REPUBLIC OF THE GAMBIA. National AIDS Secretariat Office of The President Republic of The Gambia. With support from

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1 REPUBLIC OF THE GAMBIA National AIDS Secretariat Office of The President Republic of The Gambia THE GAMBIA 2010 UNIVERSAL ACCESS COUNTRY REPORT With support from February 2011

2 ACRONYMS AAITG AIDS ART ARV ELISA GFPA HC HIV HOC IDSS OIs M&E MDGs MIPA MTCT NAS NSF NSS OVC PLHIV PMTCT PUDR STI UA UNAIDS UNGASS VCT ActionAid International The Gambia Acquired Immune Deficiency Syndrome Antiretroviral Therapy Antiretroviral drug Enzyme-Linked Immunosorbent Assay The Gambia Family Planning Association Health Centre Human Immunodeficiency Virus Hands on Care International Development Support Services Opportunistic Infections Monitoring and Evaluation Millennium Development Goals Meaningful Involvement of People Living with HIV and AIDS Mother-to-Child Transmission of HIV National AIDS Secretariat National HIV and AIDS Strategic Framework National Sentinel Surveillance Orphans and Vulnerable Children People Living with HIV Prevention of Mother-to-Child Transmission of HIV Progress Update and Disbursement Report Sexually Transmitted Infection Universal Access Joint United Nations Programme on HIV/AIDS United Nations General Assembly Special Session on HIV and AIDS Voluntary Counselling and Testing Page i

3 Table of Contents 1. Background Methodology Brief Overview of the HIV Epidemic Assessment of the National Efforts and the Resources for the National Response National Targets and the Status of the Response Gaps/Obstacles Actions Required at Country Level to overcome Gaps/Obstacles References Annexes List of Tables Table 1: HIV1 prevalence among pregnant women (15-49 years) attending antenatal clinic, by sentinel site, Table 2: Young people: Knowledge about HIV prevention... 6 List of Figures Figure 1: National prevalence for HIV-1 and HIV-2 among pregnant women (15-49 years) attending antenatal clinic, 1993/ Figure 2: National prevalence of HIV-1 by age group among pregnant women attending antenatal clinic, 2000/ Figure 3: 2010 Universal Access: Prevention indicators... 9 Figure 4: 2010 Universal Access: Treatment Indicators Figure 5: 2010 Universal Access: Care and support indicators Page ii

4 1. Background In 2006, the world made a historic commitment at the United Nations to dramatically scale up the AIDS response. The political declaration committed countries to provide Universal Access to HIV prevention, treatment, care and support services to all those in need by The achievement of Universal Access (UA) remains a fundamental priority for all countries. Although progress has been achieved in some countries in areas of PMTCT and ART, many countries are hindered by insufficient progress in addressing the underlying social determinants of HIV risk and vulnerability. High levels of discrimination against People Living with HIV (PLHIV), against women and girls, MSM, people who use drugs and sex workers combined with punitive laws, policies and practices continue to hold back effective national responses. The Gambia is committed to achieve her Universal Access targets. As agreed in 2006, all countries have to report in 2010 about the achievements vis-à-vis these targets in order to take appropriate steps for enhanced efforts and commitment of all partners. The 2010 Universal Access review builds on the monitoring provided for in the UNGASS Declaration of Commitment and on the political declaration of commitment to be as close as possible to Universal Access to HIV prevention, treatment, care and support services to all those in need. Both these instruments support achieving the Millennium Development Goals (MDGs), and particularly MDG 6 that seeks to halt and reverse the spread of HIV by In that regards, UNAIDS and its partners will support in-country review of the UA achievements based on the agreed UA targets through a collaborative process whereby stakeholders will discuss and agree on the way forward. This UA review is coming at the right moment as The Gambia is planning for the Kampala Summit. It is therefore expected that this UA review will critically review and update the UA targets and inform the upcoming summit and therefore help to identify the necessary strategic changes in the national response. The UA review should seize this opportunity to initiate and support deeper discussion and discourse on a variety of important elements of UA. This includes the need to build on momentum established with treatment particularly in light of the new guidelines recommending an earlier start to ART and in light of the recent concerns about the reduction of donors funding. Furthermore, there will be a number of high level intergovernmental meetings and global events where Universal Access will be raised The General Assembly review meeting,, the Page 1

5 African Union consultations, the G8 and G20, the MDG Summit, the Global Fund Replenishment meeting, and others. The findings of country and regional Universal Access review reports will feed into the UN Secretary General s report which will be subsequently discussed at the High Level Meeting on AIDS under the Theme Unite for Universal Access in June Purpose of the UA review The aim of the 2010 UA review is to provide an opportunity for stakeholders to take stock, dig deep, have an honest look at where the country is going and together deliberate and agree on updated UA targets as well as on what needs to be done now in order to achieve UA and ultimately the MDGs. a) To discuss with stakeholders and review and update the UA targets in line with the on-going multisectoral response initiatives b) To develop a road map highlighting key milestones and major interventions required to achieve UA and ultimately the Millennium Development Goals based on the review findings c) To undertake an in depth discussion and analysis of the 2010 country UNGASS report, joint review report, progress reports on the milestones and other relevant country data, to take stock of the achievements, gaps and bottlenecks and agree on what needs to change in the response. 1.2 Specific objectives of the review: a) Analyze the UA achievements to date; b) Analyze existing approaches to HIV prevention, treatment, care and support, and what is required to achieve the targets; c) Analyze available data about who gets HIV and how those populations have changed in the past few decades. d) Review and update UA targets for The Gambia e) Define strategies to accelerate progress where it is lagging. Page 2

6 2. Methodology The 2010 UA review approach used desk reviews of key documentations (see Reference section), consultation with stakeholders, and interviews with key partners. The process included the following steps: An initial consultation with stakeholders in the form of a workshop to discuss and review the previous UA country report, discuss the 2010 UA review format and process. Interaction and sharing information with the Monitoring and Evaluation Reference Group (MERG) to discuss/agree on objectives and process of the review; Desk review of the 2010 Gambia UNGASS Report, the National Strategic Framework (NSF) , the Health Sector Strategic Plan, Joint Review Report of The Gambia HIV/AIDS National Response, National Composite Index, the 2010 Behavioural Sentinel Surveillance report, the 2008 National Sentinel Surveillance, NAS Annual Report 2008 and NAS monitoring and evaluation data and reports. Consultation with key partners in government, CSO including PLHIV support groups and networks, NGO and the UN System. Prepare an aide-memoire and a final report including. In-country consultation with stakeholders to discuss and validate the findings of the assessment. Page 3

7 3. Brief Overview of the HIV Epidemic 3.1 HIV Prevalence Figure 1: National prevalence for HIV-1 and HIV-2 among pregnant women (15-49 years) attending antenatal clinic, 1993/ The first AIDS case in The Gambia was diagnosed in May As can be seen in Figure 1 above HIV-1 has been on the increase between the years 1993/5 to In 2005 the country saw its first drop in the prevalence of HIV-1 among antenatal women attending clinic in the six sentinel sites. Between 2005 and 2008 HIV-1 prevalence first increased by more than 150% in 2006, then dropped by 50% in 2007, and increased again by 14% in HIV-2, on the other hand, has maintained a fairly steady declining trend from 1.0% in 1993/5 to 0.4% in Table 1: HIV1 prevalence among pregnant women (15-49 years) attending antenatal clinic, by sentinel site, Sentinel Site Serre Kunda Brikama Sibanor Farafenni Kuntaur Basse Essau N/A N/A N/A Soma N/A N/A N/A Banjul 1.4 N/A N/A N/A National Page 4

8 The national sentinel surveillance for HIV and AIDS started in among women attending antenatal clinic in four health centres, Basse, Farafenni, Sibanor and Serre Kunda. By 2002 two more health centres were added to the list of sentinel sites, Kuntaur and Brikama; and in 2005 another two were again added, Essau and Soma. In 2006 Banjul was added as an HIV and AIDS sentinel site. Within the sentinel sites HIV-1 prevalence has also shown variations yearly. Up to 2004 Sibanor has had the highest prevalence for HIV-1. Between 2005 and 2006 Brikama had the highest prevalence for HIV-1; in 2007 it was Serre Kunda; and in 2008, Sibanor has reemerged with the highest HIV-1 prevalence. Between 2007 and 2008 Serre Kunda changed from the having the highest to the lowest HIV-1 prevalence among the 9 sentinel sites; whilst Sibanor, between 2005 and 2007, had the second highest HIV-1 prevalence. Figure 2: National prevalence of HIV-1 by age group among pregnant women attending antenatal clinic, 2000/ The prevalence of HIV-1 by age group among antenatal women has shown great variance between 2000/1 and For three of the eight years (2000/1, 2002, 2004 and 2005) the age group years had the highest HIV-1 prevalence. The age group years also had the highest HIV-1 prevalence for 3 years (2003, 2006 and 2007). In 2008 the year age group had the highest prevalence for the first time. Overall HIV-1 has increased from 1.2% in 2000/1 to 1.9% in 2008 among those aged years and has declined from 1.5% to 1.3% among those and from 1.8% to 0.4% for those years during the same period. 3.2 Mother-to-Child Transmission of HIV The number of infants infected with HIV each year through MTCT is growing with the increasing number of women infected with HIV. About 55% of all new HIV infections in Africa occur among women, most of whom are in their childbearing years. Ten percent of Page 5

9 infections representing some half a million infants are believed to be attributable to MTCT. In the absence of any intervention, the risk of mother-to-child-transmission of HIV is about 15% 30% if the mother does not breastfeed the child. With prolonged breastfeeding, the likelihood of infection can be as high as 45% (De Cock, 2000). In The Gambia analysis of October 2007 to September 2008 data from a sample of eight facilities 1 revealed that out of a total of 101 infants born to HIV positive women, only 34 (33.7%) were tested for HIV and 24 (70.6%) out of the 34 were HIV positive. Whilst this data is not conclusive it may be an indication of a high mother-to-child transmission of HIV. 3.3 Young People: Knowledge about HIV prevention HIV epidemics are perpetuated through primarily sexual transmission of infection to successive generations of young people. Sound knowledge about HIV is an essential prerequisite albeit, often an insufficient condition for adoption of behaviours that reduce the risk of HIV transmission (UNAIDS, 2007). Knowledge about HIV prevention is based on the composite of five individual indicators, derived from the GUIDELINES ON CONSTRUCTION OF [UNGASS] CORE INDICATORS, 2006 reporting; UNAIDS Geneva, Switzerland, May These are: 1. Can having sex with only one faithful, uninfected partner reduce the risk of HIV transmission? 2. Can using condoms reduce the risk of HIV transmission? 3. Can a healthy-looking person have HIV? 4. Can a person get HIV from mosquito bites? 5. Can a person get HIV by sharing a meal with someone who is infected? The purpose of the composite indicator is to assess universal knowledge of the essential facts about HIV transmission. According to the 2010 BSS Table 2: Young people: Knowledge about HIV prevention Age group Males Females years 28.6% 18.8% years 34.0% 28.9% Total (15-24 years) 31.7% 22.9% study report, 31.7% males and 22.9% females aged years had all five questions answered correctly, see Table 2. In % males and 24.8% females had all five questions answered correctly. Knowledge about HIV prevention among youths therefore fell slightly between 2005 and In 2006 an ambitious target of 95% was set for both males 1 The 8 facilities are: Basse Health Centre (HC), Bansang Hospital, Soma HC, Essau HC, Faji Kunda HC, JFP Hospital, GFPA Kanifing Clinic, and ASB Clinic. Page 6

10 and females to be achieved in 2010; alongside a realistic target of 60% for males and 55% for females. None of the targets were achieved. 4. Assessment of the National Efforts and the Resources for the National Response The new National HIV and AIDS Strategic Framework (NSF) ( ) prioritises the following fundamental principles to guide the implementation of this NSF: Result Based Management of HIV response, evidence based planning, application of Gender and Human rights principles, operationalisation of the Three Ones, working towards universal access, upholding MIPA, efforts by all stakeholders to support to the NSF and harmonise their work and finally working towards achievement of HIV-related commitment at all levels. Implementation of the new NSF would require the support and participation of all stakeholders in the national response. In the area of prevention a lot has been done. VCT is on the increase. In 2005 it was estimated that 11.1% of persons years have ever had an HIV test compared to 38% in 2010, more than a two-fold increase. The number of VCT sites has increased from approximately 14 VCT in 2006 to 34 in According to IDSS (2010) approximately 45% of the population have access to VCT and 43% have access to PMTCT services. In spite of these achievements, however, there are still significant gaps and challenges, including major misconceptions in HIV prevention and transmission, and fear of stigma and discrimination. In addition VCT services are still limited to health facilities, many of which do not have any outreach VCT programmes in their catchment areas. Under treatment, care and support services, there has been a significant improvement. Laboratory infrastructure and services have expanded. The use of rapid test kits have facilitated the availability of same-day laboratory results, compared to 2003 when clients had to wait for 2-4 weeks for ELISA results to be returned from the central laboratory. There are now 9 ART centres and over 300 health staffs have received specialised in-service training in HIV care and treatment of opportunistic infections and ART. In 2003 there were only 2 PLHIV support societies; whilst in 2010 there are 9 Support Groups and two Networks. Support and care offered to PLHIV is in the form of nutritional support, transport refunds, and educational support for orphans and vulnerable children (IDSS, 2010). Apart from MRC, HOC, WEC and ASB, there are no non-governmental or private health facilities (hospital, clinic or medical centre) that have registered interest and are accredited to offer comprehensive services (including ART) to PLHIV. This is a notable gap and barrier Page 7

11 to access to HIV and AIDS treatment and care. Another challenge is the rate of uptake of ARV prophylaxis by HIV positive pregnant women who received services at PMTCT sites remains low at 30% (IDSS, 2010). The sustainability of support to PLHIVs and OVCs is a major challenge and great concern, especially since most current support is externally funded. The Gambia is heavily dependent on externally provided resources for the national response to HIV and AIDS. In 2009 over US$4.8m was provided by bilateral and multilateral partners, with the Global Fund being the main funder. Page 8

12 5. National Targets and the Status of the Response 5.1 Prevention Figure 3: 2010 Universal Access: Prevention indicators Prevention targets set for the country were based on knowledge about HIV prevention, among young persons aged years, as defined by UNAIDS using the five questions mentioned under section 2.3 above. All data were taken from the BSS datasets. Table 2 contains the composite results of all 5 questions by age group, whilst Figure 3 shows the responses to the individual questions in 2005 (which was the baseline), and in 2010, measured against the targets that were set for As seen in the graph, none of the targets set for 2010 were achieved. Only 2 of the 5 indicators showed a slight increase between 2005 and The failure in registering any significant increase in the prevention indicators may be an indication of the effect of the lack of continuation or sustainability of externally funded programmes and activities. The WB funded HARRP project injected multimillion dollars into IEC/BCC and community led HIV prevention programmes. At the end of the project most of these prevention programmes and the structures and processes that supported them were discontinued, suspended or dormant. Page 9

13 5.2 Treatment Figure 4: 2010 Universal Access: Treatment indicators The following treatment indicators were agreed in 2006, viz: Percent of people with advanced HIV infection receiving ART who have not died during the past 12 months (% alive at 12 months after starting ART). Percent of HIV-infected pregnant women receiving a complete course of antiretroviral prophylaxis to reduce the risk of MTCT. Percent of patients with STIs at health facilities who have been diagnosed, treated and counselled according to national management guidelines. Figure 4 shows the indicators at baseline, 2010 actual data, and targets that were set for The 2010 actual data for percent of people alive at 12 months after starting ART is from the 2008 Impact Study; whilst that of HIV-infected pregnant women receiving a complete course of antiretroviral prophylaxis to reduce the risk of MTCT is from the NAS PUDR quarter 3 report; and patients with STIs at health facilities who have been diagnosed, treated and counselled according to national management guidelines is taken from a random assessment conducted in Sukuta Health Centre. The STI target was the only one out of the three targets achieved. Significant efforts, however, were made in increasing the other two indicators, especially with the survival rate for PLHIV on ART. The smaller increase among proportion of HIV-infected pregnant women receiving a complete course of antiretroviral prophylaxis to reduce the risk of MTCT, may be an indication of the challenge faced by the PMTCT programme. Page 10

14 5.3 Care and support Figure 5: 2010 Universal Access: Care and support indicators Indicators for HIV care and support were on external basic care and support for orphans and vulnerable children (OVC) and the chronically ill. The 2010 data were obtained from ActionAid International The Gambia (AAITG) PUDR report for quarter 3. All baseline indicators have increase more than threefold, although they fall short of the targets that were set in Page 11

15 6. Gaps/Obstacles In spite of the achievements in many areas there remain gaps and obstacles to Universal Access to HIV and AIDS prevention, treatment, care and support services. Key among these is that more than half of the population do not have access to VCT and PMTCT services. Out of the 9 ART centres, 4 of them are located within the Greater Banjul Area; and only 1 in the north bank of the river and none in the Lower River Region. Other gaps and obstacles which continue to pose challenges to the HIV and AIDS response include: Sustainability of the national response since more than 90% of funding is from external sources Vulnerable populations such as MSM and sex workers are still not receiving the scale (and quality) of service they are entitled to. Limited capacity in surveillance and epidemiology Stigma and discrimination, including self imposed stigma Inadequate skilled human resources Page 12

16 7. Actions Required at Country Level to overcome Gaps/Obstacles The following are actions required at country level to help in addressing gaps and overcoming obstacles to achieving universal access to HIV and AIDS prevention, treatment, support and care: i. Establish VCT and PMTCT services in all public, NGO and private health facilities (clinics, health/medical centres, hospitals). Provide the necessary support to enable all such facilities meet the criteria for setting up such services. ii. Increase the number of ART centres in both urban and rural parts of the country. iii. Increased government budgetary allocation for the national response to the HIV and AIDS epidemic. iv. Develop programmes specially targeting youths years and high-risk groups v. Reduce stigma and discrimination through social mobilization, using government, media, educational, community and religious leaders and increase the visibility, involvement and empowerment of people living with HIV and other vulnerable groups. vi. Harmonize the Global Fund targets with the NSF, and align sectoral targets and plans with the NSF. vii. Review and revise the training curriculum of the schools of nursing and public health to include training in HIV prevention, treatment, care and support. viii. Mainstream HIV into public and private sector institutions and organizations. There should be an HIV plan and budget in all public and private sector institutions and organizations. ix. Implement the revised PMTCT policy. x. Improve on the procurement process for drugs, HIV test kits, condoms and other supplies and equipment xi. Strengthen the capacity in the NAS M&E to conduct epidemiological surveillance and research especially with most-at-risk populations. xii. Review and expand the OVC support: 100% support towards OVC who have no surviving parent, 75% support towards OVC who have at least one surviving parent, and 50% support towards OVC who have both parents surviving. xiii. Establish methods for routine evaluation and care of infants born to HIV positive mothers, including timely ARV prophylaxis, breastfeeding, prophylaxis for OIs, immunization, growth monitoring, and clinical management and laboratory monitoring. Page 13

17 References Bannerman M., Nyan O., Jallow C., Sarr E., Tchupo J.P. (2008) Joint Review Report of The Gambia HIV/AIDS National Response. National AIDS Secretariat, Banjul. IDSS (2010) Final Evaluation for End of Grant Evaluation of the GFATM Round three funded HIV/AIDS activities: National AIDS Secretariat, Banjul Jallow C.O.A. (2011) The Gambia 2010 Behavioural Sentinel Surveillance on HIV & AIDS Final Report, National AIDS Secretariat, Banjul Ministry of Health and Social Welfare (n.d.) Strategic Plan Final Report. Ministry of Health and Social Welfare, Banjul NAS monitoring and evaluation data and reports National AIDS Secretariat (2008) National Sentinel Surveillance Results National AIDS Secretariat, Banjul [Unpublished PowerPoint presentation] National AIDS Secretariat (2009) The Gambia 2010 NCPI. National AIDS Secretariat, Banjul [Unpublished document] National AIDS Secretariat (2009) The National HIV and AIDS Strategic Framework (NSF) for The Gambia: June 2009-June National AIDS Secretariat, Banjul National AIDS Secretariat (2009) The National HIV/AIDS Annual Report National AIDS Secretariat, Banjul National AIDS Secretariat (2010) 2010 UNGASS Country Report - Report on Progress Towards Implementation of the Declaration of Commitment on HIV/AIDS, National AIDS Secretariat, Banjul Page 14

18 Annexes Annex 1a: Summary of the prevention, treatment, care and support outcome and output results set in the new National HIV and AIDS Strategic Framework (NSF) Outcome Results Output Results 1. PREVENTION 1.1 Sexual Debut: The median age of sexual debut is increased from 17 yrs (2005) to 18 yrs for males and 16 yrs (2005) to 18 yrs for females by June VCT: The percentage of women and men aged who received an HIV test and know their results increased from 9.6% (2005) to at least 25% by June HIV/AIDS Knowledge: The % of young males and females (15-24) who correctly identify ways of preventing sexual transmission of HIV and reject major misconceptions is increased from 34% (M) and 25% (F) in 2005 to at least 85% (M) and 80% (F) by June The percentage of HIV infected infants born to HIV+ mothers is reduced from 9.1% (2006) to 5% by June Blood Safety: The percentage of donated blood units screened for HIV in a quality assured manner is increased from 0% (2007) to at least 100% by 2014 Programme interventions addressing challenges of early sexual debut are developed and implemented by 2010 The number of men and women aged who receive VCT and know their status annually is increased by 50% each year (19, NAS) by June 2014 At least 90% of VCT Centres offer quality gender responsive service (in accordance to the National VCT Guidelines) Number of VCT sites in country is increased from 34 (2008) to 50 by June 2014 National SBCI strategies developed which explicitly target: CSW and clients, youths, uniformed people, MSM and other MAR & vulnerable groups. The number of centres that provide key HIV prevention and STI services is increased from 2 (2006) to at least 10 by June 2014 National condom strategy is developed by 2010 At least 50% of most-at-risk populations (CSWs, MSM, etc) reached with HIV prevention programmes by June 2011 Number of babies born to HIV positive women and put on cotrimoxazole prophylaxis within 2 yrs is increased from 139 (2008) to at least 500 by June % of transfusing facilities have HIV screening machines available and functional by June 2014 Page 15

19 Annex 1b: Summary of the prevention, treatment, care and support outcome and output results set in the new National HIV and AIDS Strategic Framework (NSF) Outcome Results Output Results 2. TREATMENT 2.1 The provision of services for treatment and prevention of OIs is increased from at least 35% (2008) to at least 90% by at least June ART and TB Co-infections: The percentage of women and children with advanced HIV infection who are receiving antiretroviral combination therapy is increased from 8.8% (2007) to at least 40% by June CARE AND SUPPORT A policy framework for PICT at national level and in 10 heath facilities is reviewed and adopted by June 2011 The availability and quality of testing technologies is improved by June 2011 The diagnosis and intervention services for OIs is improved by June 2011 The capacity of health service personnel to provide PICT is enhanced by June 2011 Nutritional needs of PLHIV is integrated into the curriculum for training of health and community workers by June 2010 The nutrition status of PLHIV at health facility level, is improved and monitored by June 2011 The number of health regions with CHBC services is increased from 2 (2008) to 6 by June The number of ART sites providing nutrition assessment, education and counselling is increased from 1 (2008) to least 4 by June The awareness of availability and benefits of early initiation on ART is enhanced by of by June 2011 Services for the assessment for early initiation for monitoring of ART are improved by June 2011 Comprehensive services for TB/HIV-co-infection are offered under one roof by June The % of OVC (boy/girl) aged under 18 who have received a basic external support package is increased from 15% to at least 65% by June The percentage of persons willing to share a meal with a PLHIV is increased from 65.7% for males and 56.1% for females in 2005 to at least 80%(M) and 70% (F) by June The quality of PLHIV ages 18 and above is improved from a qualitative rating of low (2004) to at least a rating of (high) by June % of OVC have access to protection, provision of food, shelter, education and health by 2010 Increase the number of national campaigns to reduce HIV stigma for each year from 4 (2008) t at least 6 by 2010 At least 6% of the national resources envelope for HIV/AIDS is used for HIV/AIDS socio-economic impact mitigation programmes At least 1 survey conducted on socio-economic impact of HIV/AIDS in The Gambia by 2012, with particular reference to impact on economic development, the labour force, women and children National policy on mitigation of socio-economic impact of HIV/AIDS developed and disseminated by 2010 All priority sectors mainstream mitigation strategies and programmes targeting vulnerable groups in their operations by 2010 Page 16