-test counseling. Both general practitioners and obstetricians briefed the pregnant women prior to the test while the pre-test counseling has been done by the staff of the County Hospital Obstetricians Department. Post test counseling have been offered, done by the staff of the Epidemiological centre, the infectious specialist, the obstetricians or the general practitioner, accordingly with the priority the women addressed to them. The staff of the Epidemiological Centre was responsible to hand in the positive result of the HIV test directly to the respective woman. The negative results were mailed to the general practitioners who requested the test or were handed in directly to Public Health Department if the woman in case came to the testing and counseling centre run by the County Public Health Department or in case she was hospitalized in an Obstetrics Clinic. Only those women who were not tested during their pregnancies were tested shortly before delivery. A connection were provided between the Epidemiological Centre and the County Maternity Hospital so that the Maternity to have access to the information on testing the pregnant women, thus allowing the obstetricians to check during delivery whether the women have been tested before. Upon the admission in the Obstetrics Gynecology Clinic, all pregnant women have had to supply the test bulletin (the HIV test) to be enclosed in the observation chart. The obstetricians required pregnant women consent for the test after counseling prior to the test, in case of testing done shortly before delivery. A quick HIV test were performed and processed by the laboratories of the County Hospital or the Medgidia Hospital, their results being available in terms of 1 to 3 hours. Women hospitalized for gynecological or obstetrical matters manifested during their pregnancies were submitted to ELISA test. The tests were processed by the County Public Health Department and the result was available within 1 to 3 days. The results of these tests were fed into the data base, which was collected, processed and analyzed by the Epidemiological Centre of County Public Health Department, except for the clinical data which pertain to the specialists. In case of positive result of a HIV test, the test result was communicated directly to the woman by the obstetrician or the infectious disease specialist, as the woman was to be referred to them by the testing and counseling centre. Communication of a positive status is followed by post-test counseling. The general practitioner was informed about the result only with the pregnant woman’s consent. The woman were to be monitored by the infectious disease specialists, who were responsible also for administering the antiretroviral medication treatment for mother and the child, and were to cooperate with the obstetrician during delivery. All HIV positive pregnant women were referred to a psychologist and a social assistant to be psychologically assessed and counseled and to have a social survey made. The clinical and para-clinical monitoring and ARV treatment of HIV positive mothers was carried out by the infectious disease specialist from the Municipal Hospital during the pregnancy, intra-partum and two months after birth. Clinical and para-clinical monitoring of children born by HIV positive mothers was envisaged as well. All children born by HIV positive mothers were assessed clinically and para-clinically by the infectious disease specialist from the Municipal Hospital. The collaboration between identified responsible parts involved in the prevention program were to be achieving under the Romanian Angel Appeal coordination, overtaking the informational barriers occurred in the general health management system, the financial difficulties of the health care institutional providers and the educational gaps identified in the general targeted population as well as educational needs assessed at the medical professional services level. Romanian Angel Appeal has a large experience in developing successful national program and implementing locally successful models based on its logistical expertise. Therefore an important credibility of the association made possible the achievement of strong support from a large number of organization, either governmental or not. Previous experience of Romanian Angel Appeal in governmental agencies networking as well as in capacity needs assessment made possible successful and efficient collaboration between health management institutions involved in this program. An expertise team with international outstanding professional expertise, coming from University of Padova – Italy and the Institute for Children’s Health in London were contributing with important expertise on medical care services addressing pregnant women as well as interpretation of study findings in accordance with internationally used statistical indicators, allowing an international comparative view over the program and study results.
a.6 What added value does your project bring to the ICT for development fora?	The overall methodology of the developed prevention program has been drafted and submitted to the National AIDS Commission of the Ministry of Health and Family, obtaining thereafter the final authorization and the governmental support for the program implementation. Aiming to locally implement, in Constanta County, the governmental protocol designed for vertical transmission of HIV prevention, the program has created procedural working routines. Procedural networking routines among medical practitioners were developed and facilitated, as well. Monitoring and assessment tools and processes were therefore created, by the program implementation needs, such as standardization of prevention, testing and epidemiological surveillance methods, developing and facilitating the use of program related reports, continuing professional medical education, regularization of monitoring, networking and evaluation site-visits, developing role description for every partner involved in program implementation. Statistical analyses were used to evaluate the results of the initiative. Test results and data on socio-demographic variables and HIV risk factors collected during pre-test counseling on a standardized form were entered onto a confidential database and statistically analyzed. Comparative analyses of data collected shown that 72% from total pregnant women population at local level has been tested for HIV infection diagnosis. The sero-prevalence of HIV infection in pregnant women has been identified. Overall prevalence of HIV infection was 1.75 per 1000 (20 / 11423). A multivariate analysis has been performed to identify independent risk factors for HIV infection in the pregnant women population targeted. Recommendation has been issued for program replication as a model of good practice, under the competence of recognized medical specialists.
b. Upscales initiatives and community-centred technologies
b.1 Please narrate specific innovative or new approaches employed by the project, if any, that contribute to its development and its relevance to the community it is serving.	The vertical HIV transmission and the education program introduced and developed by Romanian Angel Appeal (RAA) in Constanta County represent a model of good practice and partnership, feasible to be developed in the whole country. Considerable efforts have been made and the initiative had achieved important results and outcomes, as follows: - 11,423 pregnant women were counseled on the risks associated with the HIV infection and the transmission of the virus to the neonate, in case of infection. Moreover, the pregnant women were counseled regarding the importance of undergoing the HIV test and of using protection measures. - The comparative analysis of data suggests that approximately 72% of the pregnant women population was tested, i.e., 11,423 women were tested on average during their 24th week of pregnancy. The percentage of tests performed during the first and second trimester of pregnancy raised from 58% in the first semester of the program to 69% in the last semester of project; 1,984 tests (17%) were carried out to women during their 38th week of pregnancy and over. - Out of the 11,423 tested pregnant women, 20 proved to be HIV positive. Due to counseling and prophylactic measures, only 4 of the 12 neonates had clinical data indicating an HIV infection (the diagnosis is established only after 1.5 years of age). - The study on the prevalence of the HIV infection among pregnant women revealed a sero-prevalence index of 0.175% for Constanta County. - Epidemiological analysis on probability of HIV infection among pregnant women showed a relative index of 0.0012 for women pertaining to Romanian and Caucasian groups, which is 6 times and, respectively, 9 times higher than the ones for the Romany and Oriental ethnic groups (e.g., Muslim Romany people, Turks, Tartars). - Epidemiological analysis of risk factors associated with the HIV infection in pregnant women revealed a relative risk index of 1,052 for women with HIV positive partners, followed by those with partners at risk (86.4) and prostitutes (60.9). The HIV infection was significantly and independently correlated with HIV positive partner, partner at risk, prostitution, and central Asian ethnic groups – Muslim Romany, Tartars, and Turks. - All 12 children born from HIV positive mothers received antiretroviral treatment at birth and 4 were born through T-section; 6 pregnant women received antiretroviral treatment intra-partum. Four children got infected with HIV (their mothers were diagnosed HIV positive during delivery). - Three different brochures, totaling a number of 12,000 copies, were used as information support for the project: "What every pregnant woman must know", "Continue to live - brochure for sero-positive pregnant women" and "Guide for family doctors". - A "Manual for the care of HIV positive pregnant woman" was issued and disseminated among a large audience of medical specialists, at the beginning of December 2002. - Four training sessions were organized for 35 obstetricians, 25 medical nurses/midwives and 350 physicians, a total of 410 professionals involved in the project. The courses covered topics such as notions of pre- and post-test counseling, pre- and post-natal assistance, obstetrical management, clinical and therapy management, post-exposure prophylaxis, universal precautions regarding the transmission of the HIV virus. The testing and counseling program was successfully implemented, despite financial and logistic difficulties the health system is confronted with (average health expenditure per person amounted in Constanta County to 42 USD for 2000). The large amount of tests effectuated was performed thanks to the efforts for training family doctors and for informing and educating pregnant women. Women pertaining to ethnic groups (Orthodox and Muslim Romany) present a high risk regarding the HIV infection and they may prove to represent the majority of untested pregnant women. These factors, combined with explosive growth of sero-prevalence in neighboring Ukraine, reveal the urgent necessity that Romania continues the efforts in the field of HIV vertical transmission prevention. The intervention has had a multipartite impact: - over the health care system at local level, sub-sectorial represented by health management and clinical and para-clinical medical services, by frame-working a practical partners’ collaboration protocol and facilitating the implementation of a specific methodology designed for vertical transmission of HIV prevention in Constanta County, although the infrastructure for a successful prevention strategy was not always in place due to the under-funded and overburdened health care system, - over the individual health improvement, through both educational and counseling services input, and access opportunities and increased quality medical services enhancement; a significant results consisted in zero vertical transmissions occurrence where a combination of interventions to prevent mother-to-child transmission were applied - over the health care system at national level, by practically pilot-testing the Ministry of Health and Family methodology for application of mandatory recommendations for antiretroviral prophylaxis to reduce vertical HIV infection transmission, reassuring the trend towards earlier testing in pregnancy, as early identification of HIV-infected pregnant women is essential for the application of a combination of interventions to prevent mother to child HIV infection transmission The overall results of the project implemented at Constanta County have shown that vertical transmission are to be considered as the most significant route of children’s HIV infection. Nationwide efforts to prevention should therefore been envisaged by the health care institutions and policies in this respect. Although the Ministry of Health and Family representatives had repeatedly agreed upon the necessity of a national program for prevention of mother-to-child HIV infection transmission, the financial restrains could not be supported from state budget resources. Still, based on the Constanta efficiency, impact and lessons learned of the program implementation, the program has been successfully started to be replicated in 2002 and is actually running till 2005, in Giurgiu County, another region in country presenting a higher rate of incidence of HIV infection among women and children. As a model of success, further replications of the program have been agreed with the Ministry of Health and Family representatives in twelve other counties in Romania, out of the total 41 counties, according with specific epidemic local situations, between 2004 and 2006.
b.2 Describe the processes or mechanisms that are in place to ensure the project's sustainability.	The utilization of information and communications technologies in the project was made in support of women’s empowerment and toward raising awareness and increasing education on HIV/AIDS among both women and medical services representative responsible in pregnancy cases. The information and communication tools were used in a way that is appropriate to the needs and contexts of the pregnant women community life-style at local level, reaching the community by integrating their own beliefs, backgrounds, values and cultural pattern and ensuring that project aims and methods are understood. Sustainability over the long term of the project results was envisaged through appropriate institutional collaboration methodology issued, frame-worked and putted in practice, also through the standardization of the methods to be used, ensuring the continuity of the prevention program for mother-to-child HIV infection transmission. Training session were organized for obstetricians, infectious diseases specialist, neonates pediatricians, epidemiologists, medical nurses, totalizing a number of 410 health care representative responsible with the medical services for pregnancy. Training modules were issued both on CD-ROM format and online. A modern approach suitable to the medical professionals’ needs was considered by offering on-line education training module. The training modules content is based on relevant international experience and officially recognized and credited by the Romanian Medical College. Educational counseling and prophylactic measures were taken to prevent HIV infection among 11,423 pregnant women, pondering 72% from total pregnancy cases at local level, at the project implementation time. Three different brochures, totaling a number of 12,000 copies, were used as information support for the project: "What every pregnant woman must know", "Continue to live - brochure for sero-positive pregnant women" and "Guide for family doctors". A "Manual for the care of HIV positive pregnant woman" was issued at the beginning of December 2002. The data collected through the performed study have been analyzed by the statistical means, in order to evaluate the results of the initiative. Data were analyzed using SAS statistical software (version 6.12, SAS Institute, Cary, North Carolina) for a multivariate analysis needed to be performed in order to identify independent risk factors for HIV infection as well as the general sero-prevalence in the pregnant women. Computerized data bases were needed to have a coherent approach upon collecting the test results and data on socio-demographic variables and HIV risks factors identified during pre-test counseling sessions and ensuring the confidentiality of data collection use.
b.3 How can your project be replicated elsewhere?	The next public health departments were identified and have been therefore active participants in program implementation: - epidemiological departments of public health management authority at local level, responsible in HIV testing and pre- also post- test counseling; - clinical HIV infection medical services, at county and municipality level; - obstetricians and family unit physicians addressing pregnancy services, also pre- and post- test counseling; - medical nurses and familial planning units’ personnel, who provide additional medical services to pregnant women. A total number of 410 medical specialists (family doctors, obstetricians, infectious diseases specialists and medical nurses) were active participants for program implementation. There were also beneficiaries of 4 training sessions covering topics such as notions of pre- and post- test counseling, pre- and post- natal assistance,, obstetrical management, clinical and therapy management, post-exposure prophylaxis, universal precautions regarding the transmission of the HIV virus. The collaboration between identified responsible parts involved in the prevention program were to be achieving under the Romanian Angel Appeal coordination, overtaking the informational barriers occurred in the general health management system, the financial difficulties of the health care institutional providers and the educational gaps identified in the general targeted population as well as educational needs assessed at the medical professional services level. Although protocol issued by the Ministry of health and family state mandatory regulations and an efficient methodology to be implemented for mother-to-child transmission prevention programs nation-wide, the pilot implemented by Romanian Angel Appeal identified disturbances of implementation at local level caused by financial strains, training gaps identified for social workers providing care and services to pregnant women while dealing with HIV positive cases and community related factors decreasing the participation expected. The pilot program ended as a model-of success, based on the capacity building, the personnel supplementary training and continuing medical education, and community involvement in raising beneficiaries’ awareness for active participation. Institutional capacity was improved by purchasing needed protection equipment necessary to perform the obstetrical maneuvers and to take blood samples, while also increasing the staff salaries. Supplementary training courses were organized for both social workers and general practitioners on both medical knowledge and current health laws binding the medical services to HIV positive patients. The Romany community of pregnant women was at risk for attending counseling sessions and to overall participation to the project due to both inside community factors, such as illiteracy and low income status, and outside community factors, such as health care workers reluctance observed when they were supposed to perform specific obstetrical maneuvers. Therefore community involvement on the program implementation constitutes another relevant factor of success.
c. Promotes cooperation and social networking
c.1 Who participates in the initiative? (Please identify participants, beneficiaries, and implementation partners. Provide specific demographic (age, income, rural/urban) information about your beneficiaries.)	The initiative's efforts have demonstrable impact, with respect to empowering and supporting individual women by implementing measure to decrease the sero-prevalence among pregnant women. These had included obstetrical maneuvers, ARV treatment, medical and social management of cases. An improve over the quality of their lives and meaningful contributions to equitable human development has been achieved through social and psychological support provided alongside with education and prevention and counseling measured introduced targeting the pregnant women population at local level, in order to prevent vertical HIV infection transmission. In the same time, social justice in overtaking HIV/AIDS issue for pregnant women was envisaged, by implementation a model of good practice among local practitioners in modeling a HIV infection of mother to child transmission prevention methodology and cases management of confirmed HIV positive pregnant women. These has been done through informative materials, issued and distributed within the project, through training sessions and through project visits and project meetings and mainly by applying the project methodology. An important contribution in women empowerment was to be considered by challenge of traditional mentalities among ethnic communities significantly living in local area. The Constanta County features a large number of ethnic communities: Orthodox Romany communities, Muslim Romany communities, Tartars, Turks, and so on, living scattered around in various localities. Some of them live in isolated areas, some others live in the largest towns in the county, thus generating lots of problems of pathology as they live in unhealthy areas and they generally have large, numerous families who live on a very low income or on no income at all. Traditional conservative mentalities decreasing women’s ability to abide personal decisions has an important impact on their and their offspring’s health status. The educational component of the program raised both the women and the women’ partners awareness on their reproductive rights, generating patterns of remodeled familial roles. Barriers to voluntary counseling and testing, stigma and fear of HIV disclosure, community/cultural reluctance to embracing breast milk substitutes, and role of mothers in patriarchal communities of origin were also overcame through the educational component addressed directly to the women, as beneficiaries of the program, and by the participatory involvement of the local communities representatives in the overall program’s activities.
c.2 Please identify the project's most important partners and explain their role in the project and in helping to mainstream gender.	The management of program has focused on implementation of a working methodology for HIV infection prevention of mother-to-child HIV infection transmission. Accordingly with the program management structure, sustainable processes and mechanism remained n place to ensure that local authorities and key relevant stakeholder are capacitated to take-over the program running after pilot ending. Training program for continuing medical education for general practitioners and medical specialists dealing with HIV positive cases are available on CD-ROM support and on-line accessibility is ensured through further project focused on continuing medical education, conducted by the Romanian Angel Appeal. Procedural working routines were standardized for prevention, testing and epidemiological surveillance methods. Procedural networking routines among medial practitioners were regularized, building a working protocol among partners and also specific methodology to prevent mother-to-child transmission at local level. Informative brochures were distributed to the pregnant women in case, the family doctors’ cabinets and the familial planning cabinets at local level. Three different brochures, totaling a number of 12,000 copies, were used as information support for the project: "What every pregnant woman must know", "Continue to live - brochure for sero-positive pregnant women" and "Guide for family doctors". The "Manual for the care of HIV positive pregnant woman" was also issued at the beginning of December 2002 at the local level and to other key relevant factors identified nationwide.
c.3 How does the project foster cooperation and active participation among the different sectors (government, private sector, civil society) in the community?	The first condition for such a program to be successful is to have co-operation among all the parties involved in the program. The poor state of all the health system, the drawbacks of the information circuit and the low level of the public health education can generate many difficulties. However, having a program methodology in place and tested can simplify the project development. Another very crucial aspect related to the success aimed for such a program is the financial efficiency. The program run for two years proved to be financially efficient if we only calculate the total expenses that would have gone into the care and treatment for the babies (whose clinical evolution is favorable and the partial laboratory tests suggest sero-negativity), if no prophylactic measures had been implemented and their present status had indicated sero-positivity. Still, the methodology of the project has been successfully replicated, starting in 2002 being actually on-going till 2005, in Giurgiu County. This county statistics registers a high number of HIV cases (328) and an increased number of infections within the adult population. Considering the risk factors (Giurgiu is a border town with all behaviors associated, such as prostitution and drug use), age of the HIV infected children (now reaching teenage years), lack of education/information within the population, and especially vulnerable groups such as Romany communities, the need to develop a prevention project became compulsory. The similar project developed in Constanta showed that counseling and treatment had the lowest effect in Romany community, resulting in further pregnancies at the same HIV woman, due to resistance in using protection and contraceptive methods (condom) and following the counselors’ advice. Therefore, it became compulsory to reach this community that has its own beliefs, backgrounds, values and cultural pattern and make sure that project aims and methods are understood. The project is developed in partnership with local authorities and local community (including Romany groups) and will target all pregnant women seen by general practitioners and obstetricians within the two years of the project. The implementation of prevention methodology will be followed up after the project is over and will decrease the mother-to-child transmission rate in Giurgiu County. The Giurgiu program replication emphasized the recommendation of the previous Constanta program implementation, strengthening the role non-governmental organizations could play in order to streamline the HIV maternal-foetal transmission prevention program, as they can supply well-trained counseling workers, are highly flexible, and are really more capable to respond to the needs existing within the affected community than the state health institutions. A further replication of the model is envisaged and will be put in practice, in partnership and with the support of Ministry of Health and Family, in twelve other counties in Romania, out of the total 41 counties, according with specific epidemic local situations, between 2004 and 2006.
c.4 How does the project strengthen the capacity of those who are involved in its implementation?	The project implementation has concluded to several specific lesson learned as well as general applicable information as resulting from prevalence and risk factors associated with HIV infection transmission study performed. Key lessons learned can be highlighted, as follows: The pregnant women’s addressability for the HIV test has obviously increased while running the program, due to the following: - improved knowledge and working techniques with the health care workers providing counseling (general practitioners, epidemiological centre staff, obstetrical and gynecological staff) as a result of their attending training courses, getting information and extending their practice; - leaflets edited and distributed to the pregnant women. Intercepting the pregnant women for the HIV test during the late stages of their pregnancy (the second and third quarters) or even during delivery was a lesson learned as it had a negative impact on the possibility to implement the whole set of prophylactic measures referring to the maternal-foetal HIV transmission. The initial assessments highlighted the need to provide health care workers with general information on the HIV infection and its prevention measures. The necessity to provide additional training to the maternity personnel, to obstetricians but also to midwives/nurses for them became evident, in order to clarify their knowledge on the obstetrical approach towards an HIV sero-positive pregnant woman: Caesarean section, avoiding rupture of the membranes, limiting the duration of their labour etc. Providing non-discriminating treatment and health services to all HIV positive pregnant women constitute a challenge identified while project implementation. We mention it as, while the program was ongoing, we came across a few cases when health care workers were reluctant when they were supposed to perform specific obstetrical maneuvers. Here are causes which are not specific to the Constanta County, but are triggered by the general state of the Romanian healthcare system, such as: - health care workers do not have the necessary knowledge on the prevention of the HIV infection transmission during their professional practice and the post-exposure prophylaxis; - lack of knowledge and observance of the relevant health laws (professional secret, the mandatory character of abiding by the universal precautions when assisting any patient and the obligatory character of granting medical assistance to an HIV-infected person by all health care workers); - a lack of protection equipment necessary for all health care personnel and especially for those working in the surgery clinics(obstetrics included); - a small number of health care workers compared to the number of people attended as well as their low salaries. Therefore, we had to adjust to the above-mentioned situations and allocate part of the program resources to buy the protection equipment necessary to perform the obstetrical maneuvers and to take blood samples, while also increasing the staff salaries. The social and psychological assistance provided to sero-positive pregnant women was an essential linking element between the medical assistance services and the future mother, on the one hand, and those services and the pair mother-child after delivery, on the other hand. As most HIV positive pregnant women identified under the program were also social cases, both the social worker and the psychologist aimed at improving the social condition of the future mother and her child, as well as providing the necessary psychological support to overcome obstacles related to the disease, the delivery and the child care. The role of the social -psychological assistance service was also obvious in counseling couples who do not use contraceptive measures and who are faced with a second pregnancy now, despite the mother’s or both partners` being sero-positive. The trend towards earlier testing in pregnancy throughout the pilot is reassuring, but identification of infected women early in pregnancy and access to and uptake of antenatal HIV testing by “hard to reach” groups will be key challenges. Although Romania appears to have a low HIV sero-prevalence compared with Eastern Europe and Central Asia, there is no room for complacency and prevention efforts should continue to be a priority The study performed mark out conclusion and recommendation that were considered in further discussion at the governmental level on mother-to-child prevention programs to be further implemented nationwide. The main conclusions were as follow. The prevalence rate in the total population was not known, till the program implementation in Constanta County. According to the study performed, the prevalence of MTCT observed among 10,426 pregnant women is 1.8‰. However, in the absence of specialized information and counseling (which were available in that project), prevalence can definitely increase for at least two reasons: - increase in risk factors within young and adult population (due to lack of prevention programs, education, drugs) - lack of specialized services, trained staff in HIV test counseling and lack of information provided to pregnant women The results of the project run between 2002 – 2002 showed that the HIV infection is indeed transmitted via the maternal-foetal route in Romania, therefore, efforts to prevent new infections have to be done national wide. In order to prevent mother to child transmission, the Ministry of Health and Family issued in 1999 an ordinance (889/1999) strongly recommending testing and counseling for risk groups (including pregnant women). However, in the absence of adequate training for medical staff and in the absence of informative materials, the ordinance is not applied or is applied incorrectly (without the written consent of the women or pre test counseling). Although there are mandatory recommendations for antiretroviral prophylaxis to reduce MTCT in Romania, the infrastructure for a successful PMTCT strategy is not always in place due to the under-funded and overburdened health care system All pregnant women identified in Constanta County in the two years of the project (100%) accepted to be HIV-tested. Of total number of 11,423 pregnant women who agreed to be HIV-tested, only 20 have proved to be HIV positive. This number was corroborated with the risk factors highlighted by the survey and with the present trends, which indicate an increased number of intravenous drug users nationwide, thus confirming what Romanian specialists had already forecast a long time ago: even if during the 1987-1989 period the main HIV transmission route was horizontal, once the eradication measures were implemented, the future would bring about all the other trans mission routes (sexual, intravenous drugs, maternal-foetal). The maternal-foetal route is the most accessible one for any attempt to eliminate the infection.
3. Learning Lessons and Sharing Strategies
a. Why, when, and how did the project begin?
b. What are the goals of the initiative?	The implementation of the program as well as the replication of the model already started in Giurgiu County and planned to be nation-wide implemented in the most relevant country counties were needs assessment proved their necessity demonstrated the importance of networking already implemented between relevant health management institutions at local level and women’s community association. Others important collateral stakeholders are yet to be geared in the program implementation. Mass-media proven to have an important effect in sustaining professional efforts addressed to the general public. Their collaboration could contribute to the further dissemination of the information to general public, demonstrating Romanian governmental and non-governmental efforts to improve the general health state of public, to address problems encountered by specific under-represented, discriminated or low-income communities, to positively act for women empowerment. Local communities leaders, such us ethnical leaders, churches’ pastors, teachers and educators, are to be more consistently reached as they are the most suitable to facilitate the communication with officials and professionals, to distribute the information to the community members taken into account their own values, beliefs and social patterns of behavior as well as to identify and efficiently communicate their specific problems to the professional and local authorities representatives. Patients’ association as well as women’s association may give their contribution to the success of the program implementation by providing peer-support and emphatic social linking. The patients’ associations are most suitable to address the specific problems occurred in case of positive HIV tests results to the relevant key factors at the health management level. The women association may identify specific problems women foresee after learning the test results, especially in case of positive results, and what kind of support those women have, in order to address their problems to relevant key factors.
c. How are decisions being made in project implementation?
d. What mechanisms are in place to ensure transparency and accountability in implementing the project?	applicant didnt provide information on this question
e. What results and/or immediate outcomes has the initiative achieved, and what impact has it had on the beneficiaries, participants, and community?
f. What tools and processes did you use to monitor and evaluate the results of the initiative?
B. GENERAL INFORMATION
1. Name of individual or organization	Romanian Angel Appeal Foundation
2. Address	Rodiei 52 Street, 032916 Bucharest, Romania
3. Region/Country	Romania
4. Telephone number	0040-21-3236868
5. Fax number	0040-21-3232490
6. E-mail address	silvia.asandi@raa.ro
7. Organisation's URL (if applicable):	http://www.raa.ro
8. Name and designation of person submitting this application form	Integrated model of prevention of mother-to-child transmission of HIV infection in Constanta County General Manager
9. Organization's Vision/Mission	Mission Statement The mission of RAA is to support children and young people in need, such as HIV/AIDS affected, by developing and improving quality medical, social and educational services, providing on-going trainig to professionals working in the HIV/AIDS field and by conducting prevention campaigns aimed to reduce HIV spread and discrimination against those affected. Vision and Values Statement Making a difference HIV epidemics start and spread in different ways in different places, but the epidemic is consistently accompanied by fear, blame and prejudice. In almost all cases, young, poor and marginalised people are disproportionately vulnerable to HIV/AIDS and its consequences. We concentrate our resources where they will make the most difference to mitigate its impact and slow the spread of the epidemic. This requires focused support to the children and young people living with HIV, a constant fight against stigma and discrimination, sustained efforts directed towards prevention and a commitment to support knowledge and resources for professionals involved in the fight against AIDS in Romania. Working in partnership No one organisation can respond to HIV/AIDS in isolation. The pandemic demands mobilisation and collaboration at community, national and international levels. Government, civil society and private enterprise all have vital roles to play. Governments have a particular responsibility for leadership, but not at the expense - or to the exclusion - of leadership from other sectors. Romanian Angel Appeal (according to its statue) will actively collaborate with all the above mentioned sectors, while respecting each other’s independence and acknowledging differences. Transparency, critical thinking, learning and sharing are essential elements of such successful partnerships, and of successful responses to AIDS in Romania or elsewhere.
10. Where did you hear about the GICT Awards?	Other