WHO-EMISTDI W7IEIL Distribution: Limited
Report on the
Twelfth intercountry meeting of national AIDS programme managers and
First meeting of the HIVIAIDS and STD Regional Advisory Group Beirut, Lebanon 23-26 April 2002
World Health Organization Regional Office for the Eastern Mediterranean Cairo 2003
O World Health Organization 2003
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Document WH(1EM/STD/047/UU07.03/PPP
10 CONTRIBUTIONS OF OTHER UNITED NATIONS AGENCIES TO HIV RESPONSE IN THE REGION ............................................................................................................ 2 6 10.1 UNDCP activities on HIV/AIDS in the Middle East and Xorth Afica ................ 26 10.2 UNESCO role in preventive education in the Region ........................................... 26 10.3 Current focus of UNAIDS in the Eastern Medterranean Region .........................27 1 1. FIRST MEETING OF THE HIV/AlDS AND STD REGIONAL
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ADVISORY GROUP ......................................................................................................... 12. CONCLUSIONS .............................................................................................................. 13. RECOMMENDATIONS ..................................................................................................
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17 28
Annexes 1. AGENDA ........................................................................................................................ 3 1 2 . PROGRAMME ................................................................................................................. 32 . 3 3 . LIST OF PARTICIPANTS................................................................................................ :
CONTENTS INTRODUCTION .............................................................................................................. I
EDIPEMIOLOGICAL OVERVIEW OF H N I P J D S ......................................................... 2 REGIONAL STRATEGIC PLAN FOR HN/AIDS FOR 2002-2005 ............................... 3 3.1 Regional epidemiological update. progress and key issues ..................................... 3 3.2 Group work 1: Country priorities in implementing the strategic plan ..................... 4 NATIONAL RESPONSES TO HIV/AIDS AND STD ....................................................... 5 4.1 Framework for assessing progress in impIementation of the strateplc plan ............ 5 4.2 Group work 2: Indicators for progress in health sector response in the Region...... 6 OPERATIONAL RESEARCH IN SUPPORT OF SCALING UP HEALTH SECTOR RESPONSE TO HIVIAIDS ................................................................................................ 6 5.1 EMRO Small Grants Scheme for communicable dlsease........................................ 6 5.2 Tools for rapid assessment of needs of vulnerable groups ....................................... 7 5.3 Studies on injecting drug use in the Region ............................................................ 9 GLOBAL INITIATIVE FOR SCALING UP RESPONSE TO H N / A I D S ........................ 9 6.1 Global Fund to fight AIDS. Tuberculosis and Malaria ............................................ 9 6.2 Experience of Palustan and Sudan on the Global Fund to Fight AIDS. Tuberculosis and Malaria ..................................................................................... 1 0 6.3 Accelerating access to care (AAC) and support for people living with HIVIAIDS ................................................................................ I1 6.4 Experience of Morocco and Tunisia on the AAC initiative ................................... 13 6.5 Group work 3: Improving access to care in countries of the Region .................... 14 TECHMCAL AND M A N A G E W ISSUES RELATED TO EPIDEMIOLOGICU SURVEILLANCE FOR HIV/AIDS h W STD ............................................................ 18 WORLD A D S CAMPAIGN 2002; REDUCING STIGMA............................................ 19 8.1 Stigma and discrimination ..................................................................................... 19 8.2 Group work 4: Developing messages and activities for reducing stigma and discrjmination in the context of the Region.......................................................... 19 8.3 Reaching sex workers, MSM and injecting drug users: Lebanon experience .......22 ESSENTIAL PACKAGES FOR W / A I D S COMPREHENSIVE CARE ...................... 23 r t ..................................... 23 9.1 Voluntary counselling and testing (VCT): state of the a 9.2 Prevention of HN infection among infants in countries of the Regon ................23 9.3 Country experience in voluntary counselling and testing: Islamic Republic of Iran and Morocco .................................................................. 24 9.4 Basic support for institutionalizing safe injection and infection control: SIGN ....25 9.5 Group work 5: Improving country plans ............................................................... 25
WHO- EWSTD/047/E/'L.
1.
INTRODUCTION
The Regional Strategic Plan for Improving Health Sector Response to HIVIAIDS in Countries of the WHO Eastern Mediterranean Region, 2002-2005, was developed to strengthen and scale up activities to fight the HIVIAIDS epidemic in countries of the Region. The pian was developed from discussions of the eleventh intercountry meeting of national AIDS programme managers held in Casablanca, Morocco, in July 200 1, and from a special consultation on improving health sector response held in Cairo. Egypt, in September 200 1. h October 2001 the plan was endorsed by Member States at the Forry-eighth Session of the WHO Regonal Committee for the Eastern Mediterranean. In resolution E?llL/RC?8,11.4, the Regional Committee called on all Member States to implement the plan and requested the Regional Director to provide the necessary t e c h c a l support to do so. It also requested the Regional Director to form a regional advisory group for HIVIAIDS and STD. The HIVi.UDS and STD Regional Advisory Group (ARAG) had its first meeting in April 2002, in conjunction with the next intercountry meeting of national AIDS programme managers. The twelfth intercountry meeting of national AIDS p r o - m e managers was held in Beirut, Lebanon, from 23 to 26 April 2002 in order to translate the regional strategc plan into effective and relevant national strategies and actions. The meeting was held by the WHO Regional Office for the Eastern Mediterranean (EMRO) and attended by AIDS programme managers and representatives from 20 countries of the Regon, as well as members of the W A D S and STD Regional Advisory Group (MUG), representatives from other United Nations agencies and nongovenunenta1 organizations and staff from WHO headquarters, Regional Office and country offices. Members of the ARAG convened for the fist time on 26 April 2002 to set the terms of reference for the Group and to review the conclusions and recommendations of the intercountry meeting. The meeting was inaugurated by Dr Hussein A. Gezairy, WXO Regonal Director for the Eastern Mediterranean, who noted that the epidemic was at a turning point in the Region. Despite early responses to W A I D S , and although the estimated prevalence in the Region was stdl low in comparison with other regions, three countries were already in a state of generalized epidemic. Moreover, many challenges were faced in the fight against AIDS in the Region. There had been several incidents where serious HIV outbreaks occurred due to infected blood or blood products, or as a result of injecting drug use. T h ~ s was in addition to increasing rates of HIV infection reported in several countries of the Region among vulnerable groups such as young people, prisoners, patients with sexually transmitted diseases, and other high-risk groups about whom little information was available. Intensified efforts were needed to keep the epidemic rates in the Region as low as possible. There was no doubt, said Dr Gezairy, that the prevalence of sexually transmitted diseases was an important factor in the progression of HIV transmission. Although these diseases were not negligrble in countries of the Regon, where millions of cases were estimated to occur annually, their control was an area in which the widest gaps in response could be identified. Early and appropriate treatment of STDs had obvious advantages in terms of reduction of the burden of both STDs and HIV, with subsequent prevention of
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complications. On the other hand, neglected or poorly treated STDs had great drawbacks i n terms of HTV transmission, economic loss and resistance to first-line antimicrobials.
In response to the changes in patterns of HlVlAIDS epidemic and as a part of the global initiatives, WHOIEMRO had introduced a new strategic perspectrve m its policies during 2001. A strategic pian for improving health sector response m the counmes of the Eastern Mediterranean Region had been deveioped for the penod 2002 to 2005. The pIan had five targets, whlch covered pnonty strategies and interventions for better response of the health sector to HIVIAIDS and STDs. The agenda of the meeting had been linktd to the strategic plan in order to build clear understanding of how to implement the plan and set the indicators for monitoring and evaluating progress. Targets and htrdteses had to be translated into tangible actions in order to protect millions of people in the Region who might be exposed to HTV or other STD pathogens. Dr Albert Jokhadar, Senior Adviser to the Minister of Public Health, delivered a message from H.E. Mr Sleiman Franjieh, Minister of Public Health, Lebanon, who emphasized the importance of reviewing plans and actions and evaluating their effects and impacts on society. AIDS had become a global hsease not only lirmted to specific countries or social groups. It was spreading in all societies and was definitely on the rise in countries of the Region. The Government of Lebanon had recognized AIDS as a dangerous public health threat as early as 1989. The Ministry of Public Health, with the support of WHO, had started a national HIVIAIDS programme and allocated a separate budget line for its activities. The Ministry had also formed technical and public information committees to support health education and was providing comprehensive care and counselling for HIV'.UDS patients and their families. Moreoxr, Lebanon had been among the first counmes of the Region to offer £ree triple therapy to HN/ALDS patients, despite heavy economic burdens. Mr Franjieh stressed that the Government of Lebanon was committed to maintaining access to care for HIVIAIDS patients.
Dr Jihane Tawilah, Regional Adviser, AlDS and Sexually Transmitted Diseases, WHO/EMRO, reviewed the objectives of the meeting, emphasizing the group work in which countries would prioritize their needs and create action plans aimed at harmonizing activities in line with the regional strategic plan for 2002-2005. Drs Mostapha El Nakib (Lebanon) and Asma Bokhari (Pakistan) shared the Chairmanshp on a rotatmg basis. Dr Abdo Jurjus was appointed as Rapporteur. The meeting agenda, programme and list of participants are included as Annexes 1,2 and 3, respectively. 2.
EDIPEMIOLOGICAL OVERVIEW OF HIVIAIDS Dr A. BalI, Department of HW/AIDS, WEO/HQ
HNIAIDS was the second leading cause of global disease burden in 1999. In the WHO Eastern Mediterranean Region, the number of HIVIAIDS cases was estimated at 680 000 by the end of 2001. Between 1996 and 2001 HIV prevalence in the Region increased by 100%.
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There is great diversity in the types of epidemic occurring in the Region, with concentrated epidemics among injecting drug users in some countries, and generalized heterosexual epidemics already exist in 3 countries. Although overall prevalence is low in the Region, there are a number of factors increasing the Region's vulnerability to future spread of the epidemic. These factors include geographica1 setting, expandmg injecting drug use, STD epidemics, and changing youth culture. Such factors can lead to rapid escalation in the incidence of HIV,such as in Eastern Europe (Ukraine and Russia) and Asia (Viet Yam and Indonesia), which have recently experienced a dramatic and unanticipated rise in HTv' incidence. Intensified effons are needed, as there are causes for optimism in the fight against H W / A I D S . Surveillance and howledge about HIVIAIDS has improved and continues to do so; effective programmes exist to prevent spread of the disease among injecting drug users, sex workers and youth; effective methods have been developed to prevent mother-to-child transmission; and blood and injection safety has improved. To date, success in developing countries has been dependent on strong political commitment. WHO'S strategic objectives in supporting countries include: addmg to the HIVIAIDS knowledge base; strengthening health sector planning and capacity; providing countries with evidence-based tools and guidance on key prevention and care interventions; and stimuIating wider multisectoral collaboration and action. Discussion
Participants agreed that the global ~nformation presented hghlighted the lack of similar information and data available in the Eastern Mediterranean Region. The Regon lags b e h d other areas of the world in the collection of data, and more vigorous efforts are needed from countries. In addition, more technical support is needed from WHO at country level 3.
REGIONAL STRATEGIC PLA1.T FOR BIVIAIDS FOR 2002-2005
3.1 Regional epidemiological update, progress and key issues Dr J. Tawilah, Regional Adviser, AIDS and Sexually Transmitted Diseases, ?TEO/ELWRO An upward trend in prevalence of HN in the Region is evident despite scarce data. In addition, there is an alarming increase in HIV rates among pregnant women. Countries that appear to conduct the most I-IIV testing include Cyprus, Islamic Republic of Iran, Palestine and Qatar, followed by Bahrain, Jordan, Kuwait and Oman. Notably, countries with hlghest burden of HIV, such as Djibouti, Somalia and Sudan, carry out comparativeiy less testing. Cumulative results of HTV testing among all countries of the Region show that the trend of HIV is rising.
Regional trends among various groups during 2001 highlight certain issues: ?? Homosexuals seem to be the group most affected
WHO- EM/STD/047/EiL Page 4 ?? ??
Rates of HIV among STD and tuberculosis cases are significantly higher than in other groups H I Y infections among pregnant women are rising and are significartly higher than among blood donors.
In addition, a number of subregional variations can be obserged. Four counmes, Djibouti, Somalia, Sudan and Republic of Yemen, represent most of the burden of KIV infections in the Region, with almost half of all reported cases. Djiboun has the highest burden, followed by the Republic of Yemen. KTV rates in Tunisia appear to be higher than in Morocco or than the regional average. This might be an artefact of interpretation of incomplete data. Qatar, followed by Oman a d Bahram, also show HTV rates hgher than the regional average, with clear rising trends. This is also the case for the Islamic Republic of Iran and Pakistan.
Factors contributing to the spread of the epidemic vary somewhat according to subregion. In the Republic of Yemen and countries of the Horn of Xfrica, STD patients, prostitutes and tuberculosis patients are the groups most affected with Hn;.Tuberculosis is also an important co-infection with HIV in the Libyan Arab J a m b y a , Morocco and Tunisia. Injecting chug users are the most affected groups in these countries. This is also true in the Islamic Republic of Iran and Pakistan.
AIDS rates in the Region are also on the rise. In addition, the sex difierentiai for .ADS cases is narrowing, with a higher percentage of cases among women in 2000 (32%) compared with 1989 (17%). Heterosexual transmission has increase4 while ransmission through injecting drug use appears unchanged, accounting for 3.4% of A I D S cases. However, for a large number of cases, mode of transmission is not specified. The age group most affected by AIDS in the Region is 30-39 year-olds. Discussion Participants drew attention to the issue of testing and suggested that different information formats might be needed to reflect the country situations accurately. In addtion, proper surveillance systems are needed, including second-generation systems whch address surveillance among highrisk groups. 3.2 Group work 1: Country priorities in implementing the strategic pIan Group discussions highhghted a number of issues that need to be addressed for improving the health sector response to HTV/A.IDS and STD in the countries of the Region. These issues included the following.
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Renewal or strengthening of political commitment is needed, including increasing the national budget and widening the multisectoral approach, implementing legislation to protect rights of patients and/or adopting new and necessary measures or regulations in
WHO-EM/STD/047/E/L Page 5 this context, and giving HNIAIDSISTD programmes priority among health programmes. ??
There is need for more training in some countries for professional, technical and key personnel. Current baining manuals need to be reviewed or new ones adopted. Medtcai and paramedical curricula need revision and improvement in introducing more information about HIVIAIDSISTD. Work with vulnerable groups needs to be improved, and to mechanisms to work with NGOs created or improved in most countries in addition to improving operational and behavioural research. Voluntary counselling and testing (VCT) is an important issue; many of the countries of the Region should put more effort and resources into this area. Implementation of an acceptable surveillance system. It is lacking in most countries and considerable effort and commitment as well as resources and WHO assistance are needed in this area. The issue of s t i p a is still very strong in the Region. More work should be done in t h ~ s area to reduce stigma. National strategc plans need to be elaborated, as many countries do not have them yet. Infection control and injection safety needs to be implemented andor improved, and universal precautions adopted.
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a r m a t i o n systems, dong with relevant indicators, need to be upgraded.
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A perioQc evaluation system is needed. The problem of refugees needs to be addressed in certain countries. NATIONAL RESPONSES TO H N / A I D S AND STD
4.1 Framework for assessing progress in implementation of the strategic plan Dr K. 0 'Reilly, Coordinator, Surveillance Research Monitoring and Evaluation,
rnO/HQ The Regional strategy developed and endorsed by the Regional Committee is a broad and ambitious document. It includes targets that are possible but will require diligence if they are to be reached in the desired time frame. The targets are in fact regonal goals and specify what d be accomplished throughout the Region in the next few years. The strategies that comprise each target are themselves ambitious and offer a variety of ways that countries can
WHO - EM/STD/047E/L Page 6 use to contribute to the progress toward those targets. They do not in themselves specify what each country will do. That additional step is necessary and must be undertaken at the national level, as each country considers its needs, priorities and capabilities. As they currently stand. the targets and strategies contained in the Regional document do not yet lend themselves to monitoring and evaluation. Monitoring and evaluation will best be $one considerins the operationalization of the Regional Strategy at the national leve!. h h e n the necessary specification (i.e. the operationalization) is supplied at each national leve!, indicators to monitor progress can then be selected and ways to collect data for those indicators can be described. The guide developed by UNAIDS and its co-sponsors and collaborators, ,Varionai AIDS programmes: a guide for monitoring and evaluation, is a useful compendium o i indicators with a description of the strengths, weakmesses and tools necessary for each. All are contained on a CD ROM distributed to each country team. Countries should use caution not to be oterly energetic in selecting indicators, as each indicator entails an expense of funds and energy if it is to be effectively measured and used. A smaller set of well-se1ec:ed indicators is probably preferable to a larger set of indicators which might not be collectible over the long term. Examples of possible indicators for some aspects of :he Regonal Strategy were also provided.
4.2 Group work 2: Indicators for progress in health sector response in the Region Participants were asked to identify the indicators used for evaluation of HTV!.UDS response in their respective countries, how frequently these indcaiors were updated, what methodology was used and how programme planning was affected by results. Groups were then asked to select the best indicators, in the context of theu respecnve countries, to be used for each target of the strategc plan. Finally, participants identified necessary processes at country level to ensure smooth implementation of indicators and their use in advocacy and programme planning.
5 .
OPERATIONAL RESEARCH N SUPPORT OF SCALNG UP HEALTH SECTOR RESPONSE TO HIVIAIDS
5.1 EMRO Small Grants Scheme for communicable disease Dr A. Bassili, TDR Fellow, Division of Communicable Diseases, WEO/EMRO The S m a l l Grants Scheme started in 1992 with the aim of fostering collaboration between researchers in academic institutions and clinicians in the control programmes of the ministries of health. It is funded jointly by EMRO and the UNDP-World Bank-WHO Speciai Programme on Research in Tropical Diseases (TDR). Specific objectives of rhe scheme are as follows:
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strengthen operational research in tropical and communicable diseases in the Region; support research contributing to prevention, control and treament of communicable diseases; promote an integrated approach in designing and conducting operational research in communicable diseases; and
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increase the research capacity of researchers in the Region.
Each year, the scheme selects specific diseases within the tropical diseases research agenda, such as Ieishrnaniasis, malaria, schistosomiasis and tuberculosis. In 2002, in view of the identified research gaps in other communicable diseases, the scheme expanded to include additional communicable dseases of regional importance, including: W , ' A I D S and STDs. In general, operational research has two outputs: direct communication of results to control programmes, and publication of results. The tenth call for applications 2002 was widely distributed to ministries of health and institutions of the Region, and displayed on the EMRO website: mw.emro.who.int. Before the closing date, 21 1 letters of intent had been submitted, out of whch 23 were for research on HIV/AIDS and STDs. These included prevalence, KAP and qualityof-care studies on HIVIAIDS and on STDs. Planned activities are development of an independent ethics committee (IEC) for ethical clearance of proposals before final acceptance, and research capacity strengthening in communicable disease control by providing t e c h c a l assistance to researchers in finalization of their proposals and o r p i z i n g research methodology and proposal development workshops. 5.2 Tools for rapid assessment of needs of vulnerable groups Dr A. Ball, Deparment o f HWAIDS, W O / H Q
The WHO Rapid Assessment and Response (RAR) methodology has been developed based on experience gained from the WHO Street Children Project and the WHO Drug Injecting Study, and from a review of other public health rapid assessment tools. It is recognized that HIVIAIDS epidemics can spread rapidly, and that many traditional research and assessment methods are too slow to produce timely infomation for planning effective responses. For example, HIV prevaIence among Injecting drug users @Us) in some cities has escalated fiom 0% to over 40% within periods of less than 12 months. Therefore, assessment methods are necessary that can provide a reliable HIV/ALDS situation analysis of the target community that, in turn, can inform effective policies, programmes and interventions, and ensue their timely implementation and sustainabhty. Successful HIVIAIDS prevention programmes: ?? ?? ??
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are based on a comprehensive assessment of local risk behaviours, context, needs and resources; are jointly developed by key stakeholders (including researchers, service providers, decision makers, affected populations and civil society); strengthen local capacity; mobilize political commitment and support; and sustain effectiveness through ongoing monitoring, re-assessment and refinement.
WHO- EM/STD/047/EiL Page 8 The RAR methodology combines rapid assessment methods with these principles of successful H N i A I D S programming. The RAR methodolog provides a methodological framework for combining multiple assessment methods (e.g. surveys, key informant studies, observation, review of existing data, mapping, etc.) with community development and mobilization approaches (e.g. community advisory committees) and strategic planning. The methodology incorporates four main steps. 1)
Building alliances: this includes establishing a multi-disciplinary assessment team, a community advisory board and mechanisms for consultation nith key s-dceholders in the community and decision makers. Mapping of key areas: thls includes using multiple assessment methods and data sources, covering different assessment domains (including context, vulnerability, risk behaviour, impact/consequences, and response assessments). Translating findings into action: this includes preparing an action plan based on the findings of the assessment step. Sustaining the difference: this includes supporting ongoing monitoring, evaluation and revision of the action plan and advocating for a broader response.
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To date WHO has produced a series of RAR guides, includingd e s .on: injecting drug use; substance use and sexual behaviour; and substance use and W , - U D S prevention among especially vulnerable young people. A generic RAR guide is under development, with specific RAR adaptation guides being developed for: HIV/AIDS prevention and care among men who have sex with men (MSM); tobacco and young people; and HIViAI13S prevention and care among sex workers (in planning stage).
WHO has undertaken or supported RAR training in a wide range of counhes and regions, with a focus on developing local and regional capacity to use the methodology. A recent WHO evaluation of the use of rapid assessment methodologes for assessing drug use and HIVIAIDS reports on its use in 322 different cities in 70 countries, which led to the implementation of programmes in 204 cities. Most recently W X O has collaborated with UNICEF in the assessment of HIVIAIDS among especially vulnerable young people in 24 sites in south-eastern Europe. Other organizations have also developed rapid assessment methods and tools for undertaking assessments relevant to H I V I A D S . For example, the United Nations Office of Drug Control and Crime Prevention (UNODCCP) has supported rapid assessments on illicit drug use in Egypt, Islamic Republic of Iran, Lebanon and Palustan. The WHO RAR tools and fuaher information on the RAR methodology are avadabk fiom the website: www.RARarchives.org
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Page 9 5 . 3 Studies on injecting drug use in the Region
Dr Ahmad Mohit, Regional Adviser, Mental Health and Substance Abuse, WHO/EMRO Studies on injecting drug use conducted by the United Xations Drug Control Programme (UNDCP) in three countries of the Region showed alarming prevalence. A rapid assessment study conducted in Egypt in 1998-1 999 showed that 17% of drug abusers interviewed used injection as the primary route of drug use. In a rapid assessment study conducted during the same period in the Islamic Republic of Iran, 22% of h g users interviewed admitted having injected drugs. Of these half reported sharing syringes and needles. In a baseline srudy o f injecting drug users corducted in Palastan in 1999, 6&?6 of drug users admitted to needle sharing. This represents a strong potenrial for W / . U D S spread. 6. GLOBAL MTUTTCrE FOR SCALING UP RESPONSE TO H I V I A I D S
6.1 Global Fund to Fight A D S , Tuberculosis and lMalaria Dr A. Ball, Department of HN/dDS, WHO/HQ
The establishment of the GFATM was announced by ivfr Kofi &an, SecretwGeneral of the United Nations, in June 2001 at the time of the United Nations General AssembIy Special Session on H I V / A I D S in New York. The Fund was established in response to increasing concern about the burden these three diseases were placing on global health and development, and the failure of existing mechanisms to respond to this crisis. In the establishment of the Fund, the SecretaryGeneral claimed "The fbundation of a new philosophy and a different way of doing business has been laid". To date approximately USS1.92 billion has been pledged to the Fund and USS 700 to US$ 800 million is available for disbursement in 2002. The objectives of the Fund are to:
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reduce W A D S , tuberculosis and malaria morbidity and mortality, particularIy in developing countries; mobilize h t h e r resources and utilize unused resources; mobiIize political commitment and action to improve health; and implement programmes rapidly.
The main principles of the Fund indude: ?? ?? ?? ?? ??
promoting a public-private partnership; supporting proposals through the provision of funds supporting balanced and comprehensive responses, including a balance across prevention, treatment and care, and a balance across the three diseases; complementing already existing programmes and efforts and scaling up best practice and innovative approaches; and supporting approaches that are consistent with national priorities.
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Page 10 The Fund comprises the following components: ??
Partnership Forum - an informal forum with representation from a wide range of interested partners, which allows for input on policies and strategies and can monitor the work of the Fund; Foundation Board - with I 8 voting members (7 developing counmes; 7 donor countries; 2 NGOs; 2 private sector) and 4 norrvoting members (WHO; LFlAIDS; a person living wiWaffected by HWINDS, ruberculosis or malaria; Swiss representative), which acts as the governing body of the Fund;
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Secretariat - based in Geneva, is responsible for the day to day operations of the Fund; Technical Review Panel - comprised of 17 independent experts chaired by France and Thailand; World Bank - acts as trustee of the funds.
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WHO is providing administrative support to the Secretariat and is providing technical support to the Fund. National ownership of countq processes is a key principle of the Fund, with country proposals being coordinated through a Country Coordinating Mechanism (CCM) involving a broad pubiic/private sector partnership, resuIting in the development of Country Coordinated Proposals (CCPs). The eligibility criteria for proposals is flexible, with priority given to countries in greatest need (disease burden or potential impact), with political commitment and demonstrabIe resource gaps. There is the potential for multi-country, subreponal or regional proposals, and in special circumstances individual proposals not submitted through the CCM process. Closing date for the fist round proposals was 10 hiarch 2002, with 8 countries of the Region submitting 19 proposals, requesting USS 43 million for the first year.
6 . 2 Experience of Pakistan and Sudan on the Global Fund t o Fight . a s , Tuberculosis and MaIaria The Federal Ministry of Health of Pakistan submitted a joint proposal for HN/XIDS, tuberculosis and malaria to the global fund. For this process the Inter--Agency Coordinating Cormnittee for tuberculosis was expanded with specialties of other sectors, United Nations agencies, multilateral and bilateral donors, private sector, NGOs and members of civil society. A CCM secretariat was established at the Health Services Academy to coordmate the whole process to provide technical guidance. All three programmes had a detailed strategic plan that guided the proposal process. The main emphasis dring the development of the proposal was the promotion of pubiic/private partnership with a clear role for NGOs and civil society. The Federal Ministry of Health is also in the process of developing a mechanism for encouraging NGOs and private sector to come forward. In this context, a number of activities
WHO-EM./STD/047E/L Page 11 have been planned to identify gaps and develop proposals to enhance/compiement government efforts to fight these diseases, while avoiding duplication. Sudan suffers from a heavy burden of HIVIPJDS, tuberculosis and malaria. The prevalence of HIVIAIDS is 1.6% in the general population; the incidence of tuberculosis is 180 per 100 000 population, and 20% of a11 registered deaths in the country are amibuted to malaria. Ln an effort to use the opportunity presented by the GIobal Fund to Fight .AIDS, Tuberculosis and Malaria, a call for proposals was issued to a variety of sectors, including governmental agencies, communitybased organizations, civil sociecy and NGOs. Meetings were held for all applicants and a technical committee was formulated to select viable proposals. Proposals covered a wide range of high-risk groups and affecred geopaphical areas, and project activities included capacipbuilding, staff training, provision of materials and equipment and case management. Important outcomes included scaling up of interventions and coverage and enhancement of partnerships benveen government, NGOs and the private sector.
6 3 Accelerating access to care (AAC) and support for people livin, a with HJYIAIDS D r B. Valeldzis,Deparment of HNAIDS, FFIO/HQ For a care and support package for HIV to be comprehensive, it shouId include elements of voluntary counselling and testing for H N infection, psychosocial support, home and communitybased care, and clinical management (including antiretroviral therapy and management of oppoministic infections). Current estimates are that approximately 40 million adults and children worldwide are living wirh HIVIAIDS. Of these, 680 000 live in the counnies of the WHO Eastern Meditemean Regon. The estimated global need for antiretrovinl (ARV) therapy was 6 million people as at December 2001, with 60 000 living in the Region. However, only 230 000 patients worldwide are estimated to be using ARV, with less than 2000 in the Eastern Mediterranean Regon.
The United Nations strategy for improving access to m - r e l a t e d drugs focuses on four issues: rational selection and use; affordable prices; sustainable financing; and reliable health and supply systems. The Accelerating Access initiative comprises a partnership between five United Nations agencies (UNAIDS, UNICEF, bTNFPA, World Bank and WHO) and six R&D based pharmaceutical companies. The principles of the initiative include unequivocal and ongoing national commiment; strengthened national capacity; engagement of all national sectors; efficient and reliable distribution systems; additional funding from national and international sources; and continued investment in research and development by the pharmaceutical sector.
In this initiative, countries drive the process of accelerating access to care and support; WHO assists countries by identifqing possible options and providing support for implementing the chosen approaches. Governments initiate the process by expressing interest; this is followed by a situation analysis, action plan, resource mobilization and
WHO-EM/STD/047E/Z Page 12 implementation. Linkages have been made to other WXO initiatives, such as in the development of ARV guidelines; mapping of sources and prices of HIVIAIDS drugs; analysis of patent status of HTV-related drugs; prequaliiication of generic suppliers; and inclusion of 15 HN-related drugs in the WHO Model List of Essential Drugs since 1997, with 10 ARVs added in 2002. The development of new WHO ARV guidelines, Scaling up ann'rehoviral therapy in resource limited sem'ngs: guidelines for a public health approach, is particularly valuable. The document is available at www.who.int/HIV tUDSif~st.hm1. The ,guidelines use srate-ofthe-art, standardized combination ARVs and eliminate the requirement for viral load tests. In addition, the guidelines entail minimal laboratory monitoring for safe use and replace individual drug resistance testing with resistance surveillance at population level. Standardization of ARV therapy allows for more rapid implementation as it facilitates training of clinicians, procurement of ARVs, evaluation of intervention effectiveness and monitor;,ng of patients. Countries are encouraged to select a single standardued first-he ARV combination regimen, several second-line combination regimens, and referral for salvage is stressed while dual therapy, of possible. In addition, the use of 3 or & h , o re--.ens regimens are not recommended as they are less effective and pose more risk of vim1 resistance. The guidelines are intended to be used as a template for the development of national
ARV treahent guidelines that take into account countr>ispccific needs. Issues specific to resource-poor countries that should be considered in developing local guidelines include: cosl and availability of drugs; limited formularies; limited health care infrastructure; need to deliver drugs to rural areas; hlgh incidence of tuberculosis and hepatitis; and presence of varied HIV groups and subtypes. Use of ARV therapy can be scaled up in resource-poor settings with concerted international collaborative efforts.
Country experiences with accelerating access to care have shown that the process can be htratingly slow. Pharmaceutical companies have been asked to come up with unified approaches, processes and prices. Such approaches have been set for least developed countries; attention is now being focused on ''middle- income" countries.
Experts who reviewed ARV drugs for the essential drug list used set criteria such as efficacy and cost-effectiveness, and drugs were excluded from the list for reasons such as side effects or low overall effectiveness. Inclusion of a drug on the essential drug list facilitates its registration in national formularies. Viral load testing requirements were eliminated i n the new ARV guidelines because of hgh cost and low disease monitoring significance. In addition, increased viral resis'ance has been associated with practices of frequently changing treatment as a result of viral load variations.
WHO-EM/STD/047/E/L Page 13 ARV therapy should initially be administered by physicians. Once significant clinical experience is gained, health care personnel at the next level, i.e. clinical officers, could be trained to administer the therapy.
Recommended drug combinations vary according to HIV subme. Tuberculosis prophylaxis for HIV patients should be undertaken according to the antituberculosis regimen established by tuberculosis programmes. WHO supports using any ARV, whether generic or research, with documented good quality. A WHO prequalification process for generic drugs has started and will facilitate access to these drugs.
6.4 Experience of iMorocco and Tunisia on the k 4 C initiative
In December 2000 the Government of Morocco issued a request to L'NMDS to include Morocco in the AAC initiative. By April 2001 negotiations began with four pharmaceutica1 firms to agree on new prices; formal contracts were established with these firms during the following six months. The negotiations resulted in very significant price reductions, enabiing the Ministry of Health to offer AIDS case care management to all eligible patients in 2002. Supporting activities included capacity building for health care personnel and development of national guidelines for HIVIAIDS diagnosis and care management. Factors for success included strong political commitment, a well-organized drug delivery system, decentralization of HNIAIDS diagnosis and patient follow-up and strong role of NGOs in providing psychosocial case management. Tunisia began offering free treatment of oppommistic infections in 1995. Triple therapy or to m i - a t became available in 1997 to health personnel as post-exposure prophyl~.ui~ Tunisians with AIDS returning back home. Use of mple therapy became generalized only in 2000. It is fiee for Tunisian residents. The treatment regimen is decided by the physician; psychosocial support to patients is provided by a psychologist and social worker.
UNAIDS was contacted in 2001 in an effort to reduce hi& costs of ARV. Consultants formulated a plan of action to strengthen the comprehensive approach for dealing with Kn/' infection. Specific objectives of the plan were enhancement of coordmation between all interventions and strengthening of epidemiological surveillance by focusing on vulnerable groups. It also included intensification of prevention strategies and stren-ethening care for people living with WIAIDS.
Participants raised the issue of patient compliance, which can be enhanced through training and awareness-raising. In addition, regional or subregional initiatives and pools of competencies are needed.
WHO- EM/STD/047E/L Page 14 . . ..
6.5
Group work 3: Improving access to care in countries of the Region
Group I: Djibouti,Libyan Arab Jamahiriya, Morocco, Tunisia The current status of HIVIAIDS care in these counmes is shown in Table I . Future plans for all four countries include improving and expanding HIV testing, strengthening capacities of reference laboratories and trammg health care personnel. In addition, plans for Djibouti include developing centres for prevention of mother-to-child transmission and advocacy for ARV therapy. In Djibouti and the Libyan X n b Jamahirilja attention will be given to reorganuing~deccntra1izing H N care managemenr and in the Libyan &ab Jamahiriya plans include implementation of a harm reduction programme and integration of STD care management into primary health care. Morocco and Tlmisia plan to implement surveillance for ARV resistance. Table 1. Status of HIVIAIDS care in Djibouti, Libyan Arab Jamahiriya, Morocco and Tunisia, 2002 Djibouti PLWA in need of treatment
Libyan .Arab Jamahiriva 100 100 rriple therapy 100 500 Yes Yes
?dorocco
Tunisia
2800 0
PLWA receiving treatment Regimen
none 100 estimarion in process yes
mple -herauv .. 400
ripie therapy 125
Counselling Expected cases 2003-2004 National budget (VSS)
yes yes yes cenczl acd :;~:oaa! yes 800/0 governex
yes yes yes ce=mi and regional yes
Guidelines SSMCCS ARV status
in process central Yes none
in process cenrral and regional yes 100% government
ARV purchased by government
Key players
in transition
goveznear
Group 2: Egypt, Islamic Republic of Iran, Pakistan Current status of HIVIAIDS care in these countries is showm in Table 2. Planned activities include securing political commitment, conducting serosurveys and behavioural s w e y s , raising public awareness of HIVIAIDS and availability of services, and integrating HIVIAIDS care into PHC. Attention m-ill be given to enhancement of the instirurional environment through development of national guidelines, conducting training for all levels of health care workers and building in mechanisms for ongoing monitoring and evaluation at all
WH~-EM/STD/O~~/E~'L Page 15 levels. I n terms of patient care, activities will focus on VCT and developing comprehensive counselling for care and compliance, including nutritional advice, psychosociaI support and rehabilitation and establishment of reliable referral mechanisms. In the area of parmership building, planned activities include establishment of suppon g~oupsthrough collaborarion with nongovernmental organizations, building capacities of specialist nongovem.enta1 organizations providing counselling and suppon and mobilizing communities to create an enabling environment. Table 2. Status of HIVIAIDS care in Egypt, Islamic Republic of I r a n and Pakistan, 2002 Number of PLWA in need of treatment PLWA receiving ARV
EEPt 150 17
Isiarnic Kepubiic oitrzn 100
Pakistan SO
therapy Regimen Counselling Expected PLWA 20032004 Political commirment Treatment budget Legislation Guideiines (treatment, 0 1 , PMTCT, PEP and laboratory) Guidelines impiemented Supervision Services Accreditation Basic services capacity Training mechanisms
triple rherapy a11
triple therapy all
01s :cformation not avaiiabie 500 yes no. proposed under ne,x. progr,inme poi~cy, no law
500 Yes no policy, no law yes
500 Yes Yes policy, no law yes
partially no governorate no mar,$nai ad hoc
pamaily well implemented provincial
jmia!iy
Yes marginal comprehensive, integrated for health and other sec:ors no avaiiable .ARVs regisxed 100%
20
nargka! z c hoc
ARV included on essential drug lisr .4RV registration ARV purchased by government
no available ARVs reglstered 0 Pnvare sector, government
peially ava:lable ARVs registered 0 government, private sector and NGOs
Key players
government only
WHO - EM/STDl047/E/L Page 16
Group 3: Jordan, Lebanon, Palestine and Syrian Arab Republic Current status of HTViiUDS care in these countries is shown in Table 3. Planned activities in these countries will focus on: training in identified gap areas; enhancing involvement of NGOs; providing social support and home care for people living with HN/AIDS; accelerating access to ARVs; and decentralizing HTV;';ZIDS care services.
Table 3. Status of mIAIDS 2002 Jordan
care in Jordan, Lebanon, Palestine and Syrian Arab Republic, Lebanon Palestine Syrian Arab
Republic PLWA in need for trcatmrnr PLWA receiving treatment PLWA receiving
35 25 (triple :herspy) 32
130 160 (tnpie therapy) 150
36
TO
5 (tr;pis :kcrlpy) 36 50
~-2~ov.~ 70
counsellin~ Expected PLWA 200%2004 Commitment (legislation) Guidelines Supervision Senices Accreditation National capacity Training
50
192 yes yes partial pernary and seconcky levels
75
Yes yes, not dissemina:cd pamai
yes yes, -or disseaisztei parria: prima? 2r.d SeCOCkj. I?..-: .-.> x
yes :r, jrccess
Z T T : ~ ~
primay and secondary leve!s no ad hoc
?r.3ar].. arid seronCa.y 1e:-cis 20
no ad hoe
no ad hoc
needs reinforcxiezt and decennslizaaon ad h o c
mechanism ARV on essextial drug list ARV regismtion hRV purchased by government
no yes 100?6
yes 10046
yes 1009'0
yes 0
Key players
government, prvate sector
government, private sector, YGOs
govezxnent. SGOs
g o v e m e n t , pevate jec:Of
Group 4: GCC countries Current status of HIV!AIDS activities in these countries is shown in Table 3 . Planned activities for GCC countries will focus on the areas of: capacipbuildi.ng, through conducting t~aining courses and seminars; enharring access to ARV therapy, through reorganizing drug distribution systems and working to reduce the costs of M V s ; and improving the number and quality of health personnel trained in HN/AIDS care.
WHU-~R/Y~~WU+I/~IL
Page 17 TabIe 4. Status of K W I A I D S care in countries of the Gulf Cooneration Council. 2002 Bahrain Kuwait Oman triple
Qatar triple
Saudi Arabia
United Arab Emirates
Treatment
2, I, BI
mple therapy public yes yes yes Yes M i n i s w of Heaith
therapy public Yes occasiona! shortage Yes Yes Ministry of Health
Funding source
public Yes Yes yes yes
therapy (partial) public yes yes yes yes M i n i s q or' Health
mple rte:apy
aiple therapy
public yes yes yes yes
public Yes yes yes yes Minlsny o i Health
Counselling Medicine Guidelines Services Commitment
secondar). and t e m a q ~ according to case requirements m d drug 3 v a i l z b i l i ~
(legislation) Budget Ministry of Health
hl~isq of Healb
Group 5: Somalia, Sudan,Republic o f Yemen
Current status of HIViAlDS care in these countries is shorn in Table 5. Planned activities in these countries include: establishment of a strong sweillauce system for vulnerable groups, especially STD surveillance; development of VCT guidelines and centres; developing standardized guidelines for management; and conducdng training in dragnosis and case management, as well as establishmg a reference centre for diagnosis and care. In addition, efforts will be directed towards fund-raising and advocacy.
Table 5. Status of HIYlMDS care in Somalia, Sudan and Republic of Yemen, 2002 Somalia
Sudan 2500 400 counselled/year
Republic of Yemen 1-00
Number of PLWA in need of treatment Counselling .4RV therapy
500
none not available
no VCT not zvailable
ARV in private phaimacies in csnrnl leve! only 4000
Expected number of PLWA 2003-2004 Guidelines
2000
9000
no political commitment, no guidelines no HIV testing, TB eeztment only no
guidelines for clinical management tertiary, central level only no limited government and XG0s
no side!ines
Services
symptomatic treafment at tertiary, central level no none govement
ARV in essential drug list
Training Key players
none local health authority,
WLIU-CIVUJ I u I V ' t l l l ; ~ ~ .
Page 18 7.
TECmCAL M&iAGERIAL ISSUES RXLATED TO EPIDE~WOLOGICAL SURVEILLANCE FOR HIVfiiLDS .i?TD STD Dr K 0'Reilly, Coordinator, SurveilIance Research Monitoring and Evaluation, WHO/HQ
Second generation surveillance, introduced in 1999, marks a departure from fist generation surveillance in some important ways. Second generation surjeillance encourages flexible data from a variety of sources to allow a country to piec= toge&er a picrure of the W A D S problem or epidemic it is facing. The seateges for second generanon surveillance are classified into three different levels: those for low level qidemics, for concenuated epidemics and for generalized epidemics. The goal of second generation sweillance and the level of effort and intensity that is recommended varies across these b e e categories. For low level epidemics, the recommended strategies include sentinel 5urr;eillmce on STD clinic populations, special studies of subpopulations with elevated risk behaviours, and behavioual studies. For concentrated epidemics, more expenditure is warranted and the addition of regular sentinel sweillance, particularly with possible bridging populations, is recommended. For generalized epidemics, regular sentinel sweilIance among antenatal clinic attendees, for example, is a common stratem, as are special studies of behaviour. STD and HIY prevalence. These latter strategies would not be useful or in many cases possible h low level epidemics. The countries of the Region represent all three caregofies. ~Llany counmes have reported difficulty in implementing second generation surveillance, no mazer what stage of epidemic the country has. In the Eastern Mediterranean Region, it is even more difficult to implement second generation surveillance as many of the key popuIations for wbch surveillance should be done are characterized by behaviours that are illegal or socially proscribed. Gaining access to these populations for the purposes of surveillance is sezn as extraordinarily difficult in the Region, if not impossible. The guidelines for second generation surveillance (distributed to each country at the meeting and available in Arabic as well) were not developed in sufficient detail nor with the particular problems and challenges of this Region in mind. $ionetheless, the guidelines do describe steps that can be taken to help a country move closer to implementing second generation surveillance. For low level epidemics, for example, the *delines recommend formative research, to better describe the size, location and behaviours of subpopularions possibly at increased risk of HTV infection. Some countries in the Rcgion have proven that, working through intermediaries a d with flexibility, fornative research can be undertaken and trust of the subpopulations slowly gained, to enable geater access. Countries are encouraged to adopt similar flexibility and creativity in considering how best to implement second generation surveillance. Assistance from the Regional Office and from headquarters should be sought whenever necessary.
...I
V
..-.Page 19
8.
WORLD AIDS CAMPAIGN 2002: REDUCING STIGMA
8.1 Stigma and discrimination Mr M. Mahalingam, Communication Adviser, W A I D S , Geneva World AIDS Day, 1 December, has been a very successful vehcle for raising public awareness about H I V / h I D S . The concept has been expanded 10 a longer campaign, which in 2002-2003 is focusing on the theme of 'Ltigrna and discrimination". Sti-ma and discrimination are the major obstacles to effective HIVIPJDS prevention and care. Fear of discrimination may prevent people from seeking treatment for AlDS or from acknowled-gins their HTV status publicly. People with, or suspected of having, W may be m e d away from health care services, denied housing and employment, shunned by their friends and colleagues, turned down for insurance coverage or refused e n u y into foreign countries. In some cases, they may be evicted from home by their f a d i e s , divorced by their spouses, and suffer physical violence or even murder. The sti-gma attached to H I V I A I D S may extend into the next generation, placing an emotional burden on children who may also be trying to cope with the death of their parents from AIDS. In focusing on sti-ma and discrimination, the campaign will encourage people to break the silence and the barriers to effecrive KW/'rVDS prevention and care. 8.2 Group work 4: Developing messages and activities for reducing stigma and discrimination in the context of the Region Current situation
With respect to the most common situations of HIV.'?JDS related sti-ma and discrimination, the group found that sti_ma and discrimination u e found in most settings, including: Health services: discrimination by health personnel including denrisis, physicians, nurses and other paramedical personnel Workplace: hiring and k g , issuing work permits Education: enrolment of people living with HIVIAIDS in schools or in universities Travei: applying for visas Marriage: in premaritai screening Prisons: by isolating HIVIAIDS patients Military: fmng or forced early retirement of people living with HIVIAIDS Society: including family at large and immediate comrnuniy. Wherever HIV or AlDS are present, they appear to be subject to stigma and discrimination. More dissemination of appropriate information about misconceptions, particularly modes of transmission, should be encouraged. Beaer approaches to policymakers, community leaders, reIigious leaders are needed, as are mass media campaigns. Other possible ways of effective preventive measures and precautions among health personnel could be useful.
WHO- EM/STD/047/E/L Page 20 Rkk groups As for the groups at risk of stigma, risky behaviour andlor modes of transmission and social and cultural boundaries were determining factors for discrimination. Such groups were identified as: ?? ?? ??
?? ??
MSM IDUs sex workers prisoners STD patients.
Factors leading to discriminan'on
Many factors were mentioned and by almost all the counmes. They included: ?? ?? ?? Fear of the disease Misconceptions or, lack of howledge, about modes oftransmission High-risk behaviours and practices that are contrary to social norms, religious beliefs or teachings and sometimes against country laws.
This calls for more provision of accurate and appropriate information to fight misconceptions about trans mission.
Legislation General laws and policies governing health and medical services in relation to stigma and discrimination do exist in countries even if sometimes not fully implemented or correctly implemented. A number of laws in most countries could decrease sti-ma. In some countries, such as Egypt, Islamic Republic of Iran, Lebanon, Tunisia and GCC countries, there is legislation protecting employment and civil rights of people living wirh HIV/ADS. In addition, some countries have positive legslation for drug users (health care, access to harm reduction programmes). Furthermore, religious laws call for non-discrimination of any kind when dealing with sick people--all sick people-including people living with WIAIDS. On the other hand, some laws against dnrg use or homosexuality or extramarital sex and commercial sex or law against incest could probably increase sti-pa. At this stage, commitment of key political and communiry leaders could, when properly oriented, could be of great help. Mass media carrpaigns, when well targeted, could be of enormous assistance. More advocacy is needed at d Ievels and among religious and community leaders and policy- makers.
WHO- EM/STD/047iE/L Page 2 1 Research concerning stigrna and discrimination
About half of the countries have undertaken research related to this subject basically through KABP studies. However, all countries recommended such studies be included in future action plans. Experience
Local experience in relation to stigma and discrimination showed that most counmes are active in media campaigns and in investing efforts at the level of d e c i s i o ~ and policy makers. Improving counselling services in quality and in coverage was recommended. In addition, most countries rely also on the wide coverage of the World AIDS Campaign and raising awareness or hosting HIV/AIDS patients on television shows. Some examples of effective interventions include: ??
?? ??
??
Publicizing on television of a child custody case that discriminated against an HTVinfected father leading to the over-turning of the ruling. The whole campaign took a positive direction and impact (Bahrain) Finding employment for HN positive people (Palestine) Use of "triangular" clinics for people living with HTVIAZDS, STD patients and injecting drug users (Islamic Republic of Iran) Keeping an HllV positive student in school using the proper educational and counselling approach (Egypt).
Feasible and priority future actions ?? ?? ?? ??
?? ??
Continue awareness campaigns and intenslfy IEC and media activities including sustaining and stressing the World A I D S Campaign theme. Increasing advocacy at all levels. Enforce implementation of appropriate laws and encouraging new similar ones. Expand HIV/STD care s e ~ c e s . Strengthening harm reduction programmes. Maintain and improve support group including H N ; people and farmlies.
The various groups identified the following list of key messages/slogans for this campaign: ?? ?? ?? ??
??
I have A-TDS, I have the right to live AIDS patients have the right to care I am sick I am not a criminal Fight the act, not the person Live and let live
WHO-EMfSTD1047WL Page 22 ??
?? ?? ?? ??
Extramarital sex without a condom leads to J3l'V/AIDS N drug use and sharing syringes leads to HIVIAIDS We need your support - not discrimination I am human I have made a mistake - Do not hold it against me for the rest of my life I have had HN for 15 years and I am still worlang
?????????-7Plan of actionfor the campaign
?"!
?"?"
-?????'3?I!S????????????? ???7)?-m77!
+ 77)
?*??
?
?
?
Four groups out of five worked on this question; major points mentioned were as follows: Stress public education campaigns emphasizing different modes of transmission Develop and air radio and television messages and spots Carry out advocacy with key religious and community leaders Conduct specific activities with vulnerable groups Use key figures in public campaigns Approach youth clubs Carry out public meetings and television programmes with W- people if possible i t h youth clubs and university groups Organize marathons or paper competitions w Produce educational materials for the occasion, Support neededfi-om the regional level ?? ?? ??
Financial support Technical support in the design, and evaluation of the campaign E C material in Arabic
8.3
Reaching sex workers, MSM and injecting drug users: Lebanon esperience
Reaching the communities of sex workers, drug users and homosexuals in Lebanon is difficult, as such communities are considered to be mar@ and illegal. This is a major obstacle to HIViAIDS and STD prevention among those vulnerable populations, as well as a reason for sarce information about the beliefs, attitude, practices and sexual behaviour of these communities. For this reason the national AIDS control programme, sponsored by UNAIDS and in collaboration with local NGOs, is executing a project entitled "HTVi-UDS prevention through outreach to vulnerable populations in Beirut and its coastal suburbs". A situation analysis was undertaken in order to develop an outreach prevention and education plan. The objectives of the situation analysis were: identifymg the potential sub-populations; exploring the range of high-risk behaviours and risks determinants; identifymg the level of knowiedge among the target groups; identifyrng accessibility of materials (e.g. condoms) and services; and idenlxfjmg channels of comrnunication
WHO - EWSTDI047WL Page 23 Qualitative and quantitative information was gathered through the utilization of tools developed for the purpose of the study, whlch are semi-structured questions for in-depth interview and a structured questionnaire. Expected outcomes include identifpg and training
outreach resource persons (social workers, health educators, ex.) and peer educators; establishing a referral network for health, counselling and social services for vulnerable populations; proposing policy changes in the areas of sex workers, MSM and TDU; and initiating regular outreach for vulnerable populations. 9.
ESSENTIAL PACKAGES FOR BI[V/AIDS COMPREHENSIVE CARE
9.1 Voluntary counselling and testing (VCT): state of the art Dr K. O'Reilly, Coordinator Surveillance Research Moniroring and Evaluation, WHO/HQ
Voluntary counselling and testing (VCT) was originally developed to help people HN, to facilitate bebaviour change to avoid future transmission or acquisition of the virus. It was developed when there were many risks to being tested and found positive, such as inadvertent discloscrre of tesr results, stigma and discrimination, and few benefits other t h a n the possibility of behaviour change and planning for the future. For fear that the intervention would be misused against peoples wills or for other than their own benefit, WHO and UNAIDS adopted the concept of voluntary counselling and testing, to convey the clear message that HIV testing should only be provided at the initiation of the client. VCT has gone on to become one of the most important interventions for HIV prevention around the world. With the advent or the promise of increased availability of antiretroviral drugs in the developing world, VCT has been seen by many, including the UNGASS declaration of 200 1, as the entry point for care. However. VCT is an expensive intervention and one that does not exist in most countries now ready to implement increased access to antiretroviral drugs. Rather than being the entry point for care, VCT may well become the bottleneck in providing care, and what was originally envisioned as a package to safeguard individuals' rights to privacy might actualIy become a barrier to the essential lifesaving drugs that AIDS sllfferers need. Efforts are currently under way to explore how best to streamline the current VCT package to make it more affordable and thus more feasible for scaling up. Similarly, efforts are also under way to explore ways to provide increased access to knowledge of serostatus for patients in various clinical care settings, where informed consent and elective counselling would be standard features but standard VCT might not be. WHO is working with partners to discover how best to increase people's access to ways to know their serostatus and in the process to remove an important potential barrier to access to care. determine whether they were infected with
9.2 Prevention of HIV infection among infants in countries of the Region Dr K. 0 'Reilly Coordinator Surveillance Research Monitoring and Evaluation, WHO/HQ
Enormous enthusiasm has attended the publication of key clinical trials on the use of antiretrovirals to prevent mother-to-child transmission of HIV. The most enthusiastically
WHO - EMfSTD/O47/E/Z Page 24
received of the various mals was the HIVNET 012 trial which evaluated nevirapine, an inexpensive antiretroviral which reduced perinatal transmission by 47%. In 2001 the UNGASS Declaration of Commitment on EWIAIDS set ambitious goals, calling for a 20% reduction in HlV in infants by 2005 and 50% by 2010. Modelhg of these goals and what it will take to reach them has shown that they are not likely to be achieved by 2005 using antiretrovirals alone and could never be reached by 2010 using newapine. Fortunately, the United Nations has set a three-pronged strategy which includes the prevention of HN infection among young women, the prevention of unintended pregnancy among HTV infected women and, finally, the use of antiretrovirals to prevent the transmission of the virus from a pregnant infected woman to her newborn. Emphasis has been placed on thts third strategy in most country plans, though little attention has been paid to how potentially effective it may be and at what cost. Using data from UNICEF sponsored demonstration projects and extrapolating to the national level in eight heavily affected countries in Afi-ica, researchers modelled the cost and effectiveness of the use of nevirapine alone to prevent HIV infants. Results presented indicated that such a programme can be extremely expensive to implement but wiII result in relatively few infant infections prevented, with many infants still being born with KrV. As countries ponder how best to address this difficult and emotional problem, it is imperative that they consider suitable investments in the first two prongs of the United Nations strategy to prevent HIV in infants, not just the k d (antireuoviral) prong. 9.3 Country experience in voluntary counselling and testing: Islamic Republic of Iran and Morocco
Use of and trafficking in drugs is illegal in the Islamic Republic of Iran. First offenders are referred to welfare rehabilitation centres for education, counselling and treatment. Second offenders are sent to day rehabilitation cenees and allowed to return home at night, and thirdtime offenders are sent to inpatient centres or prison. It is estimated that 12%-16% of drug users are intravenous users. Methadone therapy and needle exchange programmes are being explored There are several choices for VCT in the Islamic Republic of I r a n : national blood transfusion centres; triangular clinics, which offer services to injecting drug users, STD and HIVIAIDS patients; and urban health centres with laboratories. All offer fiee-of-charge and confidential services. Informational tools are used during counselling. This approach has shown a steady increase in the number of people ~ i n VCT g services between 1997 and 2000. Morocco is a signatory to two agreements on the rights of people living with AIDS. Ethical considerations on HN screening are taken into consideration in the national strategy on management of HN/AIDS. VCT started in 1993 through partnership between an NGO and the national AlDS programme in which the NGO was responsible for counselling, t e s h g and blood sample collection and the national programme subsidized the cost of testing carried out by laboratories of the Ministry of Health. By 2001 there were 10 functional VCT sites in the country. The experience has resulted in the establishment of a network of screening centres compliant with ethical considerations and enhanced partnershrp and collaboration between the NGOs and national AIDS programme.
WHO- EM/STD/W7/E/L Page 25 9.4 Basic support for institutionalizing safe injection and infection control: SIGN M s S. MacKay, Technical Oficer, Safe Iqection Global Network, KYO/HQ
Injections are one of the most common medical procedures. Each year 16 billion injections are administered in developing and transitional countries. In some counmes use of injections has completely overtaken the real need, reaching proportions no longer based on rational medical practice. A safe injection does no harm, yet breaks in infection control are i t h unsafe injection practices results in the common. Injection overuse combined w transmission of bloodborne pathogens. Preliminary analysis of the I W O Global Burden of Disease study suggests that reuse of syringes and needks in the absence of sterilization may account for 5.4% of new MV infections globally, and 7.1% of new Hn/- infections in the Eastern Mediterranean Region. The Secretariat of the Safe Injection Global Network (SIGX), based in WHO headquarters in Geneva, is undertaking a project to develop a series of tools to assis: countries to assess, plan, implement and evaluate injection safety interventions. As injection safety is a health sector wide problem these interventions are best implemenred by a coalition of partners, including immunization services and essential drugs progarnmes. HTV/AlDS progammes have a key role to play in high level advocacy for the need to improve injection safety and infection control, and in communicating the risks of transmission of HIV and other bloodborne pathogens to both health workers and the community. Further information is available from: The SIGN Secretariat, Blood Safety and Clinical Technology, World Health Organization, 20 Avenue Appia, Geneva, CH 1211 +4 1 22 79 1 1275 fax -41 22 79 1 483 6 sim@,who.int
Discussion Countries where VCT has been used most effectively are those counmes where HIV/AIDS has the highest levels of political commitment. Infection control is of paramount importance in prevention of HlV/AIDS, and includes more than simply safe injections. Some countries, such as Egypt, are uudertaking large-scale assessments of infection control practices and may be able to share experiences. 9.5 Group work 5: Improving country plans
Action plans were formulated for each corntry for the period 2002-2005 with the aim of harmonizing activities in line with the regional strategic plan for improving health sector response to HTV/AIDS.
WHO- EMISTDI047/E/L Page 26 10. CONTFUBUTIONS OF OTHER UNITED NATIONS AGENCIES TO HN RESPONSE IN THE REGION 10.1 UNDCP activities on EIIVIAJDS in the Middle East and North Africa Mr Wolfgang Schiefer, Programme Management Oflcer, W D C P
The United Nations Office of Drug Control and Crime Prevention (LPiODCCP) consists of two programmes: the United Nations International Drug Control Progmmne (UNDCP) and the Centre for Lnternational Crime Prevention. Most of the Office's activities with regard to HIVIAIDS relate to the drug control sector and are undertaken by LBDCP, which is also a cosponsor of UNAIDS. The activities of UNDCP on HIVIAIDS are prirnariiy guided by the Declaration on the Guiding Principles of Demand Reduction, adopted by h e General Assembly Special Session on the World Drug Problem in 1998, which states that states that programmes should cover all areas of demand reduction, including reducing the negative health and social consequences of drug use. This declaration was the first clear mandate for UNDCP to work in the field of HIVIAIDS. Cases of HIV transmission through injecting drug use hive been reported from almost all countries of the Eastern Mediterranean Region, several of whlch report significant IDLr innmission rates (91.7% in Libyan Arab Jamahiriya; 73% in Bahrain). Althougb these data should be interpreted with caution, there is real possibility of development of a high-risk scenario. UNDCP activities with regard to HIVIAIDS are focused on four areas: data collection; prevention; treatment and rehabilitation; and NGO cooperation. Data collection includes conducting situation assessments, including rapid assessments, and capacitybuilding workshops. Prevention activities include youth and public awareness projects. .An example of such projects is the global youth network, for whch more information is avaiIable at httu://odccu.ord~outhneu'. 10.2 UNESCO role in preventive education in the Region Ms Noha Bawazir, Regional Programme Adviser, UNESCO
Health has become an important issue for UNESCO. The 1990 World Conference on Education for All i d d f i e d poor health and malnutrition as major underlying factors for low school enrolment, absenteeism, poor classroom performance and early school dropout. In 2000 health was identified as a key sector for collaboration in achieving education for all. One way in which UNESCO is addressing health is in the formulation of a global strategy for HIVfAIDS preventive education. This strategy consists of advocacy at all levels; customizing messages; promoting safe behaviour and reducing vulnerability; caring for the infected and the affected; and coping with institutional impact. Among UNESCO's WIAIDS-related plans for 2002-2003 in counh-ies of the Eastern Mediterranean Region are: zsessment of school health programmes in selected countries with a special focus on HIV/AIDS; promoting teacher training in sldls-based health education; and awareness-raising among youth about H W risk factors and vulnerability.
WHO- EM/STD/047/E/L Page 27 1 0 3 Current focus of UNAIDS in the Eastern Mediterranean Region Mr Osama Taoil, Team Leader, UNAIDS The Joint United Nations Programme on H I V / A I D S (UNAIDS) was formed in 1996 to promote multisectoral efforts to combat HIVIAIDS. The WAIII)S Secretariat is based in Geneva and includes several country offices. Cosponsors include LO,'Li?uDCP, LXDP, UNESCO, UNFPA, UNICEF, WHO and World Bank.
UNAIDS efforts in the Eastern Meditenanean Region in 2002-2005 are focused on the following areas: support for planning, assessment and programme development across sectors; mobilization of cosponsors in the areas of commitment and human and financial resources; and capacity-building. 11. FIRST MEETING OF THE HIVIAIDS AND STD REGION-IL.DVISORY GROUP The first meeting of the HrV/AJDS and STD Regonal Advisory Group (AR4G) was held on 26 April 2002 in Beirut, Lebanon, in order to set the terms of reference for the Group, elect a Chairman and review the conclusions and recommendations of the twelfth intercountry meeting of national AIDS programme managers. 1 2 . CONCLUSIONS In relation to Target I ??
The adoption of the strategic plan by the Regonal Committee will give important momentum and support to the action of the countries for the fight against HIV/.UDS and STD. Participants are committed to translate this political commitment into effective and relevant national strategies and actions. Reducing stigma is one of the major steps to be taken to improve the quality of the life of the PLWA and those at risk of the intection.
??
In reIation to Target 2 ??
The need for training in different aspects related to HIVIAIDS and STD is a key issue for success of prevention and care interventions.
Z h relation to Target 3
??
There are growing concerns regarding the spread of substance abuse in the Region. Two relatively new alarming trends affecting the vulnerability to HTV/AZDS are an increase in the number of drug abusers who have turned to injecting drug use, and a decrease in their average age.
WHO- EM/STD/047/E/L Page 28 ??
Response in STD control and care has been slow at country level. However, STD control is an essentiaI strategic component in HIV control.
In relation to Target 4: ??
There is. urgent need for countries to improve generation of data and information about the spread of the epidemic, and to expandlintroduce behavioural surveillance.
In relation to Target 5: ??
The HN/A.IDS problem is urgent in countries with complex emergencies.
13. RECOMMENDATIONS
To Member States In relation to Target 1
1.
Conduct a national consultation to address the issue of W/..UDS-related stigma and discrimination. The objectives of the consultation would be to produce a set of recommendations and a plan of action to decrease HIVIAIDS-related sti-ma, h g into consideration special conhtions of national situation. Develop national strategic plans as soon as possible based on strong national response.
2.
3.
Include HNiALDS in any national plans for poverty reduction.
In relation to Target 3 4.
Adopt a multisectoral, interministerial approach to confront substance abuse, allowing the health sector to be involved in all issues, particularly those related to demand reduction linked to harm reduction. Intensify efforts to put into operation syndromic case management for ST13 care. Prepare action plans for negotiating price reductions with pharmaceutical companies, adopting ARV treatment guidelines and training health professionals.
5.
In relation to Target 4
6.
U s eH t V sentinel surveillance, including surveillance among STD patients and STD prevalence assessment, as the basis for monitoring the epidemic. Use rapid assessment studies for injecting drug use and HIV to clarify vulnerability situations.
7.
WHO-EWSTD/047/E/L Page 29 lit relation to Target 5
8.
For countries in complex emergency situations, enhance efforts to secure support from global initiatives such the Global Fund to Fight AIDS, Tuberculosis and malaria.
To WHO
Strengthening capaciq building
9.
Develop a roster of experts on ADDS in the Regon to assist countries in addressing different aspects of the problem. Develop structured training courses in HIVIAIDS and STD priority areas. Support training on rapid appraisal methodologies, and establish a core group of experts in support of this activity. Assist countries in improving the available data through capacity buildmg in different areas of research, includmg methodologies related to rapid assessment and response, in collaboration with other concerned agencies such as Ulu'XIDS and L3DCP. DeveIop relevant indicators for a periodic evaluation system.
10.
11.
12.
13.
Supporting comprehensive and inregratedprevention and care approaches 14.
Support countries in conducting sentinel surveillance and behavioural studies and develop appropriate manuals. Develop essential packages for H I V I A I D S and STD prevention and care and pilot them in counby sites. Enhance interagency collaboration for all aspects of prevention of substance abuse (primary prevention, treatment and rehabilitation), with particular emphasis on injecting drug use. Develop a core goup of experts to support countries in negotiating with pharmaceutical companies and providing access to ARV drugs. Develop plans with other UN agencies for crossborder collaboration in cowimes with complex emergencies.
15.
16.
17.
18.
WHO - EM/STD/047/E/L Page 30
Promoting and sustaining political commitment, public infomarion and mobilization of
resources 19.
Support countries in the deveIopment of proposals for the Global Fund to Fight AIDS, Tuberculosis and Malaria, with special focus on countries in complex emergency situations.
20. ??
Focus on three lines of action to increase awareness and s t r e n o e n national health sector response to KN/AIDS : Enhancing political commitment, including key community, media and religtous leaders Providing technical support to planning, monitoring and evahation of AIDS programme activities at national and regional levels Intensifying resource mobilization.
??
??
WHO-EM/STD/047/E/'L Page 3 1 Annex 1 AGENDA
Inaugural session Global and regional update on HIV/AIDS and STD situation and The regional slrategic plan 2002-2005 for improving the health sector response to HIVIAIDS and STD in the countries of the Eastern Meditenanean Region: What action at country level? Measuring success of the national W A D S and STD health response Operational research in support of scaling up the health sector response to HIV,!AIDS and STD in the Region
-
-
EMRO Small Grants Scheme for communicable diseases Orientation on tools for rapid assessment of needs of vulnerable groups including young people and injecting drug users
Global initiatives for scaling up A I D S response:
-
Global Fund for AIDS, Tuberculosis and Malaria: oppormnity for scaling up the national response to HIVIAIDS and STD epidemic and communicable diseases integrated control Accelerating access to care and support for People Living wirh HIVIAIDS
Technical and managerial issues related to epidemiological sweillance of 13V/A4JDS and STD; review of estimates
Planning for the World AIDS Campaign 2002 Developing essential packages for providing W a i d s comprehensive care
-
-
Voluntary counselling and testing: what options in the context of the Region? Approaches for the prevention of HCV infection among children for the countries of the Region Basic support for institutionalizing safe injection and infection control: the SIGN tools Revised plans for STD prevention and control: what role to inte-gation?
D r a f treport and recommendations Closing session
WHO-EM/STD/047/E/L Page 32
Annex 2 PROGRAMME Tuesday 23 April 2002 08:30-09:00 09:OO-10:30 R e g stration Agenda item 1 : Inaugural session r Zuhair Hallaj, DCDEhlRO Moderated by D Address by Dr Nussein A. Gezairy, WHO Regional Director for the Eastern Mediterranean Message from H.E. Mr Sleiman Franjieh, Minister of PubIic Health, Lebanon Objectives of the meeting, programme and methods of w o r k 0 J. Tawilah, WHOIEMRO Nomination of officers and adoption of agenda of work Agenda Item 2: Global update on HTV/AIDS/STD Global epidemiological update1 Dr A. Ball, WHO/HQ Discussion Agenda Item 3: The Regional Strategic Plan 2002-2003 for Improving the HeaIth Sector Response to HIV/,UDSiSTD in the countries of the Region, regional epidemiological update, progess and key issued Dr J. Tawilah, WHO/EMRO
10:30-11:OO
1l:00-1 l:30
11:30-14:30
Group work 1: implementing the regional strategic pIan at country level Group work I : plenary presentation Agenda Item 4: measuring success of the national W / A I D S and STD health response Framework for assessing the progress in the implementation of the strategic plad Dr K. O 'Reilly, WHO/HQ Group work 2: indicators of progress in health sector response i n the context of the Region Group work 2: plenary presentation Agenda Item 5: Operational research in support of scaling up the health sector response to HJY/AIDS and STD in the Eastern Mediterranean Region EMRO S m a l lG r a n t s Scheme for communicable diseases1Dr A. Bussili, WHO/EMRO
14:30-16:30
16:30-17:30
WHO- EM/STD/047/E/L Page 33
Orientation on tools for rapid assessment of needs of vulnerable groupslDr A. Ball, WHO/HQ Wednesday 24 April 2002
09:OO- 11:30
Agenda Item 6 : Global initiatives for scaling up AIDS response Global Fund for ADS, Tuberculosis and Malaria: opportunity for scaling up the national response to HIVIAIDS and STD epidemic and integrated control of communicable d~seasesl D r A. Ball, WHO/HQ Presentation by Pakistan and Sudan onGFATM Accelerating access to care (AAC) and support for people living with HIVlAIDSIDr B. Varel&, WHO/HQ Presentation by Morocco and Tunisia on AAC initiative Plenary discussion Group work 3: Improving access to care in the countries of the Region Discussions and plans of action Agenda Item 7: Technical and managerial issues related to epidemiological surveillance of HIV/AIDS and STDIDr K. O'Reilly, FHO/HQ Review of reporting forms and estimates by countries Plenary discussion Agenda Item 8: Planning session for the World AIDS Campaign 2002 Presentation by UNAIDSI Mr M. Mahalingam, UNAIDS Group work 4: developing messages and activities for reducing stigma and discrimination in the context of the Region Group work 4 plenary presentations Optional evening session Reaching sex workers, MSM and injecting drug users: findings of assessment study and lessons learned f?om Lebanon (organized and presented by Lebanon NAP team)
11:30-14:30
14:30-16:OO
16:OO-17:30
19:OO-20:30
Thursday 25 April 2002
08:3&11:30
Agenda Item 9: Developing essential packages for HlV/AIDS comprehensive care
VCT: state of the art/ Dr B. Vareldzis, WHO/HQ
WHO - EM/STD/047/E/L Page 34
Experiences in voluntary counselling and testing Presentation by the Islamic Republic of Iran on VCT for injecting drug users Presentation by Morocco on VCT for MSM and other goups and the role of NGOs Approaches for the prevention of HN infection among children for the countries of the Regiod Dr K. 0 'Reilly, KHO/HQ Basic support for institutionalizing safe injection and infection control: the SIGN tools1 Ms S.MacKay, WHO/HQ Presentation b y Egypt on the results of national assessment of injection safety Revised plans for STD prevention and control: role of integration/ Dr C. Soliman, FHI 11:30-14:30 Group work 5: Improving country plans for operationalization 05 HIV voluntary counselling and testing Prevention of HN infection among children
Safe injection and infection control Integrated STD prevention and control 14:30-15:30 15:30-17:30 Group work 5: plenarypresentations Contribution of various United Nations agencies to the HIV response in the Region Presentations by UNALDS, UNDCP, UNESCO, UNICEF Discussion
Friday 26 April 2002 09:OO- 11:OO First meeting of the HTV/AIDS and STD Regional Advisory Group
ARAG (closed meeting for members and on special invitation) 11:00-11:30 Presenting the Plan of ASDDCDIEMRO in support of countries of the Region for 2002-20031 Dr J. Tawilah, U?HO/EiWRO Agenda Item 10: Plenary discussions of draft report and recommendations Closing ceremony/ Dr 2. Hallaj, ?VHO/EMRO
11:30-12:30
12:30-13:OO
WHO-EM/STD/047/E/L Page 35 Annex 3
LIST OF PARTICIPAWS BAHRAIN Dr Somaya Abdul A l Jowdar Chairman of AIDS Counselling Committee Ministry of Health Manama
DJIBOUTI Dr Fatouma Mohamed Ahrned Deputy National AIDS Programme Manager Ministry of Heath Djibouti
EGYPT D r Nasr Essayed National AIDS Programme Manager Ministry of Health and Population Cairo
ISLAMlC REPUBLIC OF IRAN Dr Mohammad Reza Saeidi Chancellor, Kernanshah University of Medical Science Teheran
Dr Seyed Mohammadjavad Parizadeh Vice Chancellor for Health, Mashhad University of Medical Science Teheran Dr Bahram Yeganeh National AIDS Programme Manager Ministry of Health and Medical Education Teheran
JORDAN
Dr Ali Asaad National AIDS Programme Manager Ministry of Health Amman
WHO-EM/STD/047/E/L Page 36 Dr Rajai Said ALAzah Director, AIDS and STD Counselling Centre M i n i s t r y of Health Amman
KUWAIT Dr Rashed AbdeI Aziz A 1 Owaish Director, Public Health Department Ministry of Public Health Kuwait
LEBANON Dr Ibrahim El Hajj Director of Preventive Medicine Miaistry of Public Heath Beirut
Dr Mostapha El Nakib National AIDS P r o ~ Manager ~ ~ e Ministry of Public Health Beirut Ms Jomanah Georges Herrnez Focal Point for Project on Vulnerable Groups National AKDS F'ro gramme Ministry of Public Health Beirut
LIBYAY ARAB J Y A D r Mobamed Ahmed Samrnud National AIDS Programme Manager Secretariat of Health Si
Dr Turkia Ibrahim El Montassir Pharmacist Secretariat of Health Sirt
WHO-EM/STD/047/E/L Page 37 MOROCCO Dr Kamal Alami Head of the STD/AIDS Unit and National ATDS Programme Manager Ministry of Health Rabat Dr Hamida Khattabi Epidemiologist STYAIDS Unit Ministry of Health Rabat
OMAN Dr Ali Ahmed Ba Omar National AIDS P r o ~ Manager ~ e Ministry of Health Muscat
PAKISTAN D r Asma Bokhari National AIDS Programme Manager National Institute of Health Islamabad Professor Abdd Gh&ar Nagi Head of Obstetrics and Gynaecology Department Bolan Medical College Quetta
Professor Shahnaz Baloch Obstetrics and Gynaecology Department Boian Medjcal College Quetta
PALESTINE Dr Izzat Abdel Aziz Joudah NationaI AIDS Programme Manager Ministry of Health Gaza
WHO- EM/STD/047/E/L Page 38 QATAR
Dr Abdul-Latif AI-Khal Chairman, Medicine Department Hammad Medical Corporation Doha
SAUDI ARABLA Dr Naser Saleh A 1 Hozairn Supervisor, H I V Programme b s t r y of Health Riyadh
SOMALIA Dr Moharned Ali Fuji National Programme Officer for Communicable Disease Control Mogadishu
D r Abdinasir Abubakar National Focal Point for WAIDSISTD Gaalkayo
SUDAN Dr Mahgoub Makki El Tayeb Nationa 1KIDS Programme Manager Federal M i n i s t r y of Health Khartoum
Dr Mohumed Siddig Abdel Gadir Mudawi Surveillance Coordinator Federal Ministry of Health Khartoum
D r Abdelgadir Mohamed El Tahir Coordinator, STD/AIDS Programme Kassala State
SYRIAN ARAB REPUBLIC Dr Mutaz Bahlawan Director of Health Centres Directorate Ministry of Health Damascus
WHO-EM/STD/047/E/L Page 39 J3r AbuEl Fadel Abdul Sarnad
Head of A D S Division M i n i s t r y of Health Damascus
TUNISIA Dr Ahmed Maamouri Deputy Manager Primary Health Care Directorate Ministry of Health Tunis
UNITED ARAB EAMIRATES Dr Ali Marzouqi Director Disease Control Department Ministry of Health Abu Dhabi Dr Zainab Nader Khazal Coordinator National AIDS Programme Minisay of Health Abu Dhabi
REPUBLIC OF YEMEN Dr Moharned Taki Eddin National A D S Programme Manager Ministry of Public Health and Population Sana'a
Dr Aaa Abdulla Azzubaidi Deputy National AIDS Programme Ministry of Public Health and Population Sana'a Dr Ali Hamood Al-Mahagry Deputy Director National AIDS Programme Ministry of N l i c Health and Population Sana'a
WHO-EM/STDi047~E~ Page 40 AIDSAWtSTD REGIONAL ADVISORY GROUP (ARAG)
H.E. Mr Marwan Hamadeh State Minister for Displaced People Member of Parliament Member of the UNESCO International Committee on Ethics Beirut
D r Ejaz Rahim Secretary of Health
Federal Ministry of Health Islamabad
Dr Abdallah Sid Ahmed Osman Undersecretary for Health Federal Ministry of Health Khartoum Df Mohammed Mehdi Gooya Director of Disease Control Ministry of Health and Medical Education Teheran
DTJaouad Mahjour Director of Epidemiology and Disease Control Ministry of Health Rabat Dr Amal Ben Said National AIDS Programme Manager Ministry of Public H e a l t h
Tunis Dr Jacques Mokhbat Infectious Disease Specialist Lebanese University Member of the Lebanon National AIDS Committee Founder of the Lebanese .AIDS Society Beirut
Dr Salah Ai Awaidy Disease Control Department Ministry of Health Muscat
WHO-EM/STD/047/E/L Page 4 1
OTHER ORGANIZATIONS FAMILY HEALTH INTERNATIONAL (FEfL) Dr Cherif Soliman STD Consultant,IMPACT Project Cairo UNITED NATIONS ORGANIZATIONS
Joint United Nations Programme on HIVIAIDS (UNAIDS) Mr Mahesh Mahalingam Communication Adviser Geneva
Mr Oussarna Tawil Team Leader Intercowtry Team, Middle East and North Africa Cairo
United Nations International Drug Control Programme (UXDCP) Mr Wolfgang Schiefer Programme Management Officer for the Middle East and North Afnca Cairo
United Nations Educational, Scientific and Cultural Organization (LTPiESCO) Ms Noha Bawazir Liaison Officer Regional Office for Education in the Arab States Beirut
Mr Samir Anouti Consultant Regional Office for Arab States Beirnt United Nations Children's Fund (UNICEF) D r Qussay Al Nahi Regional Health Adviser/Immunization Officer Middle East and North Afiica Regional Office Amman
WHO- EM/STD/047/E/L Page 42
United Nations Relief and Works Agency for Palestinian Refugees in the Pear East (tnVRWA) Dr Jarnil Yusef Chef, Disease Prevention and Control UNRWA Headquarters Branch Amman OBSERVERS
Ms Nathalie El Chemaly National AIDS Programme Ministry of Health Beirut
MI Elie Aaraj Soins Infirmias et Development Cornmunautaire (SIDC) Beirut
Mrs Rana Ibrahim H e a l t h Educator National AIDS Programme Ministry of Health Beirut WHO SECRETARLQT
Dr Hussein A. Gezairy, WHO Regional Director for the Eastern Mediterranean Dr Habib Latiri, WHO Representative, Lebanon D r Hashim El Zein, WHO Representative, Republic of Yemen Dr Zuhair W a j , Director, Communicable Disease Control, Tn;HOE?/fRO Dr Jihane Tawilah, Regional Adviser, KN/A.IDS and STD, WHOtEMRO Dr Akihiro Seita, Regional Adviser, Stop Tuberculosis, WHO/EMRO D r Ahmad Mohit, Regional Adviser, Mental Health and Substance Abuse, WHOEMRO Dr Andrew B a l l ,Responsible Officer for EUROEMRO, Department of WIAIDS, WHOIXQ Dr Kevin OYReilly, Coordinator, Surveillance Research Monitoring and Evaluation, WHOHQ Dr Basil Vareldzis, HN/AIDS Department, WHO/HQ D r Abdo Jurjus, WHO Temporary Advisor, WHOtEMRO Dr Emanuele Capobianco, Medical Officer, STB, WHO/Somalia Dr Susan Mackay, Technical Officer, Safe Injection Global Network (SIGh?, WHOfHQ Dr Keiko Inaba, MedicaI Officer, HTV/AIDS and STD, WHOEMRO Dr Hany Ziady, AIDS Information Exchange Centre, Officer, WHOEMRO D r Amd Bassili, Fellow, Tropical Disease Research, WHOtEMRO Mrs Catherine Foster, Short-term Professional, Editorial Services, WHOlEMRO Mrs Omnep Mahmoud, Administrative Assistant, DCD,WHOZMRO Mrs Maha Metwdy, Senior Secretary, DCD, WHO/EMRO Mrs H a m Awad, Support Administrative Staff, DCD, WHOEMRO Ms Zeinab Aboul Fadl, Support Admitllstrative Staff, DCD, WHO/EAMRO