HIV and AIDS/STI and TB Multi-sectoral Strategic Plan Jan 28, 2015 EAST AFRICAN COMMUNITY DRAFT TWO

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1 HIV and AIDS/STI and TB Multi-sectoral Strategic Plan Jan 28, 2015 EAST AFRICAN COMMUNITY DRAFT TWO HIV and AIDS/STI and TB Multisectoral Strategic Plan and Implementation Framework EAC Secretariat, P. O. Box 1096, Arusha, Tanzania. Tel: / Fax: / Website: http// January i

2 HIV and AIDS/STI and TB Multi-sectoral Strategic Plan Jan 28, 2015 Table of Contents Table of Contents... i List of Tables... iii List of Figures... iv Acronyms and abbreviations... i Acknowledgement... iv Preamble... vi Chapter One... 1 EAST AFRICA COMMUNITY BACKGROUND INFORMATION Regional Economic Communities East Africa Community EAC Members States in other Regional Economic Communities EAC protocols EAC Health protocol Other EAC protocols HIV and AIDS, STI and TB Situation HIV and AIDS Sexually Transmitted Infections Tuberculosis... 6 Source: WHO (2014)Chapter Two... 7 Chapter Two Background information EAC HIV and AIDS strategic plan EAC STI and TB strategic plans Review of EAC HIV and AIDS strategic plan 2012/ The HIV and AIDS response in the region SWOT Analysis Development of the Strategic Plan Rationale for review of the strategic plan The strategic planning process Chapter Three REVISED HIV/AIDS, TB AND STI STRATEGIC PLAN Vision, Mission, Goal and Key Results Areas Guiding principles Alignment to the overall EAC strategic plan, EAC protocol on health Key Results Areas KRA 1: Regional alternative and sustainable financing models for HIV and AIDS, TB and STIs established KRA 2: Access to integrated, quality HIV and AIDS, TB, STIs and SRH services and commodities in the EAC regional improved KRA 3: Regional programmes targeting mobile, vulnerable and key populations established and implemented KRA 4: EAC research and knowledge management platform for evidence-based programming established KRA 5: A good Governance, Leadership and Stewardship framework established in the EAC region Chapter Four: Framework for Implementation Institutional arrangements Organizational Strategies i

3 HIV and AIDS/STI and TB Multi-sectoral Strategic Plan Jan 28, Roles and Responsibilities of Stakeholders Communicating the plan Monitoring and Evaluation Funding, Sustainability and Risk Management Funding the Strategy Sustainability Plan Risk Management Plan Appendices Appendix 1: The logical framework matrix...27 ii

4 HIV and AIDS/STI and TB Multi-sectoral Strategic Plan Jan 28, 2015 List of Tables Table 1: Selected Articles in the EAC Protocol on Health... 2 Table 2: Selected Key Features of HIV epidemic in EAC Partner States, Table 3: Sexually transmitted infections among Female Sex Workers in EAC Region... 6 Table 4: Estimated burden of disease caused by TB, 2011 (Number in Thousands)... 7 Table 5: National Strategic Plans for EAC Partner States... 8 iii

5 HIV and AIDS/STI and TB Multi-sectoral Strategic Plan Jan 28, 2015 List of Figures Figure 1: Trend in HIV Prevalence in East Africa Partner States, Figure 2:Prevalence of HIV by Gender... 4 Figure 3: Prevalence of HIV by Age... 4 Figure 4: Percentage respondents reporting having an STI/genital discharge/sore or ulcer in the past 12 months.. 5 Figure 5: Self Reporting of STIs During Past 12 Months Prior to Interview... 6 Figure 6: Percentage of TB Patients in relation to HIV Positivity... 7 iv

6 HIV and AIDS/STI and TB Multi-sectoral Strategic Plan Jan 28, 2015 Acronyms and abbreviations AIDS ANC ART ARV BCC BDHS COMESA CSO CSW DRC EA EAC FSW GARPR GFATM GLIA HAU HCT HIV HMIS IEC IGAD KDHS KNASP LVBC M&E MARP MDAs MDG MoH MSM MTCT NAC NMSF NSP PEPFAR PLHIV PMTCT RDHS REC SADC SGBV SMC SRH STI SWOT TACAIDS TB TDHS THMIS Acquired Immune Deficiency Syndrome Ante Natal Clinic Anti Retroviral Treatment Anti Retro Viral Behavior Change Communication Burundi Demographic and Health Survey Common Market for Eastern and Southern Africa Civil Society Organization Commercial Sex Workers Democratic Republic of Congo East Africa East African Community Female Sex Workers Global AIDS Response Progress report Global Fund for Fighting AIDS, Tuberculosis and Malaria Great Lakes Initiative on AIDS HIV and AIDS Unit HIV Counseling and Testing Human Immune Virus Health Management Information System Information, Education and Communication The Intergovernmental Authority on Development Kenya Demographic and Health Survey Kenya National HIV and AIDS Strategic Plan Lake Victoria Basin Commission Monitoring and Evaluation Most At Risk Population Ministries, Departments and Agencies Millennium Development Goal Ministry of Health Men having sex with Men Mother to Child Transmission National AIDS Council National Multi-sectoral Strategic Framework National Strategic Plan President's Emergency Plan for AIDS Relief Person Living with HIV Prevention of Mother to Child Transmission Rwanda Demographic and Health Survey Regional Economic Community South African Development Community Sexual and Gender Based Violence Safe Male Circumcision Sexual Reproductive Health Sexually Transmitted Infection Strengths, Weaknesses, Opportunities and Threats Tanzania Commission for AIDS Tuberculosis Tanzania Demographic and Health Survey Tanzania HIV and AIDS and Malaria Indicator Survey i

7 HIV and AIDS/STI and TB Multi-sectoral Strategic Plan Jan 28, 2015 TWG TWG UAC UAIS UDHS UHSBS UNAIDS WB WHO ZAC ZNSP Technical Working Group Technical Working Group Uganda AIDS Commission Uganda AIDS Indicator Survey Uganda Demographic and Health Survey Uganda HIV Sero-Behavioural Survey Joint United Nations Programme on AIDS World Bank World Health Organization Zanzibar AIDS Commission Zanzibar National HIV&AIDS Strategic Plan ii

8 HIV and AIDS/STI and TB Multi-sectoral Strategic Plan Jan 28, 2015 iii

9 HIV and AIDS/STI and TB Multi-sectoral Strategic Plan Jan 28, 2015 Acknowledgement iv

10 EAC HIV and AIDS Program Vision An East African Community free of HIV and AIDS, TB and STIs Mission Ensure a coordinated, evidence based and sustainable regional HIV and AIDS, TB and STIs response Guiding Principles 1. Rights based approach 2. Gender transformative approach 3. Respect for autonomy for the Partner States 4. Integration of services 5. Investment approach (Promote efficiency, effectiveness and Sustainability) 6. Country and regional ownership 7. Equitable regional capacity enhancement 8. Multisectoral accountability 9. Meaningful community engagement Niche Regional coordination of the HIV and AIDS, TB and STIs response v

11 Preamble This plan lays out the strategic intents for East African Community (EAC) HIV and AIDS programme for the period The strategic plan will set the boundaries within which the EAC will implement its HIV and AIDS, TB and STIs interventions within the ambits of its mandate. The costed plan will further be a tool for resource mobilization as well as being a reference point for addressing HIV and AIDS, TB and STIs issues that are transboundary in nature within the region. The strategic plan review process: The EAC Secretariat adopted an extensive consultation process of its stakeholders both in the public and private sector domains. This was done in order to take into account the changes in the socio-political, economic, technological and legal environs, and how they influence the dynamics of the HIV and AIDS, TB and STIs response. The approach further sought to generate buy-in by the different stakeholders for purposes of joint ownership and implementation of the strategic plan. To this end, consultative workshops, individual country assessment of areas of focus and assessment of performance of the previous strategy were carried out. East African Community HIV and AIDS programme strategic intents: Through a consultative approach, the vision and mission were reviewed in the context of policy, legislation, technological, political and economical landscape dynamics. These will guide the strategic intents and priority setting in the HIV and AIDS, TB and STIs response. The overall thrust of this plan is to contribute to the reduction in the incidence of HIV, TB and STIs infection in the EAC region in order to secure sustained socioeconomic development. In order to achieve the strategic intents, the EAC Secretariat will depend on the financial, political and technical support from the member states as well as development partners. The secretariat will adopt effective and efficient strategies while mitigating risks to have a more significant impact on the lives of the people in the EAC region and other parts of Africa and the world. Organization of the strategic plan: The strategic plan is organized as follows: Chapter one provides the contextual analysis of HIV and AIDS, TB and STIs globally and in the EA region in particular. Chapter two outlines the background information about EAC HIV and AIDS, TB and STIs program and its past performance. Chapter three delves into the strategic intents based on the gaps identified in the contextual analysis. Chapter four details the institutional arrangement for implementing the plan. The risk analysis and mitigation plan, the monitoring and evaluation framework, and organizational structure are provided as appendices. vi

12 1.1 Regional Economic Communities East Africa Community Chapter One EAST AFRICA COMMUNITY BACKGROUND INFORMATION East African Community (EAC) is the regional intergovernmental organization of the Republics of Burundi, Kenya, Rwanda, United Republic of Tanzania and the Republic of Uganda. The Treaty establishing the EAC was signed on November 30, The vision of EAC is to attain a prosperous, competitive, secure and politically united East Africa. The Mission is to widen and deepen economic, political, social and cultural integration in order to improve the quality of life of the people of East Africa through increased competitiveness, value added production, enhanced trade and investment. The Brand of the East African Community is One People, One Destiny. To-date, the EAC Treaty and the associated protocols signed and implemented have resulted in the achievements of gradual currency convertibility and macro-economic convergence; adoption of common travel documents, work permits and fees for education, tourism, etc; common negotiating frameworks; substantial progress in harmonization of academic and professional qualifications; free movement of capital and harmonization of transport facilitating instruments. Furthermore, there are now many on-going processes to move the EAC to the next phase of integration into a Monetary Union and ultimately a Political Federation of the East African States. The headquarters of the EAC is at Arusha in Tanzania EAC Members States in other Regional Economic Communities In addition to EAC, there are other regional economic communities (REC) that the five partner states belong. These include Common Market for Eastern and Southern Africa (COMESA), The Southern African Development Community (SADC) and The Intergovernmental Authority on Development (IGAD), Southern African Development Community (SADC): SADC was established in 1992 as a regional economic community with a commitment to regional integration and poverty eradication within Southern Africa through economic development and ensuring peace and security. SADC has 15 member states including Tanzania in EAC and Angola, Botswana, Democratic Republic of Congo, Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Seychelles, South Africa, Swaziland, Zambia and Zimbabwe. Common Market for Eastern and Southern Africa (COMESA): COMESA was formed in 1994 to replace the former Preferential Trade Area (PTA) which had existed from the earlier days of It is constituted by 19 member states, namely, Burundi, Kenya, Rwanda, Uganda, Libya, Egypt, Sudan, Eritrea, Djibouti, Ethiopia, DRC, Madagascar, Malawi, Mauritius, Zambia, Zimbabwe, Swaziland, Comoros and Seychelles. The partner states have agreed to co-operate in developing their natural and human resources for the good of all their people' and as such it has a wide-ranging series of objectives which necessarily include in its priorities the promotion of peace and security in the region. The Intergovernmental Authority on Development (IGAD): IGAD was created in 1996 to supersede the Intergovernmental Authority on Drought and Development (IGADD) founded earlier in The Authority has seven members, namely, Kenya and Uganda of EAC and Djibouti, Ethiopia, Somalia, Sudan and Eritrea. One of the objectives of IGAD is to promote and realize the objectives of the Common Market for Eastern and Southern Africa (COMESA) and the African Economic Community. Africa Union: The Sirte Extraordinary Session (1999) of African Heads of State decided to establish an African Union with the vision of: An integrated, prosperous and peaceful Africa, driven by its own citizens and representing a dynamic force in global arena. One of the key objectives of AU is to work with relevant international partners in the eradication of preventable diseases and the promotion of good health on the 1

13 continent; it also endeavors to coordinate and harmonize the policies between the existing and future Regional Economic Communities for the gradual attainment of the objectives of the Union. Against this background, NEPAD is a programme of the African Union (AU), adopted in 2001 the African leaders in 2001 adopted The New Partnership for Africa's Development (NEPAD) as a programme of the AU with the primary objectives of poverty eradication, promotion of sustainable growth and development, and the empowerment of women through building genuine partnerships at country, regional and global levels. NEPAD is active in six thematic areas, namely, -Regional Integration and Infrastructure that is pertinent in this study. The other five areas are Agriculture and Food Security; Climate Change and Natural Resource Management; Human Development; Economic and Corporate Governance; and Cross-cutting Issues, including Gender, Capacity Development and ICT. 1.2 EAC protocols EAC Health protocol The East African Legislative Assembly passed a Bill in 2012 requiring governments to ensure that persons living with or affected by HIV and AIDS are protected from all forms of abuse, discrimination and are provided with appropriate support, care and treatment services. Thereafter, in 2013, the EAC agreed on a protocol on Health whose purpose is to give guidance on how to govern regional co-operation on health and related matters among the Partner States. The vision of the protocol is to have a harmonized and integrated regional health system and services for the improvement of the health and general well-being of the peoples of the Community. The protocol also states that its mission is to provide legal mechanisms for coordination and integration of health systems and services in order to enhance the health of the people in the Community, as spelt out in Article 118 of the Treaty. In line with this, the principal objective of the protocol is to establish, harmonize and operationalize regional health policies and legal frameworks and mechanisms, to facilitate and govern regional cooperation on health and related matters among the Partner States. In general, the Partner States also agreed to cooperate in strengthening regional collaboration and coordination in the health sector, including HIV & AIDS and sexually transmitted infections (STI) control and management. Other relevant articles are as shown in the table below. Table 1: Selected Articles in the EAC Protocol on Health AREAS OF COOPERATION ARTICLES Cooperation on health systems Article 7: Health Systems development and strengthening, Article 8: Regulation of Training, Licensing and Practice of Health health research and policy Professions Cooperation in disease prevention and control Cooperation on HIV and AIDS and sexually transmitted infections prevention, control and management Cooperation in sexual and reproductive health and rights Cooperation in medicines, food safety and quality Source: EAC (2012) Article 10: Prevention and Control of Communicable and Non- Communicable Diseases Article 10: Joint Cross-Border Disease Surveillance and Response Article 11: Epidemiological Surveillance Article 12: Improving Medical Laboratory Services Article 15: Social Mobilization to Prevent and Control Diseases Article 16: Exchange of Surveillance and Epidemic Information Article 21: Prevention and Control Measures Article 22: HIV and AIDS Treatment, Care and Support Article 23: Sexual and Reproductive Health and Rights and Gender Health Issues Article 24: Integration in Sexual and Reproductive Health Services Article 28: Regulation of Medicines and Food Safety and Quality Article 29: Promotion of Local Pharmaceutical Production and Pooled bulk Procurement of Medicines and Health Supplies Other EAC protocols 2

14 The EAC partner states have signed other protocols that have a bearing on the social and economic well being of the population in the individual countries. This includes the Monetary Union Protocol and Protocol on the Establishment of the East African Community Common Market. The objective of the Monetary Union is to promote and maintain monetary and financial stability aimed at facilitating economic integration to attain sustainable growth and development of the community. On the other hand the Protocol on the Establishment of the East African Community Common Market provides for free movement of goods; free movement of persons and labor; rights of establishment and residence; and free movement of services. These two protocols significantly enhance particularly trans-boundary movement of the population which is highly associated with elevating the risk and vulnerability to infection from HIV, tuberculosis (TB) and sexually transmitted infections (STI). 1.3 HIV and AIDS, STI and TB Situation HIV and AIDS Trend in HIV prevalence: According to the UNAIDS 2012 report, the estimated prevalence of HIV among adults years of age in the EAC region was 1.3% for Burundi, 6.1% for Kenya, 2.9% for Rwanda, 7.3% for Uganda and 5.1% for Tanzania. In general, this represents a significant decline from a high of.5% for Burundi in 2005, 10% for Kenya in 1996, 6% for Rwanda in 1990, 13% for Uganda in 1992 and 8% for Tanzania in 1996 as is shown in the Figure below. This overall downward trend in the prevalence of the HIV needs to be sustained during the period of implementing this strategic plan. Secondly, the wide variation in prevalence between 1% and 7% across the partner states requires concerted effort for reducing it in order to ensure that limited sexual transmission occurs in the region. Figure 1: Trend in HIV Prevalence in East Africa Partner States, Burundi Kenya Rwanda Uganda Tanzania Prevalence (%) of HIV Source: UNAIDS Report on the Global AIDS Epidemic HIV prevalence by Gender: In the region, the prevalence of HIV is disproportionately higher among the women than men for all the five partner states. Thus, women become an important target population in this strategic plan. 3

15 Figure 2:Prevalence of HIV by Gender Female Male Total Prevalence (%) of HIV Burundi Kenya Rwanda Uganda Tanzania Partner States Source: UNAIDS Report on the Global AIDS Epidemic HIV prevalence by age: Figures ## shows the trends in HIV prevalence for the general population by age group. The graph indicates that HIV prevalence is more concentrated in the age groups 30 to 44. This age group in general is economically and sexually active, has families and responsibilities and hence those living with HIV need to be protected to live longer productive lives. Figure 3: Prevalence of HIV by Age Prevalence (%) of HIV Burundi Kenya Rwanda Uganda Tanzania Age Groups Source: UNAIDS Report on the Global AIDS Epidemic

16 In 2012, there was a total of 333,400 new infections in the region with the majority being found in Kenya, Tanzania and Uganda. In general, about 4.9 million people were living with HIV out of which nearly 2 million were eligible for ART although only 75% of these were receiving treatment. Since ART became more widely available in the region, there has been a consistent decline in the number of AIDS related deaths in all the countries in the East African Community. Thus, in 2012, a total of 210,000 people were estimated to have died from AIDS with the majority being in Tanzania, Kenya and Uganda (24%) as is shown in the table below. Table 2: Selected Key Features of HIV epidemic in EAC Partner States, 2012 Partner States New Infection PLHIV Number of Adults Deaths Eligible for ART Adults on ART (%) Burundi 4,600 89,000 40, ,800 Kenya 98,000 1,600, , ,000 Rwanda 7, , , ,600 Tanzania 83,000 1,500, , ,000 Uganda 140,000 1,500, , ,000 TOTAL 333,400 4,899,000 1,990, ,400 Source: UNAIDS Report on the Global AIDS Epidemic Sexually Transmitted Infections Prevalence of Sexually Transmitted Infections by gender: STIs other than HIV constitute a big public health problem. I general too, (i) a person with any STI is more likely to acquire HIV through sexual means, and also has an increased risk of sexually transmitting it to others; and (ii) a high incidence of STIs in a population is a marker for a high underlying incidence of unprotected sexual activity, which may contribute to HIV transmission. In the region, a relatively higher percentage of women have STI/genital discharge/sore or ulcer than men as is shown in the figure below. Figure 4: Percentage respondents reporting having an STI/genital discharge/sore or ulcer in the past 12 months Female Male Percentage (%) Respondents Source: Burundi Kenya Rwanda Uganda Tanzania Partner States 5

17 Prevalence of Sexually Transmitted Infections among different groups: There is no consistent data on prevalence of STI among different groups. However, two surveys conducted by IOM in and indicated that the prevalence of STIs among truck drivers and their assistants was 15% for those on the Northern transport corridor but extremely high at 68% for truckers plying the Kampala-Juba transport route, as is shown in the figure below. Figure 5: Self Reporting of STIs During Past 12 Months Prior to Interview Kenya Uganda Percentage of Truckers Urethra Discharge Genital Sore Either Symptom Source: Morris and Ferguson (2005) & Ferguson and Kriitmaa (2007). Among femalse sex workers, there is a varying level of STI infection in the partner states. While in Kenya and Uganda bacterial vaginosis is very common, in the other partner states, Trichomonas vaginalis occurs among about 10% of the female sex workers as is shown in the table below. Table 3: Sexually transmitted infections among Female Sex Workers in EAC Region Types of STIs Partner States Kenya Uganda Tanzania Bacterial vaginosis Syphilis Trichomonas vaginalis Vaginal N. gonorrheoaea Vaginal C. trachomatis Mycoplasma Genitalium 3.2 Chlamydia 1.8 Source:??? Tuberculosis TB disease burden: Globally, there are 22 high-burden countries that account for approximately 80% of all new TB cases arising each year; out of these, nine are in Sub-Saharan Africa including Kenya, Uganda and Tanzania 1 Morris C N & Ferguson A (2005). Hot-spot Mapping of the Northern Corridor Transport Route: Mombasa-Kampala. International Organization for Migration. Nairobi. 2 Ferguson A and Kriitmaa K (2007). Hot-spot Mapping along the Kampala-Juba Transport Route. International Organization for Migration. Kampala 6

18 in East Africa. According to the WHO report of 2012 and , the estimates of the burden of disease caused by TB in the EAC region has decreased during the two reporting periods as is shown in the table below. Mortality rate has decreased in all the three partner states (b) prevalence has increased in Kenya and Tanzania, but decreased for Uganda and (c) Incidence has decreased for Uganda but increased for Tanzania; it remained constant at a high of 120,000 people. Table 4: Estimated burden of disease caused by TB, 2011 (Number in Thousands) Country Mortality Prevalence Incidence HIV+ve Incident TB Cases Change Change Change Change Kenya Uganda Tanzania Source: WHO (2012) & WHO (2014). Many TB patients are also infected with HIV. In the region, at least one in five TB patients are HIV positive. However, in Burundi, Uganda and Tanzania, less than 50% of the HIV positive TB patients have been started on ART. In Rwanda four out of five such patients are on ART compared to a third in Kenya as is shown in the figure below. Figure 6: Percentage of TB Patients in relation to HIV Positivity TB Patients Tested HIV Positive HIV Positive TB Patients Started on ART Percentage (%) of TB Patients Burundi Kenya Rwanda Uganda Tanzania Partner States Source: WHO (2014) 3 7

19 2.1 Background information EAC HIV and AIDS strategic plan Chapter Two REVIEW OF HIV/AIDS STRATEGIC PLAN The national responses to HIV and AIDS in the five EAC countries are guided by their respective national strategic plan as is shown in the table below. In the strategic plans, truckers, host communities, returnees, women and girls affected by sexual and gender based violence, migrant workers, IDUs, MSMs, women petty traders, married couples and young women are mentioned as important target populations. However, the recent Annual EAC report has noted that size estimation of these populations is still a major challenge. Hence, the EAC needs to ensure that the region has adequate capacity and information for guiding the development of effective strategies for an integrated HIV and health service provision to the population in the transport corridor of the region. Table 5: National Strategic Plans for EAC Partner States Partner State National HIV and AIDS Strategic Plan Timeframe Burundi National Strategic Plan on HIV/AIDS Control Kenya Kenya AIDS Strategic Framework 2014/ /19 Rwanda Rwanda HIV and AIDS National Strategic Plan United Republic of Tanzania Mainland???? Zanzibar Zanzibar National HIV&AIDS Strategic Plan Uganda National HIV and AIDS Strategic Plan 2015/ /20 Source: The Burundi strategic plan has a focus on the following key areas: prevention of new infections; prevention of transmission through blood; prevention of MTCT; and, prevention and management of gender based violence. It will also address socio-economic support to PLHIV and comprehensive care of OVC including medical care and educational support. Putting in place a favorable environment for implementation of the NSP and strengthening coordination for the entire national response will be key areas of attention in the period The current Kenya AIDS Strategic Framework has eight strategic directions. Strategic direction one is on reducing new HIV infections while the second one is on improving health outcome and wellness of all people living with HIV. The third strategic direction is on using a human rights approach to facilitate access to services for PLHIV, key populations and other priority groups in all sectors. The fourth strategic direction is on strengthening integration of health and community services while strategic objective five is on strengthening research and innovation to inform the KASF goals. Strategic objectives six, seven and eight are, respectively on: promoting utilization of strategic information for research and monitoring and evaluation (M&E) to enhance programming; increasing domestic financing for a sustainable HIV response; and, promoting accountable leadership for delivery of the KASF results by all sectors and actors. The Rwanda national strategic plan has three impact level results areas towards which all interventions are oriented. These are prevention (reducing new infection in children; reducing new infections through sexual transmission in the population; and, maintaining low levels of blood borne transmission); care and treatment (People living with HIV receive adequate care and support; increasing coverage of ART; and, reducing morbidity related to STI, OI and other co-morbidities among PLHIV); and, mitigation of impact (improving economic status of people infected and affected by HIV; improving social and economic protection of OVC; and, reducing stigma and discrimination towards people infected and affected by HIV). 8

20 Uganda s strategic plan 2015/ /20 has four focus areas, namely, prevention, care and treatment, social support and systems strengthening. Prevention objectives are: to Increase adoption of safer sexual behaviours and reduction in risky behaviours; to scale-up coverage and utilization of biomedical HIV prevention interventions delivered as part of integrated health care services; and, to mitigate underlying socio-cultural, gender and other factors that drive the HIV epidemic. the objectives under care and treatment are to increase access to pre- antiretroviral therapy care for those eligible; to increase access to antiretroviral therapy and sustain provision of chronic-term care for patients initiated on art; to improve quality of chronic HIV care and treatment; and, to strengthen integration of HIV care and treatment within health care programs. in social support and protection, the objectives are to scale up efforts to eliminate stigma and discrimination of PLHIV and other vulnerable groups; to mainstream the needs of PLHIV, OVC and other vulnerable groups4 into other development programs; to develop and implement a life cycle sensitive comprehensive package of social support and protection interventions for PLHIV and other vulnerable groups; and, to engender all social support and protection programs to address the unique needs, gender norms, legal and other structural challenges that make women, girls, men and boys vulnerable to HIV/AIDS. in systems strengthening the objectives are to strengthen the governance and leadership of the multi-sectoral HIV/AIDS response at all levels; to ensure availability of adequate human resource for delivery of quality HIV/AIDS services; to strengthen the procurement and supply chain management system for timely delivery of medical and non-medical products, goods and services required in the delivery of HIV/AIDS services; to ensure coordination and access to quality hiv/aids services; to strengthen the infrastructure for scaling-up the delivery of quality HIV/AIDS services; and to mobilize resources and streamline management for efficient utilization and accountability. In Tanzania, the second National Multi-sectoral Strategic Framework (NMSF) on HIV and AIDS provides strategic guidance in the national response and has eight goals, namely, to (1) create a political, social, economic and cultural environment for the national response to HIV (2) reduce the HIV transmission (3) reduce morbidity and mortality due to HIV and AIDS (4) improve the quality of life of PLHIV and those affected by HIV and AIDS, (5) use relevant and comprehensive evidence provided in HIV-related planning and decisionmaking (6) provide well coordinated, effective, transparent, accountable and sustainable leadership and management structures (7) provide financial, human and technical resources for the implementation of the national response to HIV and (8) translate the NMSF into well-defined operational plans at national and local government authority levels. For Zanzibar, their national HIV&AIDS Strategic plan has five strategic priority areas, namely, prevention of new infections; treatment, care and support of the PLHIV; mitigation of socioeconomic impact of the epidemic; creation of an enabling environment; and research, monitoring and evaluation. (Need Tanzania Strategic Plan) Need TB Strategic plan for aech partner state. Partner State National TB Strategic Plan Timeframe Burundi Kenya Rwanda United Republic of Tanzania Uganda Mainland Zanzibar EAC STI and TB strategic plans Zanzibar Integrated Hiv, Tuberculosis & Leprosy Programme (ZIHTLP) National strategic Plan Vulnerable persons include PWD, the elderly and key populations 9

21 Since the emergence of HIV in the 1980s, STI control efforts in East Africa have increasingly been defined in relation to HIV programme priorities. Although HIV is itself an STI, efforts to prevent its transmission are largely managed through programmes that are funded, implemented and evaluated independently of other STI control efforts. Such a fractured paradigm in East Africa has had unfortunate consequences. Too often, neglected STI programmes the foundation upon which HIV prevention efforts were built collapse due to reduced funding. As a result, In some member states, STI clinics and services are understaffed, understocked or disappearing altogether; pregnant women may be offered HIV tests but are no longer screened for syphilis; and STI reporting, an important marker of sexual transmission trends, has largely collapsed. 2.2 Review of EAC HIV and AIDS strategic plan 2012/ The HIV and AIDS response in the region The EAC strategic plan 5 for addressing HIV/AIDS had four objectives, namely, (i) To scale up regional and national leadership involvement, commitment and ownership for sustainability of HIV and AIDS response (ii) To facilitate the adoption, harmonization and implementation of international and regional protocols, guideline, policies and strategies; (iii) To improve the designing, management, and sustainability of HIV responses at national and regional level; and (iv) To strengthen the coordination and implementation of regional responses for mobile and key populations in the EAC region. Achievements Many achievements were made during the implementation of the Realigned EAC HIV and AIDS Multisectoral Strategic Plan These include the following: i. A comparative analysis of the EAC Partners States HIV, health and related legislation, bills, policies and strategies was carried out by the EAC Secretariat and EANNASO with support from UNDP. The study identified gaps and challenges in the domestic HIV and AIDS legal and regulatory frameworks of Partner States. These findings were used to develop a legal and policy reform framework for the EAC Partner States. ii. The EAC Secretariat in conjunction with civil society spearheaded advocacy for the assent of the HIV and AIDS Prevention and Management Bill by the Partner States. iii. The Secretariat generated vital information to inform policy and programming in the EAC Region by producing the first ever HIV and AIDS Response Report iv. The EAC worked with USAID-East Africa in conducting a cross-border study to provide a regional perspective on the HIV disease burden at cross border communities in the East Africa region; the study also documented the gaps in health and HIV and AIDS services. The results of the study have since been used to design a regional programme to address these gaps. In addition, a regional taskforce for scaling up an integrated Health and HIV and AIDS programming along the transport corridors was formed comprising experts from the Partner States and other stakeholders including the International Organization for Migration (IOM), North Star Alliance (NSA), Family Health International (FHI 360) and EANNASO. The role of the task force is to among others, develop a minimum package of care for mobile and key populations along the transport corridors, conduct mapping of services available at cross-border points and transport corridors in the region and to develop a regional strategy for integrated, health and HIV and AIDS programming along the transport corridors v. The EAC has also conducted sero-behavioural studies among plantation workers and university students in the Republic of Rwanda, in collaboration with the Lake Victoria Basin Commission (LVBC). The outcomes of these studies have been adopted for implementation in the national strategic plan. 5 EAC (2012). Realigned EAC HIV and AIDS Multisectoral Strategic Plan ( ) 10

22 vi. vii. viii. The Secretariat has strengthened partnerships with national and regional stakeholders in the HIV and AIDS response and holds regular Partnership fora to enhance collaboration and buy-in in the implementation of the HIV and AIDS agenda. Key structures have been formed to facilitate the implementation and quality assurance of the activities undertaken by the Secretariat. These structures include the NAC Directors Forum, the Technical Working Group on HIV and AIDS, TB and STIs and the M&E subgroup. The EAC Secretariat also spearheaded the sustainable financing agenda in the region and has been involved in planning a study on Health and HIV and AIDS financing situation in all the EAC Partner States and exploring current financing arrangements to identify issues, risks and innovative options for sustaining the response. After the study, a think tank on sustainable financing will be formed. Challenges: Some of the challenges faced in the implementation of the current plan include: i. Limited resources and over reliance on external funding ii. Frequent release of WHO guidelines has affected the harmonisation process and the EAC has opted to instead work with Partner States to set minimum standards iii. Limited Human Resource capacity SWOT Analysis This sub-section presents the strengths, weaknesses, opportunities and threats as experienced during the implementation of the Realigned EAC HIV and AIDS Multisectoral Strategic Plan Strengths and weaknesses: Strengths are factors which the EAC partner states and the Secretariat can optimize to deliver on this strategic plan while the weaknesses should be addressed to minimize their negative impacts on achievement of the desired outcomes in the implementation of the strategic plan. The table below summarizes the identified strengths and weaknesses. Strengths 1 Legal and political mandate drawn from the EAC treaty 2 Programming and policy framework - national multisectoral Strategies and plans 3 There are institutional arrangements and structures (NACs/CNLS, including decentralized service delivery structures) 4 There is strong leadership and political commitment and support from partner states 5 The EAC Secretariat has qualified and committed human resource and expertise 6 There is research capacity to generate evidence to inform regional interventions 7 Availability of experiences and best practice from other RECs to inform programming 8 Good relations and established partnerships with other RECs 9 There is political stability in the EAC region conducive for effective programming Weaknesses 1 There exist many unharmonized strategic plans within the partner states thus leading to duplication and resource misallocation 2 The shortage of sufficient number of staff at the EAC secretariat affects the scope and scale of programming 3 The multiplicity in planning cycles across the partner states minimizes the effectiveness in coordination of monitoring performance in the region 4 The capacity by EAC secretariat to monitor work plans and provide technical support to partner states is limited by small number of staff 5 Weak financial base affects the scope and scale of programs 6 There is lack of harmonized data about the HIV/AIDS/TB and STIs in the region Opportunities and Threats: Opportunities are factors in the external environment to the EAC secretariat and its partner states that can be harnessed to support implementation of the strategic plan. On the other hand, threats are factors that are likely to interfere with the achievement of the desired outcomes in the implementation of the strategic plan. In both cases, they present as global or regional changes in policies, politics, laws, science and technology, economic climate, social trends among others that directly or indirectly impact on implementation of strategic plan. The table below outlines some of these factors. 11

23 Opportunities 1 Willingness and commitment of donors to support interventions (GF-New Funding Model, WB, SIDA, CHAI, UN family, PEPFAR) 2 There is room for integration of TB and HIV interventions under NFM 3 Presence of other Regional Economic and Health Communities (SADC, ECASA, GLIA) 4 Presence of CSOs to support implementation of programs 5 Improving political willingness to health interventions 6 Establishment of sustainable funding mechanism (AIDS Trust Funds) 7 Implementation of Maputo declaration (declaration of diseases such as TB, HIV as emergency) 8 Potential for local production of commodities and bulk procurement 9 Potential for technical expertise e.g. for joint research with academic institutions in the region 10 Existing Common Market protocol (and other legal regional, continental and international instruments and frameworks within and with the EAC) 11 On-going harmonization processes within the Health Sector (e.g. Medicines regulation harmonization) 12 New technologies for prevention Threats 1 Delayed contributions from the partner states 2 inadequate capacity in Human Resources at EAC 3 Lack of enough professional staff adequate number of staff 4 Sustainability of fund at EAC 5 Inadequate of harmonized focus at the partners states level 6 Political instabilities & elections 7 Outbreak of communicable diseases 8 Dependency on external donors 9 Rapid change of global policies/guidelines that affect EAC Partner States 10 Coalition of the willing 11 Competition between/among RECs 12 Post 2015-agenda ----what it will focus on vs HIV/AID, TB and STI 13 Other competing agendas at the international level 14 Competing mandates e.g between EAC and ECASA 2.3 Development of the Strategic Plan Rationale for review of the strategic plan This strategic plan is designed to address changes in the HIV/AIDS, TB and STIs context globally and in the EAC region in particular. It recognizes the new threats and opportunities that have emerged overtime within the realms of the EAC and the need to improve on the efficiency in the way the EAC Secretariat and partner states do business. The costed operational plan will further serve as a resource mobilization tool given the changing priorities not captured in the previous strategic plan. The strategic plan is designed for the EAC secretariat and the partner states in order to address HIV/AIDS, TB and STIs issues which are transboundary in nature and upon which individual states do not have the sole mandate to manage. Some of these issues require managing through strategies that take into account economies of scale, and comparative advantage of individual partner states. The EAC Secretariat will therefore support partner countries to look at global and regional issues related to HIV/AIDS/TB/SRH in a coordinated manner through fostering regional capacity in research, knowledge management and monitoring and evaluation. This plan will also provide a linkage with other partner state strategic plans as well as other existing plans of the EAC and other regional economic blocks through setting the agenda to guide other sectors and to mainstream some of the activities in their work plans. It will further create a linkage with other social sector plans under the EAC secretariat like tourist, education, transport and infrastructure at country level in order to foster coordination, minimizing duplication of efforts and efficient resource use through strategic focus on high impact areas that are of transboundary in nature. Furthermore, this strategy will enhance cross country learning through adoption of good practices, developing uniform standards and continuity of interventions across the regions. It will also enable partner countries belong to more than one REC to make guided commitments beyond health The strategic planning process 12

24 The EAC Secretariat adopted an extensive consultation process of its stakeholders both in the public and private sector domains. This was done in order to take into account the changes in the socio-political, economic, technological and legal environs, and how they influence the dynamics of the HIV and AIDS, TB and STIs response. The approach further sought to generate buy-in by the different stakeholders for purposes of joint ownership and implementation of the strategic plan. To this end, consultative workshops, individual country assessment of areas of focus and assessment of performance of the previous strategy were carried out. Questions and KI interviews Sectoral committee on health TWG on research research priorities in Mombasa 13

25 Chapter Three REVISED HIV/AIDS, TB AND STI STRATEGIC PLAN Vision, Mission, Goal and Key Results Areas Vision: An East African Community free of HIV and AIDS, TB and STIs Mission: Ensure a coordinated, evidence based and sustainable regional HIV and AIDS, TB and STIs response. Goal: To reduce the incidence and mitigate the impact of HIV, TB and STIs in order to secure sustained socioeconomic development in the region. Key Results Areas: The key results areas (KRA) are: 1. Regional alternative and sustainable financing models for HIV and AIDS, TB and STIs established 2. Access to integrated, quality HIV and AIDS, TB, STIs and SRH services and commodities in the EAC regional improved 3. Regional programmes targeting mobile, vulnerable and key populations established and implemented 4. EAC research and knowledge management platform for evidence-based programming established 5. A good governance, leadership and Stewardship framework established in the EAC region 3.2 Guiding principles In implementing this strategic plan, the EAC Secretariat and partner states will be guided by the following principles: 1 Rights based approach; 2 Gender transformative approach; 3 Respect for autonomy for the Partner States; 4 Integration of services; 5 Investment approach (Promote efficiency, effectiveness and Sustainability); 6 Country and regional ownership; 7 Equitable regional capacity enhancement; 8 Multisectoral accountability; and 9 Meaningful community engagement. Right based approach: In this strategic plan, efforts will be made to support the development of the capacities of duty-bearers to meet their obligations and/or of rights-holders to claim their rights. Gender transformative approach: Efforts will be made to transform unequal gender relations in order to promote shared power, control of resources, decision-making, support for women s empowerment and achieve positive development outcomes. Respect for autonomy for the Partner State: Regional approaches undertaken at the EAC level shall not be allowed to conflict with those at the national level so as not to undermine the autonomy and sovereign structures and systems of the individual Partner States. Country and regional ownership: The EAC shall take responsibility for setting its own Vision and Goals and Objectives of the regional response to HIV and AIDS epidemic. In this respect, the EAC Secretariat, being the executive arm of the Community, shall make a conscious effort towards the ownership of the processes during the operationalisation of this Strategic Plan, which entails the building of a supportive policy environment and a EAC-led system that would increase space for Member States to take the lead in, and ownership of, region-wide interventions. In the context of this ideal, the EAC shall encourage the form of cooperation and collaboration with all strategic stakeholders that is consistent with the Community s identified programmes and activities. Multisectoral accountability: In adherence to one of the key principles of EAC s 4th Development Strategy of accelerating wider and deeper integration among the people of East Africa, this plan has been driven by a strong multisectoral engagement through engaging big across section of stakeholders in the arena of EAC/ HIV & AIDS. In the same way the implementation of the plan shall be driven by a multisectoral approach. This will involve building viable, strategic partnerships with other EAC sectors, in collaboration with Partner States and various stakeholders at the various levels as a way of raising and galvanizing partnerships so as to attain the 14

26 optimum impact needed in the elimination of new infections and keeping people alive, HIV&AIDS towards count down to zero in 2015 and the realization of Global targets. In this regard, EAC HIV and AIDS unit will strongly seek for support to foster harmony and complimentary framework within the EAC, at the national and global level to champion responses to the HIV and AIDS epidemic. Meaningful community engagement: xx Equitable regional capacity enhancement: xx Integration of services: xx Investment approach: xx 3.3 Alignment to the overall EAC strategic plan, EAC protocol on health There is a strong linkage between the EAC Development Strategy 2011/ /16, the EAC Protocol on Health and the EAC strategic plan on HIV/AIDS, TB and STI in terms of vision, goal and objectives as is summarized in the table below. This underscores the fact that indeed EAC (a) in the response to HIV/AIDS, TB and STI, is complaint with other EAC instruments for enhancing cooperation in the region, (b) is going to focus on aspects of the health protocol that it has comparative advantage in coordinating and/or facilitating implementation by the partner states (c) will be contributing to the regional and national goals and aspirations as encapsulated in the overarching EAC development strategy. Table: Alignment between EAC strategic plan, EAC protocol on health and EAC Development Strategy EAC Development Strategy 2011/ /16 EAC Protocol on health 2013 EAC HIV/AIDS, TB and STI Strategic Plan Vision To attain a prosperous, competitive, secure and politically united East Africa To have a harmonized and integrated regional health system and services for the improvement of the health and general well-being of An East African Community free of HIV and AIDS, TB and STIs Mission Goal To widen and deepen economic, political, social and cultural integration in order to improve the quality of life of the people of East Africa through increased competitiveness, value added production, enhanced trade and investment. To develop policies and programmes aimed at widening and deepening cooperation among the Partner States in political, social and cultural fields; research and technology, defense, security and legal and judicial affairs. the peoples of the Community To provide legal mechanisms for coordination and integration of health systems and services in order to enhance the health of the people in the Community, To establish, harmonize and operationalize regional health policies and legal frameworks and mechanisms, to facilitate and govern regional cooperation on health and related matters among the Partner States. To provide coordinated, evidence based and effective regional HIV and AIDS, TB and STIs response To reduced incidence of HIV, TB and STIs infection in the East African Community region in order to secure sustained socio- economic development 3.4 Key Results Areas KRA 1: Regional alternative and sustainable financing models for HIV and AIDS, TB and STIs established Rationale Provision of adequate resources in a timely manner is one of the key pre-requisites for the region response to HIV and AIDS epidemic; this should be accompanied with effective and efficient allocation and utilization of the resources. Domestic investment in HIV and AIDS has continued to increase in the partners states although in general, the amounts remain lower than the contribution from development partners. Based on the national AIDS Spending Assessment, all the five Eastern Africa countries have a donor dependency of over 50%. In 15