Implementation of the Declaration of Commitment on HIV/AIDS 2006 National Report

KINGDOM OF MOROCCO MINISTRY OF HEALTH Implementation of the Declaration of Commitment on HIV/AIDS 2006 National Report - January 2006

CONTENTS Page Synthesis Table of Guidelines... 3 I. Introduction... 5 II. Overview of the HIV/AIDS epidemic... 6 III. National response to the HIV/AIDS epidemic... 9 1. Leadership... 9 2. Prevention... 10 3. Care, support and treatment... 12 4. HIV/AIDS and human rights... 14 5. Reducing vulnerability... 15 6. Resources... 16 7. Follow-up... 17 IV. Major challenges faced and actions needed to achieve the goals/targets... 18 V. Support required from development partners... 20 Appendices Appendix 1: Preparation process for the national report on monitoring the Declaration of Commitment on HIV/AIDS... 22 Appendix 2: National Composite Policy Index Questionnaire... 24 Appendix 3: Forms for knowledge, behaviour and impact indicators (CRIS database)... 47 Appendix 4: Details on the core indicators... 68 1

LIST OF ABBREVIATIONS AIDS ALCS ARV CCM CHU CRI CRIS Dh. GTO IDU(s) LM-LMST MENA MENJ MS NA NAP NGO(s) NSP OPALS PLHA PMTCT SEJ STI(s) SW TV UA UN UNAIDS UNGASS UNS VIH WHO - Acquired Immunodeficiency System - Moroccan AIDS Control Association - Antiretroviral drugs - Morocco Coordination Committee - Academic Hospital - Cross-sectoral Regional Committee for the Prevention of AIDS - Country Response Information System - Moroccan currency (Dirham) - Theme Group for UNAIDS - Injecting Drug User(s) - Moroccan League for the Prevention of Sexually Transmitted Diseases - Middle East and North Africa - Ministry of National Education and Youth - Ministry of Health - Not Applicable - National STI/AIDS Programme - Nongovernmental Organization(s) - National Strategic Plan - Pan-African Organization against AIDS - People living with HIV/AIDS - Prevention of Mother-to-Child Transmission - Secretary of State for Youth - Sexually Transmitted Infection(s) - Sex Workers - Television - Unavailable - United Nations - Joint United Nations Programme on HIV/AIDS - United Nations General Assembly Special Session - United Nations System - Human Immunodeficiency Virus - World Health Organization 2

SYNTHESIS TABLE OF MONITORING GUIDELINES FOR THE DECLARATION OF COMMITMENT ON HIV/AIDS National Actions and Commitments Expenditure 1. Amount of national funds allocated for the AIDS programme 2001 $US 2,000,000 2003 $US 5,230,000 2005 $US 5,581,400 Policy development and implementation situation 2. National Composite Policy Index 2005 See Appendix 2 (Questionnaires A et B) National Programmes: HIV testing and prevention programmes for populations most at risk 3. Among the [most-at-risk populations], percentage of persons UA who received HIV testing in the last 12 months and know the results Number of most-at-risk persons having received confidential HIV 2003 * 3,300 testing in 2005 2005 * 11,363 Percentage of drug users having received an HIV test 2005 ** 12.5% 4. Among the [most-at-risk populations], percentage of persons UA reached with prevention programmes Related Guidelines Number of most-at-risk persons having benefited from prevention 2003 * 24,019 programmes * 2005 * 50,822 Number of women and young having benefited from prevention 2003 * 17,000 programmes * 2005 * 407,400 UA guidelines unavailable such as described; linked guidelines are proposed References: * Data from programmes implemented by partners ** Study on the risks linked to drug injecting (493 IDU sample), Ministry of Health 2005. 3

SYNTHESIS TABLE OF MONITORING GUIDELINES FOR THE DECLARATION OF COMMITMENT ON HIV/AIDS (cont.) Knowledge and Behaviour 5. Among the [most-at-risk populations], percentage of persons UA who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission Related Guidelines Percentage of sex workers having knowledge of AIDS transmission 2003 *** 72% from sex without condoms Percentage of drug users declaring that abstinence is a means to 2005 ** 43% prevent HIV Percentage of drug users declaring that loyalty to the partner is a 2005 ** 28% means to prevent HIV Percentage of drug users declaring that the use of a condom is a 2005 ** 52% means to prevent HIV Percentage of drug users declaring that not using an already-used 2005 ** 57% needle is a means to prevent HIV Percentage of drug users declaring being aware of all four means 2005 ** 7% mentioned above 6. Percentage of female and male sex workers reporting the use 2003 ** 38% of a condom with their most recent client 7. Percentage of men reporting use of a condom the last time UA they had anal sex with a male partner 8. Percentage of IDU(s) who have adopted behaviours that Not Applicable reduce transmission of HIV, i.e. who avoid using non-sterile (HIV transmission injecting equipment and use condoms, in the last month in Morocco mainly (country where injecting drug use is an established mode of sexual type) of HIV transmission) Impact 9. Among the [most-at-risk populations ], percentage of persons who are HIV-infected Pregnant women 2004 **** 0.10% Prisoners 0.61% Sex workers 1.95% STI carriers 0.34% Tuberculosis sufferers 0.34% UA guidelines unavailable such as described; linked guidelines are proposed References: * Data from programmes implemented by partners ** Study on the risks linked to drug injecting (493 IDU sample), Ministry of Health 2005 *** Study on street prostitution (316 SW sample), ALCS 2003 **** HIV sentinel surveillance, National AIDS programme, Ministry of Health 2004 4

1. INTRODUCTION Since the first case of AIDS appeared in 1986, the Kingdom of Morocco has progressively introduced a series of measures and countless provisions to cope with the spread of the epidemic. In a National response to AIDS, the Moroccan authorities have demonstrated sheer determination to achieve the goals presented in the 2002/2005 National Strategic Plan. This report describes the overall developments made by the Kingdom of Morocco to implement the Declaration of Commitment on HIV/AIDS, adopted in June 2001 during the United Nations Extraordinary Session on HIV/AIDS in New York. It is the result of wide-ranging discussions carried out among the National AIDS programme (NAP) and its partners, comprising Ministries, civil society and international organizations. The report process has been enacted in several stages with the support of UNAIDS: - Recruiting a national consultant to assist preparation of the report - Setting up a Committee in charge of preparing the report comprised of NAP partners (Social sectors, NGOs, United Nations Agencies) - Organising a discussion group and collecting opinions from partners on the contents of questionnaires - Gathering information and necessary data to prepare the report - Presentation of a preliminary report during a national forum organised in conjunction with World AIDS Day. This forum provided an opportunity to share the contents with all partners, as well as with representatives from various national media. - Organising a discussion group with partners to finalise the contents of the report, during which working groups were set up to analyse the following issues: Implication and National Policy, Prevention and Handling, Human Rights, and Participation from Civil Society. After first analysing the epidemic situation in Morocco, the report gives a general overview of the progress made in accordance with the main issues stipulated in the Declaration of Commitment. It then highlights the main difficulties encountered and the challenges needing to be overcome to reinforce the national response to HIV/AIDS in years to come. The appendix to the report includes the questionnaires on national policy, as well as a synthesis of the guidelines regarding behaviour and impact. 5

II. OVERVIEW OF THE HIV/AIDS EPIDEMIC Morocco has organised a threefold epidemic surveillance system for both STI(s) and infection by HIV/AIDS, i.e. clinical notification of cases of both STI and HIV/AIDS infections; surveillance during blood-donor transfusions; and sentinel surveillance of the HIV infection. This last element enables to monitor the tendencies of HIV prevalence among the different population groups coming from various selected sites in the different regions of the country, while respecting the ethical rules as provided for by the WHO at international level (anonymousunlinked testing). It should be noted that the sentinel surveillance system has been extended to reach 24 sites in 2005 and that vulnerable groups have been included since 2001. Table 1: HIV prevalence rate by population groups (%) according to sentinel surveillance data Morocco, 2002~2004 Year 2002 2003 2004 Group Pregnant women 0.12 0.13 0.10 Prisoners 1.18 0.18 0.61 Sex workers 3.14 2.36 1.95 STI carriers 0.1* 0.23 0.34 Tuberculosis sufferers 0.50 0.19 0.34 (*) Data for 2001 Sentinel surveillance of HIV first demonstrates that HIV prevalence in pregnant women is relatively low and has remained almost stable since the year 2000 when the highest prevalence rate (0.15%) was recorded (chart n 1). Chart 1: Evolution of the HIV prevalence rate in pregnant women from 1994 to 2004 (%) Morocco, 1994~2004 [insert chart 1] The HIV prevalence rate in vulnerable groups covered by sentinel surveillance shows notably higher figures in sex workers, even though these are far below the 5% mark (the lower limit for a concentrated epidemic level). The prevalence rate within this group has nevertheless remained stable since 2001. For male prisoners, the prevalence rate was 0.61% in 2004, and for two other groups concerned by sentinel surveillance, i.e. STI carriers and tuberculosis sufferers, the prevalence rate shows more moderate figures (0.34%). 6

Estimations, made using data on HIV prevalence, show a regular increase in the number of persons living with HIV, passing from an average estimate of 14,500 in 2003 to 18,000 in 2005 (chart 2). Chart 2: Estimation of the number of persons living with HIV Morocco, 2003~2005 [insert chart 2] Another example is to take the accumulated number of AIDS cases notified to the NAP since the first case in 1986 and to note that the number of cases was 1,839 at the end of November 2005. The annual rate of AIDS cases is thus steadily rising. If we are to compare five-year periods, we can note a considerable increase in the number of cases: only approximately 70 cases between 1986 and 1990, rising to 236 cases between 1991 and 1995, then to 528 cases between 1996 and 2000, and to 1,005 cases between 2001 and 2005 (chart 3). Chart 3: Evolution of the number of notified AIDS cases according to a given period Morocco, 1986~2005 [insert chart 3] The number of cases of AIDS sufferers in Morocco has not just progressed, but rather has suffered a major change in profile. If during the initial 1986~1990 period, a balance was observed among the modes of heterosexual, homosexual, perinatal and drug-use transmission, the heterosexual route itself now (2001~2005 period) covers almost 83% (chart 4). Chart 4: Percentage evolution of the heterosexual transmission mode Morocco, 1994~2004 [insert chart 4] 7

Changes in the profile of AIDS cases in Morocco also concerned the types of illnesses. If women only represented approximately 18% between 1986 and 1990, this percentage rose to 40% between 2001 and 2005; a phenomenon closely linked to the other AIDS profile changes, i.e. transmission route and risk factors. Chart 5: Evolution of the proportion of women among cases of AIDS Morocco, 1986~2005 [insert chart 5] With regard to areas having a high concentration of AIDS cases, five out of sixteen regions in Morocco account for almost three-quarters of the AIDS cases. The first region is Souss Massa Draa (23% of cases), followed by the Grand Casablanca (17% of cases), Marrakech Tensift Al Haouz (15% of cases), Rabat Salé Zemmour Zaër (9% of cases) et finally Doukkala Abda (8% of cases). III. NATIONAL RESPONSE TO THE AIDS EPIDEMIC The National AIDS Programme began as of 1988, the year in which a national technical AIDS control committee was established. The first activities planned concerned a short-term AIDS control plan for 1989, after which two medium-term plans were set up for the periods 1991~1994 and 1996~2000. Morocco then established the 2002~2004 National Strategic Plan, which was extended until 2005 to allow actions to be pursued. The strategy is now under review in order to prepare a new national strategic plan for the 2006~2010 period. In this section, we shall stress the efforts deployed by the government and its partners in response to the HIV/AIDS epidemic, as well as the progress achieved. These efforts shall be highlighted for each of the areas mentioned in the Declaration of Commitment on HIV/AIDS. 8

1. LEADERSHIP The governments are committed: to implementing multisectoral strategies and financing plans for combating HIV/AIDS by addressing silence, denial, stigma and discrimination, which involve partnerships with civil society, the business sector, people living with HIV/AIDS, vulnerable groups, women and young people, and are resourced, to the extent possible from national budgets to promote and protect all human rights and gender equality, by integrating age, risk and vulnerability, to ensuring the promotion of prevention, care, treatment, support and the reduction of the impact of the epidemic, and to strengthening health, education and legal system capacity; to integrating prevention, care, treatment, support and impact-mitigation priorities into the mainstream of development planning. The Moroccan Government has often demonstrated its implication in AIDS issues, even at the highest level. For example, during the UNGASS session in June 2001, His Majesty King Mohammed VI stressed Morocco s commitment for having established an integrated national strategy against HIV/AIDS, including prevention for vulnerable persons and care for patients. On another occasion in November 2002, His Majesty the King inaugurated the day-care hospital for HIV/AIDS in Casablanca and visited patients in April 2005 to enquire about the care administered. In addition, Her Royal Highness Lalla Salma attended the meeting for the First Ladies of Africa on AIDS, which was held in New York in June 2005. It is also important to underline the organisation of many scientific and social events for AIDS under the high patronage of His Majesty King Mohammed VI. The most recent action, Sidaction [ActionAIDS], was broadcast on the two national television channels in an effort to make the population more aware of AIDS and to receive donations. The Ministry of Health has made it its duty, alongside other government members, to participate in the various national events for AIDS. Thus, a number of implicated Ministries has adopted the cause that it coordinates. Among them, we can quote the Ministries of National Education, of Higher Education, of Professional Training and of Scientific Research, the Secretary of State for Youth, the Secretary of State for the Family, for Childhood and for Handicapped Persons, the Ministry of Communication, the Ministry of Justice, the Ministry of Habus and Islamic Affairs, as well as the Royal Army Forces. Several of these Ministries have elaborated their own sectoral plans for combating HIV/AIDS. Implication is also extended to NAP partners, whether this is for developing the strategic plan or for its implementation. Thus, the 2002~2004 National Strategic Plan, extended to 2005, is now at the end of the discussion and strategic planning process, having brought together all the national and regional players. This plan is based on the implementation of preventive actions 9

and the care of persons living with HIV. Single-focused NGOs and some multi-sector NGOs play a crucial role in soliciting decision-makers and in actively participating in AIDS campaigns. Implication is also shown by the Ministry of Health s annual budget, which provides a specific allocation for the National AIDS programme (NAP). 2. PREVENTION The governments are committed: to establishing prevention targets to address factors which lead to the spread of the epidemic and which reduce the HIV incidence for those identifiable groups where infection rates are high; to implementing prevention and care programmes in the world of work, as well as for migrants and mobile workers; to implementing universal precautions in health-care settings to prevent the transmission of HIV infection; to ensuring that a wide range of prevention programmes, which take account of cultural values, is available in all countries and proposed in the local languages, to encouraging responsible sexual behaviour to reduce risks linked to the use of drugs and to expand access to condoms, sterile injecting equipment and safe blood supplies, to the treatment of sexually-transmitted infections, and to voluntary and confidential counselling and testing; to ensuring that young people (15 to 24 years) have access to the information, education and services necessary to develop the life skills required to reduce their vulnerability to HIV infection; to ensuring that women infected by HIV and their infant receive antenatal care to reduce mother-tochild transmission, and that women infected by the virus receive voluntary and confidential counselling and testing, and have access to treatment, including antiretroviral therapy, and, where appropriate, breastmilk substitutes. Actions lead over the past two years include the signing in 2004 of a charter, Initiative Média contre le SIDA [Media Initiative against AIDS], between the Ministries of Health and Communication and the Directors of television and radio channels, and with the Federation of Newspaper Editors. 2004 was also marked by the preparation of a national social communication strategy for AIDS, which took the form of a national campaign planned in four phases during 2004 and 2005. The first phase concerned awareness and the understanding that AIDS is an existing phenomenon in Morocco. The second phase focussed on how HIV/AIDS is transmitted and how to prevent it, by promoting in particular the use of condoms. The third phase concerned the prevention of both stigma and the discrimination of people living with HIV/AIDS. The last phase promoted anonymous testing services at no cost. The types of communication used during this national AIDS public communication campaign included TV and radio adverts, announcements in newspapers, and fixed or mobile display boards. The campaign totalised 1,320 TV and radio adverts, 100 newspaper announcements and 200 urban posters, in addition to 4,000 km covered by awareness-promoting vehicles. 10

Various communication approaches have been devised to reach vulnerable populations and/or high-risk groups. Thus for young people and women, awareness and peer education has been recommended. For populations most at risk, such as sex workers, the approach again concerns peer education, but also anonymous testing at no cost and the treatment of widespread STI(s) in several towns. In 2005, more than 407,400 women and young persons received advice and education; over 31,700 persons from identifiable high risk groups were given counselling; and almost 3 million condoms were distributed. Finally, anonymous and free testing centres have been opened up in several towns of the country enabling to significantly increase the number of persons tested. Thus, we witness that the number of persons tested sextupled between 2001 and 2005 from 1,500 to 11,300 (chart 6). Chart 6: Evolution of the number of persons advised and tested Morocco, 2001 to 2005 [insert chart 6] 3. CARE, SUPPORT AND TREATMENT The governments are committed: to elaborating strategies to strengthen health-care systems and to address factors affecting the provision of HIV drugs, such as affordability, pricing and the health-care system capacity. Also in an urgent manner make every effort to provide the highest attainable standard of treatment for HIV/AIDS, including the prevention and treatment of opportunistic infections and antiretroviral therapy; to developing comprehensive care strategies to strengthen family and community-based care to provide treatment to people living with HIV/AIDS to include children, the support of individuals, households, families and communities affected by HIV/AIDS to improving the capacity and working conditions of health-care personnel, to strengthening supply systems, financing plans and referral mechanisms to provide access to medicine, to diagnostics and medical care, both palliative and psychosocial; to developing national strategies to provide psychosocial care to individuals, families and communities affected by HIV/AIDS. With regard to the treatment of persons living with HIV, it should be noted that the national strategy developed in 1998 for the diagnosis and care of HIV/AIDS infection cases was reviewed and revised in 2002 in terms of its organisational and technical aspects, then again in 2004 with the participation of all the national partners. 11

Financing antiretroviral drugs (ARV), equipment and reagents for the biological monitoring of HIV/AIDS patients is ensured through the State budget, with conversion of a complementary budget in the context of the Global Fund to Fight AIDS, Tuberculosis and Malaria support programme. Regarding HIV/AIDS medical centres, we note a tendency towards decentralisation. Thus, in addition to the two priority CHU centres in Casablanca and Rabat, six regional referent centres have been established in Tanger, Fès, Marrakech, Agadir, Meknès and Oujda. Among them, some are equipped for carrying out biological monitoring, particularly CD4 cell dosing. Since 2004, the genotyping of resistances to ARVs has been introduced at the National Hygiene Institute (INH), the national referent centre for diagnosing and monitoring the HIV/AIDS infection. Since 2004, child care services have been reinforced in the Rabat and Casablanca centres through actions, such as training the paediatricians concerned and adapting to needs. The cost of antiretroviral drugs has considerably diminished thanks to the combined efforts by the Ministry of Health and civil society. Since 2002, Morocco has benefited from low prices through the ACCESS initiative; furthermore, taxes and customs duties have been abolished. As of 2004, generic medicine was introduced onto the national market. Thanks to these efforts, the monthly cost per patient for ARV treatment has passed from 13,000 Dirham (Dh) in 1988 to 800 Dh in 2004, i.e. more than 16 times less (chart 7). Chart 7: Evolution of the monthly cost per patient for ARV treatment (in $US) Morocco, 1998~2004 [insert chart 7] NGOs play a major role in life-skills support for Persons Living with HIV (PLHA); thus we note that a therapeutic education programme has been implemented in collaboration with NGOs to improve patients respect of the ARV prescriptions. As of 2003, treatment via triple therapy was generalised to all AIDS patients. At the end of November 2005, 1,120 patients were receiving no-cost ARV treatment, thus representing a significant increase in numbers in comparison to 2001 (167 patients treated). 12

Chart 8: Evolution of the number of patients living with HIV/AIDS receiving ARV treatment Morocco, 2001~2005 [insert chart 8] Finally, when considering the statistics regarding the percentage of persons requiring ARV treatment and who actually receive it (10% of persons living with HIV require ARV treatment), we note in Morocco a steady increase, passing from 38% in 2003 to 62% in 2005 (table 2). Table 2: Percentage of persons living with HIV requiring ARV treatment and who receive triple therapy Year 2003 2004 2005 Estimation of the number of 14,000 16,000 18,000 Persons living with HIV Number of persons requiring 1,450 1,600 1,800 ARV treatment (10%) Number of persons receiving 553 884 1,120 ARV Percentage of persons treated 38% 55% 62% by ARVs 4. HIV/AIDS AND HUMAN RIGHTS The governments are committed: to enacting legislation, regulations and other measures to eliminate all forms of discrimination against people living with HIV/AIDS and members of vulnerable groups, and to ensure their full enjoyment of all human rights in particular access to education, inheritance, employment, health care, social and health services, prevention, support, treatment, information, legal protection, their right to privacy and to confidentiality and to developing strategies to combat stigma and social exclusion; to implementing strategies which enable women s full enjoyment of all human rights and to increase their ability to protect themselves from HIV infection; to implementing measures enabling women and adolescent girls to protect themselves from the risk of infection through the provision of health services, particularly sexual and reproductive, as well as prevention education to promote gender equality; to developing strategies for women s empowerment, the protection of their full enjoyment of all human rights and the reduction their vulnerability to HIV/AIDS through the elimination of all forms of discrimination, as well as all forms of violence against women and girls, including harmful traditional practices, abuse, rape, sexual violence, battering and trafficking in women and girls. 13

In the preamble of its constitution, Morocco is committed to respecting the specific and general instruments regarding human rights, such as through declarations, treaties and agreements signed by the Kingdom. Although no specific laws or regulations exist regarding the elimination of any form of discrimination or stigma towards people living with HIV/AIDS, the current legislation provides for equality among all male and female citizens in terms of access to schools, to health, to housing and to all other services. Having said that, the Moroccan legal provisions were enhanced in 2004 with the entry into force of a new Family Code. This Code topped the action lead for several years by both the human rights and women s NGOs with the aim of achieving gender equality and women s empowerment. Thus, the Moroccan society has registered appreciable progress for women s rights in terms of her status and position within family and society. It is also important to note that the Strategy to Fight against Violence towards Women, promoted by the Secretary of State in charge of the Family, Childhood and Handicapped Persons, constitutes another asset for fighting against HIV/AIDS. Finally, the national public communication campaign for AIDS, organised by the Ministry of Health in 2004/2005, was directed in its third phase at combating discrimination and the stigma of persons living with HIV. This campaign used various communication means to fight discrimination and the stigma of PLHAs, whether at family or community level. It was not only targeted at the general population, but also, in more local terms, at the workplace, the family and health service providers. 5. REDUCING VULNERABLITY The governments are committed: to implementing programmes which establish targets and address factors that make individuals particularly vulnerable to HIV infection, including under-development, economic insecurity, poverty, lack of empowerment of women, lack of education, social exclusion, illiteracy, discrimination, lack of information, lack of commodities for self-protection, sexual exploitation of women, girls and boys; to developing programmes which recognize the importance of the family, culture and religion to reduce the vulnerability of children and young people by ensuring access to all children to primary and secondary education, including HIV/AIDS in curricula for adolescents, by expanding information and sexual health education and counselling services, by strengthening reproductive and sexual health programmes and by involving families and young people in prevention and care programmes; to developing programmes through a participatory approach to protect the health of those identifiable groups where infection rates are high or where there is the greatest risk of infection. 14

Several actions are being conducted regarding the strategies implemented to better protect vulnerable persons against HIV/AIDS. Such actions have an indirect impact on the vulnerability to HIV/AIDS, for example, those that aim at reducing the dependence of women and at participating in their empowerment through micro-lending, as well as at activities that generate income. The new Family Code has particularly contributed to the empowerment of Moroccan women. Likewise, literacy campaigns organised in Morocco provide a form of protection for vulnerable populations, particularly young girls and women. Thus, through these programmes, certain NGOs have integrated modules regarding HIV/AIDS. It should also be noted that actions for schooling with regard to young girls, particularly in rural areas, have reduced vulnerability in this population category. Thus, the net schooling rate for girls in rural area primary schools (aged between 6 and 11) has increased from 22.5% to 78.5% between 1991 and 2004, and that for girls in rural area colleges (aged between 12 and 14) has passed from 1.1% to 8.9% over the same period. The National Action Plan for the Child, recently drawn up in association with three Ministries (Ministry of Health, Ministry of National Education, Secretary of State in charge of the Family), aiming at an integrated strategy, incorporates a chapter for HIV/AIDS. Thus, several associations are taking concrete actions for children in the streets by taking them in, providing them with necessary care, counselling them and setting them off in the right direction to make them less vulnerable. The implicated ministerial departments are partners to the national AIDS control strategy and some have already prepared their own sectoral strategies in this field. Finally, the National Initiative for Human Development (INDH), launched by HIS MAJESTY KING MOHAMMED VI, is the new strategic framework against poverty, marginalisation and the insecurity of vulnerable population sectors. It directly targets the poor in rural areas and those living in slums, in improper parts of towns and the homeless. 6. RESOURCES The governments are committed: to increasing national budgetary allocations for HIV/AIDS programmes and ensuring that adequate allocations are made by all the Ministries concerned; to supporting the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria to enable it to finance a rapid and broadened response centred in priority on the most affected countries. 15

An integrated strategy exists for allocating resources, particularly as funds have considerably increased since 2001. In addition to the regular annual budget from the Ministry of Health allocated to the National AIDS Programme, Morocco received a grant from the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria. This grant, amounting to a budget of US$ 9.23 million, received after acceptance of Morocco's proposal in April 2002, is destined to implement the National AIDS Control Strategic Plan. Morocco is the only country in the MENA region to have obtained finances at the end of the first round of Global Fund grants. Thus, when analysing the funds allocated by all partners of the AIDS control programme, we note that the global amount has considerably increased, i.e. from US$ 2.1 million in 2001 to US$ 5.2 million in 2003, then to US$ 5.6 million in 2005. The donors implicated in this strategy are the Global Fund, the United Nations Organizations, Bilateral Cooperation and international NGOs. 7. MONITORING AND EVALUATION The governments are committed: to conducting periodic reviews with the participation of civil society, people living with HIV/AIDS, vulnerable groups and caregivers of the progress achieved in realising the commitments of this Declaration and to ensuring wide dissemination of the results; to developing mechanisms to monitor and evaluate the progress, with adequate epidemiological data; to establishing monitoring systems for the protection of all human rights of people living with HIV/AIDS. The surveillance system for HIV through the sentinel network has progressively been extended to reach 24 sites in 2005. The groups observed were gradually increased as of 2001 to include other vulnerable population groups, particularly sex workers and prisoners. Epidemiological studies have been conducted on a regular basis to enable the monitoring of STI tendencies and to detect any signs of antibiotic resistance. Evaluation of the National AIDS Control Strategic Plan is now in its preparative stage, and shall be conducted to enable participation by the various partners of the programme, particularly NGOs, social sectors and local actors. This review shall provide an opportunity to analyse the situation, identify progress and any hurdles that may impede the implementation of activities, as well as to orientate strategies and actions for the next plan covering the 2006 to 2010 period. 16

The Morocco Coordination Committee (CCM) was established in 2002. Made up of AIDS prevention partners, it has reinforced its operating mode by setting up a management structure and various working groups. Provincial and regional intersectoral committees for AIDS, including all actors, have been established in priority regions, as identified by the National Strategic Plan. In 2004, a study was made to evaluate experiences gained by such committees and to propose actions aimed at strengthening their operations. The monitoring and evaluation system, set up in the context of the National Strategic Plan, is now in the review phase for the purpose of integrating information from programmes and projects lead by all partners. IV. MAIN OBSTACLES ENCOUNTERED AND NECESSARY ACTIONS TO REACH THE AIMS/OBJECTIVES Implication from partners Implication by the key sectors and necessary partners for AIDS control should be strengthened in order to improve the coverage by care in vulnerable populations. Thus, we note that certain sectors, such as labour, tourism, transport or agriculture, are not yet directly implicated in the AIDS control process and are not represented in the CCM. Furthermore, the private sector is not sufficiently implicated. Linking the world of work, particularly in companies where the risk of infection is potentially higher, can only become effective if such sectors are implicated, and this is dependent upon their actual integration into each one of the sectoral strategies to combat HIV/AIDS. Implication by the NGOs often remains limited to single-focused NGOs fighting against AIDS, where numbers are lacking and where participation is low due to their participation in the different development programmes. We note the lack of foresight for the PLHAs who are not yet grouped together in an association. Finally, participation by the local authorities remains limited, although they do not hinder the outreach activities performed by the NGOs. Prevention Despite the outreach activities carried out by partners for those populations having risk behaviours or who are vulnerable, such as the young, women and workers, certain inadequacies can be noted in terms of coverage and sectoral implications. Certain programmes set up for targeted populations have a punctual nature and remain limited to certain towns and villages. As mentioned above, the number of single-focused NGOs is limited, while the majority of multi-sector NGOs is not sufficiently aware of the problems surrounding HIV/AIDS to be able to integrate it into their activities as a cross-cutting issue. 17

Other high-risk populations are not targeted, such as drug injecting users, who lack specific programmes to understand no-risk injection practices and treatment. Migrant populations, particularly those from sub-saharan Africa, although receiving care free-of-charge in public health institutions, are not targeted by any particular structured prevention programme and are only very partially covered by the activities run by national and international NGOs. In public health centres, systematic precautions for using needles do exist, although they remain insufficient due to the lack of single-use equipment in all establishments in the country. Care, support and treatment The decentralisation process for the care of AIDS sufferers that started in 2003 is not yet sufficiently operational. The medical centres in Marrakech, Oujda, Fès and Tanger only cater for approximately ten patients each, while almost 200 patients are treated in Agadir and over 800 are cared for in Rabat and Casablanca. There are also other provinces where an appreciable number of patients has been notified, but which do not have care centres. The Prevention of Mother-to-Child Transmission (PMTCT) is only integrated via therapy programmes; it has thus become apparent that real strategies now need to be developed for that purpose. Furthermore, the care of HIV-positive children remains confined at central level in Rabat and Casablanca, which needs to be decentralised to Agadir and Marrakech. AIDS sufferers are not given sufficient support in terms of psychosocial advice as this task is limited to just a few NGOs, other departments not being implicated in this sector. HIV/AIDS and human rights The obstacles that come to light in the area of Human Rights in relation to HIV/AIDS can be resumed by the lack of specific provisions for the right to health, an insufficient application of the laws, and finally the lack of an ethical committee in charge of fighting discrimination and stigma within the NAP. Protection of vulnerable persons Vulnerable populations are scattered nationwide. The action carried out up until now has been concentrated on a reasoned regional choice. Coverage is expected to extend to other areas, thus requiring increased activity from the NGOs and social sectors. The strategies recommended by several ministerial departments do not clearly integrate the fight against AIDS. The National Initiative for Human Development targets the indirect factors of a person s vulnerability, but does not mention any direct actions for HIV/AIDS control, these actions being able to be developed through local initiatives and according to needs. It is necessary to develop and implement an integration strategy (mainstreaming) against HIV/AIDS within those NGO sectors targeting vulnerable populations, particularly the women and young. 18

The programmes for very vulnerable children remain limited, but should particularly be extended to street children and to children who are victims of delinquency and sexual exploitation networks. Financial resources The funds used, for the most part, stem from donations, and in particular from the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, thus giving rise to the question of the durability of actions. Furthermore, additional financial means should be given to provincial and intersectoral committees in order to implement and reinforce activities out in the field. Monitoring and evaluation The current information system does not give sufficient information about the prevention activities lead by the different partners, such as peer education or other mechanisms established by the NGO sector. Thus, in the context of the new 2006~2010 National Strategic Plan, a unique monitoring-evaluation system should be established, taking account of both international and national requirements. IV. Necessary support from partners for development in the country Following analysis of the adopted response to fight against HIV/AIDS, as well as the problems raised prior to its adoption, it has become obvious that strengthening the coverage of young persons and other vulnerable or high-risk populations is a crucial factor. In order to do so, support from partners should be centred on developing actions against HIV/AIDS in the following four main areas: broader partnership and implication; reinforcing national coordination; taking account of other specific groups; reinforcing decentralisation. For partnership, it is crucial to implicate other key Ministries, such as the Ministry of Labour, the Ministry of Equipment and Transport, the Ministry of Tourism, the Ministry of Agriculture, Rural Development and Maritime Fishing, and to ensure that their respective sectoral plans are integrated into the National Strategic Plan against AIDS. Furthermore, it is important that the programmes and strategies for development and reducing poverty, as well as programmes against illiteracy, integrate the fight against HIV/AIDS as cross-cutting issues. It is also crucial to involve other multi-sector NGOs, private and public health, the business 19

sector and trade unions. It is also necessary to encourage implication by people living with HIV when planning actions against AIDS. The setting up of a unique information system shall enable improved follow-up to the responses coming from various national partners. For coordination, it has become crucial to extend the mission of the Morocco Coordination Committee to enable it to become a fully-fledged national body for coordinating actions against AIDS, and to raise such coordination to ministerial level. It is also necessary to ensure the implication, in a durable manner, of local, national and international financial resources. For prevention, it is important to reinforce the coverage of young people and other vulnerable populations in particular, to implement specific programmes for certain high-risk populations, such as drug users and sub-saharan migrants, and to establish a prevention strategy for mother-to-child transmission. These programmes should also cover Moroccans living abroad via representative associations. It is also important to reinforce universal precautionary measures in health institutions and to ensure that such measures are respected by traditional practitioners and all those who "manipulate" sharp instruments. Prevention is a crucial factor for stopping the proliferation of HIV/AIDS; thus global public communication must be used as a permanent means for encouraging behavioural changes in populations. It is also important to reinforce the care for children suffering from AIDS, the implication by the NGOs and the relevant departments, as well as those persons implicated themselves in psychosocial care. Reinforcing decentralisation is also most important for the purpose of ensuring better outreach in actions against AIDS. Sectoral strategies are best combined with actions lead by local actors. The decentralisation process for preventive actions will no doubt constitute a hoard of experiences achieved from knowledge and practice-based exchange processes, and where the already-participating NGOs shall obligatorily have a key role to play. Decentralising care for AIDS sufferers at regional level must also be reinforced through the establishment of new regional referent centres. 20

APPENDIX 1 CONSULATION/PREPARATION PROCESS FOR THE NATIONAL REPORT ON MONITORING THE DECLARATION OF COMMITMENT ON HIV/AIDS 21

NATIONAL REPORT S CONSULTATION AND PREPARATION PROCESS 1) Which institutions/bodies were responsible for filling out the indicator forms? a) NAC or equivalent Yes No b) NAP Yes No c) Others Yes No 2) With inputs from Ministries: Education Yes No Health Yes No Labour Yes No Foreign Affairs Yes No Others (*) Yes No (*) Habus and Islamic Affairs Youth and Sports Justice Civil society organizations Yes No People living with HIV/AIDS Yes No Private sector Yes No United Nations Organizations Yes No Bilaterals Yes No International NGOs Yes No Others (please specify) 3) Was the report discussed in a large forum? Yes No 4) Are the survey results stored centrally? Yes No 5) Are data available for public consultation? Yes No Name / title: Dr. Mohamed Cheikh Biadillah Ministry of Health Date: Signature: 22

APPENDIX 2 NATIONAL COMPOSITE POLICY INDEX 2006 23

NATIONAL COMPOSITE POLICY INDEX 2006 Country: KINGDOM OF MOROCCO Name of the National AIDS Committee officer in charge, Morocco: Dr. Noureddine CHAOUKI Signed by: Name and title: Director of Epidemiology and the fight against Disease Ministry of Health Address: 71, Avenue Ibn Sina Agdal, RABAT - MOROCCO TEL: 00 212 37 67 12 71 FAX: 00 212 37 67 12 98 E-MAIL: nchaouki@sante.gov.ma Date: Signature: 24

PART A OF THE QUESTIONNAIRE ON THE NATIONAL COMPOSITE POLICY INDEX 1. Strategic plan 1. Has your country developed a national multi-sectoral strategy/action framework to combat HIV/AIDS? (Multisectoral strategies should include, but not be limited to, those developed by Ministries such the ones mentioned below.) Yes No Not Applicable (N/A) Period covered: 2002/2005 1.1 IF YES, which sectors are included? Sectors included Strategy/Action framework Focal point/responsible Health Yes No Yes No Education Yes No Yes No Labour Yes No Yes No Transportation Yes No Yes No Military Yes No Yes No Women Yes No Yes No Youth Yes No Yes No Others to specify Islamic affairs Yes No Yes No Communication Yes No Yes No Justice (Prisons) Yes No Yes No Comments: The Ministries of Labour and of Transportation will no doubt be included in the next plan. Implication by the Ministries of Social Development and of Tourism is desired. The sectoral plans from Ministries already implicated National Education, Youth and the Family, and Justice are in the final stages before conclusion, and specifically integrate the fight against HIV/AIDS. 1.2 IF YES, does the national strategy/action framework address the following areas, target populations and cross-cutting issues? (Yes/No) Programme a. Voluntary counselling and testing? a. Yes b. Condom promotion and distribution? b. Yes c. Sexually transmitted infection prevention and treatment? c. Yes d. Blood safety? d. Yes e. Prevention of mother-to-child transmission? e. Yes (on-going) f. Breastfeeding? f. Yes g. Care and treatment? g. Yes h. Migration? h. No 25

Target populations i. Women and girls? i. Yes j. Youth? j. Yes k. Most-at-risk populations? k. Yes l. Orphans and other vulnerable children? l. No Cross-cutting issues m. HIV/AIDS and poverty? m. Yes n. Human rights? n. Yes o. PLHA involvement? o. Yes (*) 1.3 IF YES, does it include an operational plan? Yes No 1.4 IF YES, does the strategy/operational plan include: a. formal programme goals? Yes No b. detailed budget of costs? Yes No c. indications of funding sources? Yes No (*) Represented in NGOs 1.5 Has your country ensures full involvement and participation of civil society in the planning phase? Yes No 1.6 Has the national strategy/action framework been endorsed by key stakeholders? Yes No Comments: All single-focussed NGOs and other socially-inclined bodies implicated in the strategic planning process, in addition to other associations. They also participate in the NSP review for preparing the next plan. 2. Has your country integrated HIV/AIDS into its general development plans (such as: a) National Development Plans, b) United Nations Development Assistance Framework, c) Poverty Reduction Strategy Papers, and d) Common Country Assessments)? Yes No S/O 2.1 IF YES, in which development plan? a) Yes b) Yes c) Does not exist d) Yes Covering which of the following aspects? (Yes/No) a) b) c) HIV Prevention Yes Yes Care and support Yes Yes HIV/AIDS impact alleviation Yes Yes Reduction of gender inequalities as relates to HIV/AIDS Yes Yes prevention/care Reduction of income inequalities as relates to HIV Yes Yes prevention/care Others: 26

3. Has your country evaluated the impact of HIV and AIDS on its economic development of planning purposes? Yes No S/O 3.1 IF YES, how much has it informed resource allocation decisions? (Low to High) Low High 0 1 2 3 4 5 6 7 8 9 10 Comments: With the low HIV prevalence rate, such evaluation was not carried out. It has not been accepted for inclusion in the next plan. A study on the impact of HIV and AIDS on economic and social development is now on-going. 4. Does your country have a strategy/action framework for addressing HIV and AIDS issues among its national uniformed services, military, peacekeepers and police? Yes No S/O 4.1 IF YES, which of the following have been implemented? HIV Prevention Yes No Care and support Yes No Voluntary HIV testing and counselling Yes No Mandatory HIV testing and counselling Yes No Others to specify: Yes No Comments: A programme exists since 1996, essentially with the Royal Armed Forces (FAR). It concerns a prevention and peer education strategy with implication by the Oulémas [or Ulema] (Islamic theologians). This programme is now being reinforced. As for care and support, this is carried out through collaboration between the Ministry of Health and the Royal Army Forces. Other uniformed services shall be integrated into the next plan, i.e. the Police, Auxiliary Forces and Civil Protection. Overall, how would you rate strategy planning efforts in the HIV and AIDS programmes? 2005 Poor Good 0 1 2 3 4 5 6 7 8 9 10 2003 Poor Good 0 1 2 3 4 5 6 7 8 9 10 In case of discrepancies between 2003 and 2005 rating, please provide main reasons supporting such difference: Due to the implication of new sectors. II. Political support 1. Does the head of the government and/or other high officials speak publicly and favourably about AIDS efforts at least twice a year? Head of government Yes No Other high officials Yes No 27

2. Does your country have a national multisectoral HIV and AIDS management/coordination body recognized in law? (National AIDS Council or Commission) Yes No S/O 2.1 IF YES, when was it created? Year: February 2003 2.2 Does it include? Terms of reference Yes No Defined membership Yes No Including civil society Yes No People living with HIV Yes No Private sector Yes No Action plan Yes No Functional Secretariat Yes No Date of last meeting of the Secretariat Date: 10~11 November 2005 Comments: Such body is the Morocco Coordination Committee (CCM Comité de Coordination du Maroc) and includes Ministerial departments, single-focussed NGOs, representatives from the Moroccan medical association and from the General Business Confederation, as well as donors (United Nations Organizations and bilateral cooperation organizations). The next plan shall provide a broader mandate to enable improved coordination at national level. It shall also become a fully-fledged institution by ministerial decree. Efforts are continuing to include PLHAs. 3. Does your country have a national HIV and AIDS body that promotes interaction between government, people living with HIV, the private sector and civil society for implementing HIV and AIDS strategies/programmes? Yes No S/O 3.1 IF YES, does it include? Terms of reference Yes No Defined membership Yes No Action plan Yes No Functional Secretariat Yes No Date of last meeting Date: Comments: As the National AIDS Programme is run by the Ministry of Health, the latter ensures such interaction and coordinates the support from donors and sponsors. 4. Does your country have a national HIV and AIDS body that is supporting coordination of HIV-related service delivery by civil-society organizations? Yes No S/O 4.1 IF YES, does it include? Terms of reference Yes No Defined membership Yes No Action plan Yes No Functional Secretariat Yes No Date of last meeting Date: 28