INTERIM STRATEGIC PLAN FOR MULTI-SECTORAL FOR HIV RESPONSE IN ETHIOPIA (2009 2010/11) Federal HIV/AIDS Prevention and Control Office (HAPCO) Addis Ababa, Ethiopia DRAFT 28 February 2009 1
ACRONYMS AACs ABC AIDS ART BCC BPR CBO CSO CT FBO FMoH GBV GF HAPCO HBC HCT HEP HEWs HIV HMIS HSDP IEC IP MAC-E MDGs M&E MoH MTCT NAC NGO OPD OVC PASDEP PEP PEPFAR PLWHA PMTCT RHAPCO RHB SOP STI TB TWG VCT WHDs WHO Anti-AIDS clubs Abstinence, Be Faithful, Condom Use Acquired immune deficiency syndrome Antiretroviral therapy Behavioral change communication Business Process Reengineering Community-based organization Civil society organizations Counseling and testing Faith-based organization Federal Ministry of Health Gender-based violence Global Fund to Fight AIDS, Tuberculosis and Malaria HIV/AIDS Prevention and Control Office Home-based care HIV counseling and testing Health Extension Program Health extension workers Human immunodeficiency virus Health Management Information System Health Sector Development Program Information education communication Infection prevention Millennium AIDS Campaign-Ethiopia Millennium Development Goals Monitoring and evaluation Ministry of Health Mother-to-child transmission of HIV National AIDS Committee Nongovernmental organization Out Patient Department orphans and vulnerable children Plan for Accelerated and Sustainable Development to End Poverty Post-exposure prophylaxis US President s Emergency Plan for AIDS Relief People living with HIV/AIDS Prevention of mother-to-child transmission of HIV Regional HIV/AIDS Prevention and Control Office Regional Health Bureau Standard operating procedure Sexually transmitted infection Tuberculosis Technical working group voluntary counseling and testing Woreda Health Departments World Health Organization 2
Executive Summary Introduction Situation Analysis Response Analysis Purpose of the Strategic Plan 2009-2010 Guiding Principles Vision Goals of the Interim SPM 2009-2010 Strategic Issues (Priority areas) for the SPM 2009-2010 1. Creating Enabling Environment Strengthening Capacity Building among all stakeholders Effective Leadership Enhancing Coordination and Partnership across and within sectors Effective Mainstreaming Creating comprehensive knowledge and behavioral change on a mass basis (Community Mobilization and Social Transformation) Promoting greater involvement of PLHIV Human resource development and retention Policy Development and addressing legal/right issues Promoting Gender Equity 2. Intensifying HIV Prevention and Control a) Behavioral Interventions o Targeted interventions for MARPs including mobile workers 1 o General population Interventions o Prevention with Positives (PwP) b) Structural Interventions o Poverty Reduction o Gender (Empowerment, GBV, HTP) o Human rights including stigma reduction o Strengthening faith-based responses o Strengthen sex-education in school curriculum o Sexual health promotion for young people (Establishing information and recreation center for youth and students) o Address the needs of children and disabled 3. Maintaining gains and enhancing AIDS Treatment and Medical Prevention Ensure Universal access to ART including young children and infants Ensure adherence to early pre-art and treatment c) Promote better HIV services within the integrated of health programs; by strengthening linkage between programs, including TB/HIV 1 Mobile workers include truck drivers, sex workers (women and men), migrant workers (men and women working in mechanized farm, transport, industrial, and road sector), cross-border populations (traders, Travelers), uniformed services, and refugees. 3
d) Strengthen health network model and task shifting e) Availability of essential drugs and supplies for treatment and care f) Increase uptake and effectiveness of services for the Prevention of Mother to child transmission (PMTCT) g) STI management; especially in MARPs h) Prevention in the health care setting i) Increase access to Male Circumcision (MC) 4. Mitigating Impact of HIV/AIDS Intensify programs for OVC and Elders Strengthen Home and community based care for PLHIV Intensify poverty mitigation programs; aligning with PASDEP 5. Monitoring and Evaluation Strengthening Multi-sectoral Program monitoring and Evaluation select objective Indicators Strengthen HMIS Strengthen standardization and quality assurance 6. Generation and use of strategic information Promote multi-sectoral collaboration in generation and utilization of HIV related information Strengthen HIV prevalence surveys in the general population and MARPs; at national and sub-national levels Establish HIV Incidence surveys; at national and sub-national levels Conduct regular behavioral studies among general population and at-risk group; at national and sub-national levels Strengthen Operational Research and Special Studies Strength the capacity to use existing information at programmatic level Strengthen surveillance system that help to generate and use strategic information related to HIV/STI co-infection, HIV/TB co-infection, AIDS mortality, and level and trends in ART and STI drug resistance. 4
1. INTRODUCTION Strategic Planning is essential to effectively response to the HIV epidemic in a coordinated manner. The strategic plan needs to be both multi-sectoral and be the outcome of processes involving major stakeholders. In part the purpose of the Plan is to identify and prioritize operational activities, and in part to serve as a mechanism of social mobilization. This Interim SPM covers only the period 2009-2010 in order to create opportunities to align strategies with other major sector (HSDP) and development (PASDEP) plans which also end in 2010. During the interim period, multi-sectoral actors at all levels working on HIV issues are expected to develop and implement their respective plans based on this SPM. During the Interim period a number of structural changes within the sector will be given chance to settle. A number of planned national surveys will also provide more accurate information to develop a five-year plan. 2. SITUATION ANALYSIS Ethiopia is among the first countries hard hit by the HIV/AIDS pandemic. Since the first two reported AIDS cases in 1986, the disease has spread at an alarming rate throughout the country. The national adult HIV prevalence is 2.1 percent based a single estimate derived from the two main information sources: the ANC based estimates and DHS conducted in 2005. Both systems are believed to have certain limitations and the estimate is considered provisional. The need for a well conducted national survey is imperative. Considering the complexity of the factors involved in the HIV epidemic much need to be done to fully understand sexual behaviors and their determinants for effective strategic planning. In Ethiopia, studies available to delineate individual, societal and environmental factors are limited to fully inform the strategic planning. However, apart from traditionally known risk factors and groups recent studies and reports indicated that new factors and groups are emerging. Generally, HIV has affected more the urban areas and females and that trend is going to continue according to the projection. Very important evidence that emerged from the analysis of the 2005 DHS data is that small market towns in Ethiopia exhibited an increased prevalence compared to big towns. The fact that small towns in Ethiopia are commercial and administrative points, they can serve as bridging site for urban to rural spread of HIV. Other 5
sexually transmitted infections that are relevant to the prevention and control of HIV are not systematically monitored and no recent data is available to make reasonable estimate of the national prevalence and the trends over time. Although sexual behaviors among different population groups are not well studied in Ethiopia there are a number of small studies and anecdotal observations that indicated new areas and population groups are emerging with high risk to HIV spread. Students and young mobile workers appear to be recognized as the most at risk group. Although sexual behaviors and networking are not well studied information on abortion indicated the high number of unprotected sex happening among students and young people. MSM that has not been recognized as a threat for HIV spread in Ethiopia has been reported to be a concern for the society and public administrators. The impact of the current situation may unfold its negative impacts in the coming years in more visible ways. As HIV/AIDS epidemics characteristically have a much-delayed impacts the more intensified actions are delayed the intensity of the epidemic may cause much disaster. The OVC produced already by the HIV epidemic has not been fully supported to ensure their healthy growth and development. 3. RESPONSE ANALYSIS The response to the HIV/AIDS epidemic in Ethiopia is a collective effort of the government, multilateral and bilateral donors, national and international non-governmental organizations, community-based organizations, faith-based organizations, the private sector, associations of PLHIV and individuals. The response has been guided the national policy issued in 1998. The National AIDS Prevention and Control Council established in 2000 is charged with implementing the multi-sectoral response. The council, chaired by the president of Ethiopia and comprising members from government, NGOs, religious bodies, and civil society, has declared HIV/AIDS a national emergency. The National HIV/AIDS Prevention and Control Office (HAPCO) was established by proclamation in June 2002 as an implementing organ of the multi-sectoral strategic plan. The Federal Democratic Republic of Ethiopia (FDRE) launched the first Strategic Plan for Intensifying Multi-Sectoral HIV/AIDS Response for the period 2004-2008 (SPM I) with guiding 6
principles that included multi-sectoralism, empowerment, shared sense of urgency, gender sensitivity, involvement of PLHIV, result oriented interventions, and best use of resources in terms of allocation, harmonization, efficiency and accountability. The major thematic areas in the SPM I were capacity building, community mobilization and empowerment, integration with health programs, leadership and mainstreaming, coordination and networking and targeted responses. SPM I had greater emphasis and assigned bigger roles for the health sector and evidently the Federal Ministry of Health spearheaded its implementation. The Federal and most Regional HAPCOs became directly accountable to the Federal Ministry of Health and Regional Health Bureaus respectively. As described below during this period tremendous achievements have been achieved in expanding health facilities and services to PLHIV but the period is heavily criticized for putting less emphasis on primarily preventive and non-health sector responses. Availability and accessibility of HIV services showed phenomenal increment. The Millennium AIDS Campaign and Universal Access to ART expanded free HCT and ART services to a very large number of eligible individuals than ever imagined before. The number of services providers increased, new categories of health workers was added at the grassroots level (Health extension workers), and task shifting was introduced, to overcome the staff turnover and attrition. Better leadership commitments were observed at both national and regional levels. Most sectoral public agencies have recognized HIV as one of their core activities and some have gone as far as establishing a coordination office. Social mobilization efforts, especially the Community Conversations (CCs), were very successful in reaching millions of people and creating awareness about HIV and available services. Efforts to involve communities and community based organizations in supporting orphans and PLHIV and mitigating the impact of HIV were observed. The responses during the SPM I period were however constrained by lack of adequately trained and experienced human resources in both technical and administrative areas, which was compounded by frequent turnover and attrition. The inadequacies of the system and the change in the HAPCOs structure have created formidable challenge in implementing a multisectoral response. The inadequate emphasis to the expansion of preventive services and 7
mitigating the effects of the epidemic has caused major concerns. Behavioural changes were not clearly observed as messages were not specific to target groups. Much of the results during the SPM I period are attributed to campaign activities that are costly and operationally difficult to sustain. Effective leadership by HAPCO for the multi-sectoral responses has been limited by its organizational structure and accountability. 4. PURPOSE OF THE INTERIM SPM (2009-2010/11) The HIV/AIDS epidemic is not monolithic and varies considerably across the country, and within communities in the country. However, much is not known or fully understood in Ethiopia about the real situation based on objective and systematic assessment. This Interim SPM is thus developed to bridge two gaps. First, it allows alignment of the SPM with other sectoral and developmental plans which are ending by 2010. Secondly, a number of large scale national studies will be completed during the interim period to provide more context specific information that allows concrete planning. The purpose of the Interim SPM includes: To sustain the gains during the SPM I implementation. To refocus responses to prevention and mitigation efforts. To formulate a Plan that is broader in its scope and encourages multi-sectoral involvement. To generate critical evidences on the magnitude, spread and determinants of the epidemic that are relevant to develop context specific interventions with potential to significantly alter the situation. To allow adequate time to changing situations and structure within HAPCO and in the country as a whole; the BPR is being completed in many sectors. 5. GUIDING PRINCIPLES The following are the guiding principles for multi-sectoral response (MSR): 8
Effectiveness partners and stakeholders of the MSR must ensure effectiveness of interventions in order to achieve desired results. Accountability partners and stakeholders shall be accountable to the Ethiopian MOH and the people of Ethiopia in conducting sound HIV/AIDS prevention and control activities. Transparency partners and stakeholders shall be open about their activities and funding to those outside the agency. Science-Based Activities partners and stakeholders shall base their prevention and control efforts on the best science currently available. Collaboration and Partnerships partners and stakeholders HIV/AIDS prevention and control interventions shall be implemented in a coordinated manner at all levels federal, state and local in the public sector, private sector and not-for-profit sector to address multiple local epidemics in the most efficient way possible. Comprehensiveness use multifaceted approaches to HIV prevention and control that includes strategies to address individual, community, and structural level prevention needs. Leadership HAPCO is the nation s coordinating agency and provides leadership in prevention and control policy and practice. Respect for Human Rights place pre-eminent value on human rights in the development of its HIV prevention programs and expects grantees to do the same. Equity: make sure that preventive and control program reaches to all segment of the population Quality: ensure provision of quality services at all levels. Gender: ensure gender equity in all programmatic areas. 9
6. VISION, MISSION, GOALS AND EXPECTED RESULTS Vision: To see Ethiopia free from HIV/AIDS. Mission: To achieve successful multi-sectoral response for HIV/AIDS prevention and control by mobilizing the community and coordinating sectors and building their capacity to create ownership; by mobilizing partners and utilizing resources appropriately; by establishing monitoring and evaluation system; and by increasing the coverage, quality of services and speed of implementation of comprehensive HIV/AIDS programs to satisfy the needs of clients in order to prevent and control the spread of the epidemic and mitigate its impact. Goals: The main goal is to prevent and control the spread of HIV/AIDS and mitigate its impact through coordinated multi-sectoral responses. Expected Strategic Results: The following are the major expected strategic results: 1) behavioral change at individual and community levels; 2) Reduce and reverse the spread of HIV; and 3) Reduce the impact of HIV/AIDS. 10
7. THEMATIC AREAS FOR INTERIM SPM (2009-2010/11) Ethiopia has made substantial progress in combating HIV/AIDS during the last SPM period. The achievements in building the health sector capacity and expanding access to HIV services through campaigns have paved the road for more interventions. The future course of the HIV epidemic is dependent on the primary prevention efforts that focus on behavioral changes at a mass scale in populations and minimizing the factors that increase vulnerability and risk to new infections in the society. Thus, the Interim SPM puts greater emphasis on maintaining past gains and making new success stories in combating the HIV epidemic. This SPM draws on the lessons learned from the evaluation of SPM I and ideas generated through consultation of wide range of stakeholders. The following sections present the thematic (priority areas) and the key targets for the Interim SPM 2009-2010/11. 7.1 Creating Enabling Environment In order to effectively fight the HIV epidemic it is essential to create the necessary capacity among the wide range of stakeholders. Enabling environment includes having basic infrastructure, the necessary policy environment and resources in order to successfully implement the HIV/AIIDS prevention and control strategies. The evaluation of SPM I (SPM 2004-08) revealed that a lot has been achieved in capacity building by expanding health infrastructure, increasing availability and accessibility of services, increasing access to HCT through the Millennium AIDS Campaign and Universal Access to ART expanded free HCT and ART services to a very large number of eligible individuals. The number of services providers increased, new categories of health workers was added at the grassroots level (Health extension workers), and task shifting was introduced, to overcome the human resource shortage as well the staff turnover and attrition and expand the desired service. However, these efforts were mainly focused on the health sector, public sector and the effort has also been challenged by the continuous staff turnover problem. The potentials in the nonhealth sector and in non-public sector remained underdeveloped and underutilized. There are shortcomings in the pre-service trainings not only in the health sector, but also in all other sectors are major concerns pertaining to the sustainability of certain interventions. 11
Successful social mobilization efforts, especially the Community Conversations (CCs), were instrumental in reaching millions and providing better access to HIV services. Those efforts were not accompanied by behavioral changes. Specific interventions to reduce HIV vulnerability due to economic challenges were also limited. At the community level, the potentials of the already existing social structures such as Idirs (CBOs) and other cultural institutions have not been fully utilized for the fight against HIV. Improved leadership commitments were observed at national and regional levels during the last SPM period; however, the level and effectiveness of leadership commitments significantly vary among regions and remained to be further intensified. Leadership has been mostly emanating from the health and administrative/political sector. Other sectors remained passive either because of lack of initiative or capacity. It is essential that the leaderships in all sectors must work together and in harmony to strongly and effectively combat the HIV epidemic. The efforts to develop one agreed national action framework based on the principles of Three Ones with HAPCO s leadership has been successful to some extent. Further efforts in that front are expected in the coming years in order to realize fully the Three One principle. Increasingly sectoral public agencies have recognized HIV as one of their core activities and made necessary preparations including assigning a focal person or by establishing a coordination office; however, the efforts and achievements in mainstreaming remain much less than desired in some sectors. Lack of conceptual understanding, unavailability of clear mainstreaming guidelines, and insufficient resources were among the major reasons for ineffective mainstreaming. In addition the mainstreaming efforts in non-public sectors have not been recognized and supported enough. The efforts to improve the human resource capacity through in-service training have been many and that has helped to alleviate the critical shortage of adequately trained professionals at all levels. These efforts coupled with task shifting to the lower level professionals brought some encouraging results. The high turnover of staff and lack of mechanism for provision of sustainable incentives limited the effectiveness of these mechanisms. It is important to create mechanisms that are sustainable and cost effective for sustainable development of human resources. 12
Efforts must be continued to provide and update policies and guidelines that are pertinent to effectively fight the HIV epidemic. Substantial improvements achieved during the last SPM period in developing and disseminating the necessary policies and guidelines. As HIV epidemic and the strategies to fighting it are dynamic it is imperative to continuously update the policy environment. Some well established equity and human right principles in the constitution and other national legal frameworks, such as gender, must be adequately integrated in all efforts to combat HIV/AIDS. Based on the above arguments and consultation with stakeholders the following key strategies for creating enabling environment among wide range of stakeholders are identified to be essential for the multi-sectoral responses: Strengthening Capacity Building among all stakeholders Effective Leadership Enhancing Coordination and Partnership across and within sectors Effective Mainstreaming Creating comprehensive knowledge and behavioral change on a mass basis (Community Mobilization and Social Transformation) Promoting greater involvement of PLHIV Human resource development and retention Policy Development and addressing legal/right issues Promoting Gender Equity Detailed activities under these strategies are going to be developed in specific plan of actions and the monitoring and evaluation framework provides how those activities are tracked and success determined. Table 1 shows the major targets under creating enabling environment. 13
Table 1. Selected Strategies and Targets for creating enabling environment to combat HIV/AIDS in Ethiopia. Selected Strategies Major Targets Key Indicators Verification Responsible Body Strengthening Capacity Building among all stakeholders 100% of health facilities provide HCT, PMTCT, and HIV treatment and care services. 80% of the health facilities provide CD4 monitoring in line with national guidelines, on site or through referral? 100% of the major stakeholders have either HIV coordinating office or a focal person working on HIV/AIDS program. Develop national HIV/AIDS supplies procurement and distribution plan. Effective Leadership Enhancing Coordination and Partnership across and within sectors None of the facilities providing HIV related services experience stock out of supplies that lasted one month or more. Strengthen HAPCOs leadership at all levels by directly linking to the executives. Establish effective and function partnership forums with agreed upon coordination mechanisms. Ensure the participation of non-public and private sectors in HIV related services and activities. 14
Selected Strategies Major Targets Key Indicators Verification Responsible Body Effective Mainstreaming Provide mainstreaming training at all levels and to all stakeholders based on the national guidelines. Ensure 100% implementation of mainstreaming in all development and economic activities in both public and non-public sectors. Creating comprehensive knowledge and behavioral change on a mass basis (Community Mobilization and Social Transformation) 100% of the target populations have comprehensive knowledge about mode of transmission and means of preventing HIV infection. Promoting greater involvement of PLHIV Human resource development and retention Enhance greater involvement of PLHIV in all HIV related activities and initiatives; from designing to implementation and evaluation through their associations Ensure inclusion of HIV/AIDS in pre service training curriculum of all health professionals Conduct training needs assessment and implement training programs accordingly. Establish tracking system to ensure the continuous presence of trained people in services. Retain 80% of trained staff on the job for at least one year. Policy Development and Conduct assessment to identify areas 15
Selected Strategies Major Targets Key Indicators Verification Responsible Body addressing legal/right issues that need new policy and revision of policy with stakeholders. Prepare policy with participation of stakeholders and translate into actions within 90 days. Promoting Gender Equity Ensure the integration of gender in policy development, program designing and implementation, and in monitoring and evaluation activities. Ensure greater emphasis for equal access to HIV services, reducing gender-based violence, and women's property and inheritance rights through wider stakeholder involvement. 16
7.2 Intensifying HIV Prevention and Control The ultimate goal of the Ethiopian Government is to see the nation free of HIV/AIDS. That goal can only be achieved if primary prevention is intensified and new infections are no more happening. Reduction of vulnerability factors and sustained behavioral changes are required to achieve that goal. These strategies require concerted efforts of all stakeholders over a long period of time. The evaluation of SPM I clearly indicated the emphasis given to primary prevention has not been to the level needed to halt the progress of the HIV epidemic; in fact much of the efforts in combating the HIV epidemic were medically oriented and the participation of the non-health sectors were marginalized. Primary HIV prevention efforts must target healthy individuals that are susceptible to HIV infection; vulnerable and high risk groups. Creating comprehensive HIV knowledge and promoting behavioral changes as a population level are essential. As in many other public health programs; targeting highly vulnerable and at risk populations need to be given priority in prevention activities to maximize the yield of efforts. The intervention programs targeting CSW, women, and street children mainly focus on preventive education, negotiation skills, condom distribution, and IGA trainings have shown encouraging results in the past. These activities are the main areas for involvement of NGOs, CBOs and FBOs. Consolidating efforts in this front and enhancing the involvement of all stakeholders is essential to create more opportunities to reduce vulnerability to HIV infection. The availability and distribution of prevention means, such as condom, need to be improved substantially. Young people and high risk groups need to have better and easy access to condoms. Prevention strategies and activities need to be tailored according to the needs of the special context. Although this SPM provides general direction at the national level with due considerations to the conditions in the regions it is essential that regional stakeholders take the necessary steps to create a more elaborate prevention strategies depending on the prevailing circumstances. For example; in some areas night markets are common and created suitable environment to alcohol abuse, rape and abduction. Some border areas are highly vulnerable to HIV because of the presence of military and refugee populations that attract commercial sex activities. Those areas serve as fertile grounds to bridge the spread of HIV from urban to rural populations. 17
Newly created opportunities for education and commercial activities have also been incriminated for creating fertile grounds for HIV spread because of increased vulnerability for violence and lack of access to HIV prevention services. Increasing concerns are voiced by concerned authorities and the media about MSM practices in Addis Ababa and in some major regional towns. Some hospital sources indicated an increasing number of cases of rape among street boys. All these conditions require special approaches because of their sensitivity as well as differing circumstances. Thus, the need to adapt prevention strategies at sub-national level and localities cannot be overemphasized. Cognizant of the lessons learnt in the last SPM period, it is important to plan more effective and targeted preventive strategies. Maintaining the effective strategies and developing new strategies for the dynamic HIV epidemic is essential. Secondary prevention strategies need to be strengthened among PLHIV to ensure a healthier life. Thus, the prevention strategies for this SPM are categorized into two major focus areas; behavioural change and reducing vulnerability. Some of the major strategies are presented below: a) Behavioral Interventions o Targeted interventions for MARPs including mobile workers 2 o General population Interventions o Workplace interventions o School based interventions o Prevention with Positives (PwP) b) Structural Interventions (Vulnerability reduction) o Poverty Reduction o Gender (Empowerment, GBV, HTP) o Human rights including stigma reduction o Strengthening faith-based responses 2 Mobile workers include truck drivers, sex workers (women and men), migrant workers (men and women working in mechanized farm, transport, industrial, and road sector), cross-border populations (traders, Travelers), uniformed services, and refugees. 18
o Strengthen sex-education in school curriculum o Sexual health promotion for young people (Establishing information and recreation center for youth and students) o Address the needs of children and disabled Detailed strategies in each of the major prevention themes are presented in Table 2.1 and 2.2. Further adaptation of the specific strategies at sub-national level is desirable. 19
Table 2.1. Selected Strategies and Targets for intensifying multi-sectoral HIV Behavioral Change Interventions in Ethiopia. Selected Strategies Major Targets Key Indicators Verification Responsible Body Targeted interventions for MARPs including mobile workers General population Interventions Workplace interventions School based interventions Prevention with Positives (PwP) 100% of the target populations have comprehensive knowledge about mode of transmission and means of preventing HIV infection. 80% of the target populations practice safe sexual behaviors by 2010.?? Expand High Risk Corridors Interventions Increase VCT coverage to 25% for the general population by 2010. Increase condom distribution to ##. 100% of the target populations have comprehensive knowledge about mode of transmission and means of preventing HIV infection. 80% of the target populations practice safe sexual behaviors by 2010. 100% of the target populations have comprehensive knowledge about mode of transmission and means of preventing HIV infection. Increase safe sexual behaviors to 90% among target populations by 2010. Provide 100% of PLHIV coming to services with information about ways of protecting their own health and counseling to prevent transmission of HIV to sex partners. Provide 100% of sexually active PLHIV coming to services with condoms. 20
Table 2.2. Selected Strategies and Targets for Intensifying structural Interventions for multi-sectoral HIV Prevention and Control in Ethiopia. Selected Strategies Major Targets Key Indicators Verification Responsible Body Poverty Reduction 3 Reduce total poverty head count from 39% in 2005 to 29% by 2010. Gender (Empowerment, GBV, HTP) Human rights including stigma reduction Strengthening faith-based responses Strengthen sex-education in school curriculum Sexual health promotion for young people Address the needs of children and disabled Reduce food poverty head count from 38% in 2005 to 28% by 2010. Strengthen the gender sensitivity of the monitoring and evaluation system Review and update policies, legislations and guidelines with participation of PLHIV and their families through associations. Develop policies, legislations and guidelines for greater participation of faith-based organizations to combat HIV/AIDS. 100% of the school communities have comprehensive knowledge about methods of HIV transmission and means of HIV infection prevention. Develop and provide comprehensive prevention package for 100% of the young population. Develop comprehensive prevention package for vulnerable population groups. 3 PASDEP targets 21
7.3 Maintaining gains and enhancing AIDS Treatment and Medical Prevention Efforts to provide HIV services in health facilities during the last SPM period have made services accessible to large number of clients. HIV related services are given in an integrated fashion with the existing public health programs. In some regions, the integrated services are given in the some private sector health facilities. Linkages and referral among HIV services require further standardization and integration to maximize benefits to clients and reduce loss of clients from services; especially from ART services. Further improvements in provision of medical services require expanding human and material resources; using existing human resources efficiently by sharing responsibilities and coordinating tasks. Some service areas, such as PMTCT and pediatric, are underutilized. It is important to identify the barriers for reaching more people with these services through operational research and take the necessary actions accordingly. The involvement of Health extension workers and other community level stakeholders could help mobilizing the community to utilize the services. Some major gaps in HIV related services identified by the SPM I evaluation include lack of minimum service package at the different levels of service delivery such as for PMTCT, referral system in HIV care, and establishing youth friendly programs. Other gaps include inadequate OI drugs, and lack of facilities for diagnosis and treatment of STI. Low utilization of medical prevention in health facilities also deserves attention to protect the wellbeing of clients and service providers. In order to maintain the gains in the past and take the HIV services to a better level the following strategies are identified as key. Ensure Universal access to ART including young children and infants Ensure adherence to early pre-art and treatment Promote better HIV services within the integrated of health programs; by strengthening linkage between programs, including TB/HIV Strengthen health network model, task shifting and mentorship Availability of essential drugs and supplies for treatment and care 22
Increase uptake and effectiveness of services for the Prevention of Mother to child transmission (PMTCT) STI management; especially in MARPs Prevention in the health care setting Increase access to Male Circumcision (MC) Table 3 shows the selected strategies and major targets to be reached during this SPM period. Further details on activities shall be available in detailed operational plans. 23
Table 3. Selected Strategies and Targets for maintaining gains and enhancing AIDS treatment and medical prevention in Ethiopia. Selected Strategies Major Targets Key Indicators Verification Responsible Body Strengthen HIV counseling and testing services 90% of the health facilities nationwide provide standard HCT services Ensure Universal access to ART including young children and infants Provide ART to 100% of eligible PLHIV Ensure adherence to early pre-art and ART treatment 100% of pre-art and ART patients take recommended drugs without interruption. 4 Promote better HIV services within the integrated of health programs; by strengthening linkage between programs, including TB/HIV Establish a standard operating procedure (SOP) for linking HCT clients to pre-art services (pre-art clinic or Medical OPD). 100% of HIV positive clients receive comprehensive pre-art services. Strengthen health network model, task shifting and mentorship 100% of the facilities providing HIV related services receive mentorship program. Availability of essential drugs and supplies for treatment and care Provide essential treatment for opportunistic infections to 100% of the needy clients 4 Road map targets. 24
Selected Strategies Major Targets Key Indicators Verification Responsible Body Increase uptake and effectiveness of services for the Prevention of Mother to child transmission (PMTCT) STI management; especially in MARPs Increase PMTCT coverage to 80% by 2010. Expand and strengthen the public and private STI services using the syndromic management approach. Establish youth friendly STI services Prevention in the health care setting Provide infection prevention services to 90% of the needy Increase access to Male Circumcision (MC) 100% of health units with surgical facilities provide safe male circumcision services Reduce death due to AIDS Reduce AIDs related mortality among PLHIV to 2.3% by 2010 25
7.4 Mitigating Impact of HIV/AIDS The impact of HIV/AIDS is not fully understood in the Ethiopian context. However, the obvious impact observed so far has been on orphans and elderly population who lost their children that can potentially support them during retirement. High level of dropout from education and failure to secure the basic life necessities such as food and shelter are serious challenges for the people affected by the HIV/AIDS epidemic. The need for multi-sector and coordinated action involving all societal resources is clear to alleviate the social impact of HIV/AIDS. A comprehensive national policy on mitigation of the impact of HIV/AIDS shall provide the framework in which all partners involved in mitigation will work. Sectoral policies in place also need to be revised to bring them in line with the national policy. The SPM supports specific mitigation programmes in line with the developing policy framework, at both national and community levels. Effective engagement of civil society and empowering community and faith-based organizations is particularly important to the success of the mitigation interventions. The following are key strategies to mitigate the impact of HIV/AIDS in the Ethiopian context: Intensify programs for OVC and Elders Strengthen Home and community based care for PLHIV Intensify poverty mitigation programs; aligning with PASDEP 26
Table 4. Selected Strategies and Targets for mitigating the impact of HIV/AIDS in Ethiopia. Selected Strategies Major Targets Key Indicators Verification Responsible Body Intensify programs for OVC and Elders Develop the policy, guidelines and standards for OVC and elderly care and support programs. Provide standard care and support services to 80% of the needy children and elderly. Strengthen Home and community based care for PLHIV Provide care and support services to 80% of the needy PLHIV. Intensify poverty mitigation programs; aligning with PASDEP Reduce total poverty head count from 39% in 2005 to 29% by 2010. Reduce food poverty head count from 38% in 2005 to 28% by 2010. 27
7.5 Strengthening Monitoring and Evaluation Considerable improvement has been observed in establishing monitoring and evaluation system for HIV/AIDS programmes in Ethiopia in the last SPM period. Objectives and indicators were stated in the SPM I. However, some objectives were not SMART and some others lack clarity. No specific targets were set for some of the thematic areas and baseline has not been established for many of the indicators thus determining whether targets are achieved or not could not be determined easily. Data sources and empirical evidences for the program monitoring and evaluation are scattered, disorganized and not easily accessible; more so in the non-health sector. Monitoring and evaluation is critical for a successful implementation of the SPM. Ethiopia has adapted the Three Ones principles and tried to put that in place for the last few years. During this SPM period a more coordinated and systematic national M&E framework to track the overall performance and impact of the national response shall be developed and implemented. All partners involved in the implementation of SPM shall report progress in their specific areas and receive feedback on the overall progress of the national response within that framework. The framework articulates the linkages, reporting relationship, and indicators to be used at different levels to measure inputs, outputs, outcomes and impact of interventions. The following key strategies are identified for this SPM period in order to ensure quality services and tracking progress in the health and non-health sectors: Strengthen standardization and quality assurance Establish Multi-sectoral Program Monitoring and Evaluation Framework Strengthen HMIS 28
Table 5. Selected Strategies and Targets for strengthening monitoring and evaluation of the multisectoral HIV/AIDS responses in Ethiopia. Selected Strategies Major Targets Key Indicators Verification Responsible Body Strengthen standardization and quality assurance Establish standard data collection, analysis and dissemination system for key program indicators Strengthening Multisectoral Program monitoring and Evaluation Establish one multisectoral HIV/AIDS database Strengthen HMIS Establish one functional HIMIS database 29
7.6 Strengthen Generation and use of strategic information A number of recent studies commissioned by HAPCO and partners indicated clear knowledge gaps in understanding fully the nature of the HIV/AIDS epidemic in Ethiopia. The statistics indicating the magnitude and spread of HIV/AIDS in Ethiopia are controversial. The specific risk factors and risk population are not clearly delineated. Hot spots in HIV spread are hypothesized but not known for sure. The effectiveness of even large scale interventions have not been studied. In the 21 st century where resources are scarce and are available only in opportune time it is absolutely important to use them wisely by guiding interventions by scientific evidences. The following strategies are identified as key for promoting the scientific basis of interventions during the SPM period and beyond: Promote multi-sectoral collaboration in generation and utilization of HIV related information Strengthen HIV prevalence surveys in the general population and MARPs; at national and sub-national levels Establish HIV Incidence surveys; at national and sub-national levels Conduct regular behavioral studies among general population and at-risk group; at national and sub-national levels Strengthen Operational Research and Special Studies Strength the capacity to use existing information at programmatic level Strengthen surveillance system that help to generate and use strategic information related to HIV/STI co-infection, HIV/TB co-infection, AIDS mortality, and level and trends in ART and STI drug resistance. 30
Table 6. Selected Strategies and Targets for strengthening generation and use for the multi-sectoral HIV/AIDS responses in Ethiopia. Selected Strategies Major Targets Key Indicators Verification Responsible Body Promote multi-sectoral collaboration in generation and utilization of HIV related information Establish national and regional priorities for HIV related strategic information. Strengthen HIV prevalence surveys in the general population and MARPs; at national and sub-national levels Establish HIV Incidence surveys; at national and subnational levels Conduct regular behavioral studies among general population and at-risk group; at national and sub-national levels Strengthen Operational Research and Special Studies Strength the capacity to use existing information at programmatic level Strengthen surveillance system that help to generate and use strategic information related to HIV/STI coinfection, HIV/TB co-infection, AIDS mortality, and level and trends in ART and STI drug resistance. Conduct national prevalence surveys among MARPS in 2009 and every other year. Conduct national prevalence surveys among the general population by 2010. Conduct national incidence surveys among the general population by 2010. Conduct national behavioral surveys among the general population and MARPS by 2010. Establish national HIV research fund for priority researches in HIV. Provide training on data management and analysis to all key stakeholders and program mangers. Strengthen sentinel surveillance systems to generate information that are strategically important to monitor trends in HIV infection, mortality and drug resistance. 31
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