1. D ISSEMINATION OF THE J OINT R EVIEW OF THE HIV/AIDS N ATIONAL S TRATEGIC F RAMEWORK II Presented by Dr Hugues LAGO Dr Agnes DZOKOTO - Dr Kwabena POKU - Dr Yao YEBOAH - Dr William BOSU - Wednesday 14 June 2010 - La-Palm Beach Hotel

2. O UTLINE OF P RESENTATION Background Objectives of the joint review Team of Consultants Methodology Findings per thematic area Key achievements Key challenges Priorities to inform NSP 2011-2015 Conclusion

3. B ACKGROUND NSF I (2001-2005); NSF II (2006-2010) 1.9% (NACP 2009) estimated National HIV prevalence 2010: end of implementation of NSFII development of the NSP 2011-2015

4. OBJECTIVES OF THE REVIEW To assess the extent to which the goal and objectives of the NSFII were achieved: Relevance of interventions to the target groups and the character of the epidemic Coverage and sustainability of interventions/services Key achievements of the multisectoral response Key challenges faced in the implementation of interventions Gaps, barriers to services and emerging issues Best practices and lessons learnt Priorities for NSP 2011-2015

5. T EAM OF C ONSULTANTS Thematic AreasName 1 Coordination and management of the decentralized multi- sectoral response Dr Yao YEBOAH 2 Prevention and MitigationDr Kwabena POKU 3 Treatment, Care and supportDr Agnes DZOKOTO 4 Research, surveillance, M&EDr William BOSU 5 Policy, Advocacy and enabling environment + Lead Consultant Dr Hugues LAGO

6. METHODOLOGY Literature review Steering committee meetings Interviews with key informants Focus group discussions Field visits Thematic working group meetings Limitations : Duration of review Availability of key informants

7. F INDINGS

8. POLICY, ADVOCACY AND ENABLING ENVIRONMENT KEY ACHIEVEMENTS 1. Key national policies and documents developed, reviewed, revised, updated – ART/CT/OI/PMTCT/STI, HIV Work place 2. NSF II informed development of APOW (2006-2010) 3. Partnership Forum established (2006) and functioning 4. Stakeholders capacitated to create an enabling environment – MARPs, PLHIV, Work place 5. Partnerships established/strengthened with key stakeholders – Media, NAP+, Parliamentarians, Legal & Human Rights Advocates, Religious & Traditional Leaders

9. POLICY, ADVOCACY AND ENABLING ENVIRONMENT KEY CHALLENGES 1. Even though there has been some level of political commitment and leadership, this has not been fully translated into action 2. The GAC Secretariat has led a multi-sectoral HIV/AIDS response, however, there is limited capacity on advocacy to sustain this momentum 3. Limited development and implementation of HIV/AIDS workplace polices & programmes 4. The degree of involvement of Policy makers throughout the policy formulation and dissemination process is limited 5. For a sustained political and policy environment, there is a need for the GAC Secretariat to create a policy forum for regular interactions with stakeholders

10. POLICY, ADVOCACY AND ENABLING ENVIRONMENT PRIORITIES TO INFORM NSP 2011-2015 1. Strengthen GAC Secretariats capacity for enhanced advocacy and communication 2. Scale-up development and implementation of HIV work place policies 3. Creation of a forum to review HIV-related policy issues 4. Develop and/or strengthen partnerships with strategic stakeholders – media, traditional & religious leaders, Uniformed services, youth, CSO, PLHIV networks etc

11. COORDINATION AND MANAGEMENT KEY ACHIEVEMENTS 1. One HIV&AIDs National Framework as a Roadmap for all Partners and Stakeholders 2. APOW (2006-2010) developed and implemented 3. A shared Responsibility to the National Response 4. Improved information sharing, networking and stakeholder participation in the National Response. 5. Relevant skills acquired by Regional and District AIDS Committee members.

12. COORDINATION AND MANAGEMENT KEY CHALLENGES 1. Unequal political & financial commitment at all levels 2. Funding for implementation- Insufficient; delayed release 3. The GAC Secretariat is perceived as an Implementer and not only as a Coordinating body 4. Coordination and management of the NSF II at the decentralized level was not implemented as planned 5. The potential of the Private Sector as a key actor in the national HIV&AIDS response has not been fully optimized

13. COORDINATION AND MANAGEMENT PRIORITIES TO INFORM NSP 2011-2015 1. A critical review of the roles and responsibilities of key actors 2. Strengthen capacity for improved coordination and management particularly at the district and community level 3. Increase Government allocation - national and decentralized level

14. PREVENTION KEY ACHIEVEMENTS 1. A stabilized generalized HIV epidemic with a low prevalence < 2% (2.22% in 2006 to 1.9% in 2009) 2. Significant decrease in HIV prevalence among MARPs (34.7% in 2006 to 25% in 2009) and in the Youth (1.4% in 2006 to 1.9% in 2009) 3. School HIV&AIDS programmes -National School HIV ALERT and Life Skills Based HIV&AIDS Education 4. Increased access to and uptake of health and social services - CT (71,307 in 2006 to 865,058 in 2009) and PMTCT (36,155 in 2006 to 381,874 in 2009) services

15. PREVENTION AND MITIGATION KEY CHALLENGES 1. Even though Ghana has a stabilized generalized HIV epidemic, however there are significant regional, district and community variations (2% in the Northern region to 4.2% in the Eastern region; 0.7% in North Tongu to 5.8% in Agormanya and Koforidua) 2. Reduced resources for implementation of prevention activities from 39% in 2005 to 12% 2007 and then increased to 22% in 2008 3. Even though there has been a significant increase in the number of persons accessing HIV prevention services (CT & PMTCT), less than 90% have ever tested for HIV and less than 30% of pregnant women benefit from MTCT services 4. Lack of gender specific goals, outcomes and indicators 5. Inadequate dissemination and use of 2006 National IEC/BCC Strategic framework

16. PREVENTION AND MITIGATION PRIORITIES TO INFORM NSP 2011-2015 1. Financial commitment to implement targeted, evidence-based and cost-effective HIV prevention programmes/activities 2. Scaling-up of HIV prevention services – CT, PMTCT, STI etc 3. Strengthen capacity (at all levels) to develop and implement HIV prevention interventions 4. Meaningful involvement of persons infected with and affected by HIV

17. MITIGATION ACHIEVEMENTS Workplace programme contributed to increase knowledge and create an enabling environment NSPS (LEAP programme) improved livelihood of poor hence less vulnerable Increased direct services to OVC and PLHIV e.g. NACP, OICI, WAAF High level goverment support e.g world AIDS day

18. MITIGATION CHALLENGES Workplace efforts commendable, but not measurable in terms of outputs and outcomes LEAP is a example of livelihood improvement, but the sustainability is an issue High political support, but not backed by funding from GoG HIV risk behaviour from sociocultural norms deeply rooted in Ghanaian

19. MITIGATION PRIORITIES Focus on socio-cultural variables affecting female HIV transmission through traditional authorities and legal bodies To increase comprehensive knowledge among general population to reduce stigma and discrimination Develop a minimum standard package of interventions for OVC Livelihood improvement (e.g. LEAP) should be part of DA efforts to enhance sustainability and reach

20. TREATMENT, CARE AND SUPPORT KEY ACHIEVEMENTS 1. Increase in the coverage of ARV services 1. ART sites - 13 in 2005 to 138 in 2009 2. PLHIV initiated on ART - 6,736 PLHIV in December 2006 to 31,977 PLHIV in 2009 2. 89.8% of clients remained on ART after 12 months 3. Over 2,000 persons trained in Treatment and care annually 4. Health system strengthened through HIV treatment programmes 5. 15,309 OVC received support in 71 districts

21. TREATMENT, CARE AND SUPPORT ART COVERAGE

22. TREATMENT, CARE AND SUPPORT KEY CHALLENGES 1. Service providers expect extra funding for AIDS activities and are reluctant to implement activities without extra funding. 2. Inadequate funding for ARVs and declining government allocation for treatment 3. Inadequate number and capacity of human resources, esp. for HBC

23. TREATMENT, CARE AND SUPPORT KEY CHALLENGES Only 50% of females and only 39% of males who needed ART had access to services. The long procurement process and supply processes leading to some irregular supply and stock-outs of ARVs Stigma and discrimination leading to reduced access to and uptake of services No national standard package for HBC and no national lead organization; weak linkages Dependency syndrome of PLHIV

24. TREATMENT,CARE AND SUPPORT PRIORITIES TO INFORM NSP 2011-2015 1. Resource Mobilisation for Treatment after 2011 2. Reassess the mechanism for the payment of fees for HIV clients 3. Expand testing to the CHPS compounds and Scale -up Provider initiated CT 4. Institute innovative training for strategies to build capacity( pre-service training, non technical staff, PLHIV) 5. Strengthen referral systems within and outside the health systems

25. TREATMENT, CARE AND SUPPORT PRIORITIES TO INFORM NSP 2011- 2015 1. Improve male involvement in treatment through increased entry points 2. Inclusion of livelihood programmes into support e.g. Microcredit services 3. Strengthen SWD to take the lead in providing support services 4. Strengthen Psychosocial support 5. Develop a standardised programme for HBC and nutrition

26. RESEARCH, SURVEILLANCE, M&E KEY ACHIEVEMENTS Improving mechanisms for dissemination – NHARCON 2008, NACP Bulletin, HSS reports, etc Improving quality of HIV Sentinel Surveillance BSS and IBBSS conducted in general population and MARPs Road Map on M&E developed Capacity building on M&E NSF II that builds on NSF I, supported with M&E Plan, 5YPOW and operationalised through APOWs

27. % of HIV Samples from PHRL Confirmed as True positive and True Negative at NMIMR, HSS 2003-09

28. Abstinence in Adult Male and Females, (GDHS 2003, 2008)

29. Multiple Partners in Adult and Young Men and Women

30. Research, Surveillance, M&E Key Challenges Sexual behaviour worsened between 2003 and 2008 Improving ethical approval processes and clarifying roles of collaborating partners in research Uncoordinated schedule of evaluations or assessments of the national response Parallel reporting systems and cumbersome tools for reporting Weak or non-use of surveillance, M&E or research findings Recurring challenges – research agenda, database on HIV studies, weak M&E capacity

31. RESEARCH, SURVEILLANCE, M&E PRIORITIES TO INFORM NSP 2011-2015 Implement research studies – MARPs, HIV incidence, drug resistance and economics-related studies Develop guidelines and monitor use of these guidelines for improved use of data for decision making at the local levels Integrate reporting systems, review reporting tools and harmonised indicator sets Motivate M&E Focal Persons Use epidemiological data for action Syphilis prevalence in AOB district Projected increase in HIV exposure in oil-rich districts Discrimination in funding allocation

32. RESOURCE MOBILIZATION KEY ACHIEVEMENTS

34. 1. National AIDS Spending Assessment (NASA) 2007 & 2008 conducted and disseminated 2. Funding from multiple sources – Government, GFATM, IDA, UN system, Private Sector etc

35. RESOURCE MOBILIZATION KEY CHALLENGES 1. 80%-90% of funds are from external sources 2. NASA not able to capture Out-of-Pocket expenditure 3. Capacity of Implementers to effectively utilize funds – low absorptive capacity 4. Delayed released of funds from Government – national, regional and district level 5. Abrupt release of funds by DPs usually during Q3 & Q4 6. Unequal level of understanding of funding modalities – direct, pooled and earmarked

36. RESOURCE MOBILIZATION PRIORITIES TO INFORM NSP 2011-2015 1. Long term sustainability plan Creation of an AIDS Fund Mobilization at country level – Private Sector, Government, DPs, UN system, Individual 2. Increase in Government funding from 10% to 15% 3. Continue to conduct NASA 4. Common understanding of funding modalities – direct funding 5. Alignment of funding to national priorities 6. Strategic partnerships – NHIS, Private Sector 7. Conduct operational and acturial studies

37. CONCLUSION 1. The findings of the joint review indicate that significant inputs contributed to commendable progress in the national HIV response. 2. However, challenges exist that have impeded the level of achievement of the expected results 3. We recommend that the development of the NSP 2011-2015 takes into account the following: efforts to sustain and scale-up the effective strategies while adequately addressing the challenges identified the priorities proposed

38. A CKNOWLEDGEMENTS GAC : Management and Staff The NSF Secretariat Ms Gertrude Adzo Akpalu* Mr Emmanuel Larbi Mrs Olivia Graham Steering Committee members Thematic working group members All key informants interviewed

39. Thank you!!!