ASSIGNMENT NO. 1- Know Your Epidemic, Part 1

Purpose:

Knowing your epidemic as well as how your government and civil society are responding will help you figure out where to best focus your energy and resource.

HISTORY of HIV/AIDS in Liberia

The first case of HIV/AIDS in Liberia—a female trader—was diagnosed in 1986, in Zorzor, Lofa County in the north-west of Liberia. This event prompted the Government of Liberia to establish the National AIDS and STI Control Program (NACP) as an umbrella organization within the Ministry of Health and Social Welfare (MOHSW) with the mandate to prevent and control the spread of HIV/AIDS in Liberia. Barely two years after its formation, the Liberian civil crisis unfolded. Since then, not much was achieved up to 2004, because the database was destroyed during the civil hostilities. It is said that the first antenatal care (ANC) sentinel surveillance survey was conducted some 15 years ago but there is no trace of any data on the study.

According to the UNAIDS/WHO report on the incidence of HIV/AIDS in Liberia, from 1986 to 1997 the following HIV/AIDS cases were reported:

1. In 1986, two HIV cases were reported;
2. In 1989, three persons tested positive;
3. In 1991, fourteen cases were reported;
4. In 1993, four persons tested for HIV;
5. In 1994, twelve persons tested for HIV;
6. In 1996, eighteen persons tested positive;
7. and in 1997, 48 patients tested positive.

These earlier test were restricted to antenatal (testing for birth defects) diagnosis on women, and men who sought clinical help for STD or sexually transmitted diseases. The reports showed the following:

1. In 1993, 4% of the women who went for prenatal test, tested positive for HIV;
2. and in 1998, 8% of the men who went to be treated for STD, tested positive for the HIV.

Liberia’s HIV/AIDS Update

In Liberia, as in most of sub-Saharan Africa, national HIV prevalence estimates have been derived primarily from sentinel surveillance in pregnant women. In 2006, with technical and financial support from the World Health Organization (WHO) and the UN Development Program (UNDP), the MOHSW represented by the NACP conducted an antenatal care (ANC) sentinel surveillance survey among pregnant women. In the first round of the surveillance, ten sites (all urban) located in the five health regions of Liberia participated in the survey. For 6-12 weeks in July-October 2006, all pregnant women attending ANC for the first time during that pregnancy were anonymously tested for HIV and the results entered, analyzed and reported by the NACP (NACP, 2007). In the 2007 round of the ANC survey, the number of sites was expanded to 15 sites including government and faith-based health facilities selected to represent the different regions and the rural and urban populations in the country and data collection was held between September and November, 2007.

The 2007 Demographic and Health Survey (LDHS) included HIV testing of almost 12,000 men and women. According to the survey,

Ø 1.5 percent of Liberians age 15-49 are HIV-infected.

Ø About half of women know each of the three major methods of preventing HIV transmission.

Ø Men are more knowledgeable, with more than seven in ten knowing that using condoms and limiting sex to one uninfected partner reduces the risk of getting HIV.

Ø One-quarter of women and one-third of men know where to get an HIV test, but very few have ever been tested and received the results.

Ø HIV prevalence is highest in the capital city of Monrovia 2.6%) and lowest in North Central al (0.6%).

Ø The survey also shows that women who are divorced or separated are almost twice as likely to be HIV-positive as those who have never been married or are currently married. Among men, those who are divorced/separated or widowed are at a higher risk of infection than those are currently married or have never been married and

Ø HIV prevalence increases with education for both women and men. Women with secondary and higher education are almost three times as likely to be HIV positive as those with no education.

According to accounts from the UNDP Country Programme 2008 - 2012, which is based on the national priorities identified in Liberia’s interim Poverty Reduction Strategy (iPRSP) (2007) and the agreed UN priority areas of support elaborated in the United Nations Development Assistance Framework (UNDAF); The Human Development Index for Liberia was estimated at 0.319 (NHDR 2006). The National Human Development Report (NHDR), 2006 (www.lr.undp.org/nhdr/2006), estimates that half of the estimated population of 3.6 million people, lives on less than half a US dollar per day with 86 percent living in rural areas. Unemployment in the formal sector is estimated at 80 percent, characterized by pervasive youth unemployment.

Adult literacy is 37% (50 per cent male and 24 per cent female) and gross enrolment in primary school is estimated at 69.5 per cent (Ministry of Education School Census 2005/2006). HIV/AIDS sero-prevalence rates tested at antenatal care surveillance sites in urban areas is 5.7 per cent (Liberia’s Global Fund Proposal), while overall the 2007 LDHS estimated the overall rate (ages 15-49) at 1.5% (1.8% women and 1.2% men). The first Liberia Millennium Development Goals Report, 2004 (www.lr.undp.org/MDGR/2004) concluded that most of the Millennium Development Goal targets may not be achieved by 2015. However, there is still a lack of nationally representative updated and disaggregated data on key socio-economic indicators to facilitate effective planning and decision-making.”

Most at risk:

• Sex workers and their clients
• Uniformed services personnel
• Miners
• Mobile populations

Most vulnerable and at risk

• Women (women are increasingly vulnerable, especially in rural areas and refugee camps, as a result of their poor economic status, high rates of illiteracy and the prevalence of GBV
• Young people

According to Humanitarian record on Liberia, less than 2% of pregnant women have access to prevention of mother-to-child transmission (PMTCT) services. UNHCR distributed 1 million condoms and HIV awareness materials nationwide in 2006.

National Health Response Mechanisms and Instruments

The government created the National HIV/AIDS/STI Control Programme in 1987 and established the National AIDS Commission to formulate policy and advocate resources under the authority of the Ministry of Health and Social Welfare. In September 2007, the National AIDS Commission was reconstituted and strengthened under the leadership of the Chairperson, President Ellen Johnson Sirleaf.

This present government is the first to systematically address the HIV situation. A new National HIV and AIDS Strategic Plan (2008 – 2012) is being developed with support from UNAIDS and co-sponsors to guide a truly multi-sect oral national response. With support from UNAIDS, the United Nations Theme Group (UNTG) and the office of the Resident Coordinator, the National AIDS Commission (NAC) was re-established and had its first meeting in August 2007 which was chaired by the president of Liberia.

Instruments

Ø THE HIV/AIDS NATIONAL STRATEGIC PLAN WAS DEVELOPED IN 2002, UPDATED IN 2004 AND WILL EXPIRED IN 2007,

Ø A NEW NATIONAL STRATEGIC FRAMEWORK (NSF) AND NATIONAL STRATEGIC PLAN (NSP) 2008-2012) IN PROGRESS, by the NATIONAL AIDS COMMISSION (NAC)

Ø NATIONAL HEALTH POLICY AND NATIONAL HEALTH PLAN 2007 - 2011

Ø NATIONAL MENTAL HEALTH POLICY AND IS IN THE PROCESS OF DEVELOPING A NATIONAL PLAN.

Ø MENTAL HEALTH HAS BEEN INCLUDED IN THE BASIC PACKAGE OF HEALTH SERVICES

Ø NATIONAL SOCIAL WELFARE POLICY HAS BEEN DEVELOPED, AND A NUMBER OF INTERVENTIONS TARGETED

Ø A NATIONAL POLICY AND PLAN ON SGBV HAS BEEN IMPLEMENTED

Ø A NATIONAL POVERTY REDUCTION STRATEGY (PRS) or LIFT LIBERIA LUNCHED

The NATIONAL YOUTH POLICY, which is recognized by young people to be a Framework for Setting Priorities and Executing Action issues affecting youth; positioning the Youth in Post-Conflict Recovery and Reconstruction, is yet to be approved by Government

The National Health Policy and Plan are designed around four strategic orientations of Primary Health Care, Decentralization, Community Empowerment and Partnerships for Health. The operational and integrated framework for implementing the National Health Policy and Plan is based on four key components –

1. Basic Package of Health Services;
2. Human Resources for Health;
3. Infrastructure Development; and
4. Support Systems

HIV is not enough of a priority on the political agenda at the highest level current financial resources to effectively address HIV is far below needs very high levels of stigma and discrimination towards people living with HIV limited access to treatment, care and support.

Care and Treatment

In Liberia there are 1,202 people on ART and 8,500 people in need of ART. Currently there are 13 sites that are providing ART; however, the government’s National Health Policy and Plan recognizes Access to health care is a universal human right within the means that society can sustain Health is a precondition for individual and societal development. Recognizing the value of health care, the Government of Liberia is committed to invest adequate resources, capacity and political capital in health sector development.

Mitigation

Ministries other than Health (Education, Labour, Defence, and Gender), civil society organizations, faith-based organizations, local and international humanitarian NGOs, PLHIV and others affected by HIV are increasingly involved in the national response.

Major barriers to prevention, treatment, care and support include:

• Weak coordination and harmonization among partners.
• Weak monitoring, evaluation and surveillance system;
• Strong stigma and discrimination of PLHIV
• Weak human and institutional capacities. (A rapid assessment of the health workforce conducted in 354 health facilities in June 2006 showed that Liberia has only 122 doctors, 668 nurses and 297 certified midwifes
• Insufficient financial resources to scale up the response.

The misconception that a healthy-looking person cannot have the HIV is not very widespread in Liberia. Sixty-four percent of women and 70 percent of men know that a healthy looking person can have the HIV. Just over half of women and men (52 percent each) know that HIV cannot be transmitted through mosquito bites. In addition, about two-thirds of women an men (67 percent of women and 70 percent of men) know that HIV cannot be transmitted by supernatural means.

Sexual and gender-based violence (SGBV) and HIV epidemic

The civil war, characterized by widespread SGBV, including rape and sexual slavery, massive population movements and chronic deprivation, contributed to the spread of the HIV epidemic.

The prevalence of SGBV is a key concern, as rule of law institutions provide limited protection due primarily to resource constraints (both human and material). The UN envoy to Liberia has called for an end to violence against women, while stressing that security is paramount for everyone.

The yet to be approve National Youth Policy also stresses gender-based discrimination among Major Issues Affecting Young People in Liberia, including Poor Public Health Care and Facilities, Poor Information, Communication and Technology, Cultural and identity crisis, and lack of employment, among others. The document further that some of the major health-related problems confronting youth today are the poor standards of sexual and reproductive health, the continuing prevalence of preventable “killer” diseases such as polio and measles and the spread of HIV/AIDS. The high incidence of the spread of the deadly disease HIV/AIDS, drugs and substance abuse are common concern of youth and must be addressed adequately.

A full Poverty Reduction Strategy (PRS) document is currently being lunched and HIV is being mainstreamed across the four key pillars (security, governance and the rule of law, economic revitalization and infrastructure and basic services.

COUNTRY PROFILE BY

Total population	3,400,000
% Under 15 (2007)	47
Growth rate % (2000- 2005)	2.1
Population distribution % rural (2007)	52
Total fertility rate (2007)	5.2
Life expectancy at birth (2007)	42
Under-5 mortality rate per 1000 (2007)	111
Maternal mortality ratio per 100 000 live births (2007)	994
Total expenditure on health as % of GDP (2008)	7.7
General government expenditure on health as % of general Government expenditure (2007)	16.8
Gross national income (GNI) per capita US$ (2007)	185
Adult (15+) literacy rate	55
Adult male (12+) literacy rate	69
Adult female (12+) literacy rate	41
% population with access to improved drinking water source	61
% population with improved access to sanitation	27

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Sources:

LDHS - 2007

MOHSW Annual Report - 2008

Funding for HIV; Sources and organizations

Ø Global Fund (GF): USD 10,381,264 disbursed as of May 2007. Principal recipient: UNDP for Rounds 2 and 6.

Ø GF West Africa Corridor program: Abidjan-Lagos Corridor Organization (OCAL/ALCO) Principal recipient. USD5.3 million dispersed as of August 2007.

Ø MYR of West Africa 2007 Consolidated Appeal (CAP): revised requirements now amount to USD 339.6 million, leaving outstanding requirements at USD 211.4 million. http://ochaonline.un.org/westafrica

Ø African Development Bank for the HIV sub regional project in the Mano River Union (MRU), Côte d’Ivoire (to support the HIV sub regional project for cross-border populations, internally displaced persons, ex-combatants and host communities); PEPFAR: USD 2,360,000 for 2007.

HIV Support structures

National:

National AIDS Commission (NAC)
Ministry of Health and Social Welfare

National Aids Control Program

UN:

UN Theme Group on HIV/AIDS and WHO Representative:

UNAIDS Country Program

UNDP Country Programme

OCHA presence

The OCHA field office closed officially at the end of 2004. A Humanitarian Information Centre (HIC) remained and formally transitioned into the National Information Management Centre (NIMAC) Project in July 2006.

One Cluster in place: Water Sanitation Health (WASH) - led by UNICEF

Humanitarian Coordinator’s Support Office (HCSO):

At country level, government and humanitarian organizations hold regular meetings for information sharing and coordination of the response. Committees for flood management are in place in affected areas. At regional level, a consultation platform on floods has been established.

A National Steering Committee comprising of the Government, United Nations agencies, International and National NGOs and Faith Based Organizations was established in March 2006 to oversee the development of the National Strategic Frame Work for Liberia. The work of the committee has been halted as UNAIDS seeks additional funding for the development of the framework.

A PMTCT Working Group was initiated in November 2006 with support from UNICEF and chaired by the National AIDS Control Program. The committee has not met for almost a year since December 2006.

SOURCES of Information

ü Ministry of Health and Social Welfare report 2008

ü National Health Policy and Plan 2008 – 2011 doc

ü UNDP Country Programme 2008 - 2012, doc

ü The National Human Development Report (NHDR), 2006 www.lr.undp.org/nhdr/2006

ü http://www.humanitarianinfo.org/liberia/

ü http://ochaonline.un.org/westafrica

ü Sources: OCHA for humanitarian information and UNAIDS for HIV information, unless

Others noted

ü ________________________________________

ü Ibid.

ü Alertnet June 2007

ü UNHCR Global report 2006: Liberia

ü CHAP Review 7 September 2007

ü UNMIL Humanitarian Situation Report No. 118, 3-9 September 2007

ü OCHA, West Africa report July 2007

ü United Nations News Service, 29 Aug 2007

ü UNHCR Global report