Sierra Leone

MDG Goal 6 - Combat HIV/AIDS, Malaria and other Diseases

HIV/AIDS MDG: Goals and Targets

 

Goal	Relevant Target
Goal 6: Combat HIV/AIDS, Malaria and Other Diseases	Target 7: Have halted by 2015 and begun to reverse the spread of HIV/AIDS.

Poverty and HIV/AIDS

The relationship between HIV and poverty is complex. HIV is very personal, but also very global. Its impact is felt by individuals, families, businesses, communities and countries. HIV makes families and communities disinvest in productive activities as resources are shifted to the care and treatment of people living with HIV/AIDS. When a member of a household (especially the breadwinner) becomes ill with HIV/AIDS, one or more family members who are not sick may leave their jobs to provide care for others in the family. Caring for a sick family member disrupts the work schedules of others, further limiting income. Families’ savings may dwindle and assets be sold off to meet living and medical expenses, and, eventually, funeral expenses. Another outcome is an increase in medical expenses to treat conditions associated with the infection; income is spent on medical care instead of food, clothing, household goods and other commodities. Children are withdrawn from school and put to work to compensate for the lost labour and income. Although HIV/AIDS is by no means the only reason for such changes, it is often a precipitating factor.

The linkage could also be better understood in the context of epidemic curve of diseases. In contrast to other epidemic curves, which are predictable (that is illness leads to death and ultimately the epidemic curve goes down). The epidemic curve of HIV/AIDS can be divided into four:

1. the wave of HIV infection;

2. the wave of diarrhoea and tuberculosis (the most common opportunistic infections in Africa);

3. the wave of AIDS illness and death;

4. the wave of impact (includes household poverty and orphaning). With AIDS it is difficult to predict. HIV ultimately leads to AIDS and death, with no recovery. What we do not know is what will happen to the epidemic curve in the aftermath of massive numbers of AIDS-related deaths.

In Africa HIV is transmitted mainly through heterosexual intercourse. Pressing concerns for short-term survival may lead poor women to engage in survival sex, which paradoxically can expose them to the long-term risk of illness and death through HIV infection. Poverty also limits people’s access to sexual health information, prevention technologies and treatment. Whilst this is true both for women and men, gender inequality shapes different experiences of poverty, and impacts on women’s and men’s ability to move out of poverty. Social spending cuts often lead to increased pressure on women and girls to take on the role of social safety net, caring for sick relatives and securing a livelihood, as earning family members become sick and die. This is one of the invisible impacts of HIV/AIDS. However, sexual behaviour cannot be seen in isolation: migration, the status of women and their (lack of) access to economic resources, general health care etc. are all important factors.

Thus, poverty in itself does not cause an AIDS epidemic but certainly contributes to it. However, more than poverty, inequality is a crucial factor (for example, rich men buying sex from poor women). Attacking poverty is important, but there are multiple factors that need to be addressed.

The youth/adult additional deaths caused by AIDS have huge implications for both health care and the division of labour and production. AIDS alters or changes population distribution. The main changes result in unfavourable ratios between dependents and producers, which has implications in terms of food availability, medical spending, care of orphans, etc. A decline in life expectancy will affect employers and organisations and ultimately have a macro-level impact. On a household/community level, the effect will be seen most clearly in terms of farming systems and food production.

The key areas in terms of the effect of AIDS are therefore:

skills structure

orphans and elderly (altered dependency ratio)

organisations (carry cost of medications and other employee related liabilities)

employment

subsistence agriculture.

All of these are potentially impoverishing issues, and will have to be taken into account for any development intervention to be effective. More especially, they are important when HIV/AIDS shifts the parameters on which development is based. So while prevention work is crucial to curb the spread of infection, there is also need to look beyond infection to address, and deal with, the impact of the epidemic.

Challenges

The National Response to HIV/AIDS faces four serious challenges:

1. First, the HIV/AIDS Response is chronically under-funded. The current World Bank-funded Sierra Leone HIV/AIDS Response Programme (SHARP), which is part of the World Bank’s Africa Multi-Country HIV/AIDS Program, was designed for activities in four districts, on the assumption that other resources would be available to target remaining districts. The funding situation is so acute that the SHARP funds have been spread over the whole country instead of the four districts planned. Responding to the acute funding situation, the National HIV/AIDS Secretariat (NAS) is soliciting additional funding from donors. Government on the 30th June 2004 was informed of an US$18 million grant from the Global Fund, to support the national response in the fight against HIV/AIDS. NAS is also soliciting additional support from other international organizations including the UN system to support the national effort.

2. The second challenge is the low level of literacy. With a literacy rate of 33%, most messages on HIV/AIDS are not understood by a great majority of the population. It is therefore not surprising that in the HIV survey conducted in 2002, it was reported that knowledge among women 15-49 years was relatively low, with only 54% (78% urban and 44% rural) having heard of AIDS, and 21% able to state three ways of avoiding HIV infection. Also, only 34% were aware of mother-to-child-transmission of HIV; 67% did not know any specific method HIV can be transmitted from mother to child. Overall, Sierra Leoneans, even in the Western Area incorporating Freetown, continue to lack knowledge and understanding regarding HIV/AIDS. For example, a recent survey indicated that many people still do not know that HIV is the virus that causes AIDS.

3. The third challenge is the low capacity of Community Based Organizations and Non-Governmental Organizations in implementing HIV/AIDS programs. National NGOs are willing to help in the fight against HIV, but most do not have a good understanding of the issues that needs to be addressed. Hence most of these programs are shallow and lack impact.

4. The fourth challenge is the low availability of reliable data. There have been no large-scale studies and almost no biological data (HIV, Syphilis, or other STI) among various highly vulnerable subgroups in Sierra Leone. Baseline and ongoing data are essential for effective program planning and later program evaluation.

There are further problems facing the National Response:

1. While affordable, acceptable male condoms are an essential part of Sierra Leone’s HIV prevention strategy, there is currently low acceptance of and poor access to condoms, leading to poor utilization.

2. People testing positive for HIV require follow-up for psychosocial, medical, and in some cases, economic support. Care and support services increase survival rates of People Living with HIV/AIDS (PLWHAs) and enable them to enjoy life with dignity and respect. Presently, very few organizations provide care for PLWHAs, and most do not benefit from any support at all. Most PLWHAs who need anti-retroviral drugs (ARVs) cannot afford them. The SHARP Programme did not budget any amount for the purchase of ARVs.

3. HIV/AIDS is bound to lead to an increase in the number of orphans and street children. Without support, these children are vulnerable to various forms of abuses, and also to HIV/AIDS. NAS does not have sufficient resources to provide support for AIDS orphans.

Priority Actions in HIV/AIDS

The national response to the HIV/AIDS epidemic is built on five pillars:

Prevention of new infections;

Care and Support;

Human and Legal Rights;

Decentralized implementation of HIV/AIDS Programme; and

Research, Monitoring and Evaluation.

The following population groups are considered as “Priority Population Groups”, especially for Prevention, Research and Monitoring:

Youth and Adolescents, Commercial Sex Workers, Uniformed Personnel, Migrant Populations, and Truck and Taxi Drivers.

Prevention is the main strategy for addressing HIV/AIDS in Sierra Leone. The implementation of the strategy is governed by the context of low awareness of basic issues such as what HIV/AIDS is; and subsequently, poor knowledge and education of how it is spread, and can be prevented. In addition there are cultural and traditional practices which may add to the risks of infection. However, to address them requires recognition of cultural values and beliefs of the people. It has been recognized that, ideally, implementation of programmes to address practices of this kind should be undertaken through the structures and leadership of the community. This approach summarizes the basic principle of the prevention approach – of a people-centered strategic framework.

Providing care to PLWHAs, as well as psycho-social support both to them and other affected persons, is considered as part of the overall continuum of care. Development of the health care system, and strengthening of the referral system and overall quality improvements, create an opportunity to provide and expand access to anti-retroviral therapy, and for prevention of mother-to-child transmission, as well as counselling and testing. This approach entails restructuring and strengthening of the public health system.

Gender focus in the Strategic Framework assumes a critical role. The relationships — social and economic — that revolve around gender require special focus. The role of women, in which they are emerging from being victims of the consequences of armed conflict, such as sexual violence or the search to acquire income and employment, especially in the urban areas, are issues that form part of this focus. The recognition of female-headed households, and of the need for mechanisms to increase their role in economic and social activities, are also crucial.

Similarly, HIV/AIDS prevention poses a challenge, more especially to the youths. The immediate historical context of Sierra Leone is well articulated in most development programmes. The importance of re-settlement and rehabilitation of sub-populations are well demonstrated. The challenge therefore is that the prevention, control and reduction efforts should address issues that make youths vulnerable to HIV/AIDS.

Human rights and legislative reform are also necessary with respect to HIV/AIDS. Since the disease is characterized by stigma and discriminatory practices that may be induced by various sources such as religion, fear, shame and essentially ignorance, it is imperative to further identify related practices, such as may concern gender, children or other traditional practices, which provide for either increased risk of infection or lead to discrimination and bias.

The implementation of the Strategic Framework recognizes the need to apply intervention with the full participation of the communities, regardless of the geographical setting, that is, whether rural or urban areas. Recognition is made of the diversity between urban and rural areas. The institutional framework or structures require the coordination capacities of the Government at the district, chiefdom and or village levels. Similarly in urban areas the coordinating role of the local Government structures and the Councils are key to the implementation process. Coordination of all stakeholder programmes in implementation, monitoring, evaluation and reporting is again similarly much more efficiently and effectively undertaken through community-based responses. To ensure that there is ownership and acceptance of programmes to prevent and address HIV/AIDS and its consequences, it is imperative that the implementation focuses on the process of local community coordinating structures and mechanisms.

Accurate an timely information on HIV/AIDS and related issues, both biomedical and other multi-dimensional data, is vital for awareness, for resource mobilization, and for formulation and implementation of appropriate policy responses and interventions. Designing and implementing surveillance, monitoring, evaluation and reporting procedures, that provide the evidence base of the social, biomedical and economic effects of HIV/AIDS, and progress in these factors, are an essential part of the framework for designing, implementing and monitoring the HIV/AIDS strategy.

The 2006 SL-HDR reports a HIV-prevalence rate of 1.5%, down from the preliminary 4.9% reported in the PRSP. The difference in reported prevalence rates in a short period of time is indicative of the difficulties associated with proper assessments of HIV prevalence.

Status of Knowledge on HIV/AIDs

TOPIC	MICS3 INDICATOR NUMBER	INDICATOR	VALUE
HIV/AIDS, Sexual behaviour, and orphaned and vulnerable children	82	Comprehensive knowledge about HIV prevention among young people	18 percent
	83	Condom use with non-regular partners	20 percent
	85	Higher-risk sex in the last year	43 percent
	77	School attendance of orphans versus non-orphans	0.81 orphans per non-orphan

Source: MICS 3 2006

Judging from the low level of comprehensive knowledge about HIV/AIDS among the sexually active proportion of the population, HIV/AIDS prevention and implementation of treatment measures is a major challenge to Sierra Leone. A high-risk behavioural pattern is discernible in the low use of condoms and high frequency of high risk sexual activity reported in the MICS.

Assessment of Needs and Cost for HIV/AIDs Programme

The MDGNA analysed the actions that would be needed to reach the HIV/AIDs targets that are shown in table 2.4.1. The costs of reaching the targets are mainly those of preventing the spread of the disease, treatment of the disease and providing care and support for the patients, shown in Table 2.5.3.

Table 2.5.3 Required Financial Resources to meet HIV/AIDs MDG Target (US$ million)

	2006	2007	2008	2009	2010	2011	2012	2013	2014	2015
Prevention	2.90	3.86	4.98	6.16	7.42	8.72	10.11	11.58	13.13	14.64
Treatment	0.01	0.02	0.02	0.02	0.03	0.03	0.03	0.03	0.04	0.04
Care and Support	4.07	4.78	5.44	6.13	6.84	7.74	8.79	10.07	11.74	12.81
Total Costs	6.99	8.66	10.44	12.31	14.29	16.49	18.93	21.69	24.90	27.49
Average Cost (US$) Per Capita of Population	US$1.3	US$1.6	US$1.9	US$2.2	US$2.5	US$2.8	US$3.1	US$3.5	US$3.9	US$4.2

^{Grand Totals – 2006-2015: US$162.2 million; 2007-2015: US$155.2 million  Source: MDGNA and Costing, June 2007}

The total cost summary of the HIV/AIDS intervention categories shown in Table 2.5.3 is UD$155.2 million for the period 2007 to 2015, with per capita cost ranging from US$1.6 in 2007 to US$4.2 in 2015. Prevention interventions account for 51.5% of the total budget, whilst care and support account for 48.3%. Treatment interventions account for only 0.2% of the total budget, because drugs, both to treat HIV/AIDS and for prevention of mother to child transmission, are provided free of charge; the minimal costs budgeted for drugs are for storage.

Furthermore, one can see from Table 2.5.3 that there is a yearly gradual increase in the costing of interventions as the projected demand for needed services increase

Interventions in all of the categories (prevention, treatment, care and support) stated above are presently being implemented by the National HIV/AIDS Secretariat. The emphasis now is on scaling up activities to make sure that access to services is available to the majority of the people. Because of the present low coverage of interventions and the widespread poverty, the majority of the people of Sierra Leone are denied access to prevention, treatment, care and support facilities. They cannot afford to walk long distances or pay to travel to access services. The implementation of programmes with available resources to reach the HIV/AIDs MDG target will solve this problem.