Prevention in Cameroon 2017 Inter-agency expert team Madiarra - - PowerPoint PPT Presentation

Rapid Assessment of HIV Prevention in Cameroon

Inter-agency expert team

Madiarra Coulibaly (Alliance Cote d’Ivoire) Dagmar Hanisch (UNFPA Zimbabwe) Clémence Bare (ONUSIDA, BR-AOC) Abdelkader Bacha (UNICEF , BR-AOC)

Yaoundé 11 to15 September 2017

Context

• New infections continue, with insufficient changes in

incidence (and stagnation among key populations and young people)

• For every 2 people initiated on ART, 5 new infections occur.
• Resources allocated for prevention are declining with the

growing focus on treatment prevention needs to be strengthened through political and financial mobilisation at all levels

• Global Coalition for Prevention to be lanced in October 2017 –

Cameroon is part of the selected priority countries

• At country level: a complimentary process to others such as

NSP, GF Concept Note, Start free, stay free, AIDS free…

Aim of the Rapid Assessment

Support/strengthen the national prevention response through a systematic evaluation of the (primary) prevention pillars* and their management at country level.

*5 pillars selected at the global level, to be adapted to the country context (see pillars in the plan)

Objectives

• Engage in dialogue with main stakeholders on the national

HIV (primary) prevention strategy, management and coordination of the response, capacities, and implementation

• Identify gaps and bottlenecks
• Strengthen national prevention strategies, especially in

strategic documents, e.g. NSP, GF Concept Note, etc

• Generating recommendations for addressing gaps in the

medium term, as well as needs for technical assistance and resource mobilisation

Rapid Assessment Team

• Regional HIV prevention experts with proven expertise

in programmes as well as strategic analysis (3 UN agencies, International AIDS Alliance)

• Local team – UNAIDS country office, UN Joint Team on

AIDS, and resource persons from government and civil society

Methodology

• Combination of desk review, key informant

interviews, and focus group discussions

• Participatory process, flexible, and adapted to

country needs and analyses (NSP, CN, CoP etc)

• Inclusive dialogue
• Checklist used as guide, adapted to the context
• Meetings with key prevention actors, including

visits to service delivery sites

Limitations

• The standard protocol includes two ‘light’

phases: evaluation and national consultation

• Process was shortened in Cameroon to one

stage only, with short evaluation of 3 days and 1.5 days of national consultation to create a road map

• Meetings were somewhat limited in the

diversity of partners: some key populations (FSW), pharmacy dept, CCM, and private sector could not be visited

Country Profile

100000 200000 300000 400000 500000 600000 560000 380540 (75,5%) 205382 (45,3%) 29962 (7,3%) 123460 175158 175420 73060 202858

• 2016 Prevalence 15-49 ys 3,8% [3,1% - 4,5%]
• Estimated number PLHIV 2016- 560 000, women 356 925,

men 203 793

• Estimated number of new infections (2016) 32 000 of which approx.

20 000 among women and among adolescents 12 509 (all sexes)

• Number of HIV+ adolescents (10-19 ans): Girls 25 446, Boys14 598
• Number of young (15-24 ans) PLHIV Girls 56 011, Boys 20 536
• Annual AIDS-related deaths 29 000

Key Populations Average Prevalence Prevalence / City

Female Sex workers

24,3% Bamenda : 32,8% Douala : 30,6% Bertoua : 24,3% Yaoundé : 23,3% Kribi : 15% Men having sex with men (MSM) 20,6% Yaoundé : 45,1% Douala : 25,7% Bertoua : 9,2% Kribi : 5,9% Bamenda : 3,9%

Analysis of planning and systems for HIV prevention

• 1. National HIV Prevention Strategy
• 2. Results framework and targets
• 3. HIV prevention coordination

structures / systems

• 4. Management and financing capacities

for HIV prevention

Notre plan

Analysis of HIV Prevention Programmes in Cameroon

• 5. Implementation
• Cross-cutting aspects of prevention

implementation

• Condom promotion & distribution
• Key Populations
• HIV prevention among girls and young women

(and their partners) in a context of high prevalence and vulnerability

• Pre-Exposure Prophylaxis (PrEP)

Notre plan (suite)

Main Results

Findings & Recommendations

Part 1- Analysis of HIV Prevention Planning & Systems

• 1. National strategic framework for HIV

prevention

• 2. Results framework and targets
• 3. Prevention architecture & systems
• 4. Management and financing capacities for HIV

prevention

• 1. National Strategic Framework

• 1. National Strategic Framework

(1)

Findings

• Recently developed National AIDS Strategic Plan

2018-2022 contains significant combination prevention component

• Standalone documents for specific prevention areas

exist (Youth & adolescents, gender & HIV, PMTCT , HIV communication strategy, Education sector HIV strategy, condom programming…)

• There are sector strategies targeting young women

(MINJEC, MINESUP , MINPROFF , MINAS, MINEDUB/MINESEC, MINDEFENSE…).

Recommendations

• Develop a two year operational plan with a prevention

component addressing the gaps in primary prevention identified in the respective pillars of this evaluation

• Strengthen the “locations / populations” angle in the
• perational plan, using the ‘cities & HIV’ approach in the 14

selected cities, including youth and key populations

• Some sector strategies need updating in view of the new NSP

and the findings of this assessment

• 1. National Strategic Framework (2)

Technical Assistance

• Development of operational plan / roadmap
• Implementation of the cities approach
• Support to partners for updating of sector strategies
• 1. National Strategic Framework (3)

• 2. Results Framework and Targets

• 2. Results Framework and Targets (1)

Findings:

• Prevention results chain is well articulated in terms of

results and measurable indicators for the major pillars of HIV prevention

• NSP impact level target for prevention (reduction in new

infections) is set at 60% for 2022, below the Fast Track recommendation which envisages a reduction in new infections by 75% in 2020 compared to 2010

• There are currently no district level targets, including for

the high-priority districts

• 2. Results Framework and Targets (2)

Recommendations:

• Analyse and build consensus on impact level targets for reduction of

new infections in light of the Fast Track recommendation – to be discussed

• Develop a Prevention Acceleration Roadmap/two year operational plan

with targets and indicators at central and decentralised levels

• Strengthen data collection by integrating community data and

standardise service packages across geographical areas and funders

Technical Assistance

• For development of road map/operational plan with disaggregated

results framework and operational follow-up systems

• 3. Prevention Architecture - Governance &

coordination

• 3. Prevention Architecture - Governance &

coordination (1) Findings:

• There is leadership of the HIV response, but with a need to

strengthen the prevention aspect

• The multisectoral response is coordinated by GTC/NAC,

located within the MOH

• The health sector response to HIV prevention remains

insufficient, as well as intra-ministerial coordination and creation of synergies between different directorates

• Other sectors (Social Affairs, Youth & Training, Education,

Defense…) are motivated with interesting perspectives but limited impact due to a lack of real coordination and financing, according to discussions

Findings – cont.

• There

is no steering committee

• r

specific technical working group for HIV prevention

• Actual private sector engagement is limited or has little

visibility although there are attempts to reinvigorate PPP in HIV prevention

• There is no partnership forum which is able to address

issues of HIV prevention

• There are thematic working groups in different areas of HIV

prevention but they lack an overall vision and fail to create synergies

• 3. Prevention Architecture - Governance &

coordination (2)

Recommendations:

• Establish a ‘light’ specific multi-sectoral working group for

HIV prevention which includes all key government sectors, civil society, private sector and key partners, with TOR and clear deliverables

• Establish a HIV partnership forum
• Develop a roadmap for HIV prevention activities to be

presented in Geneva (launch of the coalition)

• Carry
• ut

a situational analysis

• f

the institutional framework of the HIV response with support from UNAIDS, with the aim of optimising the existing structures and improving performance

• 3. Prevention Architecture - Governance &

coordination (3)

Technical Assistance:

• Setup of national partnership forum including UNJT
• Consultations on analysis of the institutional framework
• National

dialogue and advocacy with stakeholders for implementation of recommendations from the institutional framework analysis

• To organise a forum with the private sector around HIV

prevention

• 3. Prevention Architecture - Governance &

coordination (4)

• 3. Prevention Architecture
• Coordination of community response (1)

Findings:

• There is a regulatory document for health-related community

interventions but there is need to strengthen coordination of the health-related community response

• 2 types of community cadres:
• Salaried ASC and APS (psycho-social counsellors) under MOH
• Sector or NGO-affiliated voluntary peer educators, whose accountability

and performance are unclear

• Task shifting in HIV prevention: self test, community testing,

community follow-up and continuum of care for PLHIV

• Validation of community cadres
• Weak NGO structures with regard to promoting community voices and

supporting civil society to speak with one voice

Recommendations:

• Follow up and continue the process of establishing one

civil society platform

• Carry out a national dialogue on the role of civil society

in HIV prevention and support implementation of the recommendations from the dialogue

• Lead dialogue on community testing in key populations

and the use of self-testing

Technical assistance: exchange visit with other West

African countries on the creation of a civil society platform ( Burkina Faso, Côte d’Ivoire, Sénégal etc)

• 3. Prevention Architecture
• Coordination of community response (2)

• 4. Prevention Management

Capacity

• 4. Prevention management

capacity

Findings

• Management for Global Fund grants through NAC and

CAMANFAW (civil society)

• Management performance improved with accelerated GF

funds absorption and reprogramming of savings on unit cost for commodities, but some funding remains unspent

• ARV procurement through PPM for GF
• Need for capacity strengthening in programme

management and M&E for most of the civil society partners in for prevention in general (strongly expressed by civil society)

• 5. Financing Prevention

Findings

• Strength: regular REDES (National Health Accounts) – ongoing data

available NHA (REDES) for 2014 and 2015 show:

• Very strong financial dependency on funding from GF and Pepfar
• 9% reduction between 2015 and 2016 of international funding,

accounting for 90% and 77% of all funds mobilised

• Difficult national resource mobilization in recent years with

failure to provide the national counterpart financing (2015, 2016, 2017)

• Unspent funds or budget without possibility of follow-up for other

government sectors

Trends in HIV&AIDS Financing from 2007 to 2015

18.049.143.415 21.302.009.059 34.636.909.946 30.488.171.198 23.985.606.917 25.420.437.252 31.670.143.289 29.020.266.956 30.810.595.582

2007 2008 2009 2010 2011 2012 2013 2014 2015

• 5. Financing Prevention (2)

Findings

• Funding for prevention is within the recommendation of ‘a

quarter for prevention’ by UNAIDS with 23.1% in 2015 and 29.7% in 2016 (treatment 56% in 2015 and 40% in 2016)

• Insufficient absorption of GF funds especially with the

government PR, largely due to delayed grant release, while the multisectoral response requires additional funding

• Anticipated funding: GF – grant negotiations ongoing,

nearly 90m Euros for 3 years, CoP PEPFAR (approx. 40 millions approved for 2017-2018 to start in October

• Need for standardizing service package and unit cost

between funders for sustainability and efficiency gains

• 5. Prevention Financing (3)

Recommendations

• Use the opportunity of GF grant negotiation and the

institutional framework analysis to to review implementation arrangements and financing of the response to realise efficiency gains

• Improve civil society involvement in implementation by

creating a consultation platform and by strengthening capacity at central and especially decentralized levels

• Strengthen domestic resource mobilization for prevention

and diversify funding sources (bilaterals, private sector, government)

• 5. Prevention Financing (4)

Technical Assistance:

• Advocate at the highest political level nationally and with

partners such as the Global Fund, UNAIDS, World Bank, USAID/PEPFAR, ADB, WHO, PNUD, private sector for a study

• n increasing the fiscal space for health/AIDS/innovative

financing and a study on the sustainability of the HIV response

• Exchange visits / consultations with countries which have

created trust funds (Zimbabwe) or national AIDS funds (Cote d’Ivoire)

Part 2 – Programmatic Analysis

Programmatic Analysis (Prevention Pillars)

• 1. Key Populations (1)

Findings

• NSP 2018-2022 takes key populations into account (use of

IBBSS data)

• Funding for the needs of key populations is available (FSW,

MSM, prisoners, part of IDU) with involvement of KP

• rganisations and coordination of key partners for

implementation

• Comprehensive service package including innovations and

TIC for FSW and MSM but not standardised or contained in a regulatory document (lack of standardised interventions and allowances for peer educators )

• Lack of follow-up for HIV positive KP who receive referral

for treatment initiation

• Insufficient

national coverage with programmes limited to big cities

• No community based testing, leading to

missed

• pportunities
• Barriers for reaching targets: self stigmatisation,

legal environment, human rights, administrative processes in the case of prisoners

• Need for recognition and protection of community

cadres working with KP (badges, certificats)

Programmatic Analysis (Prevention Pillars)

• 1. Key Populations (2)

Findings- cont.

• Develop

a manual

• r

implementation guidelines for key populations

• Improve national service coverage
• Continue

advocacy for a harm reduction programme and PreP in NC

• Develop

innovative approaches for BCC, reduction of stigma and discrimination, and promotion of the rights of key populations

Programmatic Analysis (Prevention Pillars)

• 1. Key Populations (3)

RECOMMENDATIONS

• Strengthen protection of community cadres
• Promote dialogue on HIV testing by KP peer educators
• Continued capacity building for medical professionals

and community cadres

• Improve data collection/generation for planning

(survey, community cohort)

Programmatic Analysis (Prevention Pillars)

• 1. Key Populations (4)

RECOMMENDATIONS - cont

• Develop normative documents for services for key

populations: official PMA, payment, and synergies between health sector and community

• Develop new approaches for advocacy against

stigmatisation with specific target groups such as health care workers, religious groups, journalists, law

• enforcement. An example is LILO: « Looking In, Looking
• ut »
• Exchange visits with Senegal for IDU and Cote d’Ivoire for

prisoners

Programmatic Analysis (Prevention Pillars)

• 1. Key Populations (5)

Technical Assistance

• Articulated in NSP for KP

, youth, PMTCT , general population but not for STI

• Distribution declined since 2015 – reason in reduced social

marketing funding for ACMS

• Limited resources for additional procurement
• Per capita distribution well below global recommended

target of 50 condoms per sexually active man per annum

• Several parallel distribution systems – public, social

marketing, NGO, private sector, black market (grey imports)

• Distribution for KP well planned through peer educators

Findings

Programmatic Analysis (Prevention Pillars)

• 2. Condoms and Lubricants (1)

• Distribution channels for other groups not clearly

defined

• Female condom distribution growing but at low levels
• Cost – effect on uptake among youth unclear,

potential access barrier

• Adolescent girls: cultural and traditional barriers,

weak negotiation skills

• Quality concerns outside public sector and project

distribution

• No data on condom distribution in private sector

channels

Findings- cont

Programmatic Analysis (Prevention Pillars)

• 2. Condoms and lubricants (2)

• Condom working group to develop operational CCP

(Comprehensive Condom Programming) plan (integrated in NSP operational plan)

• Integration of condom promotion and distribution in

maximum range of health services (STI, FP , maternity…) – requires health worker training

• Rationalise distribution systems – e.g. NGO collect

supplies at district instead of national level

• Explore non-traditional distribution channels/outlets

such as community, PPP , tertiary institutions) – targeting adolescent girls, their partners, KP outside covered hot spots

Recommendations

Programmatic Analysis (Prevention Pillars)

• 2. Condoms and lubricants (3)

• Strengthen female condom education & distribution – targeted

approach, training of health workers

• Include community strategies targeting religious & traditional

leaders, parents, to reduce access barriers for youth

• Rejuvenate communication targeting young people – channels

& messages (triple protection, Condomize!, etc)

• Establish extent of quality problem and rectify if necessary
• Resource mobilisation for additional supplies, distribution and

promotion

• Establish data collection system for all sectors

Recommendations - cont

Programmatic Analysis (Prevention Pillars)

• 2. Condoms and lubricants (4)

Programmatic Analysis (Prevention Pillars)

• 2. Condoms and lubricants (5)
• Development of CCP – Comprehensive Condom

Programming operational plan

Technical Assistance

Programmatic Analysis (Prevention Pillars)

• 3. Young women and girls and their

partners (1)

Findings

• Multitude of initiatives and programmes for youth and

adolescents, in and out-of-school, led by different ministries (education, youth, family, social affairs) and civil society, but…

• Limited in duration and geographical coverage
• « business as usual » approach
• Duplication and lack of coordination
• Insufficient links with SRH & GBV
• Weak links with services

(testing, STI, GBV..)

Sector-specific Findings

• HIV not included in teacher training
• Weak involvement of education / school system
• Resistance from parents and religious leaders
• Marginalised populations (disabled, prisons…)
• Decision making by young people
• Use of platforms (CMPJ, CIEE..)

Irregular and insuffient funding

➔ Insufficient contributions by line ministries from their domestic funding (despite approved budget allocations)

Programmatic Analysis (Prevention Pillars)

• 3. Young women and girls and their

partners (2)

A momentum which Cameroun could use to bounce back…

• The ALL IN initiative has since 2015 facilitated a national

move towards ending HIV among adolescents

• As the first country in both West and Central Africa to

adopt ALL IN (global initiative launched by UNICEF- UNAIDS and other actors), Cameroon has generated an unprecedented wealth of epidemiological and programmatic data (HIV, SRH, adolescent health, nutrition, violence, education etc) and an in-depth analysis (locations/cities, populations) of bottlenecks for service access. Programmatic Analysis (Prevention Pillars)

• 3. Young women and girls and their

partners (3)

Recommendations

• Coordination platform for prevention actors working with

youth and adolescents (Groupe ALL IN)

• Integrated service package SHR-HIV-STI-GBV (duplicate

models such as the adolescent consulation by HGOPY)

• Establish referral and backwards referral models between

prevention implementers and health and social services

• Harmonisation, collection and disaggregation of data
• Involvement of line ministries in the GF grant making

Technical Assistance

• Develop referral / backwards referral models
• Harmonisation and decentralisation of data collection

Programmatic Analysis (Prevention Pillars)

• 3. Young women and girls and their

partners (4)

Programmatic Analysis (Prevention Pillars)

• 4. Pre-Exposure Prophylaxis (PrEP)

Findings

• Key populations express demand (7,5% of FSW and MSM

use ‘unauthorized’ PreP, IBBSS 2016)

• Stakeholder dialogue ongoing
• Pilot introduction in certain projects (Pepfar, GF) for

populations at high risk

Recommendations

• Undertake cost-effectiveness analysis to provide better

information for scale-up considerations

Technical Assistance

• Exchange visit to a country with scaled up PreP

programme for KP and young girls (South Africa)

Conclusion, Way Forward

• Maintain the political and social momentum for

prevention ➔ roadmap + deliverables

• Synthesis of the rapid assessment
• Prepare Cameroon’s contribution for the launch of the Global

Prevention Coalition

• Need for continued dialogue and refining the analysis of

gaps and bottlenecks in the prevention programme

• Structural adjustment (governance and coordination)
• Increased resource mobilisation (to start with the grant

making negotiations with GF regarding prevention component in the coming grant)

The mission team would like to thank you for your outstanding collaboration and valuable contributions!