Southern Africa HIV and AIDS Programme. In brief. Appeal No. MAA August This report covers the period 01/01/09 to 30/06/09

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1 Southern Africa HIV and AIDS Programme Appeal No. MAA August 2009 This report covers the period 01/01/09 to 30/06/09 Malawi Red Cross Society HIV awareness sports competitions In brief Programme purpose: Based on the UNGASS Declaration of 2006 where Governments committed to scale-up towards universal access to HIV prevention, treatment, care and support by 2010 and in line with the Millennium Development Goal 6, stating that by 2015, the world will have halted and begun to reverse the global HIV epidemic- the International Federation of the Red Cross and Red Crescent Societies (IFRC) Southern Africa launched an innovative and dynamic five year ( ) regional HIV and AIDS programme and appeal (MAA63003). The ten Red Cross National Societies 1 (NS) embarked on a consolidation and capacity building exercise to improve the overall management of the programme and, should resources become available, to eventually scale-up. The regional HIV and AIDS programme was initially launched with the aim to quadruple target beneficiaries by 2010 with a total of 50 million people to be reached with various prevention strategies, 250,000 people to benefit from an expanded prevention, care, treatment and support programme, and 460,000 orphans and vulnerable children (OVC) to be provided with a holistic package of educational, material and psychosocial support. To achieve these ambitious objectives, expanding on UNAIDS three ones principles for effective country level action (one agreed AIDS action framework, one National AIDS coordination body, one agreed monitoring and evaluation system), the southern Africa HIV programme operated under the IFRC Global Alliance on HIV; a framework and working principles established in 2006 as a basis for coordinating the work of all partners supporting HIV and AIDS programmes in order to align goals and outputs, enhance efficiency and quality, and make better use of capacities and resources. The Global Alliance on HIV further committed its partners to seven working principles (one set of working principles; one national HIV plan; one set of objectives to achieve together; one division of labour understanding; one funding framework; one performance tracking system; one accountability and reporting system). 1 Angola, Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe Red Cross Societies in Southern Africa Zone

2 Three years of implementation, the IFRC Secretariat and the National Societies have started reflecting on the future of the programme beyond 2010 taking into consideration various factors impacting on the funding level, the current programme reach, and the collective capacity to meet the established targets. This programme update provides an overview of achievements for the first six months of 2009, whilst some data presented provides information on cumulative reach since the inception of the programme. Programme summary: Table 1: Overview of beneficiaries reached to date Key Result/Output Target 2010 Baseline 2006 Achieved Jan-Dec 2007 Achieved Jan-Dec 2008 Achieved Jan-Jun 2009 Cumulative Reach Reach against 2010 Tats 1: Prevention 50,000,000 4,782,711 6,549,900 7,602,529 1,269,403 15,421,832 31% 2: CHBC 250,000 65,000 68,630 60,421 60,750-24% 2: OVC 460, , , , ,979-22% 100% of NS 3: Stigma staff in 32% of 41% of 38% of and None workplace 1,671 staff 2,224 staff 2,208 staff discrimination programmes - - 4: Capacity Building Volunteer hours mobilized 6,963 volunteers and 774,773 hours 7,716 volunteers and 858,559 hours 8,435 volunteers and 894,110 hours 8,055 volunteers and 418,860 hours - - The table above provides a summary and general overview of the programme reach against the established indicators since its inception. Financial Situation: The total budget per the appeal (MAA63003) remains at CHF 384,895,997. The table below provides an overview of funds received through the IFRC and directly by National Societies since Table 2: Summary of financial resources collectively raised towards the Global Alliance programme Funding Channel Year Amount received in CHF Through IFRC ,654,297 Through National Societies ,893,186 Sub total 37,547,483 Through IFRC ,100,371 Through National Societies ,466,097 Sub total 29,566,468 Through IFRC 2009 (January to June) 4,978,595 Through National Societies 2009 (January to June) 7,575,210 Sub total 12,553,805 Total received towards Appeal ,667,756 The budget for 2009 has been extensively revised taking into consideration the collective operational and fundraising capacity. Coverage to date of six months budget (CHF 6,630,705) has been at 75 percent and in recognition of the decreasing funding support every year, the budget for the second half of 2009 and 2010 will be further revised downwards to meet the realities on the ground. To date, multiple year funding from the Royal Netherlands Embassy (RNE) and the Swedish Red Cross/SIDA has been received. Bilateral and multilateral support from Partner National Societies (PNS), local authorities, UN agencies, faith-based organisation, non-governmental organisations and private donors also aligned with the regional appeal of has been instrumental in achieving the results described in this report. The funding support is however coming to an end and/or already there are indications of a reduction. In relation to the global economic crisis the trend and expectation is for the existing and potential funding support to substantially reduce. Another source that might be negatively impacted is overseas development assistance allocation from donor governments/countries, with UNDP reporting an expected drop of 30 to 40 percent following a financial crisis of the current magnitude. The uncertainty of external funding sources has already diluted the ability of National Societies to ensure sustainable and quality support to the vulnerable people. 2

3 Our Partners: The southern African National Societies and the HIV team in Johannesburg continued strengthening partnerships with local, regional, and multilateral organizations in an effort to: advocate for greater support to the programme and beneficiaries; learn from experiences and best practices; widen the funding base; and increase quality of service delivery. Collaboration continues to be sought and strengthened with embassies international organizations, UN agencies, development agencies and internally with the PNS. Funding support to this appeal (MAA3003) in 2009 has been received through the IFRC Secretariat from Finnish, Japanese, Norwegian, Swedish Red Cross Societies, Swedish RC/SIDA and the RNE (Royal Netherlands Embassy), and the Lars Amundsen Foundation. The Ministries of Health, National AIDS Councils (primarily with funding from the GFATM), WFP, European Union (EU), and various international non governmental organizations (IntraHealth, OXFAM GB, HAI ) provided financial resources to National Societies. WHO, UNAIDS, WFP, UNICEF, Regional Psycho-Social Support Initiative (REPSSI), the Southern Africa Technical Support Facility, and many other local, regional, and international organizations partnered with the Zone Office and National Societies over various initiatives described below. Click here to go directly to the attached financial report. Context Southern Africa remains the epicentre of the HIV and AIDS pandemic, and continues to bear a disproportionate share of the global burden of HIV: 35 percent of HIV infections and 38 percent of AIDS deaths in 2007 occurred in that sub-region. It harbours the highest burden in sub-saharan Africa and the world. Almost one third of the world s people living with HIV (PLHIV) live in this sub-region. In seven countries, HIV prevalence exceeds 15 percent (Botswana, Lesotho, Namibia, South Africa, Swaziland, Zambia, and Zimbabwe); about 43 percent of all children under 15 living with HIV are in southern Africa, as are approximately 52 percent of all women above the age of 15 living with HIV. Most epidemics in sub-saharan Africa appear to have stabilized, although often at high levels, particularly in southern Africa, and HIV prevalence seems to have declined slightly since, for example in Zimbabwe and Botswana amongst pregnant women. The estimated 5.7 million South Africans living with HIV in 2007 make the largest HIV epidemic in the world, and the 26 percent HIV prevalence in Swaziland is the highest prevalence ever documented in the world. While there is some notable progress in the provision of antiretroviral (ARVs) in sub-saharan Africa, fewer than one in five of the millions of Africans in need of treatment are receiving it. Botswana pioneered the provision of free ARVs in Africa; by 2007 the coverage rate was at around 80 percent. While most African countries have now started to provide ARVs, progress in providing sufficient quantities of the drugs has been uneven and Botswana s success has not been emulated elsewhere. For instance, Namibia has achieved a coverage rate of about 70 percent, but many countries in the sub-region including South Africa have only so far reached less than 30 percent of those in need of treatment. It is expected that the impact of the AIDS epidemic in many societies will continue to be felt most strongly in the course of the next ten years and beyond, without sustained and massively expanded prevention, treatment and care efforts. The Red Cross regional HIV and AIDS programme covering ten countries was initiated to address some of the specific needs and gaps through strategies that aim to complement national government priorities and contribute to the MDGs: Prevent further infections through targeted community-based peer education and information, education and communication (IEC) activities, and promote uptake of services including voluntary counselling and testing (VCT) and prevention of mother-to-child transmission (PMTCT); Scale-up HBC and support OVC through a holistic approach to address needs in education, food and nutrition, psychosocial support, social inclusion, and income generating activities; Address stigma and discrimination through targeted communication and advocacy activities and by tackling gender inequalities and gender-based violence through community mobilisation, girls empowerment initiatives and by engaging men and boys. Build the National Societies capacity to plan, implement, track performance and manage the programme through IFRC Zone Office technical assistance on globally accepted HIV and AIDS intervention standards; and information sharing and south-south learning. 3

4 Progress towards outcomes By June 2009, a total 1,432,971 people were reached with the various activities in the ten countries. The table below provides an overview of people reached with the various programme components during the first half of Table 3: Overview of people reached with various activities in 2009 Preventing further Care, Treatment Reducing Stigma Country infections and Support and Discrimination Total Angola 27,432 1, ,759 Botswana 5, ,916 Lesotho 21,960 14,627-36,587 Malawi 177,487 10, ,321 Mozambique 89,024 11, ,081 Namibia 158,225 9, ,083 South Africa 364,850 35, ,389 Swaziland 89,461 3, ,813 Zambia 1,335 1, ,318 Zimbabwe 333,951 74, ,704 Total 1,269, , ,432,971 Source: National Society Programme Updates The HIV and AIDS team in close collaboration with the senior management had been advocating for the future of the programme to the leadership of the National Societies. At the June 2009 Southern Africa Partnership of Red Cross Societies (SAPRCS) meeting attended by National Societies governance and management, the following key issues were presented for discussion and decision making 2 : Resource mobilization: The programme was launched with the ambition of reaching over 50 million in prevention, 250,000 clients under CHBC, and 460,000 OVC over five years. The programme to date has reached less than 30 percent of these target figures. The CHF 384 million appeals was one of the largest launched in the IFRC s history, however, as of June 2009, only 37 percent has been secured. The ambition to scale-up has not necessarily translated into capacity for increased resource mobilization and implementation. The HIV and AIDS funding is also competitive and complex. National Society staff has insufficient experience in developing proposals for funding by non-red Cross entities and in adapting to different and changing funding architecture: e.g. resources are being disbursed at country level rather than at international and regional levels. Donors are seeking to build the capacity of local organizations and are increasingly looking at local investment, underscoring the need for increased National Society resource mobilization and outreach capacity. Operational and technical capacity: Many National Societies increased the geographic scope of their programmes in 2007/2008 without necessarily improving on quality and depth of services provided. Although human and related structures were put in place to support this expansion, it exceeded the available resources, leaving National Societies with the legal and financial implications to address. It is critical that all National Societies revisit the geographic scope, scale, and depth of their programmes not only to ensure quality, but to also avoid future financial deficits. There is also insufficient integration between HIV and other major interventions of the National Society (HIV and tuberculosis, HIV and Malaria, HIV and food security, HIV and Water and Sanitation), but also between HIV and branch capacity building and volunteer/youth programmes. Better integration would have led to better and more efficient use of both financial and human resources (especially for core operations and management costs). Volunteer management: The strength of the Red Cross Movement is built on its volunteers. However, volunteer management systems (training, coaching, supervision, and tracking) are not as strong as they need to be, resulting in high turnover and slow rates of recruitment. The payment of volunteer allowances, while legally required in some countries and undeniably warranted in others in order to remain competitive, is an expensive practice and will eventually prove to be unsustainable. It has also created internal competition in other programmes where no allowance is secured, and it raises some questions in relation to the Red Cross Values and the Fundamental Principle of Volunteerism. 2 The full reflection paper presented at the June 2009 SAPRCS meeting is available upon request from the Zone HIV team 4

5 Branch capacity development: There is a need to strengthen community leadership and Red Cross branch structures involvement at the project site level to enhance understanding, acceptance, participation, ownership, and future sustainability. Application of the Global Alliance principles: Many bilateral donors are yet to commit to and apply fully and effectively the principles of the Global Alliance on HIV, a reluctance that impacts on the operational capacity of the National Societies and the quality of programming. For instance, a number of National Societies receive funds bilaterally from within and outside the Movement. The higher the number of partners and funding sources all with competing priorities, the more difficult it becomes for National Societies to ensure effective coordination and application of the Global Alliance principles. In determining the future scale, scope, and direction of the programme, key potential scenarios were presented to National Societies leadership for further consideration: 1. The review and scale-down of current appeal MAA63003 and integration under Health and Care: revision of the geographical scope of the programme, the scaling-down/handing over of beneficiary case loads, and adjustment of the collective resource mobilization intentions after The platforms developed over the past ten years (human resources, volunteers and systems) would be useful when integrating HIV with other health and care activities and resource mobilisation. 2. The maintenance of current operation levels under appeal MAA63003 and integration under Health and Care: revision of the geographical scope of the programme, and the scaling down of appeal and beneficiary targets. Aggressive and sustained fundraising by all is needed, with all National Societies in Southern Africa at the forefront in order to maintain the current levels of programming; and 3. The extension of the current appeal MAA63003: this course of action would allow all partners to continue with the shared ambition of scaling up HIV interventions beyond 2010; also demanding significantly improved resource mobilization capacities by all Partners. At the June 2009 SAPRCS meeting, the National Societies all agreed that: While HIV remains a priority for all National Societies, the current appeal targets are ambitious and that it is not optional to continue at the current scale and scope; To realign their national strategies with those of their government and in relation to the trend of the epidemic in the country; To adapt and adjust the plans and budgets for 2009 and 2010; To integrate HIV and AIDS activities with other Health and Care components in the 2010/2011 planning cycle; To conduct a rapid assessment to understudy the implications of scaling-down or maintaining the actual caseloads/beneficiary figures in 2010 and beyond, so that National Societies can make an informed decision. Outcome 1:Prevention of further HIV infection Key Strategies: Working at community level to reduce vulnerability to acquiring or transmitting HIV by conducting in and out of school youth peer education and community mobilization; Information, education, and communication (IEC) for general population and targeted vulnerable groups so as to increase knowledge, influence attitudes and change behaviour; Promoting voluntary counselling and testing (VCT); Promoting the prevention of mother-to-child transmission (PMTCT); Promoting skills for personal protection, including condom use. Progress In a region with the highest number of HIV infection, sustained and targeted prevention, education and outreach is critical. Governments are asking for a focus on prevention activities in order to sustain the positive gains made so far in some countries. However, the prevention component has been of late underfunded in comparison to prior years. For instance in 2008, only 32 percent of the minimum budget required for this component was received through the IFRC, with a further reduction to 19 percent in the first half of

6 The gap in funding determines the realistic way in which the National Societies are able to respond to the epidemic. It can also, in a broad sense, be interpreted as undermining, to a certain extent, the strategic architecture of the programme. By scaling-up prevention and by influencing sustained behavioural change especially among vulnerable and at risk groups, National Societies had, in the longer-term, hoped to see meaningful impact across the other three programme components. It should however be noted that whilst the different programme components are segmented in the programme s architecture, they remain integrated at the community level. As was intended from the programme s outset, prevention has been an integral part of all the other components. For example, as part of the care, treatment and support component, care facilitators carry out prevention activities at household level (through awareness of universal precautions, education on positive prevention, HIV prevention, TB management, VCT, PMTCT, sexual and reproductive health), and the community (through community awareness and dialogues with community members and the leadership on HIV, TB, Malaria, gender-based violence (GBV), stigma and discrimination, support to vulnerable children etc ). Despite efforts by some National Societies to roll-out targeted prevention interventions, most of them are focussing on in and out-of-school youth using various peer education training packages and methodologies. This made it difficult for the IFRC Southern Africa under the Global Alliance on HIV framework to monitor, evaluate behaviour change in sexual and reproductive health, at the same time supporting the National Societies on peer education activities. During the period under review, the peer education sexual and reproductive health and life skills training package was completed and pretested in South Africa and Zimbabwe. Currently, it is being tested in multiple countries with the final tool expected to be disseminated in the latter half of The training package has also been translated into Portuguese to cater for the Portuguese speaking countries. This training manual has been under discussion and development since 2007 at the regional level through a process, which started with a consultative meeting with National Societies HIV coordinators, prevention officers and youth, followed by a workshop in October 2008 to review the draft manual. The development of the manual was completed with a training of trainers (ToT) manual and activity kit designed to be used at community level by peer educators. It is a practical tool focussing on life skills development and includes case studies, games, and other activities designed to engage youth in peer discussions on how they can protect from HIV, sexually transmitted infections and unwanted pregnancies, with a particular on at risk situations (multiple concurrent partners, intergenerational sex, alcohol and substance abuse, gender-based violence). The language used is simple and appealing to the audience for youth in limited resources setting. As illustrated in table below, there is a marked decrease in the number of people reached through prevention activities compared to the same period last year. The high figures reported in 2008 were primarily due to the mass media initiatives from the South African Red Cross. Table 4: Overview of the total number of people reached with prevention activities in the first half of 2009 Country Pregnant People People People who PLHIV women who Total reached by reached by were referred supported were referred Output 1 peer IEC to VCT on positive to PMTCT education programmes services prevention services Angola 27,432 7,140 18,713 1, Botswana 5,678 3,798 1, Lesotho 21,960-9,901 7,304 2,966 1,789 Malawi 177,487 66, ,344 1,260 1,878 1,425 Mozambique 89,024 37,391 48,058 1, ,894 Namibia 158,225 3,500 36,500 85, ,240 South Africa 364, , ,029 13,680 2,336 13,225 Swaziland 89,461 16,625 71, Zambia 1, Zimbabwe 333, ,032 87,068 6,091 1,666 8,094 Total Region 1,269, , , ,754 10,550 30,035 Source: National Society Programme Updates 6

7 During the reporting period, all National Societies carried out prevention activities and some notable achievements from National Societies are further described below: Zimbabwe Red Cross launched its prevention strategy in the presence of officials from the Ministry of Health and Child Welfare and National Aids Council (NAC) in May The prevention strategy is aimed at standardizing activities at a critical time when the government is advocating for increased focus on HIV prevention. Angola and Malawi embarked on designing interventions targeting commercial sex workers through in country funding mechanisms (CCM and NAC respectively). Baphalali Swaziland Red Cross through support from Government and the Swiss Red Cross have made great strides in prevention in and out of the Baphalali clinics in Sigombeni and Mahwalala through scaling-up of provision of VCT and PMTCT services. They also introduced the health worker provider initiated HIV testing as complementary strategy, which has proved to be efficient - all documented as a good practice by the Government and WHO. Equally through a Finnish Red Cross/EU grant, the National Society displayed excellence in drama performance which have been also documented as best practices. Challenges: The National Societies should continue to target other vulnerable and at risk populations for their peer education and prevention activities. Peer education activities and messages need to reflect gender, age and culture sensitivities - hence the need for active dissemination of the peer education minimum standards and focus on the epidemic key drivers in each country and setting. More balanced and concerted efforts should be put in prevention activities as it is certainly a more cost effective strategy to prevent new HIV infections compared to care and support for the patients. To date, there is little integration between the various programmes of the National Society. Prevention messages can and should be easily incorporated in water and sanitation, First Aid, tuberculosis (TB), malaria, food security, disaster response and management activities of the National Society further capitalising and maximising on use of financial and human resources. 18 June, :00:00 by Calsile Masilela The Baphalali Swaziland Red Cross Society together with Finland Red Cross yesterday launched a drama series. The event which was attended by parents of the drama actors was held at Thokoza Church Centre in Mbabane. Secretary General of the Society Nathi Gumede said the drama series was part of the integrated HIV and AIDS and livelihoods project embarked on by the organization in the northern Hhohho and Lubombo regions. He said the project sought to create awareness through drama performances which he said was the cornerstone of the project. It is clear that the wider impact of our work comes especially on this action that is part of the prevention of new HIV and AIDS infections, said Gumede. He said they were grateful and extremely happy about the active co-operation with several organizations in the project including the Ministry of Health through the European Union (EU) funded HAPAC and Population Services International (PSI). He said last year children and adults saw the drama presentation and 3200 people got tested and counselled through the services of PSI. He said their plan was to have the series screened on television for the community to benefit and possibly view the HIV and AIDS aspects the drama aims at bringing out. The secretary general encouraged the youth to continue addressing the challenges brought about by the pandemic. Integrated HIV and AIDS and Livelihoods Project Manager Jukka Ilomaki of the Finnish Red Cross said the partnership between the Finland Red Cross and Swaziland Red Cross had existed for ten years. He thanked the Government of Finland and the EU for funding the project that would end in 2010.He said if everyone in Swaziland could know his or her HIV status, the HIV rate would be reduced dramatically. Ilomaki said the Swaziland Red Cross Society was trying to achieve that by conducting dramas and educational sessions on HIV prevention in communities and schools in the Lubombo and Northern Hhohho regions. The drama groups from Siteki and Pigg s Peak divisions conduct the plays and education sessions in their respective regions. The dramas motivate people to know their status so that they can take care of themselves as well as live long and healthier lives, said the project manager. He further said they were happy to have reached a lot of men through making performances during the dipping days at the Dip Tanks. He said a lot of men attended the dipping tank days thus the Society achieved its goal of educating them on HIV and AIDS. 7

8 Output 2: Expanding Care Treatment and Support Key strategies: Assisting orphans and other children made vulnerable by HIV and AIDS (OVC); Providing home-based treatment, psychosocial support and HBC for PLHIV; Promoting community support groups and networks; Promoting livelihood and food support for the most vulnerable. Progress OVC Programme The approach to OVC programming is anchored in the regional Red Cross OVC strategy and guided by the regional OVC working group. Eight of the National Societies have national OVC officers with some working at provincial/district level. As such, the National Societies have taken a holistic approach in supporting the children, thus educational, material, psychological, social and improved access to health services, although with varying degrees of success. The programme has not been expanded in terms of beneficiary number, but in quality through a gradual inclusion of the elements described under the holistic approach to service delivery. Lesotho and Malawi are good examples where several of their projects now include most aspects e.g. Kids Clubs, recreational activities, educational support through school fees, uniforms and educational materials, psychosocial support through hero work and establishment of local child care committees. Lesotho Red Cross is also successfully incorporating water and sanitation activities into its OVC programme. Table 5: Overview of OVC reached with services provided in the first half of 2009 OVC OVC receiving receiving OVC OVC material OVC educational receiving receiving support receiving Country support RCRC food (blankets, psychosocial (books, services assistance clothes, support uniforms, mosquito school fees) nets) 8 OVC reached by RCRC kids or youth clubs Angola Botswana Lesotho 10,500 10,500 1,870 10,500 8,900 3,888 Malawi 8,041 1, ,365 8,041 2,718 Mozambique 6,545 1,900 1, Namibia 3, ,780 2, South Africa 15,072 2,350 1,299 3,389 4,222 3,467 Swaziland 1, ,577 Zambia Zimbabwe 55,031 22,768 5,115 5,136 11,295 10,150 Total 101,979 40,575 14,552 24,700 33,846 24,183 In most countries, the OVC programme encompasses support to the guardians, most of whom are grandparents who are often frail, elderly and in need of assistance. Because of the burden of looking after the OVC, psychosocial support is provided through grannies clubs particularly through memory work, and small self support projects such as goat rearing. The regional OVC working group took part in training on mainstreaming psychosocial support into paediatric ART. The training was provided in collaboration with REPSSI in April Although ART for adults is now available in most countries in southern Africa, access to paediatric ART is still a challenge and has not yet reached community level health services. The OVC officers became the first to take part in this very practical and interactive training, which provides tools on psychosocial support for children on ART and their carers. The psychosocial support helps in building resilience in children in order to increase their ability to cope with difficult situations. The OVC working group is also working on developing a regional Child Protection Strategy, which aims to promote awareness amongst Red Cross management, staff, and volunteers on the need to protect children. When accepted and implemented by National Societies, the strategy should ensure that everyone working directly with children, including staff and volunteers, are aware of their responsibilities on how to report and address concerns on issues such as abuse.

9 The strategy includes sections on minimizing risk, human resources, child participation, procedures for dealing with abuse, and guidelines on the correct protocol for ethical reporting, publications on children, and photographing children. Below are some highlights from National Societies: Zimbabwe Red Cross undertook an assessment of the needs of OVC guardians and plans to implement a comprehensive support during the second half of the year. Zimbabwe Red Cross also produced a documentary on OVC psychosocial support life skills training initiative. The documentary has already proved to be a useful resource mobilisation tool. With support from the Norwegian Red Cross, new life skills camp equipment were procured in March 2009 and a test run camp was successfully conducted in June. The National Society has noted the need to further establish monitoring indicators for psychosocial support camps for children. Baphalali Swaziland Red Cross currently supports 1,804 OVC including through the Neighbourhood Care Points, strategically structuring its OVC support work. The National Society carried out a vulnerability assessment in Sigombeni district and a situation analysis in Silele to ensure that both projects reach the most vulnerable children. Findings from the vulnerability assessments revealed the following key areas allowing the National Society to refine its interventions in these communities: a substantial number of children do not have birth certificates; lack of food was common to most OVC households; many OVC live in houses which are not suitable for human habitation; most of the households have to walk great distances to collect water; forty-two percent have no access to a latrine. Short-term funding from Norwegian Red Cross allowed the Lesotho Red Cross to meet the immediate needs in project areas where funding had or expected to phase- out ( NAC funded sites of Linakaneng and Thaba Tseka, and German Red Cross funded sites of Berea and Leribe); or where funding was not adequate to provide holistic support to children. The National Society used the funds to provide school fees, access to health, memory work materials, sports equipment, and material support. For instance, assisted 84 OVC with school fees in Mafeteng, Maseru, Berea, Leribe Linakaneng, and Thaba Tseka. A total of 120 OVC were provided with school uniforms (shoes, shirts, pants, dresses, track-suits, and jerseys). Educational support is a fundamental initiative in which one can immediately see short-term changes on the supported children. For example supported children attend school regularly, and teacher s verbal reports as well as written reports prove that student s performance is also improved. Participation of children in daily school activities such as school choirs, sports and drama is also improved. Lesotho Red Cross procured vegetable seeds, crop seeds, piglets, medication and feed to support 2,000 OVC and 500 HBC clients living with supported children in seven project areas. These activities are aimed at improving nutrition, with extra yield sold to the community to generate cash for the families. A total number of 279 new OVC in Mafeteng, Leribe, Berea, Linakaneng and Thaba Tseka were provided with material support including blankets and mattresses - in time before winter. Butha Buthe and Leribe communities were assisted with the construction of four water points to help people have access to clean water and sanitation. At the local pre school, 10 toilets were constructed and 8 existing toilets were repaired and fitted with new doors, seats, ventilation pipes, and painting. This activity is assisting a total number of 7,314 people to access clean water and sanitation facilities in the project areas. In order to provide psychosocial support to chronically ill OVC, other OVC and their household members, Memory Work materials were procured and arrangements made to distribute them amongst trained Care Facilitators in the seven projects areas. The materials will be used to facilitate PSS at community level working with youth clubs, care facilitators, and child rights protection committees formed by Red Cross Volunteers. Community home-based care (CHBC) It has been noted that there is a slight increase in the number of CHBC clients. At the end of 2008, the National Societies were providing care and support to a total of 60,421 clients but the number has slightly increased to 60,750. The care facilitators in some National Societies left the programme because of lack of activities and incentives leading to a decrease in total registered volunteers from 8,435 at the end of 2008 to 8,055 by June Where project funds came to an end, some volunteers decided to automatically stop Red Cross activities. Low funding support for CHBC activities has generally affected the implementation. Clients received no support with regard to standard packages such as blankets, food parcels and hygiene articles, whilst HBC kits were irregularly refilled, also as a result of erratic supply from the local Ministry of Health. 9

10 Table 6: Overview of clients supported through CHBC related activities in the first half of 2009 No. of care Number of HBC Number of HBC No. of people in Country facilitators/ Projects Clients Support groups Volunteers Angola Botswana Lesotho 7 4, ,487 Malawi 13 2,687 1,024 1,049 Mozambique 29 4, Namibia 7 6,122 2,765 3,240 South Africa 24 20, ,791 Swaziland 5 1, ,425 Zambia 2 1, Zimbabwe 27 19,560 1,453 8,094 Total ,750 8,055 20,385 Source: National Society programme updates Support group members actively participating in activities also decreased from 36,585 in 2008 to 19,443 at the end of June 2009 due to lack of funding to support the local initiatives on income generating activities. As indicated above, some support groups are weak thus demanding a revamp and reactivation. With funding support from the Norwegian Red Cross, a total of 400 care facilitators were trained in Namibia and Swaziland. More financial support is needed to train additional care facilitators in the remaining countries, particularly in Mozambique, Angola, Malawi, and Zimbabwe to ensure quality service provision and Adherence for All (AFA). The training reports certainly highlighted the need for translating prevention, treatment, care and support training package into local languages. In order to address the recommendations of the 2008 SARAWO meeting and in tandem with the WHO/UNAIDS approach on task shifting, the Zone embarked on a rapid assessment in Lesotho, Malawi, Mozambique, Namibia, South Africa and Swaziland to review the following: - Assess the coverage of Antiretroviral treatment (ART) among clients/ovc in at least two selected programme sites per National Society; - Assess how clients and OVC on treatment are fairing in terms of well-being (physical, psychological, mobility, health and ability to perform daily chores); - Assess the number of clients/ovc who still require care and support in the home; - Identify and document the needs of clients/ovc on ART and compare with other chronically ill patients not on treatment; - Establish the current inadequacies and refine the roles, responsibilities, and required skills of care facilitators in view of the roll out of ART; and assist in the formulation of CHBC minimum standards. The team conducted visits in two districts in each country along with national level interviews with the National Society staff, health officials, National AIDS commissions and networks of people living with HIV (PLHIV). District level interviews were conducted with health facilities, community-based organizations and district health offices and administrators. At project site levels interviews were held with project officers, supervisors, HBC clients, family members, and community leaders to solicit their opinions along with focus group discussions with care facilitators and support group members. Observations were conducted among clients and transect walks in the community revealed a number of issues. 10

11 Some of the key findings from the assessment are noted below: The number of CHBC clients accessing ART from health facilities in the Red Cross project sites is continuously increasing. On average percent of all clients in the visited sites during the rapid assessment on task shifting were on ART, which can primarily be attributed to the care facilitators efforts and motivation for community members to go for HIV test and thereafter to go for ART. This is not the same in sites were there are no Red Cross volunteers, as was observed in Lesotho and Namibia, and Zimbabwe during the mid-term evaluation. In Zimbabwe, anecdotal evidence showed that in the areas where Red Cross care facilitators are working, many people are being referred for VCT/ART services and their adherence to ART is impressive. This could be due primarily because the Red Cross volunteers are providing information on the importance of adhering to treatment and they are closely monitoring the uptake of drugs. Hospital records in Mount Darwin indicated that, where the Red Cross was not operational, there were very few people accessing treatment and among those who were on ART a bigger number of them had a history of defaulting. The well-being of the clients was remarkable; impressive example was observed in South Africa where facilitators keep records of the different categories of clients bedridden, home-bound, and mobile. Approximately 80 percent of all clients are mobile and only 5 percent are bedridden. This has impacted positively on the activities of the volunteers in many countries. Volunteers have reduced numbers of clients to care for; although it should be noted that in many instances the numbers of OVC the care facilitators and volunteers are caring for is increasing. For instance, the care facilitators in Lesotho (Mafeteng project) indicated on average to be caring for OVC while they were providing care to only 5-10 CHBC clients. Traditional home-based nursing care is not the norm in many of the countries visited. Opportunistic infections have drastically reduced among the clients, hence there is need to review the content of the HBC kit- with a positive bearing on the cost of provision of CHBC services. Volunteers are mostly providing information on treatment and adherence among the clients taking ART and TB treatment. Referral to support groups has also increased and education on positive living has become more important. Good nutrition has become fundamental among ART/TB clients especially in the first six months after initiating ART/TB for a better and quicker recovery. Thereafter, clients should transition to long-term food security and viable income generating initiatives gardening (Backyard Gardens, Key hole gardens), horticulture, and livestock rearing as a prudent alternative. During the assessment, a key observation was made; that many volunteers have low knowledge on ART putting into question the relevance and quality of information and advice provided to clients and family members. National Societies have trained trainers, but due to lack of funding, existing care facilitators and lower level volunteers/care providers have not been trained in the majority of National Societies. Extensive lobbying should be done with existing donors and partners for more funding to retrain the care facilitators in all countries. General awareness on treatment is also lacking at the community level. A radical and aggressive campaign on treatment literacy and positive prevention which strongly embraces HIV prevention messages should be embarked on in all project sites in All the care facilitators should be engaged in a systematic social mobilization at grass-root level and distribution of IEC materials on treatment literacy, adherence, nutrition, living positively- complementing government efforts in the roll-out of ART. Resource mobilization should be done specifically for this intervention in the second half of 2009 in preparation for implementation in Clients should no longer be seen as terminally ill but should be viewed as people who can be productive and able to engage in advocacy activities, and community support initiatives. Focus should be on psychosocial support and positive living and prevention. Strong support networks should be established, where clients can be discharged as a way of ensuring sustainability. Many National Societies have weak and few support groups. This component should be the focus for CHBC in IFRC Southern Africa also brought on board a short-term consultant to support the development of the CHBC minimum standards, in order to guide the National Societies on level of quality of services expected of them. In addition, the standards guide volunteers on the minimum tasks taking into consideration the task shifting induced by the advent of ART in many countries. 11

12 As part of the process, country visits were conducted to South Africa and Swaziland to assess the current level of workload, specific tasks of volunteers and the prevailing situation with the HBC clients. The minimum standards will be presented at the SARAWO meeting in September 2009, whilst the final document will be produced in October National Societies HIV and health staff at all levels will be trained on the minimum standards in Below are some notable highlights from National Societies engaged in CHBC activities: While many National Societies have not developed exit strategies for CHBC projects, Lesotho Red Cross jointly with German Red Cross developed an exit strategy for Berea and Leribe projects. The two projects were funded through the European Union and the funding came to an end in June The National Society was able to put in place mechanisms to handover the beneficiaries and the volunteers to the Ministry of Health. Notably; - the branches have assumed responsibility of monitoring the activities of the volunteers; - the volunteers were supported with income generating activities from which their incentives will be derived, and - the community structures were sensitized on their role in the on-going implementation of the project after the funding of the project comes to an end. As a result of the excellent work, a good practice DVD of the two projects was compiled to highlight the experiences and lessons learnt. Zimbabwe Red Cross integrated ART/CHBC project in Mt Darwin and Chivi districts is a good practice in its own right. The inclusion of an outreach component a team of health professionals from the district hospital reaching out to beneficiaries in remote areas taking with them ART and TB drugs has become a model for decentralization of services in rural-resource-limited settings. Clients on ART have appreciated the services by the Zimbabwe Red Cross and their adherence levels have improved. The support from British, Danish, Swedish, Icelandic, Swiss, Finnish, Japanese, German and Spanish Red Cross Societies have to a large extent sustained the CHBC activities in many National Societies. Without the bilateral support, many National Societies in the region implementing CHBC would have collapsed leaving huge numbers of CHBC clients and care facilitators in jeopardy. For instance, the British Red Cross is supporting the Lesotho Red Cross to implement the integrated HBC programme together with the food security component. The Swiss and the Finnish Red Cross are supporting the Baphalali Swaziland Red Cross to implement an integrated HIV and livelihoods project. A state-of-the-art rural modern clinic is being supported by the Swiss Red Cross in Swaziland providing HIV and AIDS services including HIV Testing, PMTCT and ART provision. Challenges The lack of funding to train care facilitators on treatment literacy in all the countries remains a stumbling block from ensuring quality service provision. Defaulting is beginning to be seen in many communities especially where Red Cross volunteers are not operational. Support groups in many project sites are not active and are not trained. Income Generating Activities (IGA) are also not working effectively where they are operational. The IFRC Southern Africa is currently finalising user friendly guidelines on IGA expected to help National Societies greatly improve on the management of IGAs. The lack of minimum standards in care treatment and support has affected the provision of quality care for CHBC clients. The development and dissemination of the minimum standards is expected to help National Societies refine their CHBC interventions. The greatest challenge for the remainder of 2009 and 2010 will be to find ways to continue to support the children when external donor funding is diminishing. The OVC working group will be looking at potential solutions to this including greater involvement of communities in the programme It is critical that National Societies determine their exit and hand over strategies in line with the end of the regional programme and their funding situations. The volatile economic situation in Zimbabwe continues to impact on programme implementation. For instance the government policy on school fees has continuously been shifting since the introduction of the multi currency economy resulting in large discrepancies in the school fees structure from one location to the other, rendering the planning and budgeting process futile. The National Society is looking into other payment methods such as block granting in lieu of cash payment for school fees. 12

13 Output 3: Reducing Stigma and Discrimination Key strategies Promoting community support groups and networks of PLHIV as well as partnerships with PLHIV organizations; Ensuring that HIV in workplace policy and programmes for all staff and volunteers are in place in Red Cross Red Crescent National Societies; Tackling gender inequalities and sexual gender-based violence (SGBV); Peer education, community mobilization, and population-based information, education and communication. Progress In 2009, a total of 20,385 CHBC clients were enrolled into self support group of PLHIV, which is a marked reduction since the last update mostly due to inactivity induced by lack of funding support. This decrease is primarily reflected in South Africa and Zimbabwe as both National Societies improve on their data collection capacities, and are now able to trace clients leaving these self support groups. It is important that strategies and financial resources are put in place to effectively support these groups, which are very important platforms for rolling-out positive living and positive prevention, ART literacy and adherence support, psychosocial support. With the availability of resources income generating activities can be incorporated to improve the nutrition or economic income of PLHIV. National Societies are partnering with National PLHIV networks to implement this very crucial strategy. National Societies made steady progress in implementing HIV and AIDS Workplace Policies mostly by disseminating existing policies to staff and volunteers at branch levels. However there has been stagnation in the first half of 2009, due to lack of financial commitment for long-term support of the workplace initiatives. The 18 Masambo Funds applications previously made by the Mozambique Red Cross were approved and funds disbursed for the first time in the region, an encouraging demonstration of the relevance of the Fund. A total of 26 new applications for staff and volunteers were made and processed during the reporting period. It is important however that the IFRC continues to disseminate the guidelines on the Fund and encourage National Societies management to promote the wider dissemination of the guidelines across all programmes. Table 7: Overview of the overall National Society staff involved in workplace programmes in the first half of 2009: Staff In January 2009, a joint study (IFRC Southern Africa participating in Country Full time staff and Geneva Secretariat) was commissioned to workplace assess the current level of the IFRC s programme capacities to respond to gender-based violence Angola (GBV)-related issues in the southern Africa region Botswana 72 7 Lesotho 74 0 Malawi Mozambique and to prepare a regional strategy on GBV to enable National Red Cross Societies to improve their effectiveness in fighting both HIV and GBV. Namibia South Africa Swaziland The assessment which essentially took place in Malawi and South Africa revealed that, despite some commendable efforts put in place to better integrate Zambia GBV issues in the Global Alliance on HIV framework Zimbabwe since its inception in 2006, understanding of GBV has remained limited within the region. Similarly, the Total 2, programming and implementation capacity on the side of National Societies lingered and resulted in very few initiatives. The assessment confirmed the importance of integrating GBV into the regional HIV programme in order to achieve its overall objectives. In collaboration with external stakeholders, Geneva Secretariat and National Societies, IFRC Southern Africa finalised a strategy to prevent and respond to GBV in the Southern Africa following a consultation and training on GBV after the Global Alliance on HIV annual review meeting held in April Based on the invariable link between GBV and HIV infection rates, the purpose of this strategy is to: a) Provide a clear framework for the integration of interventions against GBV into HIV programmes currently implemented by National Societies across southern Africa; b) Outline concrete interventions to mainstream GBV issues in all IFRC s programmes. 13