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24 hours in Bucharest

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Last week I went on a short visit to Bucharest to understand the origin of the recent outbreak of HIV among people who use drugs in the city. I am disheartened to say that the fears of many of us working in global health held about the potential negative impact on the HIV/AIDS epidemic caused by the withdrawal of the Global Fund to Fight AIDS, Tuberculosis and Malaria from a number of countries, including Romania, have been realized.

Romania's "middle income" country status has ruled it ineligible to receive Global Fund money and since 2011, the gap in service provision, especially to people who inject drugs (PWID) cannot be met by a civil society sector that receives no State funding whatsoever.

After meetings with the Ministry of Health and the country's National anti-Drug Agency I spent time one evening with an NGO called ARAS, as they conducted their outreach service in the area in and around the North Station of Bucharest.

On a cold and windy evening at around 10 pm, ARAS parked its bus across the street from the station. Two small buses (actually, more of a van) were bought five years ago on Global Fund money. One remains parked in the courtyard of a hospital, since no funding is available for the repairs that it needs. The other still operates and undertakes outreach five to six evenings a week.

Within minutes, people rushed from a neighboring park and seemingly from nowhere and over the next two hours queued for clean syringes provided by a doctor and a social worker. Each night the ARAS bus supplies between 5000-15 000 needles; the needles are of a type preferred by injectors as opposed to an inferior cheaper type purchased last year by the government which most users subsequently returned unused.

Extreme poverty is exacting human devastation upon a group of people who are injecting legal highs up, many up to 10 times per day. It is estimated that some 50 per cent of injectors use legal highs, originating, from what users told me, from China, with
the remaining half use poor quality heroin.

I saw two boys of fifteen years of age, one of whom have been living on the street since he was born; a wandering/drifting pregnant woman, who was "high" that night; a man nearing his 40s who was raised in a children's institution in the years of the Ceausescu regime, saw his mother only once in his entire life and subsequently kicked out of the institution for using glue. He'd been living on the streets for 25 years.

Many clients also asked for condoms but ARAS no longer has the funds to provide them as they used to do up until two years ago.

These tragic Bucharest stories are being or will be repeated in other countries where the Global Fund is leaving and it is no coincidence that increases in HIV amongst PWID have begun to surface in Romania. The struggles facing NGOs trying their best to contain a both fragile and volatile situation there under extremely trying circumstances are being exacerbated at the same time by an explosion in the supply and use of legal highs which has in turn fuelled injecting and so increased the risk of needle sharing.

And the evidence is already in.

At the end of 2012 the Anti Drug Agency reported a 20 fold increase in the number of new infections diagnosed amongst people who inject drugs. Around the same time a separate survey of 480 people who inject drugs was published indicating an astonishingly high and sudden prevalence of HIV of 53 percent.

Eastern Europe nations and other economies in transition are facing dramatic HIV/AIDS emergencies amongst PWID. Decision makers within those countries remain blind to this reality.

After my meetings with government officials I'm of the view that the HIV/AIDS scenario in Romania and countries that find themselves in a similar funding situation will not change in the coming months or indeed, years.

And it is the people in the region like those I met on the streets of Bucharest who are ultimately paying a high human price for such inaction and neglect.