An effective, well-coordinated response to HIV in Djibouti (2006)

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An effective, well-coordinated response to HIV in Djibouti

Sameh El-Saharty and Omar Ali

A Grant from the World Bank provided a strong impetusto Djiboutis national HIV response in 2003. Clearobjectives and priorities, effective government action andcommitment, and close cooperation among the keydonors and government organizations have contributedto strong results in the national response to HIV. TheGlobal Fund cites Djibouti as a best practice exampleof donor coordination and harmonization and UNICEF

recognizes the outreach to young people and communityinterventions as best practices.

Initiating Djiboutis HIV response

In 2002, Djiboutis HIV prevalence was estimated atthree percent for the whole population, but higher thanfive percent among people aged 20-35 years, andsurveys showed that rates had risen dramatically insome groups. The tuberculosis rate was the secondhighest in the world, and malaria was spreading rapidly.These diseases were fueled by rapid urbanization, andlarge population movements from trade, migrants and

refugees, and in the case of HIV, low literacy, thepresence of military bases and a major trade corridorwith Ethiopia, an active sex trade, low age of sexualdebut among young men and teenage boys, andextensive use of khat by men. The situation was mademore difficult by high poverty and unemployment levels.

The Government of Djibouti requested World Banksupport in mounting a concerted effort to prevent furtherspread of these infectious diseases, and to providetreatment and care to infected and affected people. TheGovernment met the eligibility criteria for theMulticountry HIV/AIDS Program for the Africa Region

(MAP), including developing a strategic approach to HIV,establishing a high-level HIV/AIDS coordinating body,and agreeing to channel funds to nongovernmentalorganizations and the private sector for HIV preventionactivities.

Designing the Program: Clear Objectives andActivities

In 2003, the Djibouti HIV/AIDS, Malaria and TuberculosisControl Project became effective, providing US$12million in grant funds.

There are three main objectives:

To prevent HIV infection by contributing to changesin behavior among the Djiboutian population,especially among high-risk groups, particularlyyoung people using social communication and peer-education to reach young men and women, andmultisectoral, civil society, and community initiatives.

To provide care, support, and treatment to peoplewith HIV in Djibouti, expanding access to treatmentfor opportunistic illnesses and sexually transmittedinfections (STIs), and mitigating the impact of HIVand AIDS on infected and affected persons.

To treat and control the spread of malaria andtuberculosis.

Figure: AIDS Posters on a building in Djibouti

Photo by Dominique Ganteille, www.alovelyworld.com

The project supports four key areas of action toachieve the objectives:

Strengthening the public health sector response toHIV and AIDS, other STIs and malaria andtuberculosis, including through voluntary counselingand testing (VCT) for HIV and treating opportunisticillnesses; diagnosis and case management of STIs;distributing condoms; improving screening andtreatment for tuberculosis; strengthening detection,prevention, and response to malaria; andstrengthening the health system.

HIV/ AIDS - Getting ResultsThese reports describe activities, challenges and lessons learned during the

World Banks HI/AIDS work with countries and other partners.orld Bank GlobalHIV/AIDS Program


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Multisectoral responses to reinforce healtheducation, counseling, and prevention activitiesthrough eleven ministries, especially targetinggroups most at-risk and vulnerable to infection suchas men in uniform, youth, women, sex workers,truckers, and dock workers.

Reinforcing the community response throughstrengthening community-based associations andNGOs so that they can implement essential activities

to reduce vulnerability to HIV, tuberculosis andmalaria and mitigate the impact of the HIV epidemic.

Supporting the national coordinating structure for thethree diseases, including the InterministerialCommittee of eleven ministries (which is chaired bythe Prime Minister), the Technical IntersectoralCommittee, and the Executive Secretariat, as well asstrengthening public, private, and nongovernmentalinstitutions.

Progress to date: Strong results in a short time

The project helped launch a national HIV response,which had been almost non-existent except for a fewsporadic and limited initiatives. Backed by strong politicalsupport, and with wide participation of governmentagencies and many non-government groups, progresshas been very good. Mid-way through the project period,many targets have already been met or exceeded.Results reported here are as of the end of 2005, unlessotherwise noted.

Health Sector Response

Comprehensive integrated care including clinical,

nutritional, social, and psychological care has beenprovided to 620 persons with HIV.

When the project was being designed, there was adebate about whether it was feasible to provideantiretroviral (ARV) treatment. After starting with asmall pilot treatment program for 200 people in2004, treatment access is being scaled up. By May2006, 425 people were receiving treatment with ARVdrugs, based on clinical eligibility criteria. There areplans for much more rapid expansion in 2006 and2007, using additional funding from the Global Fundto Fight AIDS, TB and Malaria.

Social support is being provided to 80% of thefamilies of people with HIV, reaching a total of morethan 3,000 beneficiaries. Decisions on whether afamily needs help, and what level and kind of help,are based on a social and economic assessmentusing well established criteria, and are validated bysocial surveyors.

At the ten prenatal care clinics in which HIV VCT isoffered, 99% of pregnant women are acceptingtesting, and all those who test HIV positive are

offered treatment free of charge to reduce the risk ofHIV transmission to their babies, and then ARVtreatment to maintain their own health, as needed.

The number of people treated for STIs almostdoubled from 1,338 in 2004 to 2,593 in 2005, wellabove the target of treating 2,000 people in 2005.

Starting from scratch, a widespread condomdistribution network has been set up that now hasover 350 sales points, and distributed more than one

million condoms in the past year, a huge increasefrom only 30,000 condoms distributed at the nationalevel in the year before the project.

Cumulative number of condoms sold or

distributed

0

200000

400000

600000

800000

1000000

1200000

2004 T12005 T2 2005 T3 2005 T4 2005

Multisectoral response

Contrary to the original plan to engage elevenministries in the national HIV response graduallyover the two years, all eleven ministries started inthe first year. All eleven ministries have developedyearly plans that are being implemented, althoughwith different degrees of achievements. Theministries for Youth, Education, Communication,Women and Welfare Affairs are the most active. InJune 2006, the Parliament ratified a new law

prepared by the Ministry of Justice to stipulate thelegal rights of persons infected with HIV in order toprevent stigma and discrimination.

Awareness and education campaigns areprogressing well. Since the start of the project, atotal of about 1,000 awareness sessions have beenconducted, and 550 community leaders, locallyelected officials, parliamentarians and religiousleaders have been trained in social mobilization

Cumulative number of HIV-positive pregnant women

Receiving ARV treatment

05

10

152025

T1 T2 T3 T4

2004 2005


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and/or social communication about HIV, more thandouble the original target of 200.

Community leaders, locally elected off icials,

parliamentarians and religious leaders trained in

social mobilization and/or social communication

0

100

200

300

400

500

600

2004 T12005 T2 2005 T3 2005 T4 2005

The number of public centers offering HIV VCT hasincreased from 8 to 12, and the number of peopletested has been rising steadily. Uptake of VCT at themilitary and police clinics has been limited due tosensitivity and confidentiality concerns, however.

Community-based response

The community-based component was carefullyplanned. Rigorous criteria for selecting subprojectswere developed, to ensure that they respond to theneeds identified. For example, the criteria includeprevious experience in managing community-basedprojects, experience with a particular vulnerablegroup (not necessarily regarding AIDS), andproximity to the vulnerable groups. A manualdescribing the criteria and procedures wasdeveloped and distributed, for easy reference by allimplementers.

Six large NGOs were selected to work with and helpsmaller community-based associations (CBAs) todevelop sound proposals. Each of the six hasresponsibility for a particular geographic area of thecountry, and/or a particular risk group. This helpsavoid gaps and duplication, and makes it easier toshare information about what works well.

In the first year, 30 subprojects were approved, 75 inthe second year, and 156 in the third year. Projects

have been successfully implemented in all districtsof the country. One very successful project operatesin the P.K.12 truck stop, where an NGO hastrained peer educators to empower sex workers topersuade their clients to use condoms, along withcondom social marketing campaigns and ensuringeasy availability of condoms. Building on thissuccess, USAID provided micro-credits forvulnerable women in the area of P.K.12 to enablethem to earn livelihoods in ways other than sexwork, and to help alleviate poverty. Other projectsinclude outreach to sex workers in Djibouti-ville and

to dock workers and truckers using peer-educators,as well as distribution of food to affected needyfamilies.

Reaching out through peer educators

The original goal was to train 300 peer educatorswho would then work with various high risk andvulnerable groups. An information toolkit wasdesigned for each of the eight vulnerable groups --truckers, dock workers, commercial sex workers,young people at school, young people out-of-school,khat chewers, men in uniform, and young girls indifficulty. Initially, there was some reluctance tosupport the peer education approach, but the earlysuccess and acceptability of the approach provided astrong impetus. To date, about 1,261 people havebeen trained as peer educators more than four

times the original target.

The various efforts to inform and educate thepopulation are showing clear results: a survey in2005 found that 69% of the population aged 15-49years could name three methods of protectionagainst HIV infection. This is an enormousimprovement over the baseline of only 20% and wellon the way to the end of project target of 90%.

Reaching young people

Young people are an important target group for HIVprevention efforts, and a variety of channels havebeen used to reach out to them. Twelve InformationPoints for Youth (IPY) have been set up at youthcenters, where 12 animators and 20 femaleinstructors are available to answer questions and talkabout HIV. With the help of trained peer educators, in

just two years, more than 25,000 young people havetaken part in information and chatting sessions toraise awareness about HIV through IPYs.

However, IPYs attracted mainly young boys and onlya few girls. So, in collaboration with the Ministry ofWomen, the project established 8 Audio ListeningCells for young girls, where information is providedin a more discreet environment. These cells haveserved 1,440 girls each year.

The animators and instructors have also worked inother information and education sites for youngpeople. Education and prevention sessions in

schools and other educational establishments havereached about 18,000 students. In addition, 12,000notebooks and 3,000 handbooks containinginformational messages targeted to young peoplehave been distributed. A network of Health Clubshas been created in high schools and other academicestablishments, and a social communication programon HIV and AIDS set up for the Health Clubinstructors and peer educators.


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Success factors

Several key factors have contributed to the successfulimplementation of the project. However, it is important tonote that the measure of progress thus far is limited toprocess and output indicators. A number of surveys areplanned at the end of 2006 to assess the impact of theprogram.

The project design was based on a rigoroussituation analysis.

The National Strategic Plan and the design of the projectand its interventions were based on evidence from thesituation analysis, which helped identify theepidemiologic patterns, the most vulnerable groups,specific risk behaviors, and the information and supportthat people needed. For example, a sero-prevalencesurvey was conducted on a nationally representativesample of 2,488 persons, which established a robustbaseline among the general population and identified theprevalence in the different age groups e.g., 3.3 percentin women, 2.5 percent in men, and 5.9 percent in theage group 15 to 34 years. Focus groups and interviewswith sero-positive people and their families revealed,among other things, that many people needed nutritionalsupport.

National commitment and institutional capacity arestrong.

There has been consistent, high level politicalcommitment to the project. The President of Djibouti, thePrime Minister and the Health Minister have providedvisible support, for example, in the inauguration ofNational AIDS Week each year. The Minister of Health

was shown on TV being tested for HIV in order topromote VCT.

Despite the weak institutional capacity and lack ofhuman resources at the national level, a strongExecutive Secretariat was established with competentand dedicated staff. The Government mobilized long andshort term international consultants whenever needed tobuild national institutional and management capacity forthe program.

Prevention is coupled with a comprehensive,integrated package of care and treatment services.

In addition to preventive interventions such as educationand information, social marketing, condom promotionand VCT, the project provides an integrated package ofcare including medical, nutritional, economic,psychological and social support to infected people andtheir families.

The different aspects of the package complement eachother. This is critically important, as the lack of any ofthese aspects may have jeopardized the results. Forexample, focusing on prevention only would exclude the

infected population; promoting VCT would be much lesseffective without also offering treatment; and whileinfected people need access to medical treatment, they,and their affected families often need psychological andsocial support as well. As access to treatment expands,interest in testing for HIV also seems to be increasing.

Interventions in health facilities are linked tocommunity interventions.

Community-based associations that know thecommunities and culture are subcontracted to deliversome of the support elements of the integrated packageof care. One innovation has been to hire and trainpeople from the community as social/psychologicalcompanions to support people with AIDS and to be alink between the care provided at home and in healthfacilities. They provide counseling to patients, help themto understand and follow the treatment regimen, andfollow up on patients who drop out, helping to ensurehigh adherence.

Effective multi-sectoral response and widemobilization

Another key success factor is the mobilization andinvolvement of all relevant government sectors, not onlythe Ministry of Health. This has enabled a broad,integrated national response, with many differentinformation channels reinforcing messages and helpingreach many different groups in society.

The engagement of the ministries responsible forcommunication, police, youth, and women and familywelfare has been particularly important. The activitiesimplemented by the Ministry of Youth were extremely

effective in actively engaging and reaching out tothousands of young people (see box on Reaching YoungPeople). Engaging religious leaders in this Moslemcountry is a continuing challenge, however.

Community-based interventions are based onidentified need and focus on results.

Three factors have helped ensure the effectiveness ofthe community-based interventions.

To ensure proper targeting, a social mapping exercisewas carried out across the whole country to identify whothe vulnerable and high risk groups were, their size, and

where they live. For example, the mapping identifiedtruckers operating along the road corridor, dock workers,and sex workers and where they worked.

To mitigate the weak capacity of the community-basedassociations (CBAs), six well-established umbrellaNGOs were hired to help mobilize and strengthen thecapacity of numerous CBAs. The CBAs have stronglocal ties and a deep understanding of the culture andsocial networks, and have played a key role in deliveringthe help, support and services that families need,


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reaching out into communities and diverse groupsacross the whole country.

To ensure effective implementation, community projectsare selected using rigorous criteria that ensure that theymeet identified needs, and are implemented underannual performance-based contracts with CBAs. EachCBA defines the results it will seek to achieve during theyear, such as deliver food each week to 25households. The CBA submits a simple progress report

each quarter, which the umbrella NGO verifies. Fundingis released according to the results achieved; forexample, a subproject that achieves only half of theplanned target for the quarter will only receive half thefunding. Each community project is funded for one year,and only those that prove successful are invited tosubmit a proposal for the following year. About half ofthe community-based associations that implementedprojects in the first year were considered to haveachieved good enough results to warrant continuedfunding.

There is a strong focus on results, backed byrigorous monitoring and evaluation.

Specific, quantitative targets were defined for projectactivities. A rigorous monitoring and evaluation systemwas set up to track progress systematically towards thetargets. Regular reporting on progress has helped keepa strong focus on the targets and results. The focus onresults was also built into the project in other ways; forexample, the way that community-based activities arefunded on the basis of results, as described above.

In preparation for the mid-term review of the project,several surveys are being planned, including one that

will examine the coverage, quality and effectiveness ofthe activities implemented by community-basedassociations, and one that will assess their costeffectiveness. A nationally representative survey willassess knowledge, attitudes and practices related toHIV, and another survey will estimate HIV prevalence.An institutional analysis will look at whether the currentimplementation structure the Executive Secretariat, thesystem of ministry focal points, the umbrella NGOs, anddistrict health offices effectively meets the needs ofDjiboutis HIV response, and whether and how it mightbe improved.

Innovative approaches and adult support help inreaching young people.

Given the sensitivity of talking about sexuality and AIDS,it was important to get the support of community leadersbefore launching the youth program, particularly for thepeer educators. The community support worked, in turn,as a source of motivation for the young people involvedin the program. The Information Points for Youth andthe Audio-Listening Cells enabled a large number of

young people to acquire information on HIV and AIDSand get condoms readily, and in a discreet way.

The project got a jumpstart from an existing healthproject.

Djibouti had begun implementing a World-Bank fundedhealth project the year before the HIV project began.The HIV project took advantage of the health projectfiduciary staff, procedures and mechanisms that were

already established, and got off to a very quick start inimplementing activities.

Similarly, when Djibouti secured a grant in 2005 from theGlobal Fund to Fight AIDS, Tuberculosis and Malaria,implementation was able to begin immediately, using thestructures and processes set up under the World Bank-funded project. A pilot for providing ARV treatment hadbeen done in 2004, and scaled up to offer twice thenumber of people access to ARV treatment in 2005. Thisenabled the Global Fund grant to be used to finance anexisting program that was already in the process ofbeing scaled up, and to show results very quickly.

Scaling up in harmonized partnership with theGlobal Fund

Djiboutis grant from the Global Fund is enabling asignificant expansion in the national program to care forpeople living with HIV and their families, and to preventinfections, especially among the most vulnerable groups.The initial two-year grant is $7.3 million, with thepossibility of an additional $4.6 million, based on grantperformance. The Global Fund agreed to use theexisting national authority as the grant recipient, tochannel the funds through the existing structures and

processes, and to rely on the existing national HIVmonitoring and evaluation system. From the start, allthree organizations the World Bank, Global Fund andnational program authority were committed to workingtogether in a fully cooperative, harmonized way. Thiscommitment, mutual respect and close interaction havemade it possible to resolve potential conflicts anddifferences quickly.

For the community response component, there is asingle set of criteria and one unified process for fundingsub-projects implemented by NGOs. For monitoring andevalution, a single set of indicators was agreed upon

with discussion and compromise, making it possible forthe national program to produce one report to alldevelopment partners, and avoid duplicative orcustomized reporting for different funding agencies. Thisdonor harmonization is efficient and time-saving. Toenable each funding agency to report on the resultswhich its funding has helped achieve, there is a clearmapping of how and where each funding source is used,for example, one source of funds is used for activitiesinside the capital city, while another source is used foractivities along the main corridor road. A tool that helps


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promote transparency and complementarity of programfinancing is a unified "General Project ImplementationPlan" that shows all the program activities planned forthe year, by quarter, and by financing agency, includingthe World Bank, the Global Fund, the FrenchDevelopment Agency and others. The plan is sentregularly to all donors contributing support to the nationalprogram.

Djibouti is a fine example of the Three Ones principlesbeing put into practice. There is a single national

authority. All donors support one multisectoral nationalprogram. And progress is tracked through a singlenational monitoring and evaluation system. This makesrational and efficient use of scarce resources one ofthe scarcest being the valuable time of the peopleavailable to manage, coordinate and implement theprogram. This excellent harmonization has helpedachieve impressive results in a very short time.

Further information

For more information on the Djibouti HIV/AIDS, Malariaand Tuberculosis Control project, please go towww.worldbank.org, select Projects in the searchwindow at the top of the page, and search for DjiboutiAIDS

About the authors:

Sameh El-Saharty is a Senior Health Specialist in theWorld Bank.

Omar Ali is the Executive Secretary of the HIV/AIDS, TBand Malaria Control Project in Djibouti.

HIV/AIDS - Getting Results series editor:

Joy de Beyer, Global HIV/AIDS Program,[email protected]

For other notes in this series, please visit:www.worldbank.org/aids and click on Getting Results

July 2006


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Map of Djibouti, Showing Location and Neighboring Countries

Documents

An effective, well-coordinated response to HIV in Djibouti (2006)