Champions mission programme- Sierra Leone

1.    Overview

The HIV prevalence in Sierra Leone has stabilized at 1.5% since 2005; it is 2.3% in urban areas and 1.0% in rural areas. HIV prevalence among pregnant women at ANC stands at 3.2%, which is twice higher than the prevalence among the general population. Currently, it is estimated that there are 55,000 people living with HIV in Sierra Leone, of which 30,000 are women aged 15 and above and 4,700 are children aged 0 to 14. Unfortunately, only 34% of these PLHIV know their HIV status as positive. Every year, 2,700 are estimated to die of AIDS. The Modes of Transmission Study also revealed that about 13.7% of HIV new infections come from Mother-to-Child Transmission and 3,300 infants are born to HIV-positive women annually. The 2013 HIV Seroprevalence Study on Key Populations indicates high HIV prevalence among Men-who-have-sex-with-men (MSM – 14%), Female Sex Workers (FSW – 6.7%), and People-who-inject-drugs (PWID – 8.5%), and Prisoners (2.2%). Women are disproportionately affected by the epidemic and key populations and vulnerable groups are the key determinants of the epidemic.

2.    HIV Epidemic and response before the Ebola outbreak

The HIV prevalence in Sierra Leone has stabilized at 1.5% since 2005; It is 2.3% in urban areas and 1.0% in rural areas. HIV prevalence among pregnant women at ANC stands at 3.2%, which is twice higher than the prevalence among the general population. Currently, it is estimated that there are 55,000 people living with HIV in Sierra Leone, of which 30,000 are women aged 15 and above and 4,700 are children aged 0 to 14. Unfortunately, only 34% of these PLHIV know their HIV status as positive. Every year, 2,700 are estimated to die of AIDS. The Modes of Transmission Study also revealed that about 13.7% of HIV new infections come from Mother-to-Child Transmission and 3,300 infants are born to HIV-positive women annually. The 2013 HIV Seroprevalence Study on Key Populations indicates high HIV prevalence among Men-who-have-sex-with-men (MSM – 14%), Female Sex Workers (FSW – 6.7%), and People-who-inject-drugs (PWID – 8.5%), and Prisoners (2.2%), Police (5.8%), Fisherfolks (3.8%), Military (3.3%), Migrant Population (2.5%). Women are disproportionately affected by the epidemic and key populations and vulnerable groups are the key determinants of the epidemic.

Figure 1: Target population with most new HIV infections

The HIV infection is highest in five main urban districts as shown in figure 2 below:

Figure 2: High burden Geographical locations 

Achievements

There has been an increase in PMTCT sites from 687 in 2012 to 691 in 2013 and Pediatric care services has been launched in 19 district hospitals. There has also been an increase in the uptake of ART from 8,529 in 2012 to 9,065 in 2013 and survival and retention rates of 93% and 71% respectively.  There is also an increase in HIV+ persons screened for TB from 5,355 in 2012 to 9,048 in 2013.  There is available evidence on key populations and their increasing involvement in planning and programming.  The main sources of funding include theGlobal Fund, the Government of Sierra Leone,  the German Development Bank, UN Partners, the Private Sector and Civil Society Organizations namely Solthis, AIDS Healthcare Foundation, Christian Aid..

Major Challenges

The achievements made were not without challenges. Current challenges include: national response largely dependent on external financing, difficulty in expanding services and retaining quality because of limited funding, shortage of qualified manpower because of high turnover of experienced staff, domestic resources are hard to come by and NAS is looked upon as a donor, high TB/HIV co- infection rate (14%) and difficulty of coordinating partners and delivery of services because of weak health systems. 

 3.    Impact of EVD outbreak on national AIDS response

The national response was greatly impacted by Ebola outbreak on the national response.  There was drop in HIV service uptake compared to the 2013 levels with sporadic use of ARVs, inconsistent PMTCT delivery, 71% decline in HIV Counselling and Testing and fear for health service delivery points.  In terms of HIV programming, the impact had been halt in in-school youth and community sensitization programmes, loss of critical 225 human resource to EVD,  increased stigma directed at PLHIVs due to mistaken identity as EVD patients, psychological impact on beneficiaries due to confidentiality breach and reallocation of funds to EVD limiting funds to HIV programmes. 

4.    Post Ebola recovery for national AIDS response

The post Ebola recovery discerned two major approaches – Immediate (July – December, 2015) and Medium Term covering the period 2016 – 2017.  The objective of the immediate approach was to restore HIV services to pre-outbreak levels.  The Interventions to be pursued to meet this objective include:

  bringing back to treatment patients who have defaulted or lost to follow up(Defaulter tracing)

•       re-establishing services in health facilities( static services)

•  re-establishing mobile outreach testing and counseling services (outreach programmes)

•  community sensitization through community radio and meetings (social mobilisation)

         condom distribution (condom promotion)

          supervision and retraining

5.    Challenges

·         Insufficient behavioural impact of prevention interventions for adolescents and young people. High rate of early marriage, low condom use and multiple sexual partners with early sexual debut

·         Large coverage gap for testing, services to prevent mother-to-child transmission and antiretroviral therapy for adults and children. Health and community systems, including procurement and supply management remain weak.

·         Over-reliance on international funding (GFATM) at 95% because actionable political commitment, multiplecompeting priorities, weak governance, low allocative efficiency and limited absorption of funds undermine the sustainability of the response.

·         Persistent stigma and discrimination, gender inequalities and violence against women.

·         Weak sex- and age-disaggregated epidemiological and programmatic national and sub-national data especially on key populations, young people and adolescents.

·         Escalating fragile political situations as well as diseases from weak health systems

·         Recurrent humanitarian emergencies (food insecurity, floods, disease outbreaks)

6.    KEY actions needed

·         Achieve 100% coverage of peadiatric ART in 12 months

·         Achieve 100% coverage of PMTCT services in 18 months

·         Reduce mother to child transmission from 12% to less than 2% in 24 months

·         Ensure provision of HIV budget in the 2006 national budget

·         Achieve 80% of ART coverage among 54,000 PLHIV

·         Provision of targeted HIV testing services for key populations and high burden geographical locations

·         Intensification of defaulter tracing and adherence support (counseling, use of expert clients, health workers, NETHIPS and vow).

·         Cities initiative with mayors and community leaders engagement and strengthening community delivery systems.

·         Self-testing and community-based testing and delivery of antiretroviral therapy through task shifting and the use of new technologies.

·         The full potential of adolescents and young women and men unleashed to help realize the demographic dividend and reduce risk of and vulnerability to HIV infection.

·         Fully leveraging TRIPS flexibilities to secure sustainable access to affordable medicines, and strengthening local capacity to develop and manufacture quality affordable health products.

·         Integrated Supply Chain management using push and pull system

7.    Objective of Mission

The objectives of the visit are as shown in box 1: 

Box 1: Mission objectives

·         Re-energize the profile of HIV in post Ebola context to achieve pre-ebola context

·         Scale of services in the high burden districts

·         Emphasize the importance of “Leaving No One Behind” – most vulnerable women and girls

·         Promote HIV testing in KP and high burden locations

·         Advocate of increased financing of the national response using global solidarity and shared responsibility

·         Advocate for reduction of stigma at community

·         Promote strengthening of Health systems and alternative community delivery models using lessons learned from Ebola