Questions/Answers

The initiative started in 2013 with the aim to scale up HIV services among outbound labour migrants (migrants), their families and community members, especially in rural and hard-to-reach areas. Before the initiative was taken the majority of PLHIV (68.3%) including migrants did not know their HIV status, and continued practicing unsafe behaviour. Self-initiated application for HIV testing was very low due to lack of access and motivation, lack of health-seeking behaviour for HIV/STIs especially among rural population. Before 2013 various activities among migrants were not implemented systematically, neither had they brought any feasible outcomes, whereas in the last ten years outbound labour migration factor has been significant in the structure of HIV registry. 56% of the HIV cases registered in Armenia in 2009-2018 represented migrants. Overall, 66% of the registered HIV cases were migrants and their partners. Generally, Armenia is considered an emigration country with migration flow mostly to Russia (>90%), where new HIV infection is the highest in the Eastern Europe and Central Asia (EECA) region. Action plan for the health sector response to HIV in the WHO European Region (2017) specifies migrants as vulnerable to social adversity and ill-health. Migration can place people in situations of increased vulnerability to HIV and other serious infections by limiting their access to health-care and, in some situations, legal services and protection in host countries because of administrative barriers, accessibility and affordability of the services, stigma, complications due to illegal residence status and host country policies (e.g. deportation of HIV-infected migrants); by separating them from their family, spouses and local support networks and inducing additional social, political and economic stressors, which also leaves migrants highly vulnerable to HIV. Fear of being deported and limited time and lack of culture of being tested lead to the increased vulnerability to HIV and other infections.

This initiative is about delivering inclusive and equitable public mobile health services for the population most vulnerable to HIV in Armenia - migrants, their families, communities based on the principles of anonymity and confidentiality. Timely initiated care allows PLHIV living their lives to the fullest, and preventing the infection transmission. The initiative is addressed by the National AIDS Programme, approved by the Government, creating platform and promoting institutional frameworks and mechanisms for collaboration between the State, civil society and international organizations/donors. Integrated policies and developed plans facilitate harmonization between different governmental bodies, strengthen linkages and accountability for the sustainable development.

This initiative is aimed to HIV/STIs/hepatitis early detection and contributes to treatment and care provision before clinical manifestations. The percentage of PLHIV knowing their status, under treatment and with undetectable viral load was dramatically increased in the course of the initiative realization. Therefore, Armenia has become one of the EECA countries having a great chance of attaining the UNAIDS 90-90-90 targets by 2020 (78-78-85), which would be a turning point in achieving one of the SDGs - ending AIDS epidemic by 2030. Armenia is located in one of the regions with the highest new HIV infection, currently, however, due to the taken comprehensive measures, HIV prevalence among adult population is stable at low level, making up 0.2%, i.e. in 4.5 times lower than the average HIV prevalence in the EECA region. The country has reached unprecedented success in the history of the global response to AIDS - the HIV epidemic in the country was halted, and what is more, was reversed from the concentrated to low-level state (HIV prevalence in each of the key populations is below 5%). Also, the preventive measures effectiveness is proven by very low new HIV infection remaining stable (<200 cases) over the last 5 years.

Residents of the remote rural areas in Armenia are the most vulnerable population considering the high level of unemployment among them, making them seek temporary job abroad, mainly in Russia. Armenia receives about 59% of its remittances from there. The remittances are important not only for migrants’ families budget, also they are a part of income flow to the country. Inward remittance made up 12-20% of Armenia’s GDP in 2013-2018, making significant financial inflow to the country and contributing to the economy growth. This initiative helps migrants to stay healthy, capable of working, which contributes to poverty reduction.

Free anonymous HIV testing for migrants and community members is not available in rural communities. In towns free access to testing is limited due to the state financing model requiring provision of ID information for free testing at primary health care facilities. It is available only in capital - at the NCAP. Therefore, the initiative created broad access to anonymous HIV/STIs/hepatitis B,C testing, TB screening linked to further testing, diagnostics, treatment, care and support services in 334 rural communities making up 35% of total rural communities of Armenia, where 72% of the country rural population resides. Also, timely referral for the specialized care and early diagnosis of diseases improve treatment outcomes. This initiative contributes to strengthening capacity and developing skills of local health care providers for HIV testing motivational consultations, for referral and management of TB/hepatitis/STIs and further follow up for positive cases. Thus, HIV testing has become one of the components of the health services provided, enabling to overcome a number of challenges related to HIV testing like anonymity, confidentiality, stigma, etc.

Under this initiative 45,281 women and 26,753 men underwent HIV testing, 71,913 women and 59,848 men received motivational consultations. For the initiative promotion in 6 regions of the country women groups (wives of migrants) are functioning, aimed at reducing women’s vulnerability to HIV and raising their motivation to undergo HIV testing. At their meetings they address issues related to HIV transmission, early diagnosis and importance of timely ARV treatment initiation. Also, the resource centres are operating aimed to raise HIV prevention awareness among adolescents using IT. Information is provided on how to avoid HIV, practice safer behaviour, get services.

The initiative targets migrants and their family members. The analysis shows that the majority (65.7%) of HIV cases were registered as a result of provider-initiated HIV counselling and testing in 2012 mainly at the stage of clinical presentations and 28.9% - people who returned to Armenia with already made HIV diagnoses for the detailed examination, follow up, and subsequent treatment and care. HIV prevention and treatment services were not accessible for them in host countries. At the mobile clinics and rural outpatient facilities migrants and their partners, as well as community members are provided with comprehensive package of public health services including counselling aimed at raising HIV awareness to motivate testing for HIV/hepatitis B, C/STIs, medical counselling, ultrasound examination, TB screening. Positive cases are then referred for further testing and, if necessary, for disease management at specialized medical institutions, for HIV - at the NCAP, for TB - at primary health care institutions, then at TB clinic, if required, for syphilis - at STI clinic, for other STI diseases - at primary health care facilities and at the NCAP, hepatitis B,C - at primary health care settings or infectious diseases clinics.

Before the initiative introduction the activities implemented among migrants, especially those related to HIV, did not have tangible outcomes. To evaluate possibilities of HIV testing services delivery to migrants relevant qualitative and quantitative researches were conducted with international assistance. The findings demonstrated that the most relevant and acceptable model for migrants communities is provision of HIV testing as a part of public health services package, where HIV testing is given alongside with other services, such as testing for hepatitis B,C/STIs, medical counselling, TB screening. This approach was incorporated into the National AIDS Programme ongoing in Armenia, approved by the Government, where one of the components is HIV prevention among migrants, via provision of comprehensive package of health services. Since the State Budget could not cover the required expenses, including this component, fundraising was implemented to realize the model. The support has been provided by the UNAIDS, AIDS Infoshare Foundation, Global Fund, IOM, Caritas Charitable Foundation. The optimal mobile services model was designed and piloted with support of the State Migration Agency of the Ministry of Territorial Administration in selected areas of the country. Further the interventions were scaled up to the country regions. The services were provided free, with adherence of the principles of voluntariness and confidentiality, which, with targeted motivational outreach work of local health workers, dramatically increased application for testing, which, in its turn, improved detection and diagnosis of HIV infection and allowed to expand treatment coverage with boosting its outcomes. Over the whole period of the initiative implementation routine monitoring and evaluation are conducted by the National M&E Unit, and at least twice a year - by the donors and technical partners representatives, who interview on-site the service providers and beneficiaries to obtain their opinion on the format, quality, etc. of the provided services.

Different studies demonstrated low HIV risk perception by migrants, due to which they do not practice safer behaviour, whereas in host countries HIV prevalence is much higher and probability of contracting HIV through unprotected sex for them is relatively higher than in home country. Prevention and testing services in host countries are not accessible for the majority of migrants because of administrative barriers. Therefore, outreach works are intensified in the period of December-February, when migrants are temporarily returning home, to motivate them to obtain the services.

Prior the initiative was taken such model of HIV-related public health service delivery to migrants, families and rural communities in the remote regions, including hard-to-reach ones had not been approbated in Armenia or in any other EECA country. The innovative idea was generated by NCAP, one of the key institutions of the existing public health care system, then implemented in Armenia due to the coordinated efforts and cooperation between NCAP, public organization under MoH and primary health care services structured under the local authorities. Also, for the first time community-based rapid testing was piloted and introduced.

Before the initiative was introduced we were inspired with and studied the experience of providing HIV services through mobile clinics to most at risk populations (mostly to sex workers) in other countries. To create our model we applied the concept of using the mobile clinics for delivering HIV services to migrants, considering that they are the most vulnerable population to HIV in Armenia having no access to such services at community level. However, before realizing our initiative we had not known about any other experience of such services provision to migrants and their families, at least in EECA region.

The initiative on mobile health services started with covering 60 communities in Armenia, currently its total coverage reached up to 334 rural communities. Within the 6-year period of implementation vast experience in provision of innovative mobile public health services has been accumulated in such small country as Armenia, with population about 3 million people and area of 29,743 sq km. To popularize HIV testing the model is also used at various expo exhibitions and public events conducted under the European HIV-Hepatitis testing week, World AIDS Day, World Hepatitis Day, International AIDS Candlelight Memorial in the country’s mid size and big cities and broadly covered by the mass media. During the events all comers are welcomed to undergo free of charge anonymous HIV and viral hepatitis rapid testing and know their status. The model was introduced and currently is being successfully used in two other EECA countries - Tajikistan and Kyrgyzstan, where 9 clinics in total are providing similar mobile services to migrants, their families and community members. Totally, in 2013-2019 about 180,000 beneficiaries in Armenia, Tajikistan and Kyrgyzstan have been provided with the mobile public health services, including testing.

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To implement the model fundraising was organized, since the State Budget could not cover all the required expenses. In 2013-2019 public health services are being delivered under various projects implemented with the support and technical assistance of donors - the Russian Government (through UNAIDS and AIDS Infoshare Foundation), Global Fund, IOM, Caritas Charitable Foundation. AIDS Infoshare Foundation and UNAIDS granted three mobile clinics to the NCAP, provided test-kits and medical supplies for testing. MoH provided administrative and consultative support, approved the mobile service structure. NCAP partially covered maintenance expenses, recruited staff, mobilized human resources, used existing capacities and infrastructures.

The three clinics have significantly increased accessibility to public health care services in distant rural communities of the country. HIV testing has become part of the provided services, enabling to overcome a number of challenges associated with HIV testing. The mobile clinics operation in Armenia has proven the services high reliability, efficiency and relevance. The initiative is integrated into the current healthcare system, which makes it sustainable in institutional terms. After 2021, if donor funding is not available, the next National AIDS Programme will consider the State financing for the initiative to ensure its financial sustainability.

Yes

UNAIDS conducted external independent evaluation of the project first phase in 2016 aimed to reveal the general achievements, strengths and weaknesses, external and internal factors impacting the project success, relevance, efficiency, lessons learned for making recommendations on strengthening the project next phase and overcoming bottlenecks. The first step of the evaluation included desk review to identify aspects and list of questions for individual and group interviews. The next step included on-site evaluation via collecting additional information and consultations. Finally, obtained data was correlated and analysed, the submitted documentation was evaluated. NCAP specialists, through site visits, conducted yearly internal evaluation.

Two evaluation methods were used - individual and group interviews, as well as desk review. Representatives of organizations responsible for the project implementation, as well as beneficiaries, health care workers, and outreach workers were interviewed. Also work plans, reports, national and international normative documents, including national HIV response strategies and financial reports, conducted surveys reports, statistical data, relevant information materials were analysed. The project urgency, efficiency and relevance were evaluated and analysed. OECD/DAC evaluation criteria were used to assess the effectiveness, fulfillment of objectives, relevance, impact and sustainability of the project.

All the stated project goals are achieved, new strategic information and innovation approaches for reducing HIV morbidity are used. Mobile clinics have strengthened routine surveillance, and HIV/STIs/hepatitis second-generation surveillance among migrants, their families, and communities in rural areas of Armenia. Services on prevention of infectious diseases, including HIV/hepatitis/STIs, provided by mobile clinics in rural areas are more popular and preferable than those given by local family doctors, because they are free, confidentiality is maintained. Success of the mobile clinics operation is attributed to the information activities implemented by outreach workers, and to provision of services package, including various types of diagnostics, free specialized consultations. This approach is very effective because the stigma associated with HIV/AIDS still persists in the society. The most hard-to-reach and vulnerable populations were covered with the mobile medical services, which, considering insufficient state funding of the health care system and social security in general, allows the country to maintain political stability, avoid excessive economic losses, improve quality of life, and ensure "Inclusion" of rural remote areas into the socio political and socio economic life of the country and the region.

The initiative works vertically through collaboration between the Ministry of Health, the NCAP, local authorities of the Ministry of Territorial Administration and horizontally - through collaboration and strong partnership between the NCAP and medical institutions, under MoH and Regional administrations where seropositive for STIs/hepatitis B,C and suspected TB cases are referred for further diagnosis, treatment and care, for obtaining, if required, relevant medical care in specialized medical institutions. As of October 2019 about 72,000 HIV tests were performed among migrants, their partners and community members at the mobile clinics and rural ambulatories. Also, more than 130,000 preventive services with motivational consultations were provided to them. All HIV-positive cases were linked to care at the NCAP with further provision of support and necessary follow up. The projects have significantly increased access to HIV testing, early diagnosis and timely treatment initiation for migrants. HIV testing in the communities covered by the project becomes acceptable, negative attitude towards HIV testing is being overcome, stigma and discrimination towards HIV patients is being reduced. Healthy life style and safer behaviour are being promoted among migrants.

This initiative is being implemented thanks to the state political will, coordination of efforts of the Ministry of Health, Migration Agency of the Ministry of Territorial Administration, local authorities, strong partnership between vertical and horizontal, local and central structures of healthcare system. Successful mobilization of domestic and external resources, engagement of local health care workers as outreach services providers and counsellors, as well as their partnership with the NCAP staff and specialized medical institutions provided opportunity to implement the initiative, covering widely the targeted population by preventive measures and by public health services. The initiative was designed and is being implemented via close collaboration between the Ministry of Health and Ministry of Territorial Administration, based on their communication round tables, arranged with local authority representatives, on envisaged activities, outreach workers identifications and piloting of the project in the country selected regions and communities. Basic principles and approaches of the initiative were discussed at the MoH working group, then circulated among other ministries, local and international NGOs, UN agencies, Country Coordination Mechanism (CCM) on HIV/AIDS/TB, established by the Prime Minister’s Decree and finally, reflected in the National AIDS Programme, approved by the Government, and being realized in a participatory manner.

This initiative is effective in terms of stated goals and achieving significant results, is focused on improving the quality of life of the migrant population and, subsequently, is socially significant. It is an example of an innovative mechanism for providing technical and public health care assistance through a partnership of stakeholders at various levels. The initiative implementation allows maximizing the migrants coverage through provision of public health services, considering geographical, cultural and ethical factors. Therefore, further continuation, development and sustainability of the initiative should be ensured. HIV services are provided in remote rural areas, making the opportunity to undergo HIV testing within the package of other medical services more attractive for the beneficiaries, allowing them to know their status, be diagnosed and timely initiate treatment. Therefore, geographical coverage of the initiative is planned to be scaled-up. Public events, where mobile clinics are used, promote popularization and access to testing, breaks HIV testing-related stereotypes, enroots an idea that HIV testing is important for health and for HIV prevention. Long lines of people who wanted to obtain comprehensive health services at the mobile clinics confirm that this services type is highly demanded. It is evident that this initiative should be maintained.