1. Current State & Challenges of Eritrea National HIV/AIDS Program Cross-Country Workshop: Malaria and HIV Impact Evaluation Programs Asmara, February 18-22, 2008

2. Outline of Presentation  Country Profile  HIV epidemiology in Eritrea  HIV/STI program goals and principles  National Response to HIV/AIDS/STI  Current Status of Key Interventions  Challenges

3. Map of the State of ERITREA Location Surface area of 125,700 square kilometers Commands > 1,000 km coastal area on the Red Sea 6 admin, 57 sub-zones & 2,564 villages. population of 3.6 million Pop. <16 years old: 50% Rural: Urban – 80:20 Religion - Christian: Muslim 50:50

4. Health Indicators  According to EDHS 2002 Total Fertility Rate: 4.8 (6.1 in 1995) Infant Mortality Rate: 48/1000 (72/1000 in 1995) Under 5 Mortality Rate: 93/1000 (136/1000 in 1995) Annual Growth Rate: 3%  Life Expectancy: 59  DHS + planned for 2008

5. Health Indicators Estimated Maternal Mortality  EDHS 1995 = 998/100,000  Mismay, 2003 = 752/100,000  WHO/UNICEF/WB 2005 = 450/100,000 MDG Target by 2015 = 250/100,000 ANC Coverage = 80% Skilled Delivery Coverage = 27%

6. HIV epidemiology in Eritrea  First AIDS case reported in 1988 in the port city of Assab  Cumulative AIDS cases at the end of 2007 reached >26,000.  Children < 15yrs comprise 6% of the AIDS cases  Peak age for AIDS is 29-34 in males and 20-29 in females  Main mode of transmission is unprotected heterosexual intercourse followed by MTCT

7. Annual AIDS cases reported by health facilities, 2000 - 2007 Shows the burden of AIDS cases to Health Facilities – occupation of beds, treatment and care offered.

8. Health Facility based AIDS Deaths, 2000-2007 With access to ART the quality of life of people living with the virus is expected to improve, although deaths are still expected for some years to come

9. HIV/AIDS/STI Program  Goals: Reduce HIV Transmission Mitigate the impact of HIV/AIDS  Treatment,  Care and Support

10. Principles for HIV/AIDS/STI Interventions  Multi-sectoral approach  Participatory policy design, strategic development, planning, implementation  Decentralization  Community Participation with community driven projects, RRI  The principle of the “three ones”

11. National Response to HIV/AIDS(1)  1992: Established National AIDS Control Program (NACP)  1997: Eritrea’s first five-year strategic plan to fight HIV/AIDS developed  1998: HIV/AIDS/STI policy and policy guidelines  2001: Launching of HAMSET I, 5-Year multi- sector Project to reduce the economic, social and disease burden due to HIV/AIDS, Malaria, STIs and TB

12. National Response to HIV/AIDS(2)  2002: 2 nd National strategic plan(2003-2007) developed  2002-2006: Developed National VCT, PMTCT, ART guide lines  2007: 3 rd National strategic plan(2008- 2012) under development

13. Current Status of selected HIV Services and Indicators  Prevention VCT PMTCT STI treatment Condom distribution and sales BCC Stigma and discrimination  Treatment Care and Support OI prophylaxis and management ART HBC IGA and Orphan support  Surveillance, Monitoring & Evaluation

14. Cumulative Number of free-standing and integrated VCT Centers, 2001-2007 47% of Health Facilities provide VCT services

15. Anseba 15 NRSZ 10 SRSZ 8 MAAKEL 27 DEBUB 22 GBZ 28 Distribution of the 110 VCT Sites by Zones, by end of 2007

16. VCT Clients and those who knew their HIV status by year (1999 –2007)

17. Percent sex distribution of VCT clients, 2005-2007

18. Cumulative PMTCT service providing sites, 2002-2007 31% of Health Facilities are providing PMTCT services

19. Anseba 10 NRSZ 9 SRSZ 9 MAAKEL 12 DEBUB 18 GBZ 20 PMTCT Sites by Zones, 2007 More or less fairly distributed according to population size

20. Pregnant women tested for HIV in PMTCT, 2004-2007 Increase of 73.6% in 2007 from that of 2006

21. HIV testing acceptance rate in PMTCT sites in 2007 95.8% of first ANC attendants in PMTCT sites tested for HIV, showing acceptance of the service. Opt-out approach Acceptance rate of 95.8%

22. PMTCT Outcome, 2007  Babies born from HIV + mothers tested at 18 months= 109  Babies born from HIV + mothers tested negative at age 18 months= 91  % of babies born from HIV + mothers and became HIV negative at age 18 months (91/109*100) 83.5% Vs 65 – 70% without prophylaxis

23. Yearly Male condoms sales & distribution, 2001 – 2007 Distribution has been less starting in 2004

24. Distribution of female condoms, 2004-2007

25. Units of Blood for Transfusion screened for HIV, Syphilis, Hepatitis B & Hepatitis C, 2002-2007

26. Treatment, Care and Support

27. MAAKEL Z. ART Sites by Zone, 2007 ART sites

28. New patients started ART 2005- 2007 & Total About 100 patients per month Survival after 12 months was 93%

29. Sex distribution of patients on ARV in 2007 54% of ARV users are females

30. Yearly Home-based Care Provision

31. Orphans and vulnerable children supported financially as implemented by the MOLHW, 2007 ZonesNumber supported 1. Maakel1718 2. Debub1250 3. Anseba350 4. NRSZ180 5. SRSZ125 6. Gash Barka480 Total4103

32. What is our conclusion in terms of HIV trends in Eritrea?

33. Health Facility based STI Cases, 2000-2007 STI cases are reducing

34. Trends in VCT Attendees HIV Positivity Rate, 2003-2007 HIV positivity rate in VCT attendees is reducing

35. Trend in PMTCT clients HIV positivity rate, 2004 –2007 PMTCT clients HIV positivity rate is decreasing remarkably each year

36. ANC SS HIV % Prevalence Trend by Zones, 2003-2007

37. ANC SS HIV % Prevalence in Major Towns, 2003-2007

38. National ANC SS HIV Prevalence 2003 -2007 Samples from Assab are not yet included

39. HIV Prevalence at ANC Sentinel Surveillance Survey, 1999-2007 Reduction/Stabilization of prevalence is observed across the years. Reduction/Stabilization of prevalence is observed across the years. Samples from Assab are not yet included. It may rise a bit but not above 2%.

40. Challenges for HIV/AIDS Program (1)  Scaling up of HIV related Services (VCT, PMTCT, BCC, ART etc…). Is provider-initiative counselling & testing cost-effective in low HIV prevalence? Do we need to expand VCT, PMTCT and ART to rural areas?  The high cost of drugs and HIV commodities – issue of sustainability. About 20 patients on 2 nd line ART.  Mainstreaming HIV/AIDS in development plan of all government and non-governmental sectors. Are resources available? Competition for resources.

41. Challenges for HIV/AIDS Program(2)  Expansion of HIV/AIDS &TB collaboration program & prevention of multiple drug resistance.  Reaching high-risks groups with effective interventions.  Strengthening M&E system and operational research in intervention areas (focus on results), especially in KAP. Evidence! Evidence!  Estimation/Projection – Is it prevalence or incidence or both or others to appropriately plan, allocate resources? Modelling?  Impact evaluations: How is each intervention area evaluated? The impact of the epidemic on each sector? The cost incurred?