TO DEVELOP A COMPREHENSIVE NATIONAL RESPONSE TO …docs.theglobalfund.org/program-documents/GF_PD_001_118bf... · 2017-03-30 · PROPOSAL GOAL: TO DEVELOP A COMPREHENSIVE NATIONAL

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PROPOSAL GOAL:

TO DEVELOP A COMPREHENSIVE NATIONAL RESPONSE TO HIV/AIDS THAT INCLUDES ADEQUATE PREVENTION, TREATMENT, CARE AND

SUPPORT FOR THOSE AFFECTED.

SIERRA LEONE

April 2004

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LIST OF ACRONYMS USED AIDS Acquired Immune Deficiency Syndrome ARG AIDS Response Group ARV Anti-Retrovirals BCC Behavior Change Communication CADO Community Animation Development Organization CBO Community-Based Organization CARE Cooperative for American Relief Everywhere CCF Christian Children’s Fund CCM Country Coordinating Mechanism CCP Country Coordinated Proposal CRS Catholic Relief Services CCSI Community and Civil Society Initiative CCSL Christian Council of Sierra Leone CDC Centers for Disease Control and Prevention CES Christian Extension Service CHASL Christian Health Association of Sierra Leone CMS Central Medical Stores CO Country Office COMAHS College of Medicine and Allied Health Sciences CSMP Condom Social Marketing Project CSW Commercial Sex Workers DHMT District Health Management Team DPI Directorate of Planning and Information EPI Expanded Program of Immunization FBO Faith-Based Organization FP Family Planning GF/GFATM Global Fund to fight AIDS, TB and Malaria GOSL Government of Sierra Leone HAART Highly Active Anti-Retroviral Therapy HACSA HIV/AIDS Care and Support Association HSDRP Health Sector Development and Recovery Project HIV Human Immuno-deficiency Virus IBRD International Bank for Reconstruction and Development ICB International Competitive Bidding IDA International Development Agency IEC Information, Education and Communication IHSIP Integrated Health Sector Investment Project IMC International Medical Corps IRC International Rescue Committee M&E Monitoring and Evaluation MAP Multi-Country AIDS Program MCH Mother and Child Health MOHS Ministry of Health and Sanitation MRC Medical Research Council MSF Médecins Sans Frontières (B-Belgium, F-France, H-Holland) MSS Marie Stopes Society MSWGCA Ministry of Social Welfare, Gender and Children’s Affairs NAC National AIDS Council NaCSA National Commission for Social Action NAS National AIDS Secretariat NCB National Competitive Bidding NGO Non-Governmental Organization OVC Orphans and Vulnerable Children PCSL Peace Child Sierra Leone PHU Peripheral Health Unit PLWHA Person(s) Living with HIV/AIDS

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PMTCT/PPTCT Prevention of Mother/Parent-to-Child Transmission PPASL Planned Parenthood Association of Sierra Leone PR Principal Recipient RH Reproductive Health SHARP SL HIV/AIDS Response Project (World Bank MAP-funded) SL Sierra Leone SSL Statistics Sierra Leone STI Sexually Transmitted Infections SWAA Society for Women and AIDS in Africa TBA Traditional Birth Attendant UAF Urgent Action Fund UCI Universal Childhood Immunizations UMC/UMCOR United Methodist Church/Committee on Relief UNAIDS United Nations Joint Program on HIV/AIDS UNDP United Nations Development Program UNFPA United Nations Fund for Population Activities UNHCR United Nations High Commissioner for Refugees UNICEF United Nations International Children’s Fund UNIFEM United Nations Fund for Women VCCT/VCT Voluntary and Confidential Counseling and Testing WHO World Health Organization WICM Women In Crisis Movement WVSL World Vision Sierra Leone YWDO Youth, Welfare and Development Organization YWCA Young Women’s Christian Association

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HIV/AIDS SPECIFIC ATTACHMENTS

1. Adolescent and HIV/AIDS in Sierra Leone - Facts and Figures (UNICEF 2002)

2. Adolescents Knowledge, Attitude and Practices concerning HIV/AIDS in Sierra

Leone – UNICEF - 2002

3. ARC KAP Survey among Commercial Sex Workers, Military and Youths in

Port Loko District 2001

4. HIV/AIDS in Sierra Leone, Situation Analysis 2001

5. HIV/AIDS Sero Prevalence and Behavioural Risk Factor Survey - Final Report

(CDC 2002)

6. Manual on Syndromic Management of Sexually Transmitted Infections for

Peripheral Health Unit Workers (September 2002)

7. National Health Policy (draft) 2002

8. Report on a Comprehensive Assessment of the HIV/AIDS Situation in Sierra

Leone and the National Response – CDC 2003

9. Sierra Leone HIV/AIDS Policy (Draft) 2001

10. Sierra Leone HIV/AIDS Project Appraisal Document (2002)

11. Survey Report on the Status of Women and Children in Sierra Leone at the

end of the Decade – 2002

12. The Health Sector Response to HIV/AIDS in Sierra Leone (January 2002)

13. Sierra Leone HIV/AIDS Strategic Plan 2004-2008

14. The HIV/AIDS Health Sector Response Annual Report 2003

15. The CCM Meeting Minutes

16. Summary of Antenatal Sentinel Surveillance Testing

17. Map of Sierra Leone

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Figure 1. Map of Sierra Leone, showing the districts

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2 Executive Summary

[Please note: The Executive Summary will be used to present an overview of the proposal to various members of the Secretariat, the Technical Review Panel and the Board of The Global Fund. NOTE: THIS SECTION TO BE COMPLETED AFTER THE OTHER SECTIONS HAVE BEEN FILLED IN]

2.1 Component and Funding Summary

Table 2.1 – Total Funding Summary Total funds requested in USD

Year 1 Year 2 Year 3 Year 4 Year 5 Total HIV/AIDS 5,279,624 3,294,634 3,427,435 3,308,768 2,594,743 17,905,204Tuberculosis Malaria HIV/TB Integrated Total 5,279,624 3,294,634 3,427,435 3,308,768 2,594,743 17,905,204

2.2 Proposal Evaluation

[Please specify how you would like your proposal to be evaluated:]

The Proposal should be evaluated as a whole X The Proposal should be evaluated as separate components

2.3 Proposal Summary

[Please include quantitative information where possible (4-6 paragraphs total):

• Describe the goals, objectives and key service delivery areas per component, including expected results and timeframe for achieving these results. Specify the beneficiaries of the proposal per component and the benefits expected to accrue to them (including target populations and their estimated number).

The goal of the HIV/AIDS component is to develop a comprehensive national response to HIV/AIDS encompassing adequate prevention, treatment, care and support for those affected in Sierra Leone

• 50 percent (approx. 1.5million) of adolescents and youth aged 10-24 will benefit from knowledge, skills and services to protect themselves from HIV infection,

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• 8 million condoms will be procured so that together with contribution from other donors so as to ensure at least 80 percent of the condom needs of the adult population, 15-49 years.

• Over four million people will be reached through well-structured mass communication programmes on HIV/AIDS prevention, care and treatment;

• 70% of the population will be sensitized on the gender dimension of the AIDS epidemic and 65% of women and girls will be provided with information and skills to protect themselves.

• Capacity will be strengthened and partnerships will be forged at all levels with the view to ensuring the care and protection of over 770 AIDS orphans and other children affected by HIV/AIDS and war, while 387 OVC will be directly assisted by the project with nutrition and education support

• At least 90 percent of adults in all districts will be made aware of the existence and location of VCCT and PPTCT services;

• At least 30 VCCT centres will be functional; • At least 30 PPTCT centres will be functional; • The number of people receiving counseling and testing will reach over

20,000 per year • 8 clinics will have developed capacity to administer ARV treatment and will

be treating 700 per year, moving onto 1000 per year as VCCT uptake improves

• The percentage of women accepting VCCT testing in the maternities where services are offered will increase to 70 percent.

• At least 50% babies born to HIV positive mothers will receive Nevirapine according to national guidelines,

• 1898 PLWHA will receive nutrition support, IGA training and home-base care, with 80% receiving at least three HBC visits a month.

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HIV/AIDS Goal: To develop a comprehensive national response to HIV/AIDS encompassing adequate prevention, treatment, care and support for those affected in Sierra Leone.

Objective with broad activity Expected results 1. To increase knowledge and promote behavioural change on HIV/AIDS through drama aappropriate communications channels in two districts

By 1) National high profile advocacy, including command drama performance to be attended by the His Excellency the President. 2) Drama and facilitation at District and Chiefdom levels.

30% of rural population know correct transmission

routes and 3 ways of preventing HIV/AIDS Program is scaled up to cover the whole country

within 5years and

500,000 rural people will be reached through drama and have their misconceptions dispelled by trained facilitators

Successful pilot developed for scale up within 2years

2. To prevent HIV/AIDS transmission by ensuring the availability of safe blood nationwide by 2009.

By 1) Training of 38 laboratory

technicians 2) Training of 130 blood

promoters 3) Training of 19 Medical

Superintendents on appropriate use of blood

100% of all blood transfusions screened by 2009

3. To provide knowledge and skills on STI/HIV/AIDS prevention to youths. By 1)School based programmes 2)Community based programmes 3)Establishment of a youth centre 4)Provision of information and services

• 70% of young people, in particular out-of-

school youth, will received information and skills by 2009 and

• 10,640 peer educators/animators

(2000/year) will be trained to educate and counsel youth.

• One youth center will be established benefiting more than 10,000 young men and women.

• Approx. 100 youth associations will receive institutional and technical support

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Ministry of education capacity will be strengthened. • 2280 school teachers will be trained on

HIV/AIDS and use of new materials/curriculum on HIV/AIDS life skills and information

• 100,000 school children will be counselled, within 2years

Parents and community leaders will be mobilized.

4. To promote access to and promote correct and consistent condom use in the general populatand amongst vulnerable groups. By Promotion and distribution of condoms

• 90% sexually active population use condoms correctly and persistently by 2009 and

• 8 million condoms will be distributed • 3 million people will be reached through

IEC • 1000 sex workers and partners will

participate in operations research on acceptability of condoms within 2years

5. To strengthen and expand services for sexually transmitted infections By: 1) Training of 802 HW in STI 2) Expansion to 200 STI

treatment sites over the next 4 years

3) Deployment of staff for STI clinics

4) Procurement and distribution, of all necessary supplies (drugs, laboratory supplies etc)

5) Development and implementation of supervisory system

90 %of STI cases properly treated by 2009

90% of persons with STIs symptoms will have access to STI syndromic management services. and

750 staff members trained and posted for STI Initially 30% later up to 70% of patients

treated for STI Initially monthly, later quarterly supervisory

visits in place within 2 years

6. To reduce the transmission of HIV from parent to child through the provision of prevention parent to child transmission (PPTCT) services in 13 districts

By 1) Mobilisation of communities for

PPTCT 2) Training of HW in PPTCT 3) Provision of VCCT in ANC 4) Provision of supplies both

drugs and laboratory supplies

80 % of women accepting VCCT in ANC 15% of partners come for VCCT 50% of mothers with HIV wean their child at

6 months after exclusive breastfeeding within 5 years and

1434 HW trained

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5) Care for mothers living with HIV and their children (antenatal, delivery, postnatal and infant feeding care)

130 counsellors trained 30 ANC sites providing full care (VCCT,

antenatal, delivery and postnatal care within 2 years)

7. To improve access to and utilization of Voluntary Confidential Counselling and Testing (VCCT) services in 13 districts

By 1) Mobilisation of communities for

VCCT 2) Training of HW in VCCT 3) Provision of VCCT centres 4) Provision of laboratory supplies 5) Implementation of a

supervisory system for quality of VCCT

• 50,000 clients accepted VCCT • 60% of all STI patients accepted VCCT • 85% of clients return for their results • 170 counsellors trained within 5 yearsand

91 HW trained after 2 years 30 VCCT centres established and

functional after 2 years supervisory system in place and functional

after 1 year 8. To improve access to and utilization of ARVs in 13 districts By: 6) Establishment of ART management

units within university and MOHS 7) Training of HW in ART for

initially 3 later several treatment centres

8) ARV pilot phase for 1 year and expansion over the next 4 years

9) Deployment of staff for ART treatment centres

10) Procurement and distribution, of all necessary supplies (ARV, lab supplies etc)


1500 PLWHA on ART by 2009 95% adherence rate for ART 80% of PLWHA on ART economically

viable within 5 years and

ART management units in place and functional Pilot phase developed and implemented at

10 centres 72 staff members trained and posted for

ART Starting with the documented 25, who have

started but who could not continue due to cost barriers, then initially 200 and later up to 1500 patients on ART

Initially monthly, later quarterly supervisory visits in place within 2years

9. To provide prevention, care, support and treatment to special groups By: 12) Training of 20 HW for special

groups 13) Procurement and distribution,

of all necessary supplies (drugs, laboratory supplies etc)


70% miners and CSWs treated by 2009 60 % miners and CSWs accessed VCCT, PPTCT and ARVs by 2009

20 staff members trained and posted for Special groups

Initially 30% later up to 70% miners and CSWs treated for STI

50 peer educators trained for miners and CSWs

600 CSWs receive vocational skills training 100 CSWs receive start vocational up kits

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Initially monthly, later quarterly supervisory visits in place within 2 years

10. To provide palliative care and support to PLWHA and OVCs, particularly in war affected areas.By 1) Training of trainers in community care 2) Mobilisation and training of

health workers and community volunteers

3) Procurement and distribution of home care supplies

4) Implementation of community care programme

50% of PLWHA feel accepted by their communities and families

50% of communities support volunteers in community care

50% of PLWHA disclose HIV status to family members

1398 PLWHA receive nutrition support and IGA training

387 OVC receive nutrition support 1,302 HW and community volunteers

trained for HBC within 5 years and

146 trainers trained 400 community volunteers functional at

chiefdom level 356 PLWHA receive home care kits 135 OVC care givers/foster parents trained 135 OVCs recive nutrition support 600 PLWHA receive nutrition support and

IGA training 625 start up kits procured for IGA 12 district home care programmes in place

within 2 years 11. To Strengthen and Expand the National Capacity to design, implement, monitand evaluate HIV/AIDS programmes in the country

By: 1) Development of new and

updating of existing manuals and training materials

2) Capacity building in all areas of HIV Care

3) Capacity building in program management and IT

4) Development and implementation of supervisory systems

95% of HW provide acceptable counselling services 95% of doctors prescribe ARV correctly 80% of PLWHA are satisfied with HS

providers within 5 years and

Manual developed for (Clinical Care, ARV, Home

base care), printed and distributed 125 government and NGO staff trained in

programme management and IT Supervisory system developed and

implemented Within 2 years

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Beneficiaries of HIV component:

Beneficiaries Benefits Target

population Estimated

Communities Knowledge on HIV/AIDS, Enabling environment for HIV Care Access to VCT Access to PTCT Access to care

General population (Approx: 5.399million)

3.5 Million (in 500 communities)

Community volunteers

Increased capacity Catalyst of change Community support mobilisation

Communities 10000

PLWHA Involvement in all aspects of care and prevention Access to PTCT Access to clinical care Access to ARV Access to community care and support Enabling environment to shared confidentiality Protection from infection

HIV –1 infected HIV-2 infected

142,500 7500

Health workers Training in VCT Training in PTCT Training in clinical care Training in ARVs Training in STIs Training in community care Training in laboratory Better protection from HIV care

Nurses of all cadres Doctors Laboratory technicians Pharmacists

1500

Mid level managers both in NGO and government sector

Capacity building in management and IT

Project staff in both public and private sector

200

Public health sector

Strengthening of the general health system Strengthening of health information system

Health facilities Health system

220

NGO sector Better integration Improved management skills

Participating NGO’s

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• If there are several components, describe any synergies expected from the combination of different components (By synergies, we mean the added value the different components bring to each other, or how the combination of these components may have broader impact).

The collaboration between the NAS and the MOHS, and the institutional strengthening of both institutions would impact positively on the national health system and its response to HIV/AIDS and communicable/endemic diseases control. The Global Fund proposal development process has catalysed the establishment of a strong public, private and NGO partnership that is speeding up the dialogue for the needed reform of the Sierra Leone Health sector. The comprehensive review of human resources requirements for the health sector’s response to HIV/AIDS. The efficiency savings from the joint training of different cadres of health providers for service provision. Cross-cutting issues like improved lab diagnosis, home based care, social mobilization, advocacy, IEC activities and surveillance systems will support HIV/AIDS and malaria activities for increased synergy and impact. They will improve efficiency in the health sector and reduce costs. The two components’ proposals will help to further strengthen the: - capacity of health staff; - improve health facilities; - improve monitoring and evaluation in the NAS and the Ministry of Health and Sanitation;

• Indicate whether the proposal is to scale up existing efforts or initiate new activities. Explain how lessons learned and best practices have been reflected in this proposal and describe innovative aspects to the proposal.]

HIV/AIDS This proposal is to scale up existing pilots of HIV/AIDS interventions. The project will build on lessons learnt such as the need for partnerships, joint planning and monitoring and avoidance of the use of the Central Tenders Board for procurement. Best practices such as; use of nevirapine for PPTCT, VCCT Services, condom promotion through the use of social marketing techniques, syndromic management of STIs, health education and the use of ANC sentinel surveillance to monitor HIV trends, are applied.

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A new component of this programme that is not in the original four MAP districts is the introduction of ARV in the treatment of HIV/AIDS. This was done to prevent the current scenario in which PLWHAs start ARVs but are unable to continue due to cost barriers, this is not ideal from the perspective of drug resistance. It is therefore better for the ARVs to be available and a proper treatment regime instituted, with the appropriate monitoring and capacity building of health personnel and institutions. Innovative aspects include, first the use of community drama with facilitation, as an enter-education mechanism to bring about behavioural change for HIV/AIDS. This would be piloted in two districts very near the capital Freetown so that it can be adequately monitored. Secondly a youth centre being built by an NGO would be equipped and supported to provide HIV/AIDS IEC/BCC to youths. Funds from the Global Fund in future applications and other sources like UNFPA would be used to scale up the two pilots in future. Collaboration with TB Control Programme in the treatment of TB positive HIV/AIDS cases.

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3 Type of Application:

Table 3 – Type of Application Type of Application:

X Country Coordinating Mechanism (to National CCM section, 3.1)

Sub-Country Coordinating Mechanism (to Sub-National CCM section, 3.2)

Regional Coordinating Mechanism (including Small Island States) (to Regional CM section, 3.3)

Regional (to Regional Organizations section, 3.4) Non-Country Coordinating Mechanism (to Non-CCM section, 3.5)

3.1 National CCM Section

Table 3.1 – National CCM Basic Information Name of National CCM Date of Composition Sierra Leone Inter-sectoral Committee to fight AIDS, TB and Malaria

August 2002

3.1.1 Has the National CCM applied previously to the Global Fund? X Yes

No [If yes, go to 3.1.2. If no, go to 3.1.3.] 3.1.2 Has the National CCM composition changed since the last

submission? X Yes No

[If yes, describe the changes (1-2 paragraphs).] More multilateral and bilateral partners like UNFPA and EU have been invited to join the CCM. 3.1.3 Did the National CCM build upon an existing body or is it a new

mechanism? X Existing

New [If existing CCM, briefly describe the work previously done, programs implemented and results achieved (1 paragraph).]

The National AIDS Control Programme, the National Leprosy and TB Control Programme and the National Malaria Control Programme are existing bodies that have led the fight against AIDS, TB and Malaria for several years. They came together to form the CCM.

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These three bodies have been at the forefront of all service delivery activities - from treatment, prevention and control, social mobilization and political advocacy for the diseases of poverty - in both pre-war and post-war Sierra Leone. During the war, they valiantly pursued health services in secure areas with very few resources.

[If new CCM, briefly describe how the CCM coordinates its activities with existing structures (e.g., National AIDS Councils) (2 paragraphs).]

3.1.4 Describe how the National CCM operates.

[e.g., decision-making mechanisms, constituency consultation processes, structure of sub-committees, frequency of meetings, implementation oversight, etc. (2 paragraphs). Provide statutes of the organization, organizational diagram, terms of reference as attachments.] The CCM has three technical committees, namely the TB, HIV/AIDS and Malaria Management Committees. Major decisions are taken by concensus and failing this a vote is held. Since being constituted, Sierra Leone’s CCM has met eight times to discuss issues of importance related to its responsibilities. Smaller sub-committees/task groups have been working on specific issues (e.g. identification of the Principal Recipient, writing of the proposal) to ensure that all proposal components are completed on time. It is anticipated that the CCM will meet at least once every other month. Various minutes of meetings are attached.

3.1.5 Do you have plans to enhance the role and function of the National CCM?

X Yes No

[If yes please describe plans and ongoing activities, including plans to promote partnerships and broader participation as well as communicating with wider stakeholders, if required (1 paragraph).] The CCM is a young organization and needs to be nurtured and its role enhanced in 2004 and beyond. One of the items on the agenda is to broaden the partnership by extending membership to the major bi-lateral donors in Sierra Leone, namely the United Kingdom and the United States Bi-monthly meetings of the CCM will be established so that even after the proposal is submitted, the CCM can meet and attend to its business. To date, CCM members have contributed in varying ways and at varying levels to its operations. For instance, meetings are held at the Ministry of Health and Sanitation, proposal preparation has been undertaken at the offices of the National AIDS Secretariat, the World Health Organization’s, ARC International and World Vision. Various members of the CCM contributed funds to the costs of the proposal production during earlier rounds. The CCM is currently reviewing its goals for the year, and will develop a modest budget to support the CCM’s operations, this is to compliment the resources of the Global Fund. It is expected that members of the CCM will assist in supporting

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the CCM’s operations, and will facilitate the strengthening of the CCM both operationally and financially.

In order to reach a wider audience of stakeholders, the CCM will develop a list of non-member stakeholders so that news and information can be shared on a timely basis via e-mail (where possible) and by circulating information in hard copies. CCM members’ networks of information will be utilized to the largest extent possible, so that coverage around the country is achieved.

Table 3.1. 6A – National CCM Leadership Information

National CCM leadership details Chairperson Vice Chairperson Name Mrs. Agnes Taylor-Lewis Mr. Davidson Jonah Title Minister of Health and

Sanitation

Country Director

Mailing address

Ministry of Health and Sanitation 4th Floor Youyi Building Brookfields Freetown

Christian Children’s Fund 8 Howe Street Freetown

Telephone 232-22-240427 232-22-228322 Fax 232-22-235036 232-22-229365 Email address [email protected] [email protected] [One of the tables below must be completed for each National CCM member.]

Table 3.1.6B – National CCM Member Information National CCM member details

Member 1

Agency/Organization Medical Emergency Relief International (MERLIN)

Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)

Non Governmental Organisation

Name of representative Dr. Babafemi Oshin Title Medical Coordinator Email Address [email protected]

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Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

Proposal Preparation Technical Input Financial Input

Member 2

Agency/Organization American Refugee Committee Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)


Name of representative Dr. Mary Gutmann Title Country Director Email Address [email protected] Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

Proposal Preparation Technical Input Former Deputy Chair of CCM

Member 3

Agency/Organization Sierra Leone Red Cross Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)

Government

Name of representative Mr. Arthur De-Winton Cummings Title General-Secretary Email Address [email protected] Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

Proposal Preparation Technical Input

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Member 4

Agency/Organization German Leprosy Relief Agency (GLRA) Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)

Non Governmental Organisation Tuberculosis

Name of representative Mrs. Antoinette Fergusson Title Country Representative Email Address [email protected] Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

Member 5 Agency/Organization People Living with HIV/AIDS (PLWHAs) Name of representative Mr. Samuel Williams Title Director Email Address [email protected] Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

Proposal Preparation

Member 6 Agency/Organization Chamber of Commerce Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)

Private

Name of representative Mr. Christopher Foster Title Member Email Address [email protected]

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Member 7

Agency/Organization Sierra Leone Medical and Dental Association (SLMDA)


Government

Name of representative Dr. Virginia George Title President Email Address Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

Member 8 Agency/Organization Inter-Religious Council Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)

Faith-Based Organisation

Name of representative Mr. Alimamy P. Koroma Title General-Secretary Email Address [email protected] Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

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Member 9 Agency/Organization Family Care (FAMCARE) Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)

Private

Name of representative Dr. Anthony Williams Title Director Email Address [email protected] Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)


Member 10 Agency/Organization Clinical and Laboratory Services Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)

Government

Name of representative Dr. Arthur Williams Title Director Email Address [email protected] Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)


Member 11 Agency/Organization Primary Health Care Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS,

Government

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tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners) Name of representative Dr. P.A.T. Roberts Title Director Email Address Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

Member 12 Agency/Organization Planning and Information Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)

Government

Name of representative Dr. Clifford W. Kamara Title Director Email Address [email protected] Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

Member 13 Agency/Organization Roll Back Malaria (RBM) Taskforce Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)

Government – Malaria

Name of representative Dr. Amara Jambai Title Chairman Email Address [email protected]

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Member 14 Agency/Organization Pharmacy Board Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)

Government

Name of representative Mr. Michael J Lansana Title Representative Email Address [email protected] Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

Member 15

Agency/Organization Ministry of Development and Economic Planning (MODEP)


Government

Name of representative Mr. Desmond Koroma Title Planning Officer Email Address [email protected] Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)


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Member 16

Agency/Organization Ministry of Information and Broadcasting


Government

Name of representative Mr. Dominic Lamin Title Deputy Director Email Address [email protected] Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)


Member 17 Agency/Organization UNDP Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)

bilateral development partners

Name of representative Mr. Allan Doss Title Resident Representative Email Address [email protected] Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

Member 18 Agency/Organization WHO Type (academic/educational sector; government; non-governmental and community-based organizations;


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people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners) Name of representative Dr. Joaquim Saweka Title Representative Email Address [email protected] Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)


Member 19 Agency/Organization UNICEF Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)


Name of representative Mr. Aboubacry Tall Title Representative Email Address [email protected] Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

Member 20 Agency/Organization Department of Community Health Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)

Academic Institution

Name of representative Dr. Bailah Leigh Title Senior Lecturer

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Email Address [email protected] Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

Member 21 Agency/Organization Defense Medicine Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)

Government

Name of representative Dr. James A. Samba Title Director Email Address [email protected] Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

Member 22 Agency/Organization Action Aid Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)


Name of representative Mr. Samuel Musa Title Country Representative Email Address [email protected] Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

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Member 23 Agency/Organization Women in Crisis Movement Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)

Community-Based Organisation

Name of representative Mrs. Juliana Konteh Title Director Email Address [email protected] Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

Proposal Preparation

Member 24 Agency/Organization Nurses Board Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)

Government

Name of representative Mrs. Marina John Title Chairman Email Address Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

Member 25 Agency/Organization World Vision Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS,


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tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners) Name of representative Mr. Leslie Scott Title Country Representative Email Address [email protected] Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

Proposal Preparation Technical Input Financial Input

Member 26

Agency/Organization National Policy Advisory Council (NPAC)


Government

Name of representative Prof. Sidi T.O. Alghali Title Member Email Address Main role in National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

3.1.6 National CCM Membership Section

Table 3.1. 6A – National CCM Leadership Information National CCM leadership details

Chairperson Vice Chairperson Name Mrs. Agnes Taylor-Lewis Mr. Davidson Jonah Title Minister of Health and

Sanitation

Country Director

Mailing address

Ministry of Health and Sanitation 4th Floor

Christian Children’s Fund 8 Howe Street Freetown

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Youyi Building Brookfields Freetown

Telephone 232-22-240427 232-22-228322 Fax 232-22-235036 232-22-229365 Email address [email protected] [email protected] [One of the tables below must be completed for each National CCM member.]

Table 3.1.6B – National CCM Member Information

3.1.7 National CCM Endorsement of Proposal

[Please note: When the proposal is complete, please print out the entire proposal form. A signature page will print, and CCM members must sign this page. The entire proposal, including the signature page, must be sent to the Global Fund Secretariat, arriving before the deadline for submitting proposals. If insufficient consultation has occurred in the course of preparing a proposal, CCM members who have not been involved should not sign the proposal. The minutes of the CCM meeting at which the proposal was endorsed must be attached as an Annex to this proposal. Please print additional pages if necessary, and including the following statement on each page: PROPOSAL TITLE: “We the undersigned hereby certify that we have participated in the Country Coordinating Mechanism process and have had sufficient opportunities to influence the process and this application. We have reviewed the final proposal and support it. We further pledge to continue our involvement in the Country Coordinating Mechanism if the proposal is approved and during its implementation”

Table 3.1.8 – National CCM Endorsement

Agency/Organization Name of representative Title Date Signature

3.2 Sub-National CCM Section

Table 3.2 – Sub-National CCM Basic Information Name of Sub-National

CCM Date of Composition

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3.2.1 Explain why a sub-national CCM mechanism has been chosen

[Describe in 1 paragraph.]

3.2.2 Describe how this proposal is consistent with national strategies and/or the National CCM plans


3.2.3 Sub-National CCM Membership Section

Table 3.2.3A – Sub-National CCM leadership Information

Sub-National CCM leadership details Chairperson Vice Chairperson Name Title Mailing address

Telephone Fax Email address [One of the tables below must be completed for each Sub-National CCM member.]

Table 3.2.3B – Sub-National CCM Member Information Sub-National CCM member details

Member 1 Agency/Organization Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)

Name of representative Title Email Address Main role in Sub-National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

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Member 2

Agency/Organization Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)

Name of representative Title Email Address Main role in Sub-National CCM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

Member 3…

3.2.4 Sub-National CCM Endorsement of Proposal

[Please note: When the proposal is complete, please print out the entire proposal form. A signature page will print, and the Sub-National CCM members must sign this page. The entire proposal, including the signature page, must be sent to the Global Fund Secretariat, arriving before the deadline for submitting proposals. If insufficient consultation has occurred in the course of preparing a proposal, Sub-National CCM members who have not been involved should not sign the proposal. The minutes of the Sub-National CCM meeting at which the proposal was endorsed must be attached as an Annex to this proposal. The proposal must include, as an Annex, either a letter of agreement from the national CCM (or, if there is none, from other relevant national authorities) or evidence of a legal framework stating the autonomy of the sub-national entity (e.g., a federal structure that devolves considerable decision-making power to states/provinces/administrative divisions). Please print additional pages if necessary, and including the following statement on each page: PROPOSAL TITLE: “We the undersigned hereby certify that we have participated in the Sub-National Country Coordinating Mechanism process and have had sufficient opportunities to

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influence the process and this application. We have reviewed the final proposal and support it. We further pledge to continue our involvement in the Country Coordinating Mechanism if the proposal is approved and during its implementation”

Table 3.2.4 – Sub-National CCM Endorsement


3.3 Regional Coordinating Mechanism Section (includes Small Island States)

Table 3.3 – Regional Coordinating Mechanism Basic Information Name of Regional

CCM Date of Composition

3.3.1 Explain why a Regional CM mechanism has been chosen


3.3.2 Describe how this proposal is consistent with national strategies and/or the Regional CM plans


3.3.3 Regional CM Membership Section

Table 3.3.3A – Regional CM leadership Information Regional CM leadership details

Chairperson Vice Chairperson Name Title Mailing address

Telephone Fax Email address [One of the tables below must be completed for each Regional CM member.]

Table 3.3.3B – Regional CM Member Information Regional CM member details

Member 1 Agency/Organization Type (academic/educational sector; government; non-governmental and

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community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners) Name of representative Title Email Address Main role in Regional CM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

Member 2

Agency/Organization Type (academic/educational sector; government; non-governmental and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners)

Name of representative Title Email Address Main role in Regional CM and Proposal Development (Proposal Preparation, Technical Input, Component Coordinator, Financial Input, Review, other)

Member 3…

3.3.4 Regional CCM Endorsement of Proposal

[Please note: When the proposal is complete, please print out the entire proposal form. A signature page will print, and CCM members must sign this page. The entire proposal, including the signature page, must be sent to the Global Fund Secretariat, arriving before the deadline for submitting proposals.

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If insufficient consultation has occurred in the course of preparing a proposal, Regional CCM members who have not been involved should not sign the proposal. The minutes of the Regional CCM meeting at which the proposal was agreed to must be attached as an Annex to this proposal. The proposal (except proposals from small island states, which are exempt from this requirement) must include, as an Annex, a letter of agreement from the national CCM (or, if there is none, from other relevant national authorities). Please print additional pages if necessary, and including the following statement on each page: PROPOSAL TITLE: “We the undersigned hereby certify that we have participated in the Regional Country Coordinating Mechanism process and have had sufficient opportunities to influence the process and this application. We have reviewed the final proposal and support it. We further pledge to continue our involvement in the Country Coordinating Mechanism if the proposal is approved and during its implementation”

Table 3.3.4 – Regional CM Endorsement


3.4 Regional Organizations Section

Table 3.4 – Regional Organization Basic Information Name of Regional Organization

3.4.1 Contact information

Table 3.4.1 – Regional Organization Contact Information Primary contact Secondary contact Name Title Mailing address Telephone Fax Email address [Please provide full contact details for two persons – this is necessary to ensure fast and responsive communication.]

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3.4.2 Rationale

[Describe how submitting this regional proposal adds value beyond activities at the national level (2–3 paragraphs).]

3.4.3 CCM endorsement details:

[Regional organizations must receive the agreement of the full CCMs of each country in which they wish to work. List below each of the CCMs that have agreed to this proposal and provide in Annexes the minutes of CCM meetings in which the proposal was agreed to (if no CCM exists in a country included in the proposal, include evidence of support from relevant national authorities).]

Table 3.4.2 – Regional Organizations Endorsement Names of CCM Country Attachment number

3.5 Non-CCM Section

Table 3.5 – Non-CCM Applicant Basic Information Name of Non-CCM Applicant

3.5.1 Contact information

Table 3.5.1 – Non-CCM Applicant Contact Information Primary contact Secondary contact

Name Title Organization Mailing address Telephone Fax Email address [Please provide full contact details for two persons – this is necessary to ensure fast and responsive communication.]

3.5.2 Indicate the type of your organization (check box):

Academic/Educational Sector Government Non-Governmental Organization (NGO) or network of NGOs International Non-Governmental Organization Community-based Organization (CBO) or network of CBOs

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Group(s) of people living with HIV/AIDS, tuberculosis, and/or malaria Private Sector Religious/Faith-based Organization Other (please specify):

3.5.3 Rationale for applying outside an existing CCM

[Non-CCM proposals are not eligible unless they satisfactorily explain that they originate from one of the following:

1. Countries without legitimate governments (such as governments not recognized by the United Nations);

2. Countries in conflict, facing natural disasters, or in complex emergency situations (which will be identified by the Global Fund through reference to international declarations such as those of the United Nations Office for the Coordination of Humanitarian Affairs [OCHA]); or

3. Countries that suppress or have not established partnerships with civil society and NGOs.]

3.5.3.1 Describe which condition(s) applies to this proposal (3–4 paragraphs)]

3.5.3.2 Describe any attempts to contact the CCM and provide documentary evidence as an Annex (2 paragraphs)

3.5.4 Non-CCM proposals from countries in which no CCM exists

[Describe how the proposal is consistent with and complements national policies and strategies (or, if appropriate, why this proposal is not consistent with national policy) (3–4 paragraphs). Provide evidence (e.g., letters of support) from relevant national authorities in an Annex.]

3.5.5 All non-CCM proposals should include as Annexes additional documentation describing the organization, such as:

• Statutes of organization (official registration papers); • A summary of the organization, including background and history,

scope of work, past and current activities; • Reference letter(s); • Main sources of funding.

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4. Components Section

[PLEASE NOTE THAT THIS SECTION AND THE NEXT SECTION NEED TO BE COMPLETED BY COMPONENT, so, for example, if the proposal targets three components sections 4 and 5 must be completed three times. The system will automatically generate separate sections for each component.]

4.1 Identify the component addressed in this section

X HIV/AIDS Tuberculosis Malaria HIV/TB Integrated

4.1.1 Indicate the estimated start time and duration of the component

[Please take note of the timing of proposal approval by Board of the Global Fund (listed on the cover of the Proposal Form), as well as the fact that funds typically will not be released for a minimum of 2 months after Board approval]

Table 4.1.1 – Proposal start time and duration From To Month and Year: January 2005 December 2009

4.2 Contact persons for questions regarding this component

[Please provide full contact details for two persons – this is necessary to ensure fast and responsive communication. These persons need to be readily accessible for technical or administrative clarification purposes.]

Table 4.2 – Component Contact Persons Primary contact Secondary contact Name Prof. Sidi T.O. Alghali Dr Brima Kargbo Title Ditrector Health Response Team Leader Organization National AIDS Secretariat National AIDS Secretariat Mailing address

15A Kingharman Road, Brookfields Freetown, Sierra Leone

15B Kingharman Road, Brookfields Freetown, Sierra Leone

Telephone 232-22-235804/242202 232-22-235842 Fax 232-22-235843 232-22-235843 Email address [email protected],

[email protected] [email protected]

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4.3 National context for this Component

4.3.1 Disease burden

[Please provide 1-2 paragraphs on each of the following]:

4.3.1.1 Latest data on prevalence, incidence and other disease measurements, including data sources used

Since the first HIV/AIDS case was detected in Sierra Leone in 1987, 2,399 individuals have tested positive for HIV/AIDS, 794 of whom have developed the AIDS disease, and 438 are reported to have died. In April 2002, a national sero-prevalence survey conducted jointly by the Sierra Leone Central Statistics Office (CSO) and the U.S. Centres for Disease Control (CDC) showed a national HIV prevalence of 0.9%; 2.1% in Freetown and 0.7% outside Freetown (Note: Preliminary results used in previous Global Fund submissions indicated higher prevalence levels, which were later revised downwards after cross-checking of results at CDC, Atlanta.) The CDC-funded study did not include former conflict zones (e.g., Kailahun) that were among the worst affected by Sierra Leone’s decade-long civil war. All the samples testing positive were reported to be HIV-1; no HIV-2 was detected. Local VCT and antenatal data, UNAIDS estimates, and WHO’s situation analysis, while based upon limited data, suggest a higher HIV prevalence of between 3% and 7%. CDC’s 2002 data estimated ca. 45,000 people living with HIV/AIDS in Sierra Leone. The preliminary results of the first antenatal prevalence study based upon a total of eight testing sites which became available on the eve of the finalisation of this proposal gave an overall national prevalence of 3.4%, and 4.7% for the capital Freetown. This more reliable figures regarding HIV prevalence in the country, further demonstrates why the country needs urgent assistance to stem a potential post conflict epidemic. MoHS data (2003) from all outpatient clinics except those in Bo district indicate that, on average, sexually transmitted infections (STIs) constitute 3.94% of all consultations (range 2.06-6.58). STIs are the fourth most common cause of morbidity in Sierra Leone after malaria, diarrhoeas, and acute respiratory infections.

4.3.1.2 Stage and type of epidemic, and most affected population groups

The national CDC sero-prevalence survey indicated that the epidemic in Sierra Leone has not yet reached the point where it has fully diffused into the general population (prevalence greater than 5% in general population). However, as mentioned above, there is uncertainty regarding the results given higher reported prevalence indicated by other studies. The recent antenatal prevalence results shows that in Freetown, the epidemic is becoming more generalized in the population. Reported prevalence remains highest among particularly vulnerable groups, in particular commercial sex workers, military, ex-combatants, and other uniformed personnel. Despite conflicting information on current prevalence levels the epidemic is most probably at the stage whereby comprehensive prevention efforts among vulnerable groups, supported by sensitisation, awareness-raising and prevention efforts in the general population, and the provision of care, support and treatment for PLWHAs, could prevent the scale of epidemic experienced in other post conflict situations. The World Bank acknowledges that, “Whatever the actual rate, it is widely accepted that the rate is on the increase, and that the critical threshold of 5% is either past or near at hand.” There are, in fact, few reliable statistics at present on the prevalence of HIV among specific vulnerable groups. A 1995 sero-survey conducted among sex workers in Freetown found that 27% tested positive for HIV-1 and estimates in the Sierra Leone Armed Forces range from 15-20% to as high as 66%, based on HIV testing of new recruits. UNAIDS estimates that military personnel are 2 to 5 times more likely than civilians to contract an STI, including HIVi. Relative to other sub-Saharan African countries, Sierra Leone has a unique but time-limited opportunity to prevent further HIV infections among vulnerable groups and the development of a more generalised epidemic.

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Key factors in Africa’s conflict and post-conflict environments that have been found to facilitate explosive increases in HIV prevalence include: • A brutal and protracted civil conflict: Sierra Leone’s lasted 10 years • Widespread rape, sexual violence and abuse • Major troop deployments including foreign troops from countries with significantly higher HIV

prevalence • High unemployment and chronic poverty • Indications of increased commercial sex work and informal exchange of sex for goods and

services • Massive population movements: Sierra Leone’s involved both internally displaced populations

and refugees from Liberia and Guinea • Destroyed public infrastructure resulting in disruptions in STI diagnosis and treatment for STIs • Low HIV/AIDS awareness especially due to the disruption of public health communication

networks. In general, knowledge about transmission and prevention is low among the population. In an American Refugee Committee (ARC International) KAP survey reportii only 6% of female and 7% male youth were able to correctly cite at least three routes of transmission. In Civil Defence Forces/ Sierra Leone Army the level of knowledge was slightly higher at 9% but condom use at sexual encounter was only 26%. Among Commercial Sex Workers knowledge regarding transmission routes was at 9% but more knew (75%) that sex is a route of transmission. Despite this only 38% reported condom use at last sex and 60% reported having ever used a condom. Only 22% CSWs worried a lot about contracting HIV/AIDS. An extensive KAP survey amongst adolescentsiii (3019 respondents of 12-21 years) showed that 58% had had sex, with 44.8% having their sexual debut by age 18. Only 4% used a condom at first sexual intercourse and only 13.5% currently use a condom, and only 10.5% know a condom is an important means to prevent HIV infection. Adolescents had low levels of knowledge and many misconceptions regarding HIV/AIDS/STIs. For example 51% do not know that healthy people can carry HIV/AIDS, and alarmingly, 47% adolescents did not know any protection method against HIViv. On the whole adolescents were unwilling to abstain from sex or stick to one partner, highlighting the importance of consistent condom use for HIV prevention. Knowledge among women 15-49 years is relatively low with only 54% (78% urban and 44% rural) having heard of AIDS and 21% able to state three ways of avoiding HIV infectionv. Also, only 34% was aware of mother-to-child-transmission of HIV; 67% did not know any specific method HIV can be transmitted from mother to child. Overall, Sierra Leoneans, even in the Western Area incorporating Freetown, continue to lack knowledge and understanding regarding HIV/AIDS. For example, a recent survey indicated that many people still do not know that HIV is the virus that causes AIDSvi.

4.3.2 Describe the political commitment in responding to the disease, including by reference to internationally agreed-to targets (e.g., the commitment by African Heads of State to increase health sector spending to 15% of public expenditure) (1–2 paragraphs)

The Government of Sierra Leone has given priority to HIV/AIDS in its national agenda. High-level government officials are aware that post-conflict countries that failed to act aggressively to prevent the spread of HIV/AIDS eventually suffered from an explosion in HIV prevalence. They recognize the risks of a generalized epidemic to Sierra Leone’s future: economic stagnation, social dislocation and a mounting disease burden. Evidences of strong political commitment to combat HIV/AIDS aggressively includes the following:

The National HIV/AIDS Council (NAC) was established with President Kabbah as chair. The council comprises public and non-public sector representatives in roughly equal parts, as well as people living with HIV/AIDS (PLWHA). The NAC meets regularly every three months.

Formation of the National AIDS Secretariat (NAS) within the Office of the President. The NAS is responsible for inter-sectoral coordination and the scaling-up of responses nationwide.

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Adoption of a National HIV/AIDS Policy that was developed with the support of the UN Thematic Group on HIV/AIDS. The policy was adopted by the full cabinet and endorsed by the President. A strategic planning process facilitated by UNAIDS culminated in a new strategy and plan of action for implementation of the national policy. The recently developed Plan of Action requires $152m over the next five years.

Annual address to the nation by the President on World AIDS Day highlighting the threat of the disease and raising awareness among the general population.

The Government is participating in difficult discussions with neighbouring countries and agencies on how to address HIV/AIDS among the sub-region’s refugees. The intent is to include the following as beneficiaries in community and civil society initiatives: refugees from Liberia and Guinea, internally displaced persons within Sierra Leone, returnees, and source/host communities.

Sierra Leone obtained a $15m loan from the World Bank to address HIV/AIDS. The Government’s multi-sectoral response to the epidemic includes establishing HIV/AIDS focal points in relevant Ministries such as Education, Social Welfare, Gender and Children’s Affairs, Transport, Defence, Agriculture, Rural Development, and Development and Economic Planning to spearhead the campaign. Partnerships are being developed with NGOs and CBOs using credit funds obtained through the World Bank’s MAP initiative. Increasingly the private sector is becoming actively involved through AIDS education of employees, reviewing health benefits and supporting various HIV/AIDS causes. Sierra Leone has come to terms with the fact that as political stability returns, and an all out development effort is undertaken, failure to contain the “hidden enemy” will have devastating consequences and undermine other accomplishments.

4.3.3 List the national disease control strategies consulted in the preparation of the proposal, and describe how lessons learned from the implementation of these strategies have been incorporated in this proposal (2–3 paragraphs)

The National HIV/AIDS, Health Sector Development Strategies and the STI Emergency Project Review were the main documents consulted in the development of this proposal. Through a participatory process, all stakeholders, particularly NGOs involved in the design and monitoring of the program, identified the following lessons learned, constraints and opportunities that informed this Global Fund proposal’s design:. • The Central Tenders Board was found to be a bottleneck for renovations and procurement for

small contracts. The capacity installed in the NAS and MoHS by earlier and ongoing World Bank Projects for planning, procurement, and financial management is offered as an alternative for this proposal.

• Financial and programmatic capacity at the district level is inadequate. Thus both political and technical personnel at this level will benefit from the emphasis on capacity building in this proposal.

• The strategy using NGOs for social marketing of condoms needs to be refined and strengthened.

The first phase of the UNFPA-funded CSWs Project was also a wealth of lessons learned for HIV/AIDS programming, particularly for the Reproductive Health Division of the MOHS, which gained expertise in dealing with a major vulnerable group. The lessons ranged from psychosocial, socio-economic and medical problems, replicated nationwide during a period of transition. Since the project was done with UN ad hoc humanitarian funding through UNFPA, the need for long-term development partners with sustained funding was especially evident. As Sierra Leone moves away from emergency and post-conflict transition into development, new HIV/AIDS initiatives and donors must also reflect that new reality. Other lessons include the following:

• The project’s lifespan of three months was not sufficient to achieve the goal and all the objectives of the project. Time was short for the development and production of IEC materials, and sensitisation activities lagged behind, affecting the logical sequence of project activities. Consequently, the CSWs for whom the clinical services were provided could not come for services in their expected numbers because of the late dissemination of the required information. Moreover, community outreach activities were very minimal in the first phase of

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the project. The timely production of IEC materials and community outreach are essential as the project seeks Global Fund support for its next phase.

• Some clients were embarrassed to disclose their identity as CSWs. • It vividly came to light that most CSWs are destitute, illiterate and unskilled which makes it

necessary to address their socio-economic difficulties. • Identifying the reason(s) why women/girls become CSWs is an important key to finding

solutions for the individual CSW’s context. Project personnel learned that most CSWs, in fact, preferred gainful employment to the sex trade. Many of those hooked to the job do so due to psychosocial reasons or drugs; they could be selected for intensive rehabilitation, vocational training and counselling.

• 250 CSWs registered with WICM and GOAL were targeted for treatment at six (6) STI Clinics in Freetown. Only 128 of them reported for treatment within the course of three months. However, it was reported from all clinics that CSWs outside the targeted groups were requesting for treatment. Also during the course of the first phase of CSWs project, it was recognised that CSWs were registered with other organisations other than WICM and GOAL. These organisations are now targeted to serve as agents for referring sex workers to the clinics and as partners in mobilising CSWs for career development and change of life-style.

• Most CSWs preferred being trained in soap making and gara (tie-dyeing), rather than tailoring. • The short program duration did not favour a logical conclusion of training activities. • Insufficient sewing machines causes scrambling by the CSWs during training sessions. • Open channels of communication with the National Commission for Social Action (NaCSA)

and other government functionaries to support CSWs with educational and micro-credit facilities was established. This helped to increase the choices for CSWs contemplating a job change.

4.3.4 List any broader development initiatives (e.g., Poverty Reduction Strategy Papers, Highly-Indebted Poor Countries initiative) ongoing in << pull country name >>, and describe the links between this proposal and these initiatives (2–3 paragraphs)

Sierra Leone’s decade-long civil war caused a devastating and massive displacement of the rural population, with an estimated 3 million people (over half of the population) dislocated from their homes. This widespread displacement subjected the population to hardship in terms of limited sources of economic activity, and vulnerability to malnutrition and disease. In this environment HIV/AIDS is recognized as a real and looming threat to the economic and social well being of the country. The economy has already been devastated, GDP per capita in U.S. dollars declined by 35 percent between 1990 and 2000. The World Bank Group's International Development Association (IDA) and the International Monetary Fund (IMF) currently provide a comprehensive debt reduction package for Sierra Leone under the enhanced Heavily Indebted Poor Countries (HIPC) Initiative. Sierra Leone reached the decision point under the Enhanced HIPC Initiative on March 19, 2002. HIPC relief of US$600 million in net present value terms will be provided, of which IDA will provide US$122 million. This amount of HIPC relief will allow for debt service of about US$37 million per annum during 2002-2005 (5% of projected annual GDP). Sierra Leone is finalizing its PRSP, having already developed an interim PRSP, which was published in June 2001. The interim PRSP lists combating HIV/AIDS as one of the key areas for reducing poverty. In the health sector analysis, HIV/AIDS will feature as one of the key subsections. The PRSP will also include a chapter on cross cutting issues and HIV/AIDS is clearly outlined as a serious concern in relation to poverty reduction requiring multi-sectoral interventions.

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4.3.5 Describe how the proposal will contribute to broader efforts to reach the Millennium Development Goals (www.un.org/millenniumgoals) (1–2 paragraphs)

Millennium Development Goal 7 seeks to have halted and begun to reverse the spread of HIV/AIDS by 2015. In order to achieve this objective it will be necessary not only to reverse the spread of the epidemic in those countries already suffering more generalized epidemics but also to forestall the development of similar epidemics in countries that already exhibit the conditions for damaging epidemics. Sierra Leone sits in this later category and investments made by the Global Fund will contribute, in addition to those of the GoSL and World Bank, to a coordinated and synergistic programme aimed at preventing the spread of the disease, and mitigating the social and economic consequences as experienced elsewhere. In doing so this will set the stage to achieve the targets for eradicating extreme poverty.

4.3.6 Describe the links to international initiatives (e.g., the World Health Organization/UNAIDS “3-by-5” initiative to address the insufficient access to antiretroviral therapy, the Global Plan to Stop TB, and the Roll Back Malaria Partnership) (1–2 paragraphs)

Sierra Leone will seek to develop in a step-wise fashion expanded access of PLWHA to anti-retrovirals, starting with small-scale pilots in Freetown and in certain districts, and enabled by health sector reconstruction and development of sufficient human resource capacities. It is the intention by 2010 to treat 90% of all patients who qualify with Highly Active Antiretroviral Therapy (HAART). The ARG-MOHS has already started the process of developing treatment guidelines that will set out the optimal first line and second line treatments to be provided consistent with WHO guidelines. The national agency for the registration of pharmaceuticals has already approved the licensing of key drugs recommended by WHO for first line treatments (Zidovudine, Stavudine, Lamivudine, Efavirenz and Nevirapine) and also Kaletra and Indinavir. The GoSL has approved US$220,000 to procure drugs for approximately 150 PLWHAs, and further funds are likely to be made available in coming years. Based upon an estimated 45,000 PLWHA across the country it is likely that 9,000-13,500 currently require treatment with HAART (20-30% of all PLWHAs). However, limited access to VCCT, the lack of awareness of HIV/AIDS and the absence of a treatment and care infrastructure in the country mean that numbers of people presenting for treatment is initially likely to be relatively small.

4.3.7 Is there a sector-wide approach or other fund-pooling mechanism in place in the health sector?

Yes X No

[If yes, briefly describe how it operates and if you anticipate using it to administer part/all of the Global Fund grant (1–2 paragraphs)]

[For HIV components only:]

4.3.8 Is there a World Bank Multi-Country HIV/AIDS Program? X Yes No

[If yes, describe how interventions in this proposal complement those financed by the World Bank MAP (2–3 paragraphs)]

Sierra Leone currently benefits from a 4-year, US$15 million World Bank loan through the World Bank Multi-Country HIV/AIDS Program. The loan has allowed the country to strengthen the HIV/AIDS program at the national level as a pre-requisite for a multi-sectoral response to the epidemic. Innovative civil society interventions and a robust expansion of the health sector response have been initiated. As of November 30, 2003, the project had spent only $1.5m, after nine months of implementation. The main components of the SHARP project are detailed as follows:

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Component 1. Capacity Building, Policy Coordination, and Refugee Activities (US$2.70 million) which aims to strengthen Sierra Leone’s capacity to cope with the spread of HIV/AIDS by supporting the National AIDS Council and Secretariat; strategic and action planning; capacity building of public and private institutions and the country’s participation in refugee and refugee related activities. Component 2. Multi-sector Responses for HIV/AIDS Prevention and Care (US$2.00 million) which aims to strengthen the capacity of non-health sector line ministries and other public sector entities to respond to the HIV/AIDS epidemic, emphasizing prevention and care. Eleven multi-sectoral institutions and ministries have been funded so far. Component 3. Health Sector Responses to STI/HIV Management (US$2.80 million) will support a whole range of prevention and treatment activities in the health sector but only initially at least in Moyamba, Bombali, Koinadugu and Kono. Since the project was conceived, agreement has been given to spread investments countrywide due to the lack of other resources in the health sector. This has spread limited resources extremely thinly. Without additional resources focused on the health sector this will undoubtedly undermine the health sector response - the foundation of a successful HIV/AIDS response. The Health sector response has an impressive implementation rate spending 75% of its first year allocation. Component 4. Community and Civil Society Initiatives - CCSI (US$7.80 million) in which grant resources are provided to support a broad range of community, civil society and private sector initiatives. As of March 2004, 159 proposals had been approved, of which 67 had received funds. The funding is least in the Eastern Region and in the rural areas. Le 70m (approximately $30,000) was allocated as counterpart funding for SHARP’s recurrent expenditure in the 2004 national budget. This amount is inadequate to carry out planned activities. MAP was designed to emphasize the empowerment of civil society, with additional resources for HIV/AIDS obtained from other sources like the Global Fund. Thus given the inadequacy of resources committed to the health sector and the negative effect this is having on the health sector response, the resources requested from the Global Fund will be allocated to expand and scale-up a range of interventions through a coordinated partnership of the public, non-governmental and private sectors. To-date, investments in the health sector have not been specifically focused on the country’s capital Freetown, whose population swelled during the years of conflict to over 2 million (SL’s total population estimate: 5.5 million). The CDC HIV prevalence study and the recent antenatal surveillance data clearly demonstrate a higher prevalence of HIV in the capital than elsewhere in the country.

To address this gap, this Global Fund proposal will focus investments on Freetown and all districts, given the post-conflict potential of a serious epidemic, and the overall poor state of health services and HIV/AIDS activities. Also none of the existing projects like the World Bank’s MAP and Health Sector Rehabilitation Grant, EU Grant or UN System Support provides a comprehensive HIV/AIDS response and intervention in any given district. Global Fund resources will therefore be used to develop a comprehensive program in which the complementary capacities of government, non-profit and for profit private sector will enable a rapid scale-up of activities piloted by SHARP (the MAP-funded project). The main thematic priorities defined are as follows:

• Expansion of network of VCCT centres • Expanded access to STI treatment and care services • Strengthening of national blood screening and supply programme • Strengthening of national and selecetd district centres for treatment of HIV/AIDS

including treatment of opportunistic infections • Developing pilot sites for the delivery of ARV therapy to PLWHA • Expansion of a condom social marketing programme both in Freetown and

districts outside the capital (general population and vulnerable groups) • Expansion of services for the prevention of mother-to-child-transmission of HIV

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• Development in collaboration with NGOs of prevention, treatment and care services for especially vulnerable groups e.g. commercial sex workers, unformed services, miners, etc.

• Interventions complementary to Global Fund-supported TB programme • Supportive coordinated IEC and BCC interventions that raise awareness of

HIV/STIs, VCCT, PMTCT and promote health-seeking behaviour, particularly in the rural areas.

Describe how the financial management approach of this proposal relates to that being used by the World Bank MAP (1–2 paragraphs)

The fund management structure of NAS which hosts the World Bank MAP project will be utilized. The Global Fund will have two accounts as MAP has, and all the signatories will be the same as those for the MAP.

4.3.9 Indicate names and types of key agencies providing technical assistance to the national response

Name of Agency Type of Agency (academic/educational

sector; government; non-governmental and community-based

organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private

sector; religious/faith-based organizations; multi-/bilateral

development partners)

Main technical focus (e.g., prevention, care and support, treatment, etc.)

MOHS Government Comprehensive HIV/AIDS prevention, care and treatment

MODEP Government Co-ordination for SHARP MOIB Government IEC/BCC MEST Government IEC/BCC MOT Government IEC/BCC MOSWGCA Government Care and Support to Orphans MOD Government Comprehensive prevention,

care and support

MSF-B NGO Screening of blood for HIV ARC NGO Training, Counselling,

IEC/BCC, TB (DOTS), Vulnerable groups and micro-credit

IRC NGO Training, STI treatment, IEC/BCC

WICM NGO Training, IEC/BCC, STIs, Vulnerable women and children

CARE International NGO Condom Social Marketing, Youth Reproductive Health, IEC/BCC, Care and Support PLWHA

SWAASL NGO IEC/BCC, Counselling, Vulnerable groups

FAMCARE NGO Care of PLWHAs, VCCT, Treatment of OIs

CADO NGO IEC, Life skills for in-school youth

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CCSL NGO IEC/BCC, Counselling, Home-based care

CHASL Faith-Based Organization STIs, Counselling, Training WORLD VISION NGO STIs, IEC/BCC, Support to

vulnerable groups IRCSL NGO IEC/BCC, Counselling,

Capacity Building, Blood services, home-based care PLWHA

YWDO NGO IEC/BCC ACTION AID NGO IEC/BCC CCF NGO IEC/BCC GOAL NGO IEC/BCC, Vulnerable groups,

care and support PLWHA SHEPHERD HOSPICE Faith-Based Organization Home-based care, Palliative

Care PLWHA, Advocacy and support

SLRCS NGO IEC/BCC, Safe Blood MARIE STOPES SOCIETY NGO Reproductive Health Services,

VCCT, PMTCT, STIs, IEC/BCC

MRC NGO VCT, IEC/BCC IMC NGO STIs, Training and Education HASA NGO IEC/BCC and care for

PLWHAs HACSA NGO IEC/BCC and care for

PLWHAs PPASL NGO Reproductive Health Services

and IEC/BCC UNFPA Multilateral Condom Supply and

Reproductive Health Services UNICEF Multilateral Support to Collaborative

partners WHO Multilateral Support to Collaborative

partners UNIFEM Multilateral Support to Collaborative

partners FAO Multilateral Support to Collaborative

partners UNAIDS Multilateral Support to Collaborative

partners WFP Multilateral Support to Collaborative

partners UNDP Multilateral Support to Collaborative

partners ILO Multilateral Support to Collaborative

partners IOM Multilateral Reproductive Health Services

and IEC/BCC UNHCR Multilateral Support to Collaborative

partners UNAMSIL Multilateral Support to Collaborative

partners DFID Bilateral Support to Collaborative

partners

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4.3.10 Earmarked financial contributions to the national response to this disease

[List the financial contributions dedicated to the fight against this disease by all domestic and external sources.] Table 4.3.10- Financial Contributions to National Response – figures in US$ millions

Financial contributions in USD 2001 2002 2003 2004 2005 2006 2007 2008

DOMESTIC MOHS 0.203 .375 .260 NGOs EXTERNAL SHARP 0.56 5.76 4.48 3.68 0.52 UNFPA 0.00 0.00 0.538* 0.735 1.00 1.25 UNICEF EU 0.3 0.3 0.3 0.3 0.3 HIPC 0.057 WHO 0.081 0.071 0.184 ADB 0.342 0.171 0.171 Total resources available

1.34 6.943 6.545 5.24 2.07

Exchange rate 2450 Leones = US$1 used for domestic resources Note: 2004 allocations, indicative figures issued MOHS 27 Jan 2004. Figure for 2003 are estimates as opposed to actual, 2005 figure remains an estimate. The 2004 figure includes uplift for ARVs which may not have been taken into account hence in 2005 estimate hence drop in allocations. SHARP figures are from the project appraisal document. * UNFPA’s 2003 figure is actual, while 2005 to 2006 are projected

4.3.11 Total resource needs

[Describe the total resources needed to combat this disease.]

Table 4.3.11- Total resource needs

In USD 2004 2005 2006 2007 2008

Total resources available

6.545 5.24 2.07 - -

Total need 19,195,705 23,900,845 32,885,545 36,051,360 40,999,065 Unmet need 12,650,715 18,660,845 30,815,545 36,051,360 40,999,065 [Describe the source of the resource needs (e.g., costed national strategies), or, if they were estimated for the proposal, how the estimates were developed (1 paragraph)}

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The resources needs were derived from the recently costed national HIV/AIDS strategy.

4.3.12 Describe plans to ensure that any Global Fund resources received would be additional to the existing and planned resources (2–3 paragraphs)

[Global Fund financing should be additional to existing and planned resources in the fight against AIDS, tuberculosis and malaria, and so should not replace existing domestic or external resources] A mapping exercise was completed to provide information to this proposal. This was done to ensure goals in coverage were being met with currently committed and planned donor, government and NGO resources. The gaps – both geographic and service components – were identified, and allocation decisions were made to close them with Global Fund resources. The map will be continuously updated to prevent overlap and duplication of services, and to ensure that population groups will equitably benefit nationwide. The following realities will ensure that Global Fund assistance will be additional to existing and planned resources: • HIV/AIDS allocations in Sierra Leone have so far been very limited; current domestic and

external commitments do not yet cover the country. Global Fund resources will help current efforts to expand coverage into new districts, making it easier to track whether or not their intended application has been followed through.

• A strong expatriate presence (UN agencies and international NGOs) in the country and in the design of this proposal will help ensure that no commitments will be withdrawn if the request from the Global Fund is approved.

• Global Fund resources will be reflected as a separate line item in the national budget alongside others, enshrining its treatment as an additional source of funding for HIV/AIDS.

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Service Delivery Area a. Services Provided 2. Gaps in service delivery

ii. Prevention

IEC

NAS recently launched its National Communication Strategy involving NAS, NGOs/FBOs involved in IEC efforts. The intention of the Strategy is to ensure consistency of messages focused on the particular needs of different population groups.

• Wider use of PLWHAs as educators to raise HIV/AIDS awareness.

• IEC/BCC messages need to incorporate information on access to services e.g. STI, VCCT, PMTCT.

• IEC/BCC aimed particularly at youth and other important target groups.

Condom Distribution

Limited condom social marketing programme in Freetown and Western area. Elsewhere, access to condoms is severely limited. Only US$ 365,000 in SHARP programme for condoms. The funding that CARE has expires in July 2004.

• National condoms social marketing programme.

• Condoms for national free distribution to the poorest.

Programmes for specific groups

i. All Vulnerable Populations

ii. Commercial Sex workers Some limited Government and NGO activities mainly in Eastern Freetown, supported by UNFPA. Military and Uniformed services

HIV/AIDS programme developed within the Sierra Leonian Armed Forces (SLAF) including awareness raising, condom distribution VCCT and PMTCT (Freetown), Peer Educators, STI management, treatment of OIs. Services for ex-

• Overall mapping of vulnerable

population groups and targeted programmes where populations are concentrated.

• Need to scale up from UNFPA

assisted pilots to a comprehensive programme of prevention, treatment and care based upon further accurate mapping of CSW activity and focused on meeting their specific health and social needs.

• SLAF programme covering prevention, care and support developed on minimal resources. Investment of

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combatants and police force more limited.

iii. Youth Some IEC and BCC interventions in Freetown and elsewhere. Miners, truckers and migratory labour

MERLIN has pilot projects with miners in Kono and Kenema districts.

resources to enable significant scale-up. Need to expand VCCT, PMTCT, Universal Precautions, awareness raising and availability drugs STIs and OIs. Potential need for interventions focused on communities in close proximity to military bases.

• Lack of a comprehensive

programme focused on vulnerable youth ensuring raised HIV awareness and linkage to youth-friendly health services.

• Lack of a comprehensive programme focused on areas of high work activity.

• Scaling up of MERLIN’s activities with miners and applying the lessons learnt to other groups.

Voluntary Confidential Counselling and Testing

Comprehensive VCCT services only available in 4 locations in Freetown. Other centres at Makeni, Bo and Kenema with a further planned in Kambia. Blood centres are testing blood using rapid test kits in many more locations but although staff trained in counselling these are not fully resourced VCCT centres.

• Lack of properly resourced VCCT centres outside centres named. NGOs interest and involvement is critical in this area. Quality Assurance required of VCCT services.

PMTCT

PMTCT provided in Freetown at four centres: UMC Hospital, Marie Stopes Obstetric Centres, PCM Hospital and Wilberforce Military Hospital. Health workers trained and one government hospital each renovated, with provision of drugs, equipment, supplies and one ambulance each by UNFPA in Western area, Bo, Kambia , Moyamba, Tonkolili and Port Loko.

• Lack of functional PMTCT services outside of Freetown. Additional resources required to rollout program after pilot phase, in collaboration with NGOs and FBOs. Need to build on and complement UNFPA’s investment.

STI Infection Diagnosis and Treatment Health workers already trained in Western area, Kambia and • Need for monitoring and

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Port Loko; training planned for remaining 10 districts. UNFPA supported government and NGOs to provide STI services to CSWs in Freetown. Drugs provided were insufficient for needs. Major problems in ensuring high quality service provision and obtaining regular supplies.

evaluation for training interventions, quality of service delivery, and regular supply of drugs and expansion of services in collaboration with NGOs/FBOs. Lessons learned from the UNFPA- assisted project need to be applied for national scale-up.

Post exposure prophylaxis

Not currently available as part of PMTCT package. • Needed especially within PMTCT/VCCT services in order to reassure staff while still placing emphasis on universal precautions and safe clinical practice.

Blood safety and Universal Precaution

Blood safety policy recently completed but not launched. Guidelines to be developed by Blood and Laboratory Service Manager. Blood transfused tested with two rapid test kits – issue of HIV positive patients in “window period”.

• Needs more investment in training, supply of prevention commodities and application of universal precautions in healthcare settings. Potential role for NGOs Like the SLRCS in strengthening blood services.

• Need for review of blood donor recruitment, donor screening based upon behavioural questionnaire to exclude high-risk donors and provide access to VCCT.

Care and Support Palliative care

Psychosocial support and home based care provided on a limited basis in Freetown through Shepherd’s Hospice. Acts as a training resource for other organisations. Also being undertaken by some NGOs and Faith-based organisations outside of Freetown e.g. CCSL in Kenema.

Need to expand access to home-based care building on successful models already in place. Large role here for NGOs and FBOs e.g. SLRC and FBOs. Essential for VCCT services to be linked to service providers delivering as a minimum psychosocial support, home based

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care and social services. Need for ongoing M&E of organisations trained to deliver services and supportive ongoing training interventions.

Support for orphans

Some support for vulnerable children affected by HIV/AIDS in Freetown linked to PLWHA home-based care – prevent withdrawal of children from school but very limited.

Opportunities to integrate scale-up social service in to packages of support provided by NGO / FBOs.

Treatment for Opportunistic Infection

Some resources provided through SHARP for drugs and training – however, lack of coordinated health care service with clinicians trained in HIV/AIDS care.

Need for OI treatment protocols. Opportunities to scale-up service provision through NGO / FBO service delivery networks integrating OI prevention and treatment, HAART, home-based care.

Prophylaxis for Opportunistic infection

Some resources provided through SHARP for drugs and training – however, lack of coordinated health care service with clinicians trained in HIV/AIDS care.

Need for OI treatment protocols. Opportunities to scale-up service provision through NGO / FBO service delivery networks integrating OI prevention and treatment, HAART, home-based care.

HIV/TB

Successful Global Fund TB programme includes an objective need to coordinate VCCT and DOT centres. Focused upon Port Loko, Kambia, Tonkolili and Kailahun.

Resources within TB programme likely to be limited and costs of TB testing, treatment and associated capacity building may not be sufficient.

Treatment Antiretroviral therapy and monitoring

ATR only provided to a limited very number of individuals through private medical practitioners.

• Need for pilot programmes within public and NGO health sectors in Freetown and then scale-up to other districts as human resource capacities and logistics allow. NGOs are interested and critical for expansion.

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2. Cross-cutting areas

Procurement and Supply management EU funded programme will strengthen MoHS Central Stores and stores in centres in focus districts: Kambia, Kailahun and Pujehun.

It may be necessary to look at some outsourcing of procurement and supply management e.g. for ARVs. Important to collaborate with EU in solving procurement/supply management capacity issues.

Monitoring and Evaluation Requirement for a follow-up general HIV prevalence study. Most other surveillance and behavioural surveys included in SHARP e.g. surveillance in vulnerable groups but not yet implemented. Support required at DHMT level in future for M&E HIV/AIDS activities.

Scale-up of HIV/AIDS programme involving numerous actors will necessitate increased HIV/AIDS M&E capacities at NAS and within partner organisations.

Stigma Two organisations of PLWHA operate in Freetown. Need to support scale-up of activities to the districts, including advocacy, awareness raising and potentially follow-up counselling using PLWHA.

Health Systems Strengthening The EU and WB have major programmes focused on health systems strengthening EU: Kambia, Kailhun and Punjehun (Direct District level support of Euro 600,000 – 1m per annum). WB: Development of capacities of District Health Management Teams.

Important for HIV/AIDS programme to dovetail effectively with programmes to support HIV/AIDS activities in the health sector. Strengthening required of laboratory services at District level.

Coordination, Partnership development NAS has a key coordination role but will inevitably require ongoing technical support as partnerships develop and coordination issues become more complex.

Significant capacity building and ongoing technical assistance required to develop partnerships between public, private, NGO/FBO sectors and major donors programmes e.g. WB and EU.

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4.3.13 Does this application focus primarily on scaling up existing interventions, introducing new interventions, or both?

Scaling up New

X Both

4.3.13.1 If “scaling up” or “both”, describe how the interventions addressed in the proposal build upon existing programs (2 – 3 paragraphs)

Existing pilots and activities of limited coverage in condom social marketing, PMCT, VCT, HAART and work with special groups (miners, CSWs) will be scaled up and expanded nationwide in a phased manner in line with national guidelines. Pilots that have not been evaluated will be evaluated as a first step. Information dissemination meetings will follow, so that lessons learned in the pilots can guide the scale up.

4.3.13.2 If “scaling up” or “both”, describe how the interventions to be scaled up were identified from among other existing interventions (1–2 paragraphs)

As stated earlier Sierra Leone is in a post conflict situation, and it has had minimal investment in HIV/AIDS, both from the government and external sources. To avoid the potential of a catastrophic HIV/AIDS epidemic in the country, all the basic interventions of a comprehensive program are being proposed. The Global Fund’s support will enable the country to mount all the critical HIV/AIDS interventions to achieve national scale and to demonstrate any impact.

4.3.13.3 If “scaling up” or “both”, indicate the major barriers to scaling up the interventions that have been identified as proven and effective have not previously been scaled up

[Check as many as apply, and then briefly (1–2 paragraphs) explain each barrier below.]

Policies, standards and guidelines National capacity (health systems, human resources, etc.)

X Stigma, discrimination and human rights Gender-related issues

X financing

The major impediment in Sierra Leone has been lack of resources, particularly funding. The hope that the country would get resources from the Global Fund would materalise with this proposal.

X Other (please specify:Conflict ________)

Other impediments like the conflict that prevented access to certain districts is now over, and the country is now in a rehabilitation phase.

4.3.13.4 If “scaling up” or “both”, describe any innovative aspects to scaling up these interventions (2 – 3 paragraphs)

The use of drama as enter-educate mechanism for rural populations, and development of a youth centre.

4.3.13.5 If “new” or “both”, describe how the new interventions addressed in the proposal complement and build upon existing programs (2 – 3 paragraphs)

It would compliment the current HIV/AIDS IEC/BCC and youth strategies.

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4.3.13.6 If “new” or “both”, describe how these interventions were identified (1–2 paragraphs)

A critical review of the implementation of the activities in the HIV/AIDS IEC/BCC strategy in the course of the development of this proposal, revealed that more needed to be done for the rural areas with low literacy and poor electronic media access. Similarly earlier attempts at establishing youth centres were not well documented and the lessons learnt not captured. This pilot would fill this gap.

4.3.13.7 If “new” or “both”, describe why these interventions were not previously in widespread use (1– 2 paragraphs)

Rural social mobilization by drama, it is quite expensive, and requires very detailed logistics, planning and monitoring. Successful models in Plateau State, Nigeria that were supported over the years by the Federal and State governments, UNFPA RH projects, World Bank agricultural development projects, APIN and Intellfit demonstrated this fact. The last two institutions managed the development of the 2003-2007 HIV/AIDS Strategic Plan for Plateau State, with funding from APIN, and technical assistance by Intellfit. This approach was brought to scale for rural HIV/AIDS education under this HIV/AIDS strategic plan, and is currently functioning smoothly. So a pilot and careful planning is needed before their widespread use in Sierra Leone. Earlier attempts at utilization of youth centres were probably not done with sufficient partnership hence they could not be scaled up.

4.3.13.8 If “new” or “both”, describe any innovative aspects to these interventions (2 – 3 paragraphs)

People in the rural areas would act the plays themselves, thus engendering community participation and mobilization. Since it would use a combination of government and NGO health infrastructure and faithbased structures in its implementation, the trained facilitators, that would moderate and guide the discussion after the drama performance would come from the nearest government or NGO rural health facility or church/mosque. Its main advantage and utility is that it would enable these key players in behavioral change to pass the same HIV/AIDS prevention messages down to the grassroots and thus reinforce attitude and behavioral change

4.3.14 Does this application complement earlier

grants from The Global Fund? X Yes

No

4.3.14.1 If yes, describe how this application complements earlier grants from the Global Fund (2 – 3 paragraphs)

In the TB Global Fund Grant sufficient attention could not be paid to linkages between TB and HIV/AIDS. In this application VCT sites will be established in close collaboration with the TB Programme so that synergies can be built. Also the earlier TB grant did not address the wider health sector system-wide issues, which this proposal addresses. This includes responses to the impending decentralization planned for intensive implementation after the district-level elections planned for May 2004. Thus advocacy for the political office holders at the district level has been built into the capacity building objective of this proposal.

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4.4 PROGRAM STRATEGY

GOAL The goal of this proposal is to develop a comprehensive national response to HIV/AIDS that includes prevention, treatment, care and support for those affected. The design of this proposal is characterized by the following: • HIV/AIDS prevention and continuum of care alongside efforts at post-conflict

rehabilitation. This proposal will, with Global Fund resources, enable the GoSL to extend/expand coverage of HIV/AIDS interventions across all districts of the country as part of the process of national rehabilitation. A large part of this proposal depends on the success of current efforts at building a sustainable and responsive health system. The aspect of rehabilitating the health system is especially critical for Sierra Leone as a post-conflict country facing the potential of a major HIV/AIDS epidemic.

• Addresses critical gaps in the national response. This proposal identifies and addresses critical gaps in the national response to HIV/AIDS - from prevention, through treatment to care and support, and mitigation of impact.

• Complements current programs and resources. Sierra Leone’s national HIV/AIDS response is chronically under-funded. The government’s resources are inadequate and its infrastructure still being rebuilt. The current World Bank MAP-funded SHARP Project was designed on the assumption that other resources, particularly those from the Global Fund, would be available for HIV/AIDS. The funding situation is so acute that the MAP has been spread over the whole country instead of the four districts planned for the program. A major proportion of the activities proposed will be implemented by civil society organizations already active in the health sector.

• Scales up successful pilots. The proposal takes existing successful pilots to scale. Nationwide coverage in a country the size of Sierra Leone would normally not be difficult to achieve under normal conditions, but poverty and the current socio-political transition present obstacles in resource mobilization. Where there are no existing pilots, and in the unlikely scenario that such an activity is not covered at all under SHARP, NAS has opened dialogue with UNICEF, UNFPA, WHO and ADB to provide funding for such pilots.

• Links with sub-regional efforts. Long distance truck drivers are deliberately not included in this proposal. However, this special group will be covered by the proposed ADB-funded Mano River Union Project, for which ADB has set aside a grant of $8.0m. While complementary Global Fund funding is also being sought for this project, with the submission of a proposal for this fourth round of applications, the project would soon begin with the ADB funds, and preparatory activities are in top gear. UNFPA is the implementing agency for this ADB project.

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GOAL Table 4.4A: Goals and impact indicators Number Goal [Code 4A] To develop a comprehensive national response to HIV/AIDS that

includes adequate prevention, treatment, care and support for those affected. Number Impact indicator Baseline 2-5 year

target Year in which target will be reached

1 Reduced adult HIV prevalence (ages 15-49)

1.98 1.6 2009

2 Percentage of young people aged 15-24 reporting the use of a condom during sexual intercourse with a non-regular sexual partner

13.5%* in 2002

25% 2009

3 Percentage of young people who have had sex before the age of 15

4 Percentage of people remaining on treatment at 6, 12, and 24 months

* UNICEF and GoSL: Adolescents Attitude and practice Concerning HIV/AIDS in Sierra Leone, Survey Report, April 2002. OBJECTIVES Overview: The objectives below correspond to programmatic gaps in areas where pilots have been done with SHARP resources, and where the capacity to rapidly scale up and implement by the partners already exists. Other pipeline programs like the UNFPA country program will assume responsibility for program areas where capacity still needs to be built or where there are no convincing pilots. While the objectives may read like individual stand-alone programs, the operational reality is that they will be implemented in a synergistic and integrated manner. The same facility would be targeted for STI, VCCT and PPTCT, to provide integrated services. The targets have a reasonably high level of being achieved because there has been a lot of dialogue and collaboration among stakeholders. The Government and the NGOs have agreed that the implementation plan will be decentralized to enhance absorptive capacity, thus funds meant for government and NGOs would go to each entity directly. All equipment, drugs and reagents would be centrally procured; while they may appear in individual budgets, this is for accounting and distribution purposes only.

All the sub-recipients have been identified in advance, and as far as practicable the personnel they would train and the equipment they will receive are spelled out in the budgets. Also the various sites for VCCT, PPTCT and STI have been budgeted for as if all sites are the same. However this is not the case, and this will be dealt with at implementation. Some sites are more difficult to access than others, while some would need more resources for renovation. It is anticipated that sites needing more resources will cancel out those who need less.

In the case of IEC, the materials e.g., posters, media buying etc, needed by each objective is left under the objective, as well as in the objectives budget. Operationally the IEC/BCC committee will oversee and coordinate all these activities, and consolidate their implementation and purchases wherever possible for cost effectiveness. However because we do not wish slow implementers to slow down fast implementers, these activities could still be implemented in a decentralized manner, should the need arise. This is to ensure that as each service is available, e.g., VCCT, the

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complementary IEC/BCC is also available. These management issues are further explained in the section on management approach.

Objective 1. To increase knowledge and promote behavioral change on HIV/AIDS through pilot drama and appropriate communications channels in 2 districts.

Objective 2. To prevent HIV/AIDS transmission by ensuring the availability of safe blood nationwide. Objective 3. To provide knowledge and skills on STI/HIV/AIDS prevention among the youth.

Objective 4. To expand access to and promote correct and consistent use of condoms in the general population and among vulnerable groups nationwide. Objective 5. To strengthen and expand services for sexually transmitted infections. Objective 6. To reduce HIV transmission from parent to child through the provision of Prevention of Parent-to-Child Transmission (PPTCT) services in 13 districts. Objective 7. To improve access to and utilization of Voluntary and Confidential Counseling and Testing (VCCT) services in 13 districts. Objective 8. To improve access to and utilization of ARVs in 13 districts. Objective 9. To provide prevention, care, support and treatment to special groups. Objective 10. To provide palliative care and support to PLWHA and OVCs, particularly in war affected areas. Objective 11. To strengthen and expand national capacity to design, implement, monitor and evaluate HIV/AIDS programmes in the country.

Objective 1: To increase knowledge and promote behaviour change on HIV/AIDS through drama and other appropriate communication channels.

Information, Education, Communication and Behaviour Change Communication (IEC/BCC) constitute an integral sector of the Sierra Leone HIV/AIDS Response Project (SHARP). Currently, NAS is supporting NGOs and CBOs to conduct HIV/AIDS activities in the country. In addition, NAS has produced and distributed 17000 posters on HIV and AIDS prevention and reduction of stigma. Promotional materials on HIV/AIDS like car stickers, T-shirts and hand bills have also been produced and distributed among partners. NAS has signed a Memorandum of Understanding with the Sierra Leone Broadcasting Service Radio and Television to produce and disseminate IEC/BCC messages on a weekly basis. FM Radio Stations throughout the country will repeat the same messages. These activities are concentrated mainly in urban and peri-urban areas where literacy rates are higher. A Communication Strategy produced by NAS provides guidelines in terms of future activities. The strategy document has been distributed to all partners. The implementation of this strategy is ongoing. However with a literacy rate of 33%, the need was observed during the Global Fund proposal development process to complement these with intensive social mobilization and animation methodologies for the rural areas. This method has succeeded in Plateau State of Nigeria, with its hard to reach rural areas. Television, radio and print media are only useful in the urban areas. In both urban and rural areas due to the low provision of electricity, even these media outlets may not be as effective as envisaged.

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Global Fund resources will be used to support the IEC/BCC Strategy by piloting enter-educate and social mobilisation activities in rural areas, using music, dance, drama, story-telling, and audio-visuals. The pilot will take place in two districts that are not similar. The plan is to get a consultant who will train a national team in the use of drama to combat HIV/AIDS. The trained team will then serve as trainers for the district teams who in turn will train chiefdom teams. The chiefdom teams will use community members to implement the dramas, songs, story-telling and dances at village level. After each exercise, a trained facilitator will lead the dialogue that will reinforce and ensure that the key messages were understood correctly. The nearest service delivery points for VCCT, STI, PMTCT, etc. will also be communicated. The facilitators trained in facilitation skills will be the health staff of the MOHS and the Red Cross. Thus the key structures that will be used include:

1. Ministry of Health and Sanitation 2. Council of Churches in Sierra Leone 3. Council of Imams in Sierra Leone 4. NGOs.

The MOHS structure comprises the Health Education Division that will serve as the national team. These will then train the District Health Management Team (DHMT) who in turn will train those in charge of Peripheral Health Units (PHU) in each chiefdom. The PHUs in-charge will use Trained Animators (who were trained with UNICEF’s support, and who have associations at community level), and the Blue Flag Volunteers (who live in the community and nominated by community leaders) to perform the drama. The Council of Churches Sierra Leone (CCSL) has a national structure that will provide training for the district structures that in turn will provide training for the chiefdom structures. The chiefdom structure will use members of constituent Churches to perform the drama. The model used for the CCSL will be used for the Council of Imams. NGOs that provide IEC/BCC activities in communities will also organize community groups to perform the drama in their communities. For the NGOs, CARE in collaboration with the Sierra Leone Red Cross Society (SLRCS) will take the lead at national level and then work with individual NGOs. This approach (enter-educate) was used by the Ministry of Health and Sanitation in 1995 to combat cholera epidemic in rural communities and was very effective. It was also used in 1990 in the Universal Child Immunization (UCI) campaign and contributed to raising immunization coverage from 26% to 75% within 12 months. However it is appreciated that the strategy is expensive and requires intensive logistics and coordination. Therefore it would be piloted in selected chiefdoms in two districts that are not similar, however one of the two districts would be near the capital Freetown to facilitate monitoring and supervision and determine if there is a distance gradient in the evaluation of the pilot. It is anticipated that funds from the Global Fund in subsequent rounds would be used to bring the pilots to scale. This activity would be funded under objective 4. One of the Assistant Project Managers to be hired by CARE under that objective would manage it, with the support of two of the three Marketing Promotion Field Officers. It will be funded specifically under the following budget lines for years 1 and 2-community based workshops, Peer Educator Training, promotional events, training of other partners, studies/research and evaluation. One of the major promotional activities would be the command performance of the drama to be attended by the President of Sierra Leone. Goal [From Table 4.4A] Number Objective: To increase knowledge and promote behaviour change on HIV/AIDS

through folklore and other appropriate cultural communication channels.

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[Code 4E] What percentage of the people reached by this objective will be women?

55%

What percentage of the people reached by this objective will be youth?

50%

What percentage of the people reached by this objective will be in:

Rural areas 90% Urban areas 10%

What percentage of the services in this objective will be delivered by:

Government 40% Non-governmental partners 60%

Private sector - What percentage of people trained will be:

Health personnel 20% Non-health personnel 80%

What percentage of people trained will be: Government 40% Non-governmental partners 60%

Private sector - Describe, for each objective, which target groups are important beneficiaries of this objective (check all that apply):

X Injecting drug users X Men who have sex with men X Mobile populations X Orphans X People living with HIV/AIDS X Sex Workers X Youth (in school) X Youth (out of school)

Objective Objective: To increase knowledge and promote behaviour change on HIV/AIDS

through pilot drama and other appropriate communication channels in two districts.

Number Services to be delivered Category Prevention

Description IEC/BCC Coverage indicator Baseli

ne Year 1 target

Year 2 target

Year 3 target

Year 4 target

Year 5 target

1 Main activity Indicator Implementing partners 1 Hire a consultant to

train national team on drama performance

Consultant hired NAS, MOHS, CCSL, and NGOs

2 Train National team to train two district teams

Functional national training team

NAS, MOHS, CCSL and NGOS

3 Train district teams to train selected chiefdom teams

Number of district teams trained


60

4 Train chiefdom teams to train community to perform drama

Number of chiefdom teams trained

DHMT Chiefdom health team

5 Develop information/advocacy kits for all levels and groups

Number of IEC/BCC material produced by type


6 Procure 3 mobile Projector Vans for dissemination of information

Number of mobile unit procured


7 Monitoring and supervision and evaluation of the pilots

Number of supervisory visits Evaluation report


8 Procure 14 motor bikes for coordination

14 motorbikes purchased NAS, MOHS, CCSL and NGOS

9 Conduct national drama performance for H.E. the President of Sierra Leone, Cabinet Ministers and VIP’s

National drama performed


10 Perform 2 district level drams

Number of district drama performed

District Health Management Team (DHMT), CCSL, NGOs and NAS

11 Conduct 20 chiefdom dramas

Number of chiefdom drama performed

Chiefdom drama team, DHMT

Objective 2. To prevent HIV/AIDS transmission by ensuring the availability of safe blood nationwide.

The Blood Transfusion Service has the mandate to ensure the availability of safe blood nationwide. Presently, Blood Transfusion Service exists only in Freetown. Even there, only 15% of donors are voluntary; the rest are relative/replacement donors. In the district hospitals, there is no proper Blood Transfusion Service; direct donation is being carried out, i.e., relatives and friends of patients are bled and transfused to the patients. Blood is screened for HIV but not routinely screened for other major blood transmissible infections such as syphilis, hepatitis B and C. At present, there are only seven trained laboratory technicians responsible for Blood Transfusion in the Western Area; this number is not sufficient. Each district hospital laboratory has one trained or untrained technician assisted by volunteers.

There is a dire need to train more laboratory technicians. Over 60%of transfusions are emergency transfusions and administered mainly to pregnant women, delivering mothers and children. It is an undisputable fact that voluntary repeat blood donors are safest and it is only through mass collection of blood from voluntary blood donors that adequate quantities of blood can be made available for patients. There is a need to scale up donor recruitment activities in the Western area and extend the activities to all the remaining 12 districts.

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Blood, because of its human origin, will always be in short supply. Therefore, alongside the promotion of voluntary blood donation there should be training for prescribers on the rational use of blood and blood products. These different training activities could be done either within each district or at provincial level (i.e., Northern, Eastern, Southern and Western Area). The Ministry of Health and Sanitation will be responsible for training both government and non-governmental personnel. The aim of this proposal is to strengthen the existing facility in the Western Area and establish Blood Transfusion Services in 19 hospitals throughout the country. By collaborating with interested NGOs, the Blood Transfusion Service will be able to provide adequate quantities of safe blood for the nation. At the end of the project the following will be achieved:

38 laboratory technicians will have been trained. 19 medical superintendents will have been trained. 130 Blood Promoters (10 per district) will have been trained. 40% of all blood donations countrywide will be voluntary. 100% of blood units will be screened for HIV, syphilis, hepatitis B & C. 100% of districts will have access to donor recruitment and blood transfusion.

SHARP is presently supporting a needs assessment of the Blood Transfusion Service in the country and the survey has been completed for the Northern and Southern districts (reports attached). SHARP is also providing HIV test kits to all hospitals for blood screening. SHARP has also provided one vehicle for the supervision of Blood Transfusion Service. All autonomous blood transfusion activities will be brought under the regulatory authority of the Blood Transfusion Service, with regular monitoring and supervision. One vehicle will be provided to enhance this. International Medical Corps (IMC) is involved in blood transfusion services in Kailahun district hospital. The Sierra Leone Red Cross is actively engaged in the promotion and recruitment of voluntary blood donors.

Table 4.4B Objectives

GOAL Objective

What percentage of the people reached by this objective will be women?

70%


75%

What percentage of services in this objective will be delivered by:- Government 80% Non-government partners 15% Private Sector 5% What percentage of people trained will be: Health Personnel 90% Non-health Personnel 10% What percentage of people trained will be: Government 80% Non-governmental partners 15%

Private Sector 5%

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Describe for each objective, which target groups are important beneficiaries of the objective (check all that apply).

Injecting drug users Men who have sex with men X People living with HIVAIDS

X Mobile populations

X Orphans

X Sex Workers

X Youth (in school)

X Youth (out of school)

X Other (please specify: women of child-bearing age, including people living with HIV/AIDS

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Table 4.4C

To ensure the availability of safe blood Nationwide

category BLOOD SAFETY

Description Promote voluntary blood donation, provide safe blood for transfusion, train health care personnel on the rational use of blood and strengthen existing laboratory facilities by providing equipment and test kits.

Coverage Indicator Baseline Year 1 Target

Year 2 Target

Year 3 Target

Year 4 Target

Year 5 Target

1 Number of service deliverers, Lab. Technicians Health Personnel

7 0

38 19

38 19

38 19

38 19

38 19

2 Percentage of transfused blood units screened for HIV 90% 100% 100% 100% 100% 100% MAIN ACTIVITIES INDICATOR IMPLEMENTING PARTNERS 1 Conduct donor promotional campaigns

Number of campaign conducted MOHS. SLRCS

2 Strengthen voluntary blood donors club in the Western Area and establish voluntary blood donor clubs in the 12 districts

Number of voluntary blood donor clubs formed and active

MOHS, SLRCS, IMC

3 Provide donor incentives (T-shirts, caps, badges, refreshments etc) and distribution

Number of voluntary blood donors who receive incentives. Receipts showing quantity of donor incentives provided

MOHS

Train 38 laboratory technicians

Number of laboratory technicians trained.

MOHS

Train 19 medical superintendents

Number of medical superintendents trained.

MOHS

4 Train 130 (10 in each district) blood donor promoters 130 donor promoters trained (10 in each district)

MOHS

5 Observe World Voluntary Blood Donors Day Award and present certificates, organize picnics

Number of Awards and celebrations held

MOHS, SLRCS

6 Implement Blood Collection strategies (mobile and static) Number of blood units collected Percentage of voluntary donation

MOHS, SLRCS, IMC

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7 Provide training materials Conduct trainings of Laboratory technicians and health staff

Number of laboratory technicians and health staff trained in blood transfusion practices

MOHS

8 Provide appropriate equipment for the proper collection of blood, screening, storage and cross-matching (See attached list)

Number of blood transfusion facilities having the right equipment for proper blood banking

MOHS

9 Conduct Monitoring and Supervision/Enforcement and Regulation visits to both government and private sites

Reports of supervision visits

MOHS

10 Provide test kits for blood screening (HIV, Syphilis, Hepatitis B & C)

Percentage of blood units screened for HIV. Syphilis, Hepatitis B and C before transfusion

MOHS

Percentage of transfusion facilities screening for HIV, syphilis, hepatitis B and C before transfusion

MOHS

10 Conduct workshop for development of SOPs (Standard Operating Procedures) Print and Disseminate SOPs

Workshop held. SOPs produced Number of blood transfusion facilities adhering to the SOPs

MOHS

11 Hold seminars/workshops (6) for prescribers on the rational use of blood

Number of health personnel trained Number of seminars/workshops held

MOHS

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Objective 3. To provide knowledge and skills on STI/HIV/AIDS prevention among the youth. Government, NAS, UNFPA, UNICEF and Youth Serving NGOs have supported various youth activities for both in school and out of school youths in the area of HIV/AIDS. In April, 2003 UNICEF carried out a Knowledge, Attitude and Practice Survey on HIV/AIDS targeting Adolescents and for which the results revealed among others that societies often compound young people’s risks by making it difficult for them to learn about HIV/AIDS and reproductive health. In March, 2004 UNICEF, NAS, CARE and MEST developed and launched a Life Skills Programme Manual titled Sissy Aminata which was adapted from the original Auntie Stella Awareness Tool with kind permission from the Training and Research Support Centre, Zimbabwe, targeting in school and out of school youth. UNICEF has supported the Ministry of Education, (MEST) to train 12 facilitators, who in turn trained 20 teachers making a total of 32 facilitators. Training of 150 teachers on life saving skills is planned UNFPA on the other hand is to pilot a revised curriculum for POP/FLE for which the in service training of teachers in Milton Margai College will commence very soon. This Global Fund proposal’s strategy will build on existing initiatives and further strengthen the institution of a multi-disciplinary and wide reaching educational programme. The purpose is to convey accurate information about HIV/AIDS among youths in order to counter or dispel misconceptions and myths surrounding the epidemic. It will provide linkages to VCCT, PPTCT, condoms and other services. The activities will include provision of IEC materials, and the training of youth representatives, peer educators, animators and teachers. Also a youth centre that would serve as a pilot would be equipped to provide IEC and other services to youths. A cadre of animators, trained by CADO for four months each, with support from various donors is available at community level. The animators are organised into associations, and they carry out community mobilisation for a fee. Animators use drama and other informal methods to disseminate messages. Table 4.4B: Objectives Goal [From Table 4.4A] Number Objective 3 To provide knowledge and skills on STI/HIV/AIDS prevention among the youth.


20%


80%

What percentage of the people reached by this objective will be in: Rural areas 70% Urban areas 30%



Private sector 20% What percentage of people trained will be:



Private sector 20%

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Describe, for each objective, which target groups are important beneficiaries of this objective (check all that apply):

Injecting drug users Men who have sex with men Mobile populations Orphans People living with HIV/AIDS

Youth (in school) Youth (out of school)

Other (please specify: ________) Table 4.4C: Services to be delivered Objective To provide knowledge and skills on STI/HIV/AIDS prevention among the youth. Number Services to be delivered IEC/BCC Category Prevention

Description Information, Education and Communication including Community Sensitization and Mobilization

Coverage indicator Baseline Year 1 target

Year 2 target

Year 3 target

Year 4 target

Year 5 target

1 # of adolescents, youths and other key community members within the project operational areas sensitized.

[Code 4C]

40,000 30,000 10,000 5,000 5,000

2 # of Peer educators/internal animators trained for disseminating information on STIs, HIV/AIDS and related reproductive health issues

6,080 4,560

3 # of youth friendly centers established

0 1 1 1 1 1

4 # of adolescents and youths sensitized and adapting positive behaviour change towards HIV/AIDS issues.

40,000 30,000 10,000 5,000 5,000

5 % of adolescents, youths in targeted areas who practice at least 3 HIV/AIDS prevention methods by 2007

40,000 30,000 10,000 5,000 5,000

6 % of adolescents, youths in targeted areas who can state at least 3 methods of HIV/AIDS prevention by 2007

15,000 30,000 12,000 10,000 4,000

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Main activity Indicator Implementing partners

Organize mass rallies, float parades, etc.

# of mass mobilization activities organized # of youth exposed to key STI and HIV/AIDS prevention messages

Ministry of Youth, Ministry of Education, Science and Technology, NAS, UNFPA, UNICEF, CADO, Sierra Leone Red Cross Society, PCSL, PPASL, YWDO

Conduct visits and talks in all operational areas.

# of visits and meetings conducted

Ministry of Youths, Ministry of Education, Science and Technology, NAS, UNFPA, UNICEF, CADO, Sierra Leone Red Cross Society, PCSL, PPASL, YWDO

Organize series of one-day sensitization sessions for youth and adolescence and school children to serve as channel to talk to their peers and community members

# of adolescents, school children and girl child prostitutes that are aware of the dangers of HIV/AIDS and adopt preventive measures thereof

Ministry of Youths, Ministry of Education, Science and Technology, NAS, UNFPA, UNICEF, CADO, Sierra Leone Red Cross Society, PCSL, PPASL, YWDO

Organize 12 District level TOT workshops for youth representatives on HIV/AIDS related issues.

# of District Level workshops organized

Ministry of Youths, Ministry of Education, Science and Technology, Ministry of Information NAS, UNFPA, UNICEF, CADO, Sierra Leone Red Cross Society

Identify and train Internal Animators/Peer Educators (6,080 in Year 1, 4,560 in Year 2) in HIV/AIDS Communication Skills.

# of internal animator and peer educators trained

Ministry of Youths, Ministry of Education, Science and Technology, Ministry of Information NAS, UNFPA, UNICEF, CADO, Sierra Leone Red Cross Society

Organize 1 Material Development Workshop to develop IEC Materials

IEC materials development workshop held

Ministry of Youths, Ministry of Education, Science and Technology, Ministry of Information NAS, UNFPA, UNICEF, CADO, Sierra Leone Red Cross Society, PCSL, YADO, PPASL

Develop and disseminate IEC materials such as Posters, T-shirts, Caps, Sign Posts, Bill Boards, and Flyers etc HIV/AIDS related issues for youth.

# and type of IEC materials produced and distributed to target groups


Facilitate the inclusion of HIV/AIDS talks in school assembly(s)

# of sessions on HIV/AIDS in school assemblies


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Organize school and community based quiz, drama, football, volleyball and essay competitions radio discussions, and talk shows among youth groups

# of STI, HIV/AIDS TV and radio programmes produced and aired to the target audience


Liaise with drama groups for school and community drama on HIV/AIDS

# of school and community drama groups with HIV/AIDS themes in their presentations


Facilitate youth-to-youth outreach programmes

# of youth-to-youth outreaches established


Organize TOT for 3,800 youth representatives in Life Skills programme

# of youth trained in Life Skills programme

Ministry of Youths, Ministry of Education, Science and Technology, UNFPA, UNICEF, CADO, Sierra Leone Red Cross Society.

Organize TOT for 2,280 Link Teachers in Life Skills programme

# of Link Teachers trained in Life Skills programme


Print and produce existing Life Skills module to carry out life skills education programme among youths.

# of Life Skills modules printed


Train 1,520 Counselors Skills for young people

# of counselors trained Sierra Leone Red Cross Society, PPASL, YADO, PCSL

Facilitate the establishment of condom sale outlets for youth

# of condom outlets established.

Sierra Leone Red Cross Society, CADO, PPASL, YADO, PCSL

Provide equipment for 1 existing YFC

Equipment delivered WVSL, NAS

Provide, 20 XL Motorcycles, Desk top computers, Laptop Computers, Mega phones, Video Cameras, Videos and Accessories, Audio Visual materials etc.

Type and # of equipment provided

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Objective 4. To expand access to and promote correct and consistent use of condoms in the general population and among vulnerable groups nationwide. Affordable, acceptable male condoms are an essential part of Sierra Leone’s HIV prevention strategy. Poor utilization, low acceptance and ruptures in the supply are critical impediments to the national HIV response. National social marketing campaigns have been highly effective elsewhere in addressing both demand and supply problems. However this requires coordination, additional funding and technical competence and capacity. USAID has supported CARE International to set up a condom social marketing program in Sierra Leone, whose aim in this initial phase is to sell 2,000,000 condoms. NAS has attempted to address this problem by bringing donors, implementing partners and other stakeholders together to review the issue, document the needs and engage in advocacy to secure funding for a national social marketing program. The lack of funds has been the main obstacle. German development aid may be available to CARE to develop a national programme in two years time. In the meantime, NAS is also distributing free condoms through the District Health Management Teams (DHMTs) to community members. NAS is also currently working with NGOs to set up 3000 additional condom outlets in the districts, and to promote their use in the communities. From October 2002 to September 2003, ARG distributed 787,680 condoms through the DHMTs. Of the total number of condoms distributed, 45% were supplied in the Western Area and the remaining 55% distributed evenly among the 12 provincial districts. These figures do not however reflect the condom consumption patterns for these districts, as some NGOs and the private sector also provide condoms. It is important to note that the armed forces received a substantial amount of condoms through other sources, primarily for their personnel. Over the past 15 months (November 2002 to March 2004), CARE Sierra Leone has been implementing a Condom Social Marketing Program (CSMP) in the Western Area, which is just one district out of 12. Some of the current local partners besides the National AIDS Secretariat (NAS), include the US Embassy, Sierra Leone Red Cross Society, Coca Cola/Freetown Cold Storage, Standard Chartered Bank, Celtel, Mobil, and others. The project targets people of reproductive age (15 – 49 years old), with more particular activities directed at members of specific, high-risk groups, i.e., commercial sex workers, youth, uniformed services, etc. The project is scheduled to end in July 2004. In a proposed expansion of the CSMP to develop national coverage, project activities will focus on the following: • A national branding exercise. Although Protector Plus condoms are widely accepted in

Freetown, the brand still needs to be pilot tested outside of the Western Area. • Develop national-level condom distribution system. • Establish effective national monitoring system. • Operationalize the national HIV/AIDS IEC/BCC strategy into an effective promotional

campaign, including piloting the rural social mobilisation and IEC/BCC through drama described under Objective 1.

• Sell 8 million condoms and use the proceeds to purchase additional commodities such as condoms and packaging.

The project will target sexually active beneficiaries in all districts (both primary and secondary). Beneficiaries will include 50% youth, and 25% women (inclusive of those in the youth category) and 25% men, not considered to be youth.

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The project will specifically target youth and commercial sex workers (CSWs) by increasing access to condoms (# of outlets) in areas highly concentrated with youth and CSWs (i.e. rural growth points, mining areas). Subsequently, the promotional/communication campaign will focus on the informational needs of these target groups.

Objective 1 would be funded and managed under this objective. One of the Assistant Project Managers to be hired by CARE under this objective would manage objective 1, with the support of two of the three Marketing Promotion Field Officers. It will be funded specifically under the following budget lines for years 1 and 2-community based workshops, Peer Educator Training, Promotional Event, training of other partners, studies/research and evaluation. One of the major promotional activities would be the command performance of the drama to be attended by the President of Sierra Leone. Table 4.4B: Objectives Goal Number 4

To expand access to and promote correct and consistent condom use in the general population and among vulnerable groups nationwide.

What percentage of the people reached by this objective will be women? 50% What percentage of the people reached by this objective will be youth? 50% What percentage of the services in this objective will be delivered by:

Government 25% Non-government partners 25%


Health personnel 20% Non-health personnel 80% What percentage of people trained will be:

Government 20% Non-government partners 30%

Private sector 50% Describe, for each objective, which target groups are important beneficiaries of this objective (check all that apply):

Injecting drug users X Men who have sex with men X Mobile populations

Orphans X People living with HIV/AIDS X Sex Workers X Youth (in school) X Youth (out of school)

Other (please specify: ________)

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Table 4.4C: Services to be delivered Objective 1

Objective 4. To expand access to and promote correct and consistent condom use in the general population and among vulnerable groups nationwide.

Category Prevention Description of service to be delivered Expand distribution system and intensify marketing approaches to

increase accessibility to and awareness of condoms Coverage Indicator Baseline Year 1

target Year 2 target

Year 3 target

Year 4 target

Year 5 Target

1 Number of condom outlets established with condoms in stock

400 800 1600

2 Number of condoms distributed through public and private channels

2,000,000 4,000,000 4,000,000

Main Activity Indicator Implementing Partners

1 Identify and hire project staff Number of service deliverers trained

CARE, SL Red Cross Society, National AIDS Secretariat

2 Establish national condom distribution system and effective Management Information System (MIS)

Number of condoms distributed CARE, SL Red Cross Society, National AIDS Secretariat, SL Brewery, Coca Cola/FCS, National Petrol, Mobil, Safecon, International NGOs, Local NGOs, private sector partners, Wholesalers, Retailers

3 Conduct both quantitative and qualitative research to further develop marketing/promotional/educational campaign

Number/% using a condom in last sexual act

CARE National AIDS Secretariat Private Sector Partners Statistics Sierra Leone University of Sierra Leone M&E Committee

4 Scale up current marketing approaches

Number of HIV/AIDS radio/television programs/newspapers produced

CARE National AIDS Secretariat Ministry of Youth and Sports Ministry of Education Talking Drum Studio Radio UNAMSIL Sierra Leone Red Cross Society UNICEF International NGOs Local NGOs

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5 Implement marketing/promotional/educational campaign

Number of HIV/AIDS radio/television programs/newspapers produced

CARE National AIDS Secretariat Ministry of Youth and Sports Ministry of Education Talking Drum Studio Radio UNAMSIL Sierra Leone Red Cross Society UNICEF UNAIDS Theme Group International NGOs Local NGOs IEC/BCC Committee

6 Further consolidate links with partners such as local and international NGOs, and private sector to ensure national level scale up of activities is well coordinated

Number of condom outlets established

CARE National AIDS Secretariat SL Red Cross GoSL/Various Ministries International NGOs Local NGOs UNAIDS Theme Group Private Sector Partners

Objective 5. To strengthen and expand services for sexually transmitted infections. HIV/AIDS and STIs are interrelated. STIs are markers of biological and social/sexual vulnerability to other STIs, including HIV. Prevention and early treatment of STIs is an HIV prevention measure in addition to its other health, social and fertility benefits. The national prevalence of STI in Sierra Leone is about 3.94% of all outpatient clinic attendances and is the fourth leading cause of morbidity amongst outpatient attendance, following malaria, diarrhoeal diseases, and acute respiratory infections. The Health Sector Response Group (ARG) plans to strengthen the management of STIs at all levels of the health care delivery system, to ensure prompt diagnosis and early treatment of STIs. • At hospital level, the plan is to strengthen laboratory diagnosis of STI and treatment. • At the PHU level, the plan is to use the STI syndromic management approach. The ARG has produced a Manual on Syndromic Management of STIs for PHU Workers. A group of 130 peripheral health care staff of three districts (Kambia and Port Loko Districts and Western Area) were trained in the syndromic management of STIs, using resources from SHARP. Resources from the Global Fund will be used to scale-up STI management at all levels: • 750 PHU staff from 8 districts will be trained in syndromic management of STIs. • District laboratory staff in 8 districts will be trained in STI diagnosis, and the laboratories

provided with testing kits for STI diagnosis. • Refurbish and strengthen 200 STI clinics in the district. • Construct a reproductive health facility in the diamond mining district of Kono. This is to

provide reproductive health including STI services to women and youth living the district. Expected Outcome: By the year 2008, 90% of persons with STIs symptoms will have access to STI syndromic management services.

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This activity will be coordinated by the MOHS for government facilities, and by Marie Stopes for NGO activities. There will be joint planning, monitoring and supervision under the auspices of the STI, VCCT and PPTCT Committee. See tables 1 and 2 in the Annex for the list of partners and sites from which the 200 health facilities would be selected. Table 4.4B: Objectives Goal [From Table 4.4A] Number

5 To strengthen and expand services for sexually transmitted infection


45% - 60%


50% - 60%


Rural areas 50 Urban areas 50


Government 70 Non-governmental partners 25

Private sector 5 What percentage of people trained will be:

Health personnel 90 Non-health personnel 10

What percentage of people trained will be: Government 70 Non-governmental partners 25

Private sector 5 Objective [From Table 4.4B] Number Services to be delivered Category [Code 4F] STI Prevention and Control

Description [Code 4G] Rollout of a nationwide STI prevention and control strategy that will cover all 13 districts of the country.

Coverage indicator Baseline

Year 1 target

Year 2 target

Year 3 target

Year 4 target

Year 5 target

1 Number of service deliverers trained

130 250 750 750 750 750

2 Number of health facilities where staff trained in STI management and equipped with appropriate drugs

130 220 340 460 580 580

3 Percentage of persons with STI seeking care for STI

47.8% 60% 70% 80% 90% 90%

4

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Main activities Indicator Implementing partners 1. Review of

evaluation of the UNFPA assisted project.

Review Report NAS, MOHS, MMISL

2. Dissemination workshop to share lessons from UNFPA-assisted project.

Workshop report and profile of participants

NAS, MOHS, MMISL

3 Identify 200 STI clinics to renovate and refurbish in the district hospitals, PHUs and NGO clinics; include supply of laboratory equipment.

No. of district hospitals/PHUs and NGO clinics

NAS, MOHS, MMISL

4 Produce and distribute 2500 training manuals on Syndromic Management of STIs.

No. of manuals produced and distributed for use.

MOHS, MSSSL, PPASL, IRC, Red Cross, GOAL, IMC, ARC, WICM, Police, Military, MSF-H, MSF-B, MSF-F, CHASL, MRC, World Vision, Famcare

5 Train 52 trainers for district in STI management.

No. of trainers trained in STI management

MOHS, MSSSL, PPASL, IRC, Red Cross, GOAL, IMC, ARC, WICM, Police, Military, MSF-H, MSF-B, MSF-F, CHASL, MRC, World Vision

6 Train 700 district health care staff (including laboratory technicians) in STI management and counselling

No. of staff trained per district No. of functional health facilities providing correct STI management

DMT/ MSSSL, PPASL, IRC, Red Cross, GOAL, IMC, ARC, WICM, Police, Military, MSF-H, MSF-B, MSF-F, CHASL, MRC, World Vision

7 Provide drugs, condoms and other supplies for STI management to 200 health facilities

No. of health facilities without stockout of STI drugs and condoms.

MOHS, MSSSL, PPASL, IRC, Red Cross, GOAL, IMC, ARC, WICM, Police, Military, MSF-H, MSF-B, MSF-F, CHASL, MRC, World Vision, Famcare

8 Community theatre performances and radio/TV programs on STI, condom usage, safer sexual practices and sexual violence

No. of theatre performance No. of radio and TV programmes

IEC/BCC Committee MOHS NAS

Objective 6. To reduce HIV transmission from parent to child through the provision of Prevention of Parent-to-Child Transmission (PPTCT) services in 13 districts.

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Implementation of prevention of parent to child transmission (PPTCT) activities have just been started in the country by the AIDS Response Group (ARG) of SHARP, the World Bank funded project. Guidelines and a training manual for PPTCT have been developed by the ARG in consultation with other stakeholders, to guide service providers in the provision of antiretroviral prophylaxis, obstetric practices relating to PPTCT, infant feeding practices in the light of maternal HIV status, and all related health and social services for the HIV-infected women and their family (reference Health Sector HIV and AIDS Response Group Annual Report for 2003 attached). Antenatal sentinel surveillance was conducted in eight sentinel sites in June 2003, five centres in Freetown (3 government and two NGO partners) and three centres in three districts (one in the eastern region, one in the northern region and one in the southern region of the country). The result of this survey, which will provide information on antenatal prevalence, is expected in April 2004. A national biological and behavioural surveillance survey has been planned by SHARP in 2004, within which high risk groups will be addressed. The results will give information on national HIV prevalence among high risk groups. Five PPTCT centres have been established in the capital, Freetown: one non-governmental organisation (Marie Stopes Society Sierra Leone - MSSSL), one faith-based organisation (United Methodist Church), two uniformed services - police and the military, and the only referral maternity hospital in the country. These centres are located as follows; two in eastern Freetown and three in western Freetown. The ARG plans to establish some more of these centres in all district hospitals, with the exception of Kailahun district, which will be done by the NGO, International Medical Corps (IMC). This service is yet to be available in Community Health Centres (CHC), which also handle deliveries and serve as referral points for the Maternal and Child Health posts within the chiefdoms. This constitutes a big gap, since a significant proportion of the population reside in rural areas. However it is planned that PPTCT services will be extended to these CHCs after experience has been gained and lessons learned from the hospital services. 13 new government PPTCT centres will be established by SHARP in 2005, in the district hospitals not already covered (i.e., 6 in the Northern, 3 in the Eastern and 4 in the Southern regions). This project will address the upgrading of 5 PPTCT centres, and establishing a total of 30 centres countrywide, in a bid to contribute to fulfilling the government’s desire to improve access to Nevirapine prophylaxis by HIV positive pregnant women.. (see Annex Table 4 for current and planned PPTCT service provision according to district). 500 doses of Nevirapine tablets and syrup have been provided to the ARG, a donation from a German company, for the entire country. Through the Global Fund, Nevirapine tablets and syrup will be purchased to ensure that the drug will be available to many more women and their babies. At present, within the SHARP project, only 50 counsellors have been trained, 30 from government institutions and 20 from other partners; 30 laboratory technicians, 27 from government and 3 from other partners; 30 midwives working in antenatal clinics were trained to provide HIV and AIDS sensitisation messages during clinic hours. There is a dire need to train more service deliverers, a need which will be fulfilled through funds from the Global Fund. The training of 103 Counsellors will be done within the VCCT objective (see Table for Training). Further training of the different cadres of health service providers, (see service provider training list attached) both within the MOHS and for other partners will be done within each district. This training will focus on the application of universal precautions for the prevention of HIV transmission and in the administration and management of anti-retroviral drug therapy. This will have been accomplished in a phased manner, with 50% done within the first two years. The thirty health facilities (total of all districts) offering the minimum package of PPTCT services will be provided with supplies and protective clothing for the practise of the universal precautions for the prevention of the transmission of HIV. Utilization of this service since its establishment in January 2004 has been on the low side. This may primarily be due to the lack of adequate information on HIV and AIDS prevention that will influence health-seeking behaviours in pregnant women, in terms of testing to know their HIV

76

status. Another reason may be that clients who have the information may be scared of doing an HIV test because of the uncertainty of ‘what next?’ and the related stigma. This proposal hopes to further raise awareness about the availability of the service and the benefits of knowing a mother’s HIV status in pregnancy. Some partner linkages have been formed to ensure the continuum of care and necessary referrals for clients. By collaborating and cross-referrals with a number of organisations, the project will be able to reach women, men, young people, commercial sex workers (CSWs), miners and people living with HIV and AIDS (PLWHA). This activity will be coordinated by the MOHS for government facilities, and by Marie Stopes for NGO activities. There will be joint planning, monitoring and supervision under the auspices of the STI, VCCT and PPTCT Committee. At the end of the project, it is expected that the following will have been achieved:

19,591 service providers will have been trained: that is, 108 doctors trained in the provision of and management of anti-retroviral therapy; 1,222 nurses and 167 midwives; 650 support teams; 1,590 Maternal and Child Aides and 16,000 traditional birth attendants trained (TBAs) in the application of the universal precautions for the prevention of HIV transmission.

30 health facilities will be offering the minimum package of PPTCT, total being reached by the second year( See Table for PPTCT).

30% of HIV infected pregnant women in the whole country, who are those who deliver in a health facility will have received a complete course of Nevirapine prophylaxis during labour, to reduce the risk of parent to child transmission.

95% of babies born to infected mothers will have received Nevirapine syrup within 72hrs of delivery.

By the end of the project beneficiaries will have access to an integrated network of service, information and counselling providers who will be able to either address their needs themselves or refer them to collaborating organizations who can serve them better. Through this, a continuum of care can be provided for the target groups. Table 4.4B: Objectives Goal [From Table 4.4A] Objective To reduce the transmission of HIV from parent to child through the

provision of prevention of parent to child transmission (PPTCT) services in 13 districts


30


40






Health personnel 95

Non-health personnel 5

77


Private sector 0 Describe, for each objective, which target groups are important beneficiaries of this objective (check all that apply):

Injecting drug users Men who have sex with men

Mobile populations Orphans

People living with HIV/AIDS Sex Workers

Youth (in school) Youth (out of school) Other (please specify: Women of child-bearing age, including people living

with HIV and AIDS________)

Table 4.4C: Services to be delivered

Objective

To reduce the transmission of HIV from parent to child through the provision of prevention of parent to child transmission (PPTCT) services in 13 districts

Category PPTCT

Description Provision of PPTCT services Coverage indicator Baseline Year 1

target Year 2 target

Year 3 target

Year 4 target

Year 5 target


500 3490 6490 9490 12,490 19,591

2 Number/ of health facilities offering minimum package of PPTCT

5 20 24 24 30 30

3 Number of infected pregnant women receiving a complete course of ARVprophylaxis during labour, to reduce the risk of parent to child transmission

0 30% 40% 50% 60% 60%

4 Main activity Indicator Implementing partners

1 Evaluate existing pilots MRC, MSSSL, PPASL, CHASL, IMC, MOHS

NAS

2 Disseminate workshop to share lessons from pilots

MSSSL, PPASL, CHASL, IMC, and MOHS

NAS

3. Identify trainers & trainees

Trainers & trainees identified MRC, MSSSL, WVSL, PPASL, ARC, CHASL, IMC and MOHS

78

4. Recruit 33 staff for PPTCT

Number of staff recruited MRC, ARC, MSSSL, WVSL, PPASL, CHASL, IMC and MOHS

5. Access training materials Training materials accessed NAS 6. Train staff for PPTCT

(doctors, nurses, laboratory technicians and counselors)

Number of staff trained MRC, MSSSL, ARC, WVSL, PPASL, CHASL, IMC and MOHS

7. Scale up PPTCT sites (provide basic equipment, facilities and staff)

Number of PMCTYC sites established

MRC, MSSSL, WVSL, PPASL, CHASL, IMC and MOHS

8. Provide Nevirapine for mothers and infants

Number of mothers and infants on Nevirapine

MRC, ARC, MSSSL, WVSL, PPASL, CHASL, IMC and MOHS

9. Develop IEC materials for PMCTC

Number of IEC materials produced and disseminated

MRC, MSSSL, WVSL, PPASL, CHASL, IMC and MOHS

10. Conduct community sensitization on PMTCT in ANC clinics

Number of community sensitization sessions conducted

MRC, MSSSL, ARC, WVSL, PPASL, CHASL, IMC and MOHS

11. Train nurses and midwives, MCH Aides and TBAs in 13 districts in universal precautions under leadership of DHMT

Number of personnel trained MRC, MSSSL, WVSL, ARC, PPASL, CHASL, IMC and MOHS

Procure and distribute to 30 health facilities: medical supplies and protective clothing for universal precautions

Medical supplies and protective clothing procured and made available to 38 health facilities for universal precautions

MRC, ARC, MSSSL, WVSL, PPASL, CHASL, IMC and MOHS

Provision of post- exposure prophylaxis for service deliverers

Number of service providers needing post-exposure prophylaxis

MRC, MSSSL, ARC, WVSL, PPASL, CHASL, IMC and MOHS

Conduct impact assessment of interventions at 18month intervals

Report of impact assessment MOHS, NAS, Statistics Sierra Leone

Objective 7

To improve access to and utilization of Voluntary and Confidential Counseling and Testing (VCCT) services in 13 districts

The formation of a VCCT working group has been facilitated by the ARG in 2003 and the following have been achieved so far (ARG Annual Report 2003):

VCCT guidelines have been developed and produced and is now currently in use by all service providers offering HIV testing.

A VCCT training manual has been developed and produced, now being used for all VCCT related training.

A National VCCT Coordinator has been recruited, with the responsibility to coordinate all VCCT activities within the country.

20 core trainers in counselling have been trained by Family Health International (FHI), and these are now conducting training for other Counsellors.

50 Counsellors have been trained as in Objective 6.

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The AIDS Response Group (ARG) of the SHARP project, established Voluntary Confidential Counselling and Testing services in 15 centres in 2003-04, one in each district hospital of the 13 districts in the country including Freetown. Two of these centres are within the police and the military health facilities in Freetown. The only other service provider is a private laboratory, Ramsay laboratories, which conducts these tests in its Freetown branch. All of these services are located in the district urban areas, with none in the peripheral units, particularly the CHCs. The project plans to establish 30 new VCCT sites will be established within existing health facilities, a lot of which will be outside of the Western area. Of these, some will be within the Community Health centres (MOHS) (see Annex Table 3 on VCCT sites). This move is in line with the planned extension of VCCT services by the MOHS into the districts and chiefdoms (see Strategic framework for HIV in Sierra Leone).— This activity will take place in a phased manner over the five years, with 50% being accomplished in the first two years. The project plans to train 113 more Counsellors, 30 of whom will be newly recruited and trained and the rest will be receiving refresher training. These will provide on-site counselling for clients visiting the health facilities. There will also be refresher training for 37 laboratory technicians in performing the rapid testing for HIV and in the adherence to the universal precautions for the prevention of HIV transmission. Consultations will be held with the gatekeepers such as religious and community leaders and household heads to find out why VCCT services are currently being under-utilised. This will inform collaborating partners on the type of interventions to implement. An impact assessment of these interventions will be conducted at 18-month intervals and at the end of the project. Outreach components, which will increase during the course of the project, will ensure that those finding it difficult to travel to the centres will not need to remain marginalized, and will be able to access quality HIV/AIDS services and information through a variety of delivery mechanisms including NGO programmes and other clinic structures. Linkages would be forged to further target youth (through peer educators/animators and working through existing youth organisations), and to involve men (through the use of a newly recruited team of male promoters) in to what have traditionally been seen as female-focussed issues. The community promoters and youth peer educators will be providing off-site counselling and referral services for VCCT. A system for follow up of referred clients will be developed. A total of 17 motorbikes, headgears, protective raingears and backpacks will be required by both MOHS and partners for the conduct of monitoring trips and for accessing difficult terrain: 11 for District VCCT Supervisors as they go on their supervisory visits to the districts, 3 for outreach teams the Medical Research Council (MRC), 1 for PPASL, and 2 for CHASL. There will be linkages with the TB Control programme to ensure that VCCT sites are accessible to DOTS sites. This activity will be coordinated by the MOHS for government facilities, and by Marie Stopes for NGO activities. There will be joint planning, monitoring and supervision under the auspices of the STI, VCCT and PMCT Committee. At the end of the project period of five years, the following will have been achieved:

Number of people receiving VCCT increased by 46,755 Number of service deliverers trained increased to 1434 the bulk of whom will have been

trained during the PPTCT training (i.e. doctors, nurses and counsellors laboratory technicians)

90% of the total population will have heard about HIV and AIDS, and will have been reached with STI/HIV and AIDS prevention messages

90% of people will know where to access VCCT services 35 public statements by religious/political leaders regarding the acceptance of HIV

infected persons (hence contributing to the reduction of stigma) X number /% of persons meeting the criteria for anti-retroviral treatment will be

referred/linked with the ARV treatment centre and have access to and receive therapy

80

Table 4.4B: Objectives Goal [From Table 4.4A] Objective 7

To improve access to and utilization of quality voluntary confidential counseling and testing (VCCT) services in 13 districts


60


70






Health personnel 95 Non-health personnel 5


Private sector 0 Describe, for each objective, which target groups are important beneficiaries of this objective (check all that apply):

Injecting drug users Men who have sex with men

Mobile populations Orphans

People living with HIV/AIDS Sex Workers Youth (in school) Youth (out of school) Other (please specify: _Men and Women in child-bearing age)


Objective

To improve access to and utilization of Voluntary Confidential Counselling and Testing (VCCT) services in 13 districts

Category VCCT

Description Provision of counselling and testing and services to those at risk of or affected with HIV and AIDS

Coverage indicator Baseline Year 1 target

Year 2 target

Year 3 target

Year 4 target

Year 5 target

1 Number of districts providing VCCT services

13 13 13 13 13 13

3 Number of people receiving VCCT

2750 13000 26000 39000 52000 65000

81

Number of service deliverers trained

67 90 90 120 120 120

Main activity Indicator Implementing partners 12. Evaluation of existing

pilots MRC, MSSSL, PPASL, CHASL, IMC, MOHS

NAS

13. Dissemination workshop to share lessons from pilots

MSSSL, PPASL, CHASL, IMC, and MOHS

NAS

1. Establish 30 VCCT sites within existing health facilities

30 functional VCCT sites established and equipped

MRC, MSSSL, PPASL, ARC, CHASL, WVSL, IMC, and MOHS

2. Recruit 39 staff for VCCT (laboratory technicians, supervisors and counselors)

Number of staff recruited ARC, MRC, MSSSL, WVSL, PPASL, CHASL, IMC and MOHS

3. Access training materials

Training materials accessed

4. Train of staff Number of staff trained ARC, MRC, MSSSL, WVSL, PPASL, CHASL, IMC and MOHS

5. Procurement of rapid testing kits and laboratory supplies

Rapid testing kits and laboratory supplies procured

MRC, ARC, MSSSL, PPASL, CHASL, IMC, WVSL, other NGOs and MOHS

6. Development of IEC materials for VCCT

Number of IEC materials produced and disseminated

7. Procure 17 motorbikes, helmets, and protective raingears for monitoring and supervisory trips

17 motorbikes, helmets, and protective raingears procured for monitoring and supervisory trips

MOHS, NAS

8. Conduct impact assessment of interventions at 18-month intervals

Report of impact assessment MOHS, NAS, Statistics Sierra Leone

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Objective 8. To improve access to and utilization of ARVs in 13 districts.

Medical care is currently being provided to PLWHAs through existing public health services and through private clinics. Presently, holistic care including the treatment of opportunistic infections (OIs) is provided for 240 patients in four centres in Freetown (FAMCARE, Connaught Hospital and two private clinics). FAMCARE, with support from SHARP, provides free treatment to patients with OIs, and free consultation and prescription to those who can afford to purchase ARV drugs. So far, only three patients among their clients can afford ARVs. The MOHS specialist physician also provides the same service as FAMCARE: free treatment of OIs with SHARP-supplied drugs to patients who visit the MOHS facilities. Private physicians have documented 23 PLWHAs who started on ARVs but could not continue due to the cost burden. This failure to continue treatment has major implications for drug resistance in the country. The World Bank MAP-funded SHARP Project did not budget any amount for the purchase of ARVs. To strengthen the provision of medical care for PLWHAs, a working group to develop HIV treatment and care guideline has been established. The initial focus for medical care has been on effective case management of OIs, including prevention, diagnosis, prophylaxis and treatment; nutritional support; and establishment of basic monitoring capacity with CD4 counts. The following gains have been made in the area of treatment of PLWHAs: ♦ A local consultant has been recruited to development guidelines for treatment and care of

PLWHAs. ♦ A CD4 cell counter has been procured and situated in the National Reference Laboratory; two

laboratory technicians have been trained in its use. ♦ The Government of Sierra Leone recently allocated 220,000 USD for the procurement of

ARVs. These drugs will be used to provide treatment for about 300-350 PLWHAs. It is expected that more funds will be allocated to ARVs in subsequent budgets.

This proposal plans to expand the provision of treatment for PLWHAs to all the districts. The plan is to establish three ARV treatment centers in the government hospitals in Bo, Kenema and Bombali districts and a treatment center in the military hospital. These towns are regional headquarters, and will serve as access points for PLWHAs in each region. The target is to provide continuous treatment for an additional 1,000 PLWHAs in the country by 2009. Treatment at these centers will be free, as most PLWHAs in Sierra Leone cannot afford the cost of treatment. However, the DOTS treatment model will be used where a patient will pay a refundable retainer of $10 to ensure compliance. To establish these centers it will be necessary to:

• train 50 medical staff in the treatment of PLWHAs with ARVs • provide 4 CD4 cell counters (one in each region) and a viral load counter in the

Connaught Hospital • supply ARVs and drugs for the treatment of OIs.

External consultants with long-term experience in treatment of PLWHAs will be engaged to train local staff. Priority candidates for training and mentoring will be doctors in government, NGOs and private clinics who are already involved in the care of PLWHAs. In turn, the local trainees will act as trainers of others in the future expansion phase of services beyond the initial three centers. This activity would be government lead, with the establishment of ARV management units within the medical school in the university and the MOHS. The close collaboration with private physicians would continue, and government would work very closely with the Sierra Leone Medical and Nursing Associations, whose members would benefit from training. The plan is to access PLWHAs through TB clinics and PMTCT activities. Treatment will be provided for 200 PLWHAs in the first year, and will increase to 500 in the second year, starting with the 25 documented above. An additional 300 patients will be added to the program for each subsequent year.

83

Table 4.4B: Objectives Goal [From Table 4.4A] Objective Number

To improve access to and utilization of ARVs in 13 districts.

8 [Code 4E] What percentage of the people reached by this objective will be women?

50%


50%






Health personnel 100% Non-health personnel -



Injecting drug users Men who have sex with men Mobile populations Orphans

X People living with HIV/AIDS Sex Workers Youth (in school) Youth (out of school) Other (please specify: ________)


Objective [From Table 4.4B] To improve access to and utilization of ARVs in 13

districts. Number Services to be delivered

Category Antiretroviral treatment and monitoring

Description Provision of ARV, Provision of Laboratory equipments, Training of health care staff in treatment with ARVs and treatment of OIs, Training of nurses in care for PLWHAs, Training of laboratory staff in use of CD4 Cell counter and viral load counter. (see above)


Year 1 target

Year 2 target

Year 3 target

Year 4 target

Year 5 target

1 Number of service deliverers trained for ARVs and OIs.

0 72 80 120 150

84

2 Number of facilities providing ARVs

0 3 3 3 3 3

3 Number of people with advanced HIV infection receiving antiretroviral combination therapy

28 200 500 800 1100 1400

Main activity Indicator Implementing partners 1 Train 30

physicians in ARV therapy for PLWHAs

# of physicians trained in treatment with ARVs

MOHS, FAMCARE, Willoughby Clinic, Corney Barnes Clinic, Sierra Leone Medical and Nursing Associations

2 Train 42 nurses in nursing care for PLWHAs

# of nurses trained in nursing care for PLWHAs


Mentor and provide technical assistance to physicians doing ARV therapy

# of physicians mentored in ARV therapy by International Expert

NAS, MOHS, University, Sierra Leone Medical and Nursing Associations

3 Training of trainers for 42 Field Staff in HBC of PLWHAs

Number of staff trained in HBC

MOHS

4 Train Health Staff (CHOs) in the treatment of opportunistic infections (OIs)

# of health staff trained in the treatment of OIs


5 Train laboratory staff in viral load estimation

# of laboratory technicians trained in viral load estimation

NAS, MOHS

6 Train 12 laboratory technicians in the use of the CD4 counter.

# of laboratory technicians trained in the use of the CD4 counter


7 Procure drugs and 2 CD4 cell counters

Quantities of different types of drugs and equipment procured.

NAS, MOHS

8 Establishment of ARV management units within university’s medical school and MOHS

Number of ARV management units established

NAS, MOHS, University

85

Objective 9. To provide prevention, care, support and treatment to special groups. The objectives covered elsewhere like provision of STIs, VCT, PMCT and ARV services, and surveillance, will not be provided for and duplicated under this objective, except for stand alone facilities based where these special groups are, or activities/services that are best conducted/provided for them alone. Only those will be included and budgeted for here. There have been no large-scale studies and almost no biological data (HIV, Syphilis, or other STI) among various highly vulnerable subgroups in Sierra Leone. Baseline and ongoing data is essential for effective program planning and later program evaluation. A national biological and behavioural surveillance survey is planned by SHARP later in 2004 on commercial sex workers. Activities delivered under this objective will use protocols developed by NAS for conducting cross-sectional studies among various high-risk subgroups (military, police, CSWs, fishermen and miners) in order to get baseline data and help direct appropriate prevention and care interventions. The proposed surveillance study is likely to be modelled on a 2001 national sero-prevalence study in Guinea as it will provide very useful biological and behavioural data among some key populations and would allow compatibility in the sub-region. Activities in this objective will be linked with objectives for Syndromic Treatment of STIs; PPTCT; VCCT, Treatment of Opportunistic Infections and the delivery of antiretroviral therapy to PLWHAs. High-risk populations: Diamond mining is a major economic activity carried out by the local population, but also increasingly by a number of ‘foreigners’ – who come from higher HIV prevalence countries such as Guinea, Nigeria and the Gambia. High numbers of commercial sex workers have resulted from years of war and poverty, and the presence of foreign troops. While the current lack of data does not allow us to show a trend suggesting that Sierra Leone might be heading in the way of a South African experience, the same factors exist in our own communities - high-risk sexual behaviour (especially CSWs), significant population movements, poor access to basic health care (e.g., effective treatment of STIs), and lack of stable family ties and structure. This objective will provide directly and through linkages preventive, curative care and support to two groups: miners and CSWs. The National Strategic Plan identifies these two migrant populations as deserving priority attention in HIV/AIDS control and prevention. These groups will be targeted with interventions such as the promotion of safer sexual behaviour, regular use of condoms, STI treatment and control, VCCT, ARV Therapy, and other institutional HIV/AIDS programs. The SHARP Project will supply drugs for the treatment of OIs, increasing these drugs’ accessibility to the vulnerable population that needs them. Linkages with the MOHS’ syndromic management of STIs, and the TB Control Program’s DOTS Strategy will also be established. The NGO partners that will bear the bulk of the responsibility in achieving targets for this objective will be the following:

• Merlin will conduct activities in the mining regions of Kono and Kenema. • SWAASL will conduct activities with sex workers in Freetown and Kailahun. • WICMS will provide employment creation/vocational equipment and materials to 100 CSW

that were trained with UNFPA and other donor assistance. Targeted beneficiaries of high risk groups include:

• 3000 miners will be primary beneficiaries and up to 100,000 will be secondary

beneficiaries in the mining areas of Kono and Kenema. • 500 CSWs will be targeted as primary beneficiaries in Kailahun. • 700 CSWs will be targeted as primary beneficiaries in Freetown. • 100 CSWs who have previously acquired vocational skills will be primary beneficiaries in

Freetown

86

At the end of this objective, it is expected that the following will have been achieved:

• HIV-positive CSWs with HIV-associated illness will be receiving appropriate treatments either in combination with ART or alone in district hospitals and other sites

• A second generation surveillance system will be functioning in Kono and Kenema districts, specifically among the mining sub-population

• A model will exist for quality HIV/AIDS integrated service delivery to high-risk groups; this model will then be applied to other districts of the country. This will include increased access to IEC, VCCT, PMCT, STIs, OIs and ARV treatments through linkages with all relevant services

• 70% of miners and sex workers and 50% of the public and other high-risk groups will have increased their knowledge of HIV and attained desirable behavioural change.

• 1200 sex workers and 3,000 miners will have received safe sex messages • 600 sex workers will have received vocational and technical training

Table 4.4B: Objectives

Goal Number To provide prevention, care, support and treatment to special groups. 9 To provide preventive, curative and care and support to vulnerable groups


75%


75%





Private sector % What percentage of people trained will be:




Injecting drug users Men who have sex with men Mobile populations Orphans People living with HIV/AIDS Sex Workers Youth (in school) Youth (out of school) Other (please specify: high risk group -miners, sexual partners and miners’

families)

87

Table 4.4C: Services to be delivered Objective To provide prevention, care, support and treatment to special groups. Number 9

Category Prevention Description Comprehensive prevention program for miners and CSWs


Year 1 target

Year 2 target

Year 3 target

Year 4 target

Year 5 target

# of miners and CSWs receiving VCCT

0 1,000 1,500 2,000 2,500 3,000

# of miners and CSWs tested for HIV

0 200 500 700 1000 1500

# of miners receiving ARV therapy

0 0 100 300 400 500

No. of CSWs identified

0 250 350 500 750 1000

% of CSWs enrolled in technical/vocational training

0 50% 60% 65% 70% 75%

% of high risk group expressing accepting attitudes towards HIV/AIDS positive persons

69% 80% 80% 80% 80% 80%

% of high-risk group using a condom the last time they had sex with a casual partner

24% 60% 60% 60% 60% 60%

Increase % of miners and CSWs who have received VCCT

0 10% 20% 30% 40% 50%

Main activity Indicator Implementing partners Develop and

produce IEC/BCC program content targeted at specific high-risk communities

# and types of IEC/BCC materials developed and produced targeting specific high-risk communities

MOHSL, NAS, SWAASL, MERLIN

Train health workers, community volunteers, peer educators and animators.

# of training events conducted # of health workers, peer educators, volunteers, and advocates trained

MOHSL. NAS. SWAASL

Organize community sensitization meetings

# of community meetings held # of participants at community sensitization meetings


88

Provide linkages of services of surveillance linked VCCT, condoms, syndromic management of STIs, treatment of OIs, TB, and ARV treatment services

# of health facilities offering minimum package of care and support services # of cases of STIs, OIs, TB and AIDS from the special groups that received adequate clinical management

MERLIN, GOAL, SWASL, MoHSL, District Health Medical Teams,NAS, CCSL (TB DOTS), German TB and Leprosy Foundation

Encourage CSWs to enroll in adult literacy programs

# of CSWs enrolled in adult literacy classes

SLADAE, MOHSL, MES&T, NAS, SWAASL, MERLIN

Identify and determine specific areas of interest of CSWs for appropriate skills training

# of CSWs enrolled in different types of skills training events


Identify appropriate technical and vocational institutions and link up CSWs.

# of technical /vocational institutions in which CSWs are enrolled


Monitor and evaluate training programs and provide start-up kits for those who successfully complete training

# of dropouts # of CSW successfully completing training programs # of start-up kits distributed

MOHSL, NAS, SWAASL, MERLIN TECHNICAL/VOCATIONAL TRAINING CENTERS, MRELIN, NAS, MOHS, WICMS

Conduct baseline surveys on STI prevalence, and at-risk behavior patterns amongst the high risk communities

# and types of completed surveys

MOHSL, NAS, SWAASL, MERLIN, University of Sierra Leone, Statistics Sierra Leone

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Objective 10. To provide palliative care and support to PLWHA and OVCs, particularly in war affected areas. People living with HIV/AIDS (PLWHAs) and orphans are the primary beneficiaries of this objective. People testing positive for HIV require follow-up for psychosocial, medical, and in some cases, economic support. These care and support services will increase survival rates of PLWHAs and enable them to enjoy life with dignity and respect as well as ensure that children and relatives left behind are taken care of. Since its establishment in 1987, the National AIDS Control Programme of the Ministry of Health and Sanitation was providing limited follow-up counselling and home visits to PLWHAs in the Western Area. The challenge of providing care and support for PLWHAs was taken up more seriously in 2000, first by The Shepherd’s Hospice (TSH). Other partners eventually getting involved in care and support are the Sierra Leone Red Cross Society (SLRCS), Society for Women and AIDS Sierra Leone (SWAASL), Christian Children’s Fund (CCF), Rufutha Development Association (RODA), FAMCARE, Association of PLWHAs (HACSA), and Kakua Hospice. Others include faith-based organizations like the United Methodist Church (UMC), Young Women Christian Association (YWCA), The Methodist Church Sierra Leone (MCSL) and the Council of Churches in Sierra Leone (CCSL). The Ministry of Social Welfare, Gender and Children’s Affairs (MSWGCA) is also involved in supporting PLWHAs and OVCs. HACSA is currently being supported by SHARP to rent an office, pay staff, buy drugs to treat OIs and provide educational materials and information kits for PLWHAs. At the moment, however only about 2,000 individuals have been recorded as testing HIV-positive. Only 356 are receiving follow-up counselling and home-based care. There is thus a large number of PLWHAs who can neither be traced due to false identity at time of testing, nor make use of available services due to fear and shame associated with stigma and discrimination. Various groups might use different approaches that are likely to help reduce stigma related to HIV/AIDS. With increased access to and use of VCCT services at the district level, the gap for care and support will likely further widen. Orphan care services, at present limited to educational support and available only in the Western Area, are provided to 135 orphans and vulnerable children. The Shepherd’s Hospice provided support for 69 OVCs, CCF 29, SWAASL 1 and MCSL has identified 36 for support. There is also a need to provide additional support for OVCs for nutrition, health care and psychosocial support. With improved access to VCCT the number of PLWHAs is expected to increase and the need for services is also expected to rise accordingly nationwide. Consequently, for mutual support, PLWHAs will require the formation of support groups. So far only three support networks of PLWHAs have emerged during the last three years, all of them in the Western area. There is a need to facilitate the formation of at least one support network in each district as access to care and support services are made available. Presently, there are only 45 trained staff in home-based care, 42 (93%) of them are health personnel and 3 (7%) are non-health personnel. Clearly the existing capacity and resources to deliver social, emotional and economic support to PLWHAs fall far below the current need. In war-affected areas, many PLWHAs have lost their relatives, leaving them with no one to care for them. The Kakua Hospice has attempted to rent a building to use as a hospice, however most house owners turned them down due to the stigma of HIV/AIDS. Finally the community met, and allocated land for the building of a hospice. Global Fund support is being asked to build this hospice which would be the only one outside of Freetown and would enable survivors in the war torn areas to receive care. The laws on fostering and adoption are outdated. The government would seek support from donors, likely UNICEF in the policy review process, but would use its own resources to move things forward to enacting new legislation if necessary.

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Expanding access to care and support services would require

• Mobilizing community awareness and participation for home-based care and support services

• Development of advocacy kits on PLWHAs • Training health and non-health personnel, community volunteers and caregivers on care

and supports services • Develop guidelines for case management • Provide home-based care kits for PLWHAs • Establish care and referral networks • Enhance economic capacity of PLWHAs, community volunteers and community members

providing foster care for orphans

Training will be provided for doctors and other health workers on clinical care for treatment of opportunistic infections. 30 doctors, 103 nurses and 312 community health workers and other staff will be trained in the first year. A total of 300 community volunteers will be trained in the first year, with an increase of 30% in the second year. The provision and expansion of care and support services for PLWHA and OVC in the13 districts will achieve the following:

• 171 service providers will be trained. Initially, 49 community caregivers will receive training in social mobilization and home-based care; this will increase by 30% every year.

• 356 HIV positive persons will be offered follow-up counselling and home-based care. 30% increase will be made every year. It is expected that 60% will be receiving the service by 2009.

• Linkages will be made with ARV service providers on behalf of PLWHAs who qualify. • 356 PLWHAs will receive a home-based care kit in the first year, supplemented by a

minimum package every quarter during the project period. • 135 OVCs will receive educational support during the first year; a 30% increase is planned

for every subsequent year of project life. • During the first year, 490 PLWHAs of the 1961 positive persons will be economically

empowered to provide basic needs for themselves and support OVCs under their care: a 30% increase is planned for every subsequent year of project life, and may include new cases.

• During the first year, 135 foster parents will be economically assisted to support OVC in their homes; a 30% increase is planned for every subsequent year of project life, and will include newly identified OVCs.

• During the first year, 135 OVCs and 490 PLWHAs will be provided with nutrition support; a 30% increase is planned for every subsequent year of project life.

Christian Children’s Fund (CCF) will coordinate all activities and the related budget for this objective. CCF will thus ensure that funds, equipment and other supplies will be provided to partners for the implementation of activities relating to this objective. CCF will coordinate a baseline survey for PLWHA and OVCs and will also provide support for monitoring and evaluation of activities related to this objective. By the end of the project, functional and sustainable community support initiatives would have been set to support the vulnerable to enjoy minimum standard of life.

Table 4.4B: Objectives Goal [From Table 4.4A] Number Objective 10 To provide palliative care and support to PLWHA and OVCs, particularly in

war affected areas What percentage of the people reached by this objective will be

women? 60%

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60%









Injecting drug users Men who have sex with men Mobile populations

X Orphans X People living with HIV/AIDS

Youth (in school) Youth (out of school) Other (please specify: ________)

Table 4.4C: Services to be delivered Objective To provide palliative care and support to PLWHA and OVCs, particularly in

war affected areas Number Services to be delivered

Category Prevention Description Information, Education and Communication including

Community Sensitization and Mobilization Coverage indicator Base

line Year

1 targetYear 2 target

Year 3 target

Year 4 target

Year 5 target

1 No of service deliverers trained

200 400 600 800 1302

2 Number of health facilities able to deliver basic level counseling and medical services to PLWHAs, especially treatment of OIs

3 Number of chronically ill with external support

92

4 Number of orphans and OVC less than 18years who receive basic external support

0 135 200 300 300 387

Main activity Indicator Implementing partners

Develop advocacy kit on PLWHAs on stigma reduction for PLWHAS

980 Advocacy kits on PLWHAs and OVCs provided to service/care givers.

CCF, TSH, SLRCS, SWAASL, RODA FAMCARE, HACSA Kakua Hospice, UMC, YWCA, MCSL, CCSL and MSWGCA

Organize series of sensitization sessions for communities, health workers on Home Based Care and Support Services

70% of community members aware of care and support services to PLWHAs.

CCF, TSH, SLRCS, SWAASL, RODA FAMCARE, HACSA Kakua Hospice, UMC, YWCA, MCSL, CCSL and MSWGCA, HACSA

Support development, production and dissemination of IEC materials

120,000 copies of 10 types of IEC materials developed, produced and distributed.


Facilitate sermon on the project in churches and mosques.

151 chiefdoms that receive messages from churches and mosques


Strengthen community support for PLWHAs & orphans

1398 PLWHA receiving community support


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Strengthen community support for orphans

387 orphans receiving community support


Identify and train nurses, other health workers, community volunteers and caregivers on Care and Support Services for PLWHAs

1,302 of nurses, other health workers and community volunteers trained in Home Based Care.

CCF, TSH, SLRCS, SWAASL, RODA FAMCARE, HACSA Kakua Hospice, UMC, YWCA, MCSL, CCSL and MSWGCA, MOHS

Train health workers and peer educators on pre and post counseling skills

1,302 of health workers and peer educators trained on pre and post counselling


Organize series of workshops for communities to address issues related to stigma, and discrimination

1398 of PLWHAs accepted and integrated among community members.


Establish care and referral networks.

151 types of care and referral networks established.


Provision of home-based care kits to PLWHA

1398 PLWHA who receive home-based care kits


Promote nutrition education among PLWHAs.

1398 PLWHAs who received nutrition education


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Facilitate linkages with service providers for treatment of opportunistic infections

151 service providers engaged in management of opportunistic infections.


Provide skills training and start up grant to trained PLWHAs

1398 of PLWHAs that received skills training. 1398 of PLWHA that received start up grant after training


Organize series of entrepreneurship training for PLWHAs

1398 PLWHAs who benefited from entrepreneurship training 1398 PLWHA profitably engaged in entrepreneurship


Facilitate care for orphans/vulnerable children

387 orphans/vulnerable children receiving support from community members and family members.


Provision of Orphan Educational Support Kit (uniforms, shoes etc)

387 orphans who received educational support kit


Hospice Care 1398 of PLWHA treated with ARVs.


Treatment of Opportunistic infections

1398 PLWHAs who receive treatment for OIs

CCF, TSH, SLRCS, SWAASL, RODA FAMCARE, HACSA Kakua Hospice, UMC, YWCA, MCSL, CCSL and MSWGCA, MOHS

Procure 4

motorcycles # of motorcycles procured

NAS

Build Kakua Hospice building

Hospice building completed

Kakua Hospice

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Objective 11: To Strengthen and Expand the National Capacity to design, implement, monitor and evaluate HIV/AIDS Activities in the country Since the first case of HIV/AIDS was reported in Sierra Leone in 1987, there have been a number of attempts by the MOHS and other organisations to keep track of the epidemic. However a major constraint has been the lack of a reliable statistics. A survey conducted by CDC Atlanta in collaboration with GOSL reported preliminary results (after testing in Sierra Leone) of 4.9% prevalence and a final result (after testing at CDC laboratory in Atlanta) of 0.9%. It should be noted that this survey did not include the former conflict areas (e.g., Kailahun, Kono districts) that were worst affected by the prolonged civil war. Therefore, a key activity in SHARP is the completion of surveys to understand the level of the epidemic and the determinants that are driving it. To this end, ARG has established eight Antenatal Clinics as sentinel sites for monitoring the trend of the epidemic. The preliminary results from the latest Antenatal sentinel surveillance testing study that was available just as this proposal was being finalised, gave an overall HIV/AIDS prevalence rate of 3.4% and a 4.7% prevalence for Freetown. Also, with support from SHARP, biological and behavioural surveys have been planned for high risk populations (CSWs, miners, fishermen, long-distance drivers, and uniformed personnel). NAS is responsible for monitoring the activities of national partners in HIV/AIDS and evaluating the overall impact of their activities. Any impact evaluation is usually done collaboratively with other partners. There is presently an M&E working group that helps to coordinate and provide technical guidance for the setting up of an efficient and effective M&E system within the NAS. This working group includes some members of the CCM, research institutions, the University, UNICEF and WHO. Global Fund support is requested to strengthen M&E, within NAS and the DHMTs. First, resources are needed to conduct a national sero-surveillance to get a reliable picture of the level of the epidemic in the country and to repeat the survey after four years to assess overall impact. Also there is a need for accurate and timely information on STIs/HIV/AIDS and related issues, both biomedical and other multi-dimensional data in areas that are vital for awareness, resource mobilization and appropriate policy response and intervention formulation and implementation. The NAS M&E will need two additional M&E Officers, a vehicle and four motorcycles to cope with the anticipated workload. Support will also be required for two M&E staff to receive external training in data management and research. Global Fund support will be needed to conduct relevant operational research (at least 2 a year) to help design better programs to combat STIs/HIV/AIDS. Specific operation research topics will include: 1. Assessment of the efficacy of commonly used antibiotics against STIs (Ramsay Laboratories). 2. Determine bed occupancy by PLWHAs in hospitals (COMAHS) 3. Conduct annual cost-benefit analyses of activities (MOHS). 4. Assess barriers to VCCT, condom use and STI management among youths and adults (NAS). 5. Investigating sexual networks among youths (COMAHS). 6. Sentinel monitoring of STIs (Ramsay) at STI clinics. Also the capacity of government and NGO partners staff will be strengthened through training, study tours and attendance at international meetings on program design and management, M&E, computer skills (Excel software), financial management, and reporting and documentation.

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Table 4.4B: Objectives Goal [From Table 4.4A] Number To strengthen and expand national capacity to design, implement, monitor

and evaluate HIV/AIDS programmes in the country. [Code 4E]


50%


30%




Government 80% Non-governmental partners



What percentage of people trained will be: Government 90% Non-governmental partners


Injecting drug users Men who have sex with men Mobile populations Orphans People living with HIV/AIDS Sex Workers Youth (in school) Youth (out of school) Other (please specify: ________)

Objective

11 To strengthen and expand national capacity to design, implement, monitor and evaluate HIV/AIDS programmes in the country.

Number Services to be delivered Category Monitoring, Evaluation, And Operations Research

Description Training of Staff, provision of computers and accessories, provision of motorcycles for monitoring and evaluation, support for research activities.


Year 1 target

Year 2 target

Year 3 target

Year 4 target

Year 5 target


0 18 40 50 - -

2 Percentage of budget spent on monitoring and evaluation

0 5% 10% 10% 10% 10%

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Main activity Indicator Implementing partners 1 Train District M&E

Officers in data management and research

# of M&E Officers trained NAS MOHS

2 Procure logistics (computers and accessories, motorcycles and vehicles) for M&E in district

# and % of districts with computers and motorcycles procured with resources from the Global Fund

NAS MOHS

3 Recruitment of M&E Officers in NAS

# of M&E officers recruited and paid with resources from the Global Fund

NAS

4 Operational cost of additional travel for data collection and supervision.

# of M&E supervision visits made each month

NAS

5 Conduct two operations research activities each year) related to STIs/HIV/AIDS

# of operations research conducted each year

NAS MOHS USL (COMAHS) Ramsay Laboratories

6 Conduct national sero-surveillance

Sero-prevalence survey report completed

NAS

7 Train government and NGO partner staff in program design and management

# of government and NGO staff members in program design and management

NAS

8 Train government and NGO partner staff in M&E

# of government and NGO staff members trained in M&R

NAS

9 Train government and NGO partner staff in financial management and reporting

# of government and NGO staff members trained in financial management and reporting

NAS

10 Train government and NGO partner staff in program documentation

# of government and NGO staff members trained in program documentation

NAS

11 Train government and NGO partner staff in Excel Software

# of government and NGO staff members trained in Excel software

NAS

12 Study Tours and international meetings

# of staff sent on study tours and international meetings

NAS

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4.3.15 Describe the quality and type of the training to be carried out (e.g., delivery of ART services according to national guidelines, or peer counseling in sexual and reproductive health, according to national youth mobilization guidelines).

The training in VCT, PMCT, STIs and OIs will be done according to national guidelines, which had been developed under the SHARP Project. Additionally, training in the use of ARVs and Home-Based Care will not be done until the guidelines are ready. The sales and marketing teams for the condom social marketing will be given business related skill sets. Their capacity will be strengthened by providing on-going training in identified areas of needs, such as reproductive health, HIV/AIDS and social marketing best practices. Technical assistance will be sought from partners from both the private and public sectors, building on the strengths and experiences of those partners with long-standing experience in marketing and distribution activities (i.e. Coca Cola, CELTEL, and Mobil). The current level of participation of the private sector will be strengthened by creating a reciprocal, exchange program. The CSMP will assist the organization in building the knowledge base of the respective staff, in exchange for support from that organization to support the sales and distribution activities. A particular strength of CARE International (implementing agency of the CSMP) is their sound financial management and monitoring systems. CARE financial staff will work closely with CSMP staff to train them on the development and use of these established systems. Subsequently, CSMP will continue to foster relationships with agencies and organizations to develop the capacity of all NGO and government staff in the implementation of effective participatory and experiential training techniques. Continued collaboration and coordination between partners such as NAS, SLRCS, IMC, Marie Stopes Society, ARC, UNICEF, and the UNAIDS Theme Group will ensure that the communication strategy is universal and consistent throughout all staff and partners. Training will be required for micro-enterprise development, for CSWs and PLWHAs. These would be contracted to institutions that have a track record in theses areas, as they are specialised areas. To ensure effective delivery of services, additional training is also required for both government and NGO staff in program design and implementation, monitoring and evaluation, and use of Excel Software etc.

4.3.16 Describe the broad approach for human resources development, including how adequate human resource capacity will be developed to support program scale up (2–3 paragraphs)

There is adequate manpower in the government and NGOs services, to deliver the manpower requirements for this proposal.. The MOHS has a total staff complement of 2,404, made up of 40 cadres. The MOHS personnel of direct relevance to this proposal include 73 general practice doctors, 24 specialist doctors, 20 public health specialists, 132 Community Health Officers, 266 staff nurses, 712 trained nurses, 42 midwives, 16 District Health Sister, 33 health sisters, 6 public health sisters, 726 MCH aides, 13 pharmacists, 117 dispensers/druggists, 6 laboratory technologists, 46 laboratory technicians and 3 Health education officers. To support program scale up, more laboratory technologists will be recruited. Also, as a result of the paucity of health education officers, the IEC/BCC strategies are NGO driven. The war caused much displacement, so that most of the MOHS staff are currently concentrated in the Western Area. As normalcy progresses, a more even spread of personnel will be achieved. There is already health and non-health personnel delivering home-based care, treating opportunistic infections and providing palliative care. What is required is the standardization of training in the provision of these services following national guidelines. A pool of specialized health and non-health personnel will be trained and/or refreshed to serve as trainers for the various components of care and support.

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The approach is to develop sustainable community capacity response for psychosocial and economic support for PLWHAs and other vulnerable members of the community. Personnel with specialized skills will be responsible for training of health care and social workers, and community volunteer caregivers who will participate in service delivery. More volunteers will be recruited to support expansion into other districts where care and support is not being accessed.

4.3.17 Describe the key risks and assumptions made in preparing this proposal (3–4 paragraphs)

Some of the key risks associated with the implementation and scaling up of these activities include:

• Problems during the next general elections, which are coming up in 2 years’ time • Insufficient condom supply • Limited ability to access rural areas • Poor infrastructure • Limited mass media outlets • Difficult monitoring conditions • Limited number of people participating in VCCT • Limited level of awareness about care and support services for PLWHAs • Limited access to PLWHA in the rural areas • HIV/AIDS-related stigma and discrimination is high • Reluctance of PLWHA to make their status known • Limited availability of support groups for PLWHAs • Insufficient community members volunteering to serve as community home-based

caregivers

Key assumptions include: • The processes/pilots have been based in the Western Area. Similar activities will work in

the districts • There will be a follow-on World Bank MAP project • Government will allocate more resources to pay for NAS staff • Private sector partners will continue to see the benefit of their involvement • People will be willing to buy condoms • Condom use will be seen as culturally appropriate by the majority • Condom supply will be sufficient to meet the demand • Implementation areas will remain stable and the country will continue to enjoy political,

social and economic stability. • VCCT services will be available in both rural and urban areas all over the country by the

end of the second year of the project • Increased number of people will make use of VCCT services • Community members, men and women will volunteer as community caregivers • The extended family system willingly accept the integration of children orphaned by

HIV/AIDS into traditional social safety network • Communities will easily accept PLWHAs • PLWHAs will voluntarily declare their HIV status and participate actively involve in social

mobilization and advocacy at community and national levels.

4.3.18 Describe gender inequities regarding access to the services to be delivered (1–2 paragraphs)

The main beneficiaries of this proposal are children, women, CSWs and people living with HIV/AIDS. Traditionally, women take care of vulnerable groups in the communities. Where stigma and discrimination against PLWHAs is strong, the women take care of them and often are the first to suffer in the community for associating themselves with them.

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Some of those affected may very well be women, spouses or mothers of the affected people. Thus women, PLWHAs themselves or care providers of PLWHAs, are likely to face discrimination in the community. This will negatively affect the utilization of support services provided in the community. Furthermore, the decision-making processes in the communities favour men more than women and children. These latter groups are hardly involved in taking decisions relating to utilization of services and other important issues affecting PLWHAs. Most CSWs are women, and they are economically disadvantaged and use health services less. They are more likely than men to have untreated STIs.

4.3.18.1 Describe how this proposal will contribute to minimizing these gender inequities (1–2 paragraphs)

In the community, most health care workers are women. This proposal seeks to train nurses, other health workers and community volunteers in the provision of home-based care and in pre- and post-test counselling. It is expected that 40% of those to be trained are health workers. Most of these will invariably be women. Efforts will be made to ensure that the majority of community volunteers selected for training are women. Overall, the majority of those trained to provide care for PLWHAs will be women. This will enhance the position of women and raise their status in the community, and thus positively impact the provision of services in the community.

4.3.19 Describe the populations that are particularly vulnerable to this disease (1–2 paragraphs)

Women, CSWs, miners and youth are particularly vulnerable. High rates of poverty in a post-conflict situation, lack of comprehensive medical treatment for STIs, and the migrant nature of unemployed young people contribute to the susceptibility and vulnerability of women and youth to HIV/AIDS 4.4.7 Describe how these populations are involved in planning the program and how they will be involved in implementing and monitoring it (including, if appropriate, describe their role as service deliverers) (1–2 paragraphs) During the initial start-up phase, beneficiaries will be involved in planning and participate in qualitative research, which will be conducted with them to determine effective price policies, distribution networks and communication strategies and messages relevant to project beneficiaries’ needs. Beneficiaries are expected to play an active role in monitoring project activities by developing messages, radio programs (i.e., Sissy Aminata), and participating in educational activities, while reporting any pricing issues that might arise from retailers/service providers not adhering to the pricing structure. In the implementation phase, the majority of health care providers in the community are women. In this proposal, more women (health care providers and volunteers) will be trained to provide services. The youth will be also be selected as volunteers for training and in the provision of services for youth and PLWHAs. CSWs and miners will also participate as peer educators. There will be joint planning as well as monitoring, and representatives of vulnerable populations will be part of all monitoring teams.

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4.3.20 Describe how principles of equity will be ensured in the selection of patients to access services, particularly if the proposal includes services that will only reach a proportion of the population in need (e.g., some antiretroviral therapy programs) (1–2 paragraphs)

Usually a woman needs permission from a husband or partner to access health facilities. By increasing access to condoms outside the formal health structure women and youth will be able take decisions to protect themselves and their partners. By focusing on increasing equitable access to condoms this will indirectly minimize inequities in the health delivery system. There will be no discrimination against any group of persons for the provision of services. All eligible women, children and youth will be selected and provided the appropriate care required in accordance with the available resources.

4.3.21 Describe how this proposal will contribute to reducing stigma and discrimination against people living with HIV/AIDS, tuberculosis, and malaria, and other types of stigma and discrimination, including gender-based, that facilitate the spread of these diseases (1–2 paragraphs)

Increased access to condoms outside the formal health sector, and complementary activities, such as home-based care, voluntary counselling and testing (VCT) will contribute to the reduction of stigma and discrimination. The project will involve PLWHAs in service delivery as peer educators, counsellors and caregivers, while being beneficiaries at the same time. In this way, staff working with PLWHAs will demonstrate positive attitude towards PLWHAs and by so doing will be able to influence individual and community behaviour, attitudes and perception towards PLWHA. The provision of basic facts on HIV transmission and prevention will drive away fear and shame associated with HIV.

4.3.22 Describe how the beneficiaries of this proposal (e.g., people living with HIV/AIDS, tuberculosis, and/or malaria) and/or affected communities are involved in planning the program and how they will be involved in implementing it (including, if appropriate, describe their role as service deliverers) (1–2 paragraphs)

The project will directly target PLWHAs. They will be represented in the planning of activities, be involved not only as beneficiaries but also as service providers serving as facilitators, counsellors, peer educators, caregivers and key opinion members in assessment. As service providers and beneficiaries, some of them will also be key informants in monitoring and evaluating the project. It is expected that 55% of this target will be women, who are also the main providers of health care in the communities.

These vulnerable groups will play an active role in identifying the most effective distribution outlets as well as the key messages that will inspire consistent use of condoms. 4.1.10 Describe how the communities involved in this proposal are involved in planning the program, and how they will be involved in implementing it (including, if appropriate, describe their role as service deliverers) (1–2 paragraphs) The various leaders in the communities will participate in the planning, implementation and monitoring this proposal. Community volunteers will be selected and trained as peer educators, providers of home-based care. They will also be trained to provide pre and posttest counselling. In the rural social mobilization using drama, members of the community will act and plan the drama, supported by skilled facilitators.

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4.1.11 For malaria components only: If the proposal contains anti-malarial drugs or insecticides, include data on drug resistance and/or resistance of vectors in the country or in the target population/area (1–2 paragraphs)

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4.5 Program and Financial Management

[In this section, CCMs should describe their proposed implementation arrangements, including nominating Principal Recipient(s). See the Guidelines for Proposals, Section V.B.3 for more information.]

X Single 4.5.1 Will implementation be managed through a single Principal Recipient or multiple PRs? Multiple

[Every component of your proposal can have one or several Principal Recipients. In table 4.5.1 below, you must nominate the Principal Recipient(s).]

Table 4.5.1- Implementation Responsibility

Responsibility for Implementation

Nominated Principal

Recipient(s) Area of

Responsibility Contact Person Address, Telephone & Fax, Email address

National AIDS Secretariat

All Prof. Sidi. T.O. Alghali (Director, National AIDS Secretariat)

15A Kingharman Road, Brookfields, Freetown, Sierra Leone. Tel: 232-22-235806 Fax: 232-22-235843 Email: [email protected] [email protected]

UNFPA All Dr M Diallo, UNFPA Representative,

76 Wilkinson Road, Freetown, Sierra Leone Tel: 232 22 230213 Email: [email protected] [email protected]

4.5.2 Describe the process by which the CCM nominated the Principal Recipient(s).

[Minutes of the CCM meeting at which the Principal Recipient(s) was nominated should be included as an Annex to the proposal] [If there are multiple PRs, questions 4.5.3 – 4.5.6 should be repeated for each one.] All institutions interested in being the PR were invited to apply to the CCM. At the CCM meeting (minutes attached) they were deliberated upon. Each institution was allowed to state its case. Finally the CCM decided on the PR, with NAS being the preferred choice, and UNFPA as the second option.

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4.5.3 Describe the relevant technical, managerial and financial capabilities for each nominated Principal Recipient.

Technical and Managerial Capacity of NAS The National AIDS Secretariat (NAS) is responsible for co-ordinating all HIV/AIDS activities in the country. It is divided into two institutional arrangements: the non-health sector and the health sector components.

• The non-health sector component is responsible for policy coordination and advocacy, coordination of multi-sectoral non-health line ministries and Community and Civil Society Initiatives (CCSI). It has the following key staff:

o a Director, o a Deputy Director who is also in charge of the CCSI component, o a Line Ministries Coordinator, o an IEC/BCC Specialist and o an M & E Specialist.

• The health component (AIDS Response Group, National AIDS Secretariat-ARG-NAS) coordinates the health sector response to the HIV/AIDS epidemic and provides technical support to the non-health sector. The Team comprises of the following key staff:

o a Team Leader, o a Health Coordinator, o an M & E Coordinator, o a Health Administrator, o an Health Education and Communication Coordinator and o a Documentation Officer

The Director is the overall head of the organisation, followed by the Deputy Director. The Health Team Leader is the third in command.

Financial Capability of NAS As there are two institutional arrangements under the NAS, there are also two separate special accounts under the NAS: one operated by NAS (for the non health sector component) and the other operated by MOHS (for the health sector component). NAS has an independent Financial and Procurement Management Agent (FPMA) that provides assistance in managing project funds and financial and procurement administration. Funds are used in accordance with the detailed SHARP project operational manual. Non-Health Line Ministries in component 2 receive funds to carry out sector HIV/AIDS program under the supervision of their designated focal person and utilizing their existing ministries’ institutional capacity to supervise and manage resources. The MOHS receives funds to carry out health sector responses. Thus the second account is managed by the financial unit of the MOHS headed by a financial director who is responsible for all the financial management issues of the MOHS. Two professionally qualified assistants (paid for by World Bank Projects) assist the financial director. This procedure for financial transactions, which has been in place for more than a decade, has been adjudged to be adequate by the World Bank for the management of its Integrated Health Sector Investment Project (IHSIP) of the Ministry of Health and Sanitation and of the SHARP.

It is evident from the above that the ARG-NAS has technical staff, and the financial system that can easily implement the largely health sector responses in this Global Fund proposal. A public health expert is designated as ARG-NAS Team Leader; it also has another medical doctor as health coordinator, and an M&E expert. It has successfully implemented and disbursed 75% of the funds under the health sector response of the SHARP Project’s first year work plan. Its financial team is composed of the Director for Financial Resources of the MOHS (DFR-MOHS), supported by the Financial Management Accountant of the World Bank-assisted HSDRP based in the MOHS. A staff member of the DFR-MOHS, the Health Administrator, is posted to the ARG- NAS office.

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The approved signatories to the NAS-ARG account are the Team Leader (Principal Signatory) and the Director General of the MOHS. This proposal will use the procurement systems of either NAS or that of the World Bank projects based in the MOHS. These procurement systems, although based in the public sector, were developed with World Bank assistance, and support ongoing World Bank projects. The World Bank has rated them adequate. To cater for the increased Global Fund-related workload, NAS will need to recruit two additional M&E officers and an accountant.

Key officials of the Government of Sierra Leone, led by the Director of NAS, who is also a key member of the CCM, have discussed with UNFPA, and the CCM has agreed that UNFPA would be the PR, in the event of NAS not being approved. UNFPA has a management team in place, along with capacities and systems that it could easily complement. One major advantage is that it has knowledge of the sub-recipients, and has the largest UN- funded HIV/AIDS Programme in Sierra Leone. It is also the current chair of the UN HIV/AIDS Theme Group.

Technical and Managerial Capacity of UNFPA UNFPA plays a very active role in Sierra Leone. Through its network of regional and Country Support Teams (CSTs), within the implementation of the NEPAD Plan of Action, UNFPA is supporting as institutional capacity building institutions in Sierra Leone with the aim of making it capable of spearheading the implementation of HIV/AIDS activities. In addition, the agency has a core group of sub-regional technical reproductive health and HIV/AIDS specialists to partner with appropriate agencies and assist with global, regional and country specific activities including training, needs assessments, technical support and M&E. Currently, UNFPA also chairs the UN HIV/AIDS Theme Group in Sierra Leone. The UNFPA Country Office in Sierra Leone is also a very strong base for various West Africa sub-regional and cross border activities on HIV/AIDS Prevention from which Sierra Leone would benefit.

Additionally, the fund has provision for resources that may be needed in strengthening M&E systems and data management to support this initiative. UNFPA has the appropriate capacity to handle the monitoring aspect of the initiative, as it is a member of the M&E sub-group of the Sierra Leone HIV/AIDS Prevention Program.

UNFPA has comparative technical advantages in managing RH commodity procurement, ensuring standard products and quality assurance testing and procedures that include condoms and STI drugs are maintained. It globally provides leadership and maintains coordination mechanisms to ensure that partners can work together effectively at global, regional and national levels to ensure that good-quality RH commodities are available and accessible to people who need them.

UNFPA also provides technical and logistical rapid response to emergencies including the immediate shipment of RH supplies and equipment to enable pregnant women to deliver safely. UNFPA Humanitarian Response helps to build capacity of health care providers to promote safe motherhood, adolescent reproductive health, and easy access to condoms. Interventions also address violence against women and the transmission of sexually transmitted infections including HIV/AIDS. Given UNFPA’s active presence in Sierra Leone, the agency has played an active role in the country to work closely with partners on ground and deliver necessary Reproductive Health supplies, commodities and technical support.

UNFPA has a corps of highly skilled professional technical advisers in various parts of the African region to rebuild the capacity in ensuring a comprehensive strategy on and HIVAIDS prevention for partners in this proposal. Possible areas of contribution will include: achieving quality RH, preventing HIV/AIDS/STIs among vulnerable communities (such as refugees/IDPs/women and young girls/uniformed services), training and capacity-building, empowering vulnerable women through better RH, supporting data collection for policy development planning process, advocacy and awareness-raising and inter-agency coordination and programme planning.

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Lastly, UNFPA maintains a well-coordinated approach to financial operations and accountability in the field. External and internal auditors are periodically engaged to audit the financial systems of implementing partners and of the Country Office itself. Additionally, all financial transactions are recorded in UNDP’s automated field office accounting systems (AFOAS).

[Please also discuss any anticipated shortcomings these arrangements might have and how they will be addressed (i.e. capacity building, staffing and training requirements, etc.).]

Yes 4.5.4 Has the nominated PR(s) previously administered a Global Fund grant? X No

4.5.5 If yes, describe the performance of the nominated PR in administering previous Global Fund grants (1–2 paragraphs)

4.5.6 Describe other relevant previous experience(s) that the nominated PR has had:

[Please describe in broad terms the relevant programs, and their objectives, key implementation challenges and results (2–3 paragraphs)] NAS is managing the World Bank MAP-funded HIV/AIDS project, SHARP, which is also co-funded by the Government of Sierra Leone. It is already capable of sub-granting and has disbursed funds. It collects financial returns from both government ministries and NGOs. To date it has disbursed grants to government ministries and several NGOs. Its financial management is that of the World Bank-assisted HDRDP. It therefore has a financial system in place. It has a Procurement Officer, and has the capacity to procure items in bulk, using World Bank Guidelines. It has completed the design of the national HIV/AIDS M&E framework and did this with key partners and stakeholders. It is currently monitoring the national HIV/AIDS response and reporting to both government and development partners. It has good office accommodation in Freetown, and has a resource/documentation centre that is visited regularly by students, journalists and others. It has adequate technical staff, and is linked with the districts through the District HIV/AIDS Committees. It has been interacting with the sub-recipients and is the Secretariat of the HIV/AIDS component of the CCM.

UNFPA has responded to the threat and opportunity for action through a comprehensive and coordinated initiative that targets different groups and involves a range of national groups and government offices. The overall aim of the initiative is to reduce the risk of HIV/AIDS, prevent STIs, reduce the need for commercial sex work among vulnerable women and girls affected, alleviate poverty and enhance family life and community security. The UNFPA-led initiative began in early 2002 and has now moved to its more comprehensive phase. The initiative was developed in close collaboration with a range of national authorities including the Ministries of Health and Sanitation, Defense, Internal Affairs, Education Science and Technology, Youth and Social Welfare Gender and Children’s Affairs, as well as NGOs and civil society organizations (CSO). The peacekeeping component was developed in collaboration with the United Nations Department of Peacekeeping Operations in New York (UNDPKO), UNIFEM and ICMH with senior military staff of the peacekeeping contingents in Sierra Leone. The initiative was designed to respond to a series of immediate needs and also indirectly satisfy additional goals such as the reduction of maternal mortality, strengthening of family life, poverty alleviation, promotion of good governance, social and economic reconstruction, and national security. UNFPA has continued to work closely with UNAMSIL, UNIFEM and ICMH to address HIV/AIDS Prevention and gender awareness programs with UNAMSIL peacekeeping contingents,. In coordination with national ministries and other partners, the country office also supports initiatives on HIV/AIDS Prevention for Sierra Leone Police Forces (SLPF) and SL Military (RSLAF), continues to strengthen capacity, introduce income generation activities for vulnerable women and girls, along with provision/training of necessary RH supplies and commodities for vulnerable

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groups such as commercial sex workers, women and young girls and Liberian refugees in Sierra Leone. UNFPA has recently provided support to ex-combatants to integrate HIV/AIDS prevention and adult literacy programs in the Disarmament, Demobilization and Reintegration (DDR) Programs. A diagram of the initiative is presented on the next page – please view.

UNFPA’s Experience in Managing Funds on behalf of other Donors

UNFPA has excellent experience in managing funds on behalf of other donors, including the UNAIDS Funds for the Unified Budget Work Plan (UBW), the Belgium Trust Fund and Finnish Funds, in addition to the $6 million Country Office (CO) 2004-2007 Budget, part of which addresses HIV/AIDS prevention amongst various high risk population and RH promotion. UNFPA provides technical and financial assistance to various government ministries to develop and implement projects in the areas of population and development, reproductive health, gender and women issues, adolescents and youth reproductive health activities, prevention of HIV/AIDS/STIs and human rights. It also collaborates with other UN Agencies in funding joint projects and provides both financial and technical support to national Non-Governmental Organizations (NGOs) such as the Planned Parenthood Association of Sierra Leone (PPASL), the Marie Stopes Society of Sierra Leone (MSSSL) and the Women In Crisis Movement (WICM). WICM is funded through funds received from Belgium Trust Project. The CO also worked closely with the Sierra Leone government in mobilising resources from the EU for the 2004 population and housing census. Such efforts were rewarded by the allocation of a grant of US$5.5 million by the EU Commission to complement UNFPA’s funding for the Census. The CO has demonstrated a strong and active role in advocating and mobilizing resources in the implementation of advocacy, reproductive health, integration of population concerns into development planning processes and data collection dissemination and management in line with the ICPD Plan of Action. The CO is working closely with the government on the ICPD agenda including PRSP, MDGs and UNDAF.

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UNFPA’S HIV/AIDS COMPREHENSIVE INITIATIVE FOR SIERRA LEONE Describe the proposed management [Outline management arrangements, roles and responsibilities between partners, the nominated Principal Recipient(s) and the CCM (1–2 paragraphs).]

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Implementation of the HIV/AIDS component will be overseen by the ARG-NAS. It will manage, supervise, disburse funds, and obtain retirements from the government ministries and NGO sub-recipients. As Principal Recipient, the ARG-NAS will be accountable to the CCM. The CCM will establish one management committee called the HIV/AIDS Management Committee, which will be responsible for the effective and efficient implementation of activities described in the HIV/AIDS component. This Committee will meet monthly, will be one of the CCM committees (others include Malaria and TB) for the implementation phase of the GFATM process. This Committee will be chaired by the NAS, with representation from the sub-recipients, and other members to be determined by the CCM. In this exercise, the CCM will rationalise the various existing committees and taskforces working on HIV/AIDS in Sierra Leone. Thus the HIV/AIDS Management Committee would incorporate and streamline existing committees/taskforces/working groups which have been working on various aspects of the national HIV/AIDS response as its technical subcommittees, this is to avoid duplication and conserve deployment of scare technical expertise. The subcommittees are:

1. IEC/BCC and Social Mobilisation chaired by NAS 2. Youths chaired by CADO 3. ARVs chaired by the University/FAMCARE 4. M&E chaired by NAS 5. Expert HIV Laboratory chaired by Ramsay Medical Laboratory 6. Condom Social Marketing chaired by CARE 7. STIs, VCT and PMTC chaired by Marie Stopes/ RH and Family Planning Division of MOHS 8. Blood Safety chaired by Blood Services Unit, MOHS 9. Antenatal HIV Surveillance, chaired by ARG-NAS 10. STI Manual Review chaired by RH and Family Planning Division, MOHS 11. Care and Support of PLWA and OVC chaired by CCF 12. Special Groups chaired by MERLIN

These technical subcommittees will be the organs through which task teams are organised to implement activities in a synergistic manner. The key departments/units responsible for the implementation of activities within each sub-recipient institution will be represented in the relevant subcommittee, e.g., the Statistical Department of the MOHS will be part of the M&E subcommittee to ensure that its activities are well synchronised and reported in national health statistics. In some instances, the funds for NGOs working in a particular thematic area will be channelled through the NGO Chair of the group, meaning this NGO would be the lead NGO. All Government funds for MOHS, and the University will go directly to the relevant institutions. The IEC/BCC sub-committee will co-ordinate and approve all advocacy and IEC activities. It will draw up the master IEC and advocacy work plan for the HIV component, ensuring that IEC activities are well synchronised with other programme activities, for example, ensuring that VCT Centres are ready and that counsellors are trained before embarking on community or mass media campaign on the use of VCT Centres. It will ensure technical standards are maintained in communication activities undertaken through this component, for example, ascertaining that all IEC materials are pre-tested. It will also coordinate and rationalise media purchases (airtime on radio and television, and newspaper advertisement space) for cost effectiveness. The M&E subcommittee is the organ through which supervision, monitoring, and evaluation activities will be coordinated and monitored. The sub-recipients will be responsible for furnishing the NAS with the data required to monitor and to evaluate programme implementation and effectiveness. Statistics Sierra Leone, which is the government’s central statistical agency, and which executes the national census, will oversee the collection of data from population-based surveys and will monitor the quality of data provided through other channels. The NAS has collaborated with other stakeholders in the development of an M&E framework for the National HIV/AIDS Programme, culminating in the production of the M&E Manuals; these are attached as appendices. M&E activities will be implemented within this M&E framework.

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Communications between the NAS and the relevant sub-recipients and sub-committees will include committee meetings, memos, emails, faxes and telephone communication, as appropriate. Implementing partners will submit yearly work plans for review by the HIV/AIDS Management Committee of the CCM. The CCM will forward approved plans and budgets through the chairman of the CCM to the Financial/Management accounts section of the ARG-NAS on a quarterly basis. Further disbursement of funds will be based on receipt of Financial and Programmatic (Activity) reports of the preceding quarter. For example, disbursement for the third quarter will be based on receipt of the second quarter’s Financial and Activity reports. Each sub-recipient will be responsible for reviewing and approving proposals for sub-contracts or grants to implement scheduled activities, and will be responsible for monitoring activity implementation and fund usage. A memorandum of understanding (MOU) will be signed between the NAS and each implementing partner who is to receive funds. The MOU will indicate the mechanism for disbursement and accounting for funds and state the expected outputs of each undertaking. Additionally it will spell out the roles and responsibilities of the NAS and the implementing partner. It will also specify the financial regulations, including clarifying activities that can be undertaken with funds and recording and reporting expectations and commitments. The MOU shall be deemed to be binding on all parties, and will be vetted by the Ministry of Justice/Attorney General as the legal adviser to the Government and its agencies. The ARG-NAS, in close collaboration with key partners such as the MOHS, Community Health Department University of Sierra Leone, and Statistics Sierra Leone will also be responsible for reviewing annual surveillance data and available national behavioural data to ascertain whether the VCT and ARV are having the desired impact. The MOHS will be responsible for ensuring effective and efficient implementation of the Treatment aspects of the HIV/AIDS component, it will in partnership with ARG-NAS conduct routine supervision visits, monitors service delivery reports submitted by each site, monitors quarterly reports submitted by the sites, and reviews the results of the mid-term external evaluation. It will be responsible for identifying significant delays or deficiencies in implementation, determining remedial action, and monitoring progress. The MOHS in conjunction with relevant partners will be responsible for developing and enforcing policy and implementation guidelines for all areas relating to medical intervention. It will be responsible for the content and, in general, the administration of training for health care professionals. The MOHS Central and District levels will be responsible for developing supervision tools for all treatment and care activities and for routine supervision of sites. The MOHS Central level will be responsible for developing and implementing a scheme for monitoring drug resistance. The MOHS Central and District levels will be responsible for ensuring stocks of drugs and supplies are available to the lower tiers in a timely manner. The MOHS Central level will be responsible for obtaining data for indicators to be reported to the CCM through the NAS. For the first two years of implementation, the District Medical Officer and the lead NGO (where applicable) will be jointly responsible for ensuring the effective and efficient implementation of the treatment and care sites in a given district. The District HIV/AIDS Committee, with the District Medical Officer as Chair, will oversee and supervise planning and monitoring of district-level activities. The District Medical Officer and the lead NGO will be jointly responsible for quality assurance and submission of service delivery reports to the central level. The lead NGO will be responsible for submission of quarterly progress reports to the District Committee and to the relevant Subcommittees of the NAS. Any problems in implementation or impediments to achievement of targets will first be addressed at the district level and, if necessary, brought to the central level. After approximately two years of implementation, MOHS personnel are expected to have been deployed to staff most government owned sites and the role of the NGOs will shift from service delivery and project management to technical assistance. At this stage, the District Medical Officer and associated MOHS staff will be responsible for effective functioning of the sites, including achievement of targets, submission of progress reports and resolution of impediments to implementation.

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During the last three years of implementation, NGO staff will serve in an advisory and training capacity, unless the MOHS determines that a particular site needs additional inputs from the NGO to become fully functional.

UNFPA as PR would adopt a similar management approach. Reporting to CCM The NAS is a key and active member of the CCM; in fact, it is the Secretariat of the HIV/AIDS component. NAS will report back to the CCM on a quarterly basis through the HIV/AIDS Programme Management Committee, which will be a committee of the CCM. Funding arrangements/Flow of Funds The funds from the GFATM, in line with NAS existing institutional arrangements would be channelled to two new special accounts that NAS would open – the non health sector account, to be managed by NAS, and the health sector account, to be managed by ARG –MOHS. Both accounts will be opened with a reputable commercial bank, preferably the same one as for the SHARP project. (PLS SEE THE ANNEX FOR A CHART DETAILING FLOW OF FUNDS/FINANCIAL REPORTING AND PROGRAMME MANAGEMENT) It has been agreed with the Ministry of Finance and Ministry of Development and Planning that NAS as the Principal Recipient will register yearly the value of the Global Fund attributed to them at the Ministry of Finance. This type of financing mechanism ensures that all stakeholders are informed of the total value of funds transferred to the Principal Recipient but it does not actually manage the funds (as funds are not transiting through the Treasury). This mechanism has the following advantages

i) Transparency: the resources managed by the Global Fund will be reflected in the State Budget, adding to other resources for the control of communicable diseases and Poverty Reduction;

ii) Efficiency: in funds transfer as the number of intermediate recipients are kept to a minimum;

iii) Monitoring and evaluation: can be performed at any time by the Government; iv) Tax exemption: for the procurement of goods (drugs and medical supplies).

After the approval of the yearly plans submitted to the CCM, the funds will be disbursed to the Principal Recipient. The Finance Department of the ARG-NAS will then transfer the funds to sub-recipient Ministries and NGOs. The Finance Unit of ARG-NAS will be responsible for the financial management and reporting to the CCM and Local Fund Agent. The ARG-NAS will disburse funds to sub-recipients through its World Bank SHARP financial management system described earlier. Under the Global Fund, ARG-NAS will not make disbursements at the district level, because it will disburse to pre- identified partners (Government and NGOs) listed in the Global Fund proposal through their respective NGO and Ministry headquarters in Freetown. The ministries and NGOs will ensure that activities implemented at the district level are adequately reported, and this will be spelled out in their respective MOUs. The Finance Unit at the ARG-NAS will be responsible for producing the yearly statements of expenses and presenting them to the CCM and Local Fund Agent for approval. Yearly external audits of the funds are planned for the Principal Recipient.

Internal auditors of the government track NAS funds on a regular basis, while external auditors are contracted annually to audit the NAS. Sub recipients must present financial reports every four months. Funding of the core staff of NAS may become an issue after year 2006. Under the current arrangements the World Bank and the government share the salaries in the ratio 90:10. Government funding has been inadequate and may not attract the desired level of expertise

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4.5.7 Explain the rationale behind the proposed arrangements

[For example, explain why you have opted for that particular management arrangement (1 paragraph)] Several key reasons are behind the management arrangement described above: • It is in the long-term interest of Sierra Leone to strengthen its key national institutions, for

strategic and sustainability reasons. As an indigenous institution, ARG-NAS will have the opportunity to gain experience in managing a major grant award. The arrangement will enhance NAS’ ability to deliver on what it was mandated to do. What it is doing well now will even de done better.

• Coordination between the two major sources of HIV/AIDS funds, the Global Fund and World Bank, will be enhanced if managed by the same institution.

• The use of the operational and financial capabilities of NAS will avoid duplication of functions to achieve better stewardship of limited resources.

• NAS has adequate experience in coordinating the national response to HIV/AIDS. It has been doing so programmatically and financially. It has already disbursed SHARP funds to some of the sub-recipients, and it is charged with the implementation of the HIV/AIDS strategic plan, so it is best placed to do both functions concurrently.

• Finally, the implementation and financial arrangements are such that funds meant for NGO and government implemented activities go to each entity directly. The NGOs have been grouped thematically under lead NGOs to facilitate disbursement, and programmatic and financial reporting. This way implementation would be fast. If for whatever reasons NAS is not able to take up this function, then the next alternative would be the UNFPA.

X Yes 4.5.8 Are sub-recipients expected to play a role in the project?

No [If yes, proceed to 4.5.10 and subsequent questions. If no, proceed to Section 4.6.]

X Yes 4.5.9 Have the sub-recipients already been identified? No

[If yes, please answer 4.5.11 and 4.5.12. If no, please answer 4.5.13 and 4.5.14.]

4.5.10 Describe the process by which sub-recipients were selected (e.g., open bid, restricted tender, etc.) (2–3 paragraphs)

All interested and relevant government ministries and NGOs were invited to submit proposals. Later all the NGOs and Ministries were invited to a meeting by the NAS. They were grouped into writing teams based on the existing working groups and committees, and focused on each objective (thematic area) and came up with harmonized work plans and a national effort to scale up response to HIV/AIDS. They balanced geographic areas, government or NGO facilities and human resource availability, based on technical and financial gaps in the existing interventions, relative to the national HIV/AIDS strategic plan. They also harmonized salaries, travel rates etc. The CCM had approved the list of sub-recipients. Where relevant a lead NGO to coordinate other NGOs inputs and complement government and take the lead in monitoring and reporting was selected for each objective. This was based on the technical, financial and programmatic ability of the NGO to play this role.

4.5.11 Describe the relevant technical, managerial and financial capabilities of the sub-recipients.

[Describe anticipated shortcomings or challenges faced by sub-recipients and how they will be addressed (i.e. capacity building, staffing and training requirements, etc.).]

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The challenge was to build on earlier initiatives within the Government sector, while scaling up the capacity of the indigenous NGOs and at the same time fostering partnership and synergies with the big international NGOs. The international NGOs bring in expertise and catalyze policy dialogue and innovative approaches, albeit sometimes at an unsustainable price, and their presence is affected by the ever-changing fads of international development. The indigenous NGOs will always be on the ground, and are the ones that would engage their government to bring about lasting reforms. In the case of the international NGOs we ensured that only needed expatriate staff would be recruited under this proposal, while for the indigenous NGOs capacity building for programme management, procurement and monitoring and evaluation, key areas of weakness are programmed for. Rationalization and synergy of NGO activities with government activities was a challenge, but we surmounted this with the participatory planning process and extensive mapping, thus producing a national framework in which players play to their strengths. Both international and local NGOs had adequate office premises, vehicles and technical programming staff for their then scale of operations, what some of the local NGOs lacked were adequate financial staff. This would be a challenge, as Global Fund resources need to be retired both programmatically and financially on a quarterly basis. Thus recruitment of adequate financial staff and their training is included for them in this proposal. A harmonized training plan that caters to the capacity building needs of all players would be developed under the capacity building objective. The table below shows the installed capacity of the major sub-recipients prior to design of this proposal. LIST OF NGOS, AGENCIES AND INSTITUTIONS PARTICIPATING IN THIS PROPOSAL

NO. NAME OF ORGANISATION OR INSTITUTION

HIV/AIDS ACTIVITIES OPERATIONAL AREAS

1 Blood Services (MOHS) Blood Transfusion Nationwide 2 CARE International Condom Social Marketing Nationwide Youth Reproductive Health Western Area Community-Based HIV/AIDS

Awareness Tonkolili and Koinadugu Districts

3 Marie Stopes Sierra Leone (MSSL)

Voluntary Confidential Counselling Freetown

STI Case Management Freetown and Port Loko District Community-Based HIV/AIDS

Awareness "

Community-Based Development " Prevention of Mother to Child

Transmission Freetown

4 International Medical Corps (IMC)

Health Facilities Kailahun District

STI Case Management " Staff Training " Health Education " 5 Family Care (FAMCARE) Care for Persons Living with

HIV/AIDS Freetown

Treatment of Opportunistic Infections " Free distribution of Condoms " Free HIV Testing "

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Voluntary Confidential Counselling and Testing

"

6 Youth Welfare and Development Organisation

Community Awareness Freetown - Waterloo Rural

IEC/BCC " VOT Dissemination " Training " 7 World Vision - Sierra Leone

(WVSL) IEC/BCC Kono and Bonthe Districts

Special support to vulnerable groups (women and youth)

"

STI Case Management " Staff Training " Management of Peripheral Health

Units "

8 Christian Health Association of Sierra Leone (CHASL)

Faith-Based Health Care Workers Western Area

Training Nationwide STI Case Management " Voluntary Confidential Counselling " Home- and Community-Based Care " 9 HIV/AIDS Care and Support

Association (HACSA) Social Work for FAMCARE Western Area

Home Visits " Condom Distribution " Referrals " 10 American Refugee Committee

(ARC) AIDS prevention Freetown and Port Loko District

Condom Distribution " Production and dissemination of

IEC/BCC Materials "

Treatment of TB (DOTS) Port Loko District Micro Credits (soft loans) 7 districts Condom Social Marketing Kambia District Community empowerment " Uniformed Service Men Port Loko District Commercial Sex Workers " 11 Community Animation and

Development Organisation (CADO)

Community-Based HIV/AIDS Awareness

Bombali District

Life Skills Program for in-school youths

Tonkolili, Pujehun and Bo Districts

12 Inter-Religious Council, Sierra Leone (IRCSL)

Community Sensitization Nationwide

Counselling " IEC/BCC " Capacity Building " 13 Sierra Leone Police (SLP) Sensitisation Nationwide STIs Case Management " Condom Distribution " Voluntary Confidential Counselling

and Testing "

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Capacity Building " 14 Ministry of Social Welfare,

Gender and Children's Affairs (MSWGCA)

Capacity Building Nationwide

Sensitisation " Awareness Raising " Working collaboration " Supporting Care-Givers " 15 Society for Women and AIDS

in Sierra Leone (SWAASL) Capacity Building Freetown

Sensitisation " Voluntary Confidential Counselling Kailahun District Condom distribution Western Area Care and support for persons living

with HIV/AIDS "

Commercial Sex Workers " 16 Women in Crisis Movement

(WICM) Health Education East End of Freetown

Free STIs Treatment " Counselling " Adult Literacy " Commercial Sex Workers Adolescent Young Girls Raped Women Disadvantaged women Children

17 Sierra Leone Red Cross Community-based health care programme

10 districts

Condom Distribution " Youth Peer Educator training Home-based care Port Loko, Bo, Ketema Blood services Bo, Kemema, Mekeni

18 Council Churches Sierra Leone

HIV/AIDS Awareness raising Nationwide

Capacity Building Nationwide Care and social service support Kenema Counselling " Development of volunteers for home-

based care "

19 Shepherd's Hospice Home-based care PLWHA Freetown Social services PLWHA " Training in palliative care Organisation-based HIV/AIDS in the workplace " PLWHA Advocacy and Support Freetown HIV/AIDS Awareness raising "

20 GOAL Commercial Sex Workers East End of Freetown Awareness Raising " Care and support for persons living

with HIV/AIDS "

21 Coca Cola HIV awareness raising among employees

Condom promotion Sensitisation

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Counselling and home visits 22 Ministry of Defence HIV/AIDS Awareness raising Nationwide

HIV/AIDS/STI Counselling " Condom Distribution " VCCT Freetown HIV/AIDS Peer Educators Nationwide STI management "

4.5.12 Describe why sub-recipients were not selected prior to submission of the proposal (1–2 paragraphs) Not applicable

4.5.13 Describe the process that will be used to select sub-recipients if the proposal is approved (1–2 paragraphs) Not applicable

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4.6 Monitoring and Evaluation (M&E)

The approach to monitoring and evaluation of Global Fund will seek to emphasize the link between program activity monitoring and impact assessment. This will be done by using a monitoring and evaluation plan that organizes a manageable set of output and outcome indicators by standard HIV/AIDS prevention, care and impact mitigation theme areas (IEC/BCC, PMTCT, VCT, STIs, Home-based care, Treatment and sentinel surveillance). Program activities will be monitored through the routine completion of standardized reporting form. The evaluation of program activities will be carried out by conducting surveys (biological, bahavioural and health facility surveys). The surveys will be contracted out to local institutions with international technical support.

The lead partners in Monitoring and Evaluation of health-related activities in the country are the Ministry of Health and Sanitation (MOHS) through the Disease Surveillance Unit, District Health Management Teams (DHMTs) and the Directorate of Planning and Information (DPI)), the University of Sierra Leone, National HIV/AIDS Secretariat (NAS), Statistics Sierra Leone, DALAN Consultancy (consulting firm) and Ramsay Laboratories. The DHMTs conduct routine monitoring and supervision of peripheral health care units and collect information on out-patient cases and service ulitization in each district. The DPI conducts regular surveys of health institution capacity and other national demographic surveys. The University of Sierra Leone also conducts various essential research on health issues. The Statistics Sierra Leone conducts behavioural surveys, demographic surveys and other surveys. NAS is responsible for monitoring the activities of national partners in HIV/AIDS and evaluating the overall impact of their activities. The impact evaluation is done in collaboration with other partners. There is presently an M&E working group that helps to coordinate and provide technical guidance for the setting up of an efficient and effective M&E system within NAS. This working group includes some members of the CCM, research institutions, University, UNICEF and WHO. Routine M&E data collection will use a revised program activity monitoring form that will be simple to use by all partners. At district level the data will be transferred to the District M&E Officer, who will enter it into the ditrict data base. Both the electronic and hard copies will be sent to the M&E Specialist of the National HIV/AIDs Secretariat. Surveys and research activities will be contracted out to academic institutions, MOHS and consulting firms. The IDA system will be used to award contracts for surveys.

Table 4.6A- M&E Table Behavioral and disease impact

Goal Impact indicator Technical partners

involved in measurement

Data source Frequency of data collection

To develop a comprehensive national response to HIV/AIDS that includes adequate prevention, treatment, care and support for those affected.

HIV Prevalence among adults (ages 15-49)

ARG, SSL, COMAHS, CDC.

National Sero-prevalence survey (baseline 2002)

Once Every 4 years

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Percentage of young people aged 15-24 reporting the use of a condom during sexual intercourse with a non-regular sexual partner


National Behavioural Surveillance (Baseline 2002)

Once every 4 years

Percentage of young people who have had sex before the age of 15


National Behavioural Surveillance (baseline 2002)

Once every 4 years

Percentage of people remaining on treatment at 6, 12, and 24 months

ARG, FARMCARE, Willoughby Clinic, Argill Clinic

Yearly data from ARV Treatment centres (Baseline 2004)

Yearly

Complete Table 4.6B for each objective, adding additional service delivery areas to each table as appropriate.

Table 4.6B- M&E Table

Goal: To develop a comprehensive national response to HIV/AIDS that includes adequate prevention, treatment, care and support for those affected.

Objective 1:

To increase knowledge and promote behavioral change on HIV/AIDS through drama and appropriate communications channels.

Service delivery area 1: Information, Education and Communication Data source Frequency of

data collection Coverage indicator 1:

Number of drama teams trained

Program activity monitoring form

Quarterly

Coverage indicator 2:

Number of drama activities organized.


Quarterly


Number of communities covered.


Quarterly

Goal: To develop a comprehensive national response to HIV/AIDS that includes

adequate prevention, treatment, care and support for those affected. Objective 2: To prevent HIV/AIDS transmission by ensuring the availability of safe blood

nationwide.

Service delivery area 1: Blood Safety Data source Frequency of data

collection Coverage indicator 1:

Number of service deliverers trained: • Lab. Technicians • Health Personnel


Quarterly


Percentage of transfused blood units screened for HIV

Program activity form; Laboratory reports.

Quarterly

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adequate prevention, treatment, care and support for those affected. Objective 3

To provide knowledge and skills on STI/HIV/AIDS prevention among the youth.

Service delivery area 1: Youth Education Data source Frequency of


Percentage of schools with teachers trained in life-skills based HIV/AIDS Education


Quarterly


% of young people exposed to HIV/AIDS education in school setting.


Quarterly


% of young people exposed to HIV/AIDS education out of school setting.


Quarterly


Number of young people trained as peer educators.


Quarterly


adequate prevention, treatment, care and support for those affected. Objective 4:

To expand access to and promote correct and consistent use of condoms in the general population and among vulnerable groups nationwide.

Service delivery area 1: Condom distribution Data source Frequency of


Number of condom outlets established


Quarterly


Number of condom distributed through private sector


Quarterly


Number of condom distributed through private sector


Quarterly



To strengthen and expand services for sexually transmitted infections.

Service delivery area 1: Sexually transmitted infection diagnosis and treatment Data source Frequency of


Number of health staff trained


Quarterly


Percentage of patients with STI comprehensive case management


Quarterly

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To reduce HIV transmission from parent to child through the provision of Prevention of Parent-to-Child Transmission (PPTCT) services in 13 districts.

Service delivery area 1: Prevention of parent-to-child transmission of HIV (PPTCT)





Quarterly


Number/ of health facilities offering minimum package of PPTCT


Quarterly


Number of infected pregnant women receiving a complete course of Nevirapine during labour, to reduce the risk of parent-to-child transmission


Quarterly



To improve access to and utilization of Voluntary and Confidential Counseling and Testing (VCCT) services in 13 districts.

Service delivery area 1: Voluntary Counseling and Testing Data source Frequency of


Number of district with VCT services


Quarterly


Number of people receiving VCT


Quarterly




Quarterly


Objective 8:

To improve access to and utilization of ARVs in 13 districts.

Service delivery area 1: Antiretroviral treatment and monitoring Data source Frequency of


Number of doctors trained


Quarterly


Number of people with advanced HIV infection receiving antiretroviral combination therapy


Quarterly

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Number of health facilities capable of providing advanced intervention for prevention and medical treatment for HIV infected persons.


Quarterly


Number of service deliverers trained for opportunistic infection


Quarterly



To provide prevention, care, support and treatment to special groups.

Service delivery area 1: Program for specific groups Data source Frequency of


Number of young people exposed to HIV/AIDS education in school setting.


Quarterly


Percentage of schools with teachers trained in life-skills based HIV/AIDS Education


Quarterly


Number of CSWs enrolled in technical/vocational training


Quarterly


Number of miners and CSWs trained as peer educators


Quarterly


Objective 10:

To provide palliative care and support to PLWHA and OVCs, particularly in war affected areas.

Service delivery area 1: Support to orphans and PLWHAs Data source Frequency of

data collection


Number of orphans and vulnerable children less than 18 years whose household received free basic external support in caring for the child.


Quarterly


Number trained in home-base care for PLWHAs


Quarterly


Number of health facilities with capacity to deliver basic level of counseling and medical care for HIV/AIDS

Health facility survey

Yearly


Number of chronically ill with external support.


Quarterly

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Objective 11:

To strengthen and expand national capacity to design, implement, monitor and evaluate HIV/AIDS programmes in the country.

Service delivery area 1: Program Management

Capacity-building for program management



Number of monitoring and evaluation officer trained


Quarterly


Percentage of budget spent on monitoring and evaluation

Financial report Quarterly

The Global Fund encourages the development of nationally owned monitoring and evaluation plans and M&E systems, and the use of these systems to report on grant program results. By answering the questions below, applicants should clarify how and in what way the M&E plan for the grant application relates to existing data collection efforts, and summarize any capacity development needs, to enable applicants to carry out the M&E plan described in Table 7.

4.6.1 Describe how the plan complements or contributes towards existing efforts to strengthen M&E plans and/or relevant health information systems.

Within NAS there is a strong M&E component that conducts monitoring and evaluation of activities of both SHARP and non-SHARP implementing partners. With coordination from NAS, a multi-sectoral M&E working group that provides continuous technical support and guidance to NAS has been established. This working group has representation from WHO, UNICEF, NGOs, PLWHAs, Statistics Sierra Leone (Central Statistics Office) and from the Ministry of Health and Sanitation. NAS provides data on HIV/AIDS to the Statistics Sierra Leone to compute National disease impact and other national demographic indicators. NAS has put in place two separate but interlinked systems for program activity monitoring and impact assessment. The program activity monitoring system is simple, structured, and standardized, and tracks how Non-SHARP and SHARP grant recipients are performing and the services they provide. The system gathers data routinely (quarterly) on 16 key indicators representing standard intervention categories. The impact assessment of the activities of SHARP and non-SHARP partners is carried out by conducting biological, behavioural and health facility surveys by using both local and external technical assistance. NAS has a comprehensive four-year M&E plan of SHARP and non-SHARP activities. However, the design of SHARP does not make provision for a separate budget line to undertake monitoring and evaluation activities. The expectation was for M&E activities to be funded out of the Policy and Coordination budget. However, it has become clear that this budget line item does not have the requisite resources to fund a comprehensive M&E Plan. Therefore, additional resources will be requested through the Global Fund to strengthen the M & E within NAS, to accommodate the M&E needs of the Global Fund.

4.6.2 Describe any capacity building that might be required to implement the M&E plan.

[2–3 paragraphs)] While NAS will take the lead in programme activity monitoring, it will use the existing structures and staff in DHMTs to collect heath information. Two additional M&E officers would be required by NAS to enable it implement the wider scope of activities that the Global Fund would entail. There is also need to provide Government (District and National) and NGO M&E officers with training in data management, especially the use of Excel and EPI-Info. The District M&E officers of the DHMT will be given priority in this type of training.

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4.7 Procurement and Supply Management

[In this section, applicants should describe their arrangements for procurement and supply management of health products, integral to this component’s proposed disease interventions, including pharmaceutical products, diagnostic technologies and other supplies related to the use of medicines, bednets, insecticides, aerial sprays against mosquitoes, other products for prevention (e.g., condoms), laboratory equipment and support products (e.g., microscopes and reagents). When completing this section, applicants should refer to the Guidelines for Proposals section V.B.5.]

X PR only Sub-

recipients only

4.7.1 4.7.1 Will procurement and supply management of health products be carried out (or managed under a sub-contract) exclusively by the Principal Recipient or will sub-recipients also conduct procurement and supply management of health products?

Both

4.7.2 Approach to procurement of health products

[Which of the following types of organizations will be involved in the procurement of health products. Check all that apply: X National medical stores, national tender board or equivalent

Sub-contracted procurement organization(s) (national) (specify which one[s]) Sub-contracted procurement organization(s) (international) (specify which one[s])

X Other (specify) [If more than one of these is checked, describe the relationships between these entities (1 paragraph)] Sierra Leone is blessed with a track record of successful implementation of World Bank assisted health sector projects that have, over the years, increased the capacity of the procurement system within the MOHS. Under the current World Bank assisted HSDRP, World Bank project paid procurement specialists are available within the MOHS. They have over the past 10 years successfully implemented all procurement for World Bank projects. Also within the SHARP in NAS, a similar World Bank assisted procurement system is in place. So although the procurement system is based in a public institution it has stood the test of time, even during the conflict it was able to successfully procure items to ensure the implementation the World Bank IHISP project. Also the UN system would be called upon for assistance as necessary. WHO, UNICEF and UNFPA, particularly UNFPA has given a commitment to support procurement of both commodities and external technical expertise. Hence it should be observed that there are no budgets for external consultants, in this Global Fund proposal, based on the arrangement with UNFPA. Therefore a mixture of existing National procurement systems, which have been strengthened by the World Bank and outsourced procurement agencies e.g., UNFPA, WHO and UNICEF will be used. The UN system has a track record of supporting Sierra Leone, and once the MOHS or NAS World Bank assisted procurement units conclude that a particular item is best procured by any of the UN agencies, it would be promptly passed on to them for assistance.

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4.7.3 Approach to supply management of health products

[Which of the following types of organizations will be involved in the supply management of health products: X National medical stores or equivalent

Sub-contracted procurement organization(s) (national) (specify which one[s]) Sub-contracted procurement organization(s) (international) (specify which one[s]) Other (specify)

[If more than one of these is checked, describe the relationships between these entities (1 paragraph)] There is an existing supply system which has a Central Medical Store and Regional and District Medical Stores, which uses inventory control and tally card system to ensure control of the drugs and medical supplies. Products are released upon submission of duly authenticated request form.

This system is currently benefiting from an EU project, that has a resident external technical expert. The EU project would amongst things is renovating warehouses, will computerise inventory, train staff and support updating of the national drug formulary. The resident technical expert represents the EU on the CCM, and would be actively supporting the Global Fund procurement activities.

4.7.4 Describe the capacity that exists to ensure compliance with the Global Fund’s policies in each of the following areas, and any capacity building and/or technical assistance needs (1 paragraph per topic):

Procurement plan development Procurement systems Quality assurance and quality control National laws and international agreements Distribution and inventory management Appropriate use

Procurement plan development The Procurement Unit within the Directorate of Support Services handles the procurement function in the Ministry of Health and Sanitation. A Procurement Manager who is assisted by a Procurement Assistant and a Secretary heads the Unit. The Unit prepares procurement plans, bidding documents and other procurement documents. The Unit draws up an 3year procurement plans which are rolled over and updated monthly and quarterly. At the beginning of each year the various Programme Managers are asked to submit their requisitions of required pharmaceuticals and medical equipments to plan and initiate procurement action. Procurement systems To prevent monopoly of procurement decisions, there exists a procurement committee in the Ministry, which reviews all recommendations for award of contracts from the Procurement Unit. The Director of Support Services with the Procurement Manager as Secretary chairs this committee. Other members of the committee include the Director of Drugs and Medical Supplies and Program Manager on whose behalf the procurement action is taken. All supplies are delivered to a Central Medical Stores (CMS) and received by a Receiving Bay Officer who check the delivery against the contracts document, and record the condition of the goods as received. The Dispatch Bay Officer at the Central Medical Stores issues supplies to respective projects/beneficiaries. From the above it can be seen that there is a complete segregation of the procurement function and responsibility between requisition, contract award, receipt of supplies and payment

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Quality assurance and quality control The procurement unit maintains a database of suppliers of various goods and services. The database is continuously updated as reliability and efficiency any time a contract is awarded. Data on the performance of suppliers is also available at the central Tender Board. New suppliers are added on the supplier list as they introduce themselves or on advertisement of contract opportunities. Suppliers are selected for supply of goods and services through a tendering process no matter the value of the contract. The procedure through which suppliers are selected is provided in the next section.

National laws and international agreements With rare exceptions, the procedures used by the MOHS for procurement of goods and services funded by international funding agencies are those prescribed by the World Bank Guidelines, Procurement under IBRD Loans and IDA Credits and Guidelines, selection and employment of consultants by World Bank borrowers. The procedures of goods fall into five general categories: National Shopping, International Shopping, National Comparative Bidding (NCB), International Comparative Bidding (ICB) and Limited Competition. The tendering process, which the MOHS intends to use for procurement under the Global Fund, will generally be an adaptation of these five categories.

The five general categories National Shopping International Shopping National Comparative Bidding (NCB) International Comparative Bidding (ICB) Limited Competition

Distribution and inventory management Distribution of supplies from the Central Medical Stores to intended beneficiary is done at two stages: Distribution from the Central Medical Stores to the District Medical Stores. Distribution from the District Medical Stores to Peripheral Health Units (PHUs)

Supplies are issued from the central medial stores on stores requisitions initiated by respective programme managers and approved by the Director-General Medical Services, and the Director of Drugs and Medical Supplies. The supplies are then loaded on the Ministries fleet of vehicles and transported to the respective District Medical Stores. The supplies are accompanied by Convoy Notes, which list all the items in the vehicle, the respective quantities, and the intended destination. The consignor, the issuing Officer and the Driver conveying the supplies, signs the Convoy Note. On arrival at its destination, the Consignee signed against each of the itemized list of supplies after verifying the quantities. The convoy note has a column where the consignee comments on the manner in which the supplies were received. Two copies of the convoy note are returned each to the respective Project Manager and the Stores Manager. Discrepancies in receipt as recorded on the convoy note are immediately investigated and action taken to retrieve any shortage.

From the District Medical Stores, supplies are issued to various PHUs in the District. The supplies are transported between the District Medical Stores and PHUs in smaller four-wheel drive vehicles. They are also accompanied by Convoy Notes. To prevent a shortage of supplies at each level of the distribution network, minimum and maximum stock levels and replenishment levels are established at the district Medical Stores and at the PHUs. Monthly consumption rates are also established for each pharmaceutical at each PHU from historical usage data. This allows stocks to be replenished as they approach minimum stock levels. At the Central Medical Stores, re-order levels are established based on annual usage rate and lead-time between ordering and delivery.

The above existing supply chain has effectively worked for the past years and could be used for

procurement under the Global Funds to achieve economy, efficiency, open competition and transparency in the procurement system.

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Appropriate use Every effort is made to ensure that procured items are delivered to the specified sites, while health personnel are responsible for their appropriate use. In this regard annual training of prescribers on the adherence to treatment guidelines and the rational use of drugs is carried out. Mass sensitization of the public to ensure compliance of drug treatment is routinely conducted including at the health facility level.

4.7.5 Drug donation programs

[Specify participation in any donation programs that are currently supplying health products (or which have been applied for) including the Global TB Drug Facility and drug donation programs by pharmaceutical companies, multilateral agencies, and NGOs relevant to this application (1 paragraph).] Sierra Leone’s National TB Program participates in the Global TB Drug Facility for the TB drug requirements described and quantified in the TB component proposal submitted in Round 2 to the Global Fund. On occasion, there have also been ad hoc donations from NGOs and bilateral sources, including limited quantities of Nevirapine and antibiotics from US and European partners. These were not meant to be sustained, but to jump start initiatives and processes as Sierra Leone transitions into a development phase. Their limited relevance to the current proposal include the provision of experience on the use of HIV/AIDS-related drugs that have previously not been available in Sierra Leone until this time. [For tuberculosis and HIV/TB components only:] Not applicable

Yes 4.7.6 Does the proposal request funding for the treatment of multi-drug resistant TB? No

[If yes, be aware that all procurement of medicines to treat multi-drug resistant tuberculosis financed by the Global Fund must be conducted through the Green Light Committee of the Stop TB Partnership. For a Green Light Committee application form see Annex C.]

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5. COMPONENT Budget Section

[Please remember that this section is to be completed for each component. Throughout “year” refers to the year of proposal implementation. For example, if Table 4.1.1 indicates that the proposal starts in June, year 1 would cover the period from June to the following May.]

5.1 Full and detailed Budget as an attachment to the Proposal Form

[By way of supporting information for the Summary Budget in Table 5.2, a detailed budget should be provided as an attachment to the Proposal Form. It should reflect and be consistent with the broad budget categories mentioned in Table 5.2 and preferably also reflect the activities of the component. The detailed budget should include assumptions and formulas used to estimate major budget items. It should cover the first and second year of the Proposal and in respect of the first year may be broken down by quarters.] [Please note that a detailed one-year action plan and an indicative action plan for the second year need to be provided with the detailed budget.]

5.2 Budget Summary

[In Table 5.2, summarize the funds requested from the Global Fund. The budget should be by year and budget category. The budget categories are explained below:] Human Resources: Salaries, wages and related costs (pensions, incentives and other employee benefits, etc.) relating to all staff (including field personnel), consultants (excluding short term consultants included under categories below) and staff recruitment costs Infrastructure and Equipment: Information Technology (IT) and building infrastructure, office equipment, audio visual equipment, vehicles, and related maintenance and repair costs, etc. Training: Workshops, meetings, training publications, training-related travel, etc. Do not include training-related human resources costs which should be included under the Human Resources category above. Commodities and Products: Bednets, condoms, diagnostics, microscopes, syringes, etc. Drugs: Antiretroviral therapy, drugs for opportunistic infections, TB drugs, anti-malarial drugs, etc. Planning and Administration: This category includes; (a) Short term technical consulting costs, travel, field visits and other costs relating to program

planning, supervision and administration (including in respect of managing sub-recipient relationships, monitoring and evaluation, and procurement and supply management).

(b) Overhead costs such as office rent, utilities, internal communication costs, insurance, legal, accounting and auditing costs, etc

(c) Printed material and communication costs associated with program related campaigns, etc. In relation to (a), (b) and (c) do not include human resources costs which should be included under the Human Resources category above

Other: Costs that do not fall within above categories – please specify

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Table 5.2a –Fund Request from the Global Fund Funds requested from The Global Fund (in USD)

Year 1 Year 2 Year 3 Year 4 Year 5 Total

Human Resources 652,804 645,334

649,121

634,491

349,436

2,931,186

Infrastructure and Equipment

1,483,002 200,769 45,744 37,503 9,512

1,776,530

Training 876,171 582,679

626,717

485,554

395,981

2,967,102

Commodities and Products

792,677 598,016

609,364

617,968

434,011

3,052,036

Drugs 729,547 737,453

879,383

976,079

988,751

4,311,213

Planning and administration

685,123 457,135

559,158

466,390

354,540

2,522,346

Other (please specify) 60,300 73,248 57,948 90,783 62,512 344,791 Total funds requested from the Global Fund

5,279,624

3,294,634

3,427,435

3,308,768

2,594,743

17,905,204

5.3 Funds requested for functional areas

[Provide the budgets for each of the following three functional areas. In each case, these costs should have already been included in Table 5.2, so the below tables should be subsets of the budget in Table 5.2, not additional to it. For example, the costs for monitoring and evaluation will be included in various of the line items above (e.g., Human Resources, Infrastructure and Equipment, Training, etc.).] Monitoring and evaluation: [This includes: data collection, analysis, travel, field supervision visits, systems and software, consultant and human resources costs and any other costs associated with monitoring and evaluation.]

Table 5.3a – Costs for monitoring and evaluation Funds requested from the Global Fund for monitoring and evaluation

(in USD)

Year 1 Year 2 Year 3 Year 4 Year 5 Total Monitoring and evaluation

519,025 175,805 113,192 135,144 403,860 1,347,026

Procurement and supply management: [This includes: consultant and human resources costs (including any technical assistance required for the development of the Procurement Plan), warehouse and office facilities, transportation and other logistics requirements, legal expertise, costs for quality assurance including laboratory testing of samples, and any other costs associated getting sufficient health products of assured quality, procured at the lowest price and in accordance with national laws and international agreements to the end user in a reliable and timely fashion; do not include drug costs].

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Table 5.3b – Costs for procurement and supply management Funds requested from the Global Fund for procurement and supply

management (in USD)

Year 1 Year 2 Year 3 Year 4 Year 5 Total

Procurement and supply management

2,928,483 1,444,119 1,304,229 1,289,962 792,959 7,759,752

Technical assistance: [This includes: costs of consultant and other human resources that provide technical assistance on any part of the proposal, from the development of initial plans through the course of implementation. This should include technical assistance costs related to planning, technical aspects of implementation, management, monitoring and evaluation, and procurement and supply management]

Table 5.3c – Costs for technical assistance Funds requested from the Global Fund for technical assistance (in USD) Year 1 Year 2 Year 3 Year 4 Year 5 Total

Technical assistance

713,104 718,582 707,069 725,274 411,948 3,275,977

5.4 Partner Allocations

[Indicate in table 5.4 below how the requested resources in Table 5.2a will, in percentage terms, be allocated amongst the implementing partners:

Table 5.4 – Partner Allocations Fund allocation to implementing partners (in %)

Year 1 Year 2 Year 3 Year 4 Year 5 Total Academic/educational sector

0.16 0.15 0.00 0.00 0.00 0.31

Government 10.74 6.78 7.63 7.87 8.33 41.35Non-governmental/ Community-Based Org.

13.34 9.37 7.75 8.26 4.11 42.83

People living with HIV/AIDS, tuberculosis, and/or malaria

2.20 2.10 2.40 2.20 1.10 10.00

Private sector 0.34 0.00 0.11 0.27 0.00 0.73Religious/faith-based organizations

1.21 1.02 0.86 0.75 0.95 4.79

Multi-/bilateral development partners

0.00 0.00 0.00 0.00 0.00 0.00

Others (please specify) 0.00 0.00 0.00 0.00 0.00 0.00Total 28.00 19.42 18.76 19.35 14.48 100.00 [If there is only one partner, please explain why (1 paragraph).]

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5.5 Key Budget Assumptions for Requests from the Global Fund

5.5.1 Specify in the tables below the Drugs and Commodities & Products unit costs, volumes and total costs, for the FIRST AND SECOND YEARS ONLY.

[Use the treatment categories that follow the tables (organized by disease). Unit prices for pharmaceutical products should be the lowest of: prices currently available locally; public offers from manufacturers; or price information for public information sources. (For example: Sources and Prices of Selected Drugs and Diagnostics for People Living With HIV/AIDS. Copenhagen/Geneva, UNAIDS/UNICEF/WHO-HTP/MSF, June 2003 (http://www.who.int/medicines/organization/par/ipc/sources-prices.pdf); Market News Service, Pharmaceutical starting materials and essential drugs, WTO/UNCTAD/International Trade Centre and WHO (http://www.intracen.org/mns/pharma.html); International Drug Price Indicator Guide on finished products of essential drugs, Management Sciences for Health in collaboration with WHO (published annually) (http://www.msh.org); First-line tuberculosis drugs, formulations and prices currently supplied/to be supplied by Global Drug Facility (http://www.stoptb.org/GDF/drugsupply/drugs.available.html)) If prices from sources other than those specified above are used, a rationale must be included.

Table 5.5.1.A – Drugs, Year 1

Year 1 Treatment category Average cost

(based on delivery duty unpaid) per person-year or

treatment course (in USD)

Number of person-years or treatment courses procured

Total cost (in USD)

PMTCT-Nevirapine Free Free First Line Treatment(ZDV+3TC+NVP)

418 200 83,600

Treatment of opportunistic infection

203,362

Treatment for sexually transmitted infections

341,179

STI DRUGS FOR YEAR 1 Item/unit (using International Non-proprietary Names for pharmaceuticals)

Purpose Unit cost (USD)

Volume (specify measure)

Ciprofloxacin tabs STI 50.00 1,360 Doxycyllin caps STI 9.90 815 Metronidazole tabs STI 3.25 1,712 Ketoconazole tabs STI 10.85 1,902 Paracetamol tabs STI 2.80 1,630 Erythromycin tabs STI 33.80 1,630 Fulcin tabs STI 38.82 1,630 Tetracyclin Eye Ointment STI 0.10 5,000 Nizoral tabs STI 9.45 1,902

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Table 5.5.1.A – Drugs, Year 2

Year 2 Treatment category Average cost

(based on delivery duty unpaid) per person-year or

treatment course (in USD)

Number of person-years or treatment courses procured

Total cost (in USD)

PMTCT-Nevirapine Free Free First Line Treatment (ZDV+3TC+NVP)

418 500 209,000

Treatment of opportunistic infection

146,749

Treatment for sexually transmitted infections

296,054

[If prices from sources other than those specified above are used, provide a rationale for using these prices] HIV/AIDS:

• Antiretroviral therapy (prevention of mother-to-child transmission) • Antiretroviral therapy (first-line for adult treatment) • Antiretroviral therapy (second-line for adult treatment) • Antiretroviral therapy (other including post-exposure prophylaxis) • Antiretroviral therapy (first-line for pediatric treatment) • Antiretroviral therapy (first-line for pediatric treatment) • Prophylaxis of opportunistic infections • Treatment of opportunistic infections (including home-based and palliative care) • Treatment of sexually transmitted infections • Other (please specify)

Tuberculosis:

• Anti-tuberculosis therapy (first-line) • Anti-tuberculosis therapy (second-line) • Other (please specify)

[Use the commodities and products categories that follow the tables (organized by disease)]

Table 5.5.1B –Commodities & Products Year 1 Year 1

Commodities and products categories

Unit (e.g., one

mosquito net, one gross of

condoms)

Unit cost (in USD)

Quantity Total cost (in USD)

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Table 5.5.1B –Commodities & Products Year 2 Year 2

Commodities and products categories

Unit (e.g., one

mosquito net, one gross of

condoms)

Unit cost (in USD)

Quantity Total cost (in USD)

HIV/AIDS

• Condoms • Diagnostic tests for HIV infection (e.g., rapid tests, ELISAs, etc.) • Diagnostics: CD4+ T cell • Diagnostics: HIV RNA (viral load) • Diagnostics: Other • Sterile injection equipment (e.g., syringes, etc.) • Universal precautions supplies (e.g., syringes, etc.) • Other (please specify)

TB

• Laboratory equipment (durable products, such as microscopes, x-ray machines, etc.)

• Laboratory supplies (non-durable products, such as slides, reagents, sputum containers, x-ray films, etc.)

• Other (please specify) Malaria

• Mosquito nets: Insecticide Treated Nets: Factory pretreated mosquito nets • Mosquito nets: Insecticide Treated Nets: Untreated mosquito nets • (Re)treatment supplies • Long lasting insecticidal mosquito nets • Insecticides for outdoor and/or indoor spraying • Spraying equipment • Diagnostics: Rapid Diagnostic Tests (RDTs) • Diagnostics: Other • Other (please specify)

5.5.2 Justification for Drugs and Commodities and Products

[Provide the rationale (e.g., assumptions or formulas used) for the volumes of drugs and commodity/products listed in Table 5.5.1. (2–3 paragraphs)]

STI DRUGS

The national prevalence of STI among outpatient cases is 4.7%. It is expected that 90% of these will be treated. The quantity of drugs requested is to ensure that there is adequate drugs to treat this number.

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ARV It is expected that ARV will be provided for 200 PLWHAs in the first year and increase to 300 PLWHAs in the second year. The quantity of ARVs requested is to ensure that there are sufficient drugs to treat this number of PLWHAs.

5.5.3 Human Resources costs

[In cases where Human Resources is an important share of the budget, explain how these amounts have been budgeted in respect of the first two years, to what extent Human Resources spending will strengthen health systems capacity at the patient/target population level, and how these salaries will be sustained after the proposal period is over (1–2 paragraph)]

There is adequate manpower in the government and NGOs services, to deliver the manpower requirements for this proposal.. The MOHS has a total staff complement of 2,404, made up of 40 cadres. The MOHS personnel of direct relevance to this proposal include 73 general practice doctors, 24 specialist doctors, 20 public health specialists, 132 Community Health Officers, 266 staff nurses, 712 trained nurses, 42 midwives, 16 District Health Sister, 33 health sisters, 6 public health sisters, 726 MCH aides, 13 pharmacists, 117 dispensers/druggists, 6 laboratory technologists, 46 laboratory technicians and 3 Health education officers. It can be sen from the above that there is already government health and non-health personnel delivering HIV/AIDS services. To support program scale up, more laboratory technologists will be recruited, and given the small number of those to be recruited and their importance government would be able to sustain their salaries after the project. The war caused much displacement, so that most of the MOHS staff are currently concentrated in the Western Area. As normalcy progresses, a more even spread of personnel will be achieved. The government personnel were not budgeted for except for the new recruitments like laboratory technicians and 4 blood recruiters.

On the NGO side only necessary new recruitments were budgeted for, and the bulk of these new recruitments are under the condom social marketing program. In terms of the sustainability of the NGO recruitments, it is clear that NGOs are into development work for the long-term, and the experience is that once staff are recruited, subject to good performance they would continue to find employment opportunities within the NGO sector. In most other cases a percentage of the time of existing NGO staff-program officers and accountants who will participate in the project is what was budgeted for.

5.5.4 Other key expenditure items

[With respect to other expenditure categories (e.g., Infrastructure and equipment) which form an important share of the budget, explain how these amounts have been budgeted for the first two years (1–2 paragraph)] The construction of the Kakua Hospice which is critical because of the consequences of the war, its budget is based on specific line items, using estimates provided by the community and reviewed by government personnel.

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CHART 1-FLOW OF FUNDS/PROGRAMATIC MANAGEMENT *Funds Downwards (solid lines) and programatic reports and financial retirement upwards

*Information laterally (broken lines)

Government MOHS 1. Blood Transfusion Services(Blood Safety)

2. RH + FP DIV - STI 3. NAS – ARG - VCCT

- PMTCT NAS – Capacity Building CARE/SLRC -Pilot Rural IEC/BCC Strategy

NAS – ARG – ARVs - University, Ramsy Laboratory, Famcare, MOHS , Private Physicians

Marie Stopes – NGO STI, VCCT, PMTCT MERLIN – NGO Miners, CSWs CADO – NGO Youth CCF – NGO PLWHA/OVC CARE – Condom Social Marketing

GBF/LFA

2 MODEP (Reports)

1.2.3 MOF (Reports) 1.2.1.1 NAS PR

CCM (Reports)

1.2.2 NAC (Reports)

NAS – ARG/MOHS Health Sector Response

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TABLE 1 DISTRIBUTION OF FACILITIES TARGETED FOR STI CLINICS

FACILITIES TARGETED DISTRICT GOVERNMENT HOSPITAL

NGO/MISSION HOSPITALS

PHUs NGO CLINICS PRIVATE CLINICS

Western Area 2 Referral 4 Satellite Hospitals

2 (Military and Police) 1 (UMC)

10 3MSSSL,PPASL, UMC KISSY (MCH Centre)

1 (Famcare)

Bombali 1 2 (Makeni and Kamakwe)

10 1 Red Cross, Gbendembu 1 CHASL

1

Tonkolili 1 1 (Masanga) 10 X X Port Loko 2 1 10 2 (MSSSL and PPASL) X Kambia 1 X 10 1 Red Cross X Koinadugu 1 X 5 1 (CES) X Kono 1 X 10 1 MSSSL

1 Red Cross X

Kenema 1 1 (Panguma) 10 X 1 Kailahun 1 1 (Segbwema)) 14+ X X Bo 1 X 10 1 MSSSL

1 PPASL 2 CHASL

1

Bonthe 1 1 Matru Jong 10 X X Pujehun 1 X 10 X X Moyamba 1 2 Sierra Rutile,

Sieromco 10 1 Red Cross X

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TABLE 2

RH/STI TREATMENT CENTRES AND STAKEHOLDERS

NGOs DISTRICTS MOHS MSSSL PPASL Red

Cross

IRC IMC MRC World Vision

GOAL WICM ARC MIL Police

MSF-H MSF-B MSF-F CHASL

Western Area X (H) X X X X X X X Bombali X (H) X X X X (H) Tonkolili X (H) X

19 PHU

Port Loko X (H) X X X X (H) Kambia X (H) X X Koinadugu X (H) X Kono X (H) X X X X Kenema X (H) X X X X (H) Kailahun X (H) X

PHU X (H)

Bo X (H) X X X X Bonthe X (H) X X (H) Pujehun X (H) X Moyamba X (H) X

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TABLE 3

CURRENT AND PLANNED VCCT SITES IN SIERRA LEONE: THE ADDITIONAL SITES TO BE FUNDED BY THE GLOBAL FUND WOULD BE SELECTED FROM THIS LIST. REGION/DISTRICTS CURRENT SITES POSSIBLE NEW/ UPGRADED SITES PARTNERS

138

rn Region Freetown

1 –in clinic in Eastern Freetown 0 CHASL (faith-based) 3:-- Connaught hospital, Military

hospital, Police hospital--SHARP 0 MOHS

Started on a small scale in its 2 laboratories attached to maternity units—SHARP

1 new in clinic in central Freetown, scale up in the two laboratories

Marie Stopes SL

0 1 new-in western Freetown - PPASL

Northern Region

Port Loko District 0 5 new- 2 in hospital, 3 in clinics CHASL (faith-based) ARC

1 District hospital--SHARP 4 new—in health centres MOHS

Kambia District

1 District hospital --SHARP 4 new—in health centres MOHS Koinadugu District

1 District hospital —SHARP 4 new—in health centres MOHS Tonkolili District

1 District hospital --SHARP 0 MOHS

0 5 new—in health centres; presently working with these but no VCCT services in any

Medical Research Council (MRC)

Bombali District

1 District hospital –SHARP 4 new—in health centres MOHS 0 2 new – 1 in hospital, 1 in clinic CHASL

Southern Region

Moyamba District 1 District hospital --SHARP 4 new—in health centres MOHS

1 new- in clinic CHASL

Bo District

1 District hospital --SHARP 4 new—in health centres MOHS

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0 1 new- in clinic Marie Stopes SL 0 1new- in clinic PPASL 4 new-all in clinics CHASL Bonthe District

1 District hospital --SHARP 4 new—in health centres MOHS REGION/DISTRICTS 5. CURRENT SITES POSSIBLE NEW/ UPGRADED

SITES PARTNERS

0 1 new-in hospital CHASL

140

Pujehun District 1 District hospital --SHARP 4 new—in health centres MOHS Eastern Region Kono District 1 District hospital --SHARP 4 new—in health centres MOHS

0 1 new-in reproductive health clinic Marie Stopes SL Kenema District 1 District hospital --SHARP 4 new—in health centres MOHS

0 1 new -in hospital CHASL PPASL Kailahun 0 4 new—in health centres MOHS

0 1 new -in hospital CHASL 0 1 in district hospital IMC

141

TABLE 4.

CURRENT AND PLANNED PPTCT SITES IN SIERRA LEONE: THE ADDITIONAL SITES TO BE FUNDED BY THE GLOBAL FUND WOULD BE SELECTED FROM THIS LIST.

REGION/DISTRICTS CURRENT SITES POSSIBLE NEW/ UPGRADED SITES

PARTNERS

142

Western Region Freetown

1 –in clinic in eastern Freetown (SHARP)

1-upgrading in year one CHASL (faith-based)

0 Upgrade and equip 1 reproductive health clinic into a maternity unit

PPASL

3:-- PC Maternity hospital, Military hospital, Police hospital—SHARP

3 new- in health centres in Freetown (SHARP)

MOHS

2 in maternity units; one in eastern Freetown and one in western Freetown—SHARP

Upgrading of the 2 labour wards and theartres attached to the maternity units

1.

Marie Stopes SL

Northern Region

Port Loko District 0 2 new-Hospital 3 new- in clinic

CHASL (faith-based) ARC

0 6 new—Two in district hospitals (SHARP), four in health centres

MOHS

Kambia District

0 5 new—one in district hospital (SHARP), four in health centres

MOHS

Koinadugu District

0 5 new—one in district hospital (SHARP),, four in health centres

MOHS

Tonkolili District 0 5 new—one in district hospital

(SHARP), four in health centres MoHS

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Bombali District


MOHS

1new-Hospital 1new-Clinic

CHASL

Southern Region

Moyamba District 0 5 new—one in district hospital (SHARP), four in health centres

MOHS

1new- Clinic CHASL

Bo District

REGION/DISTRICTS CURRENT SITES POSSIBLE NEW/ UPGRADED SITES

PARTNERS


MOHS

4new— in clinics CHASL Bonthe District


MOHS

1new-Hospital CHASL

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6. Pujehun District 0 5 new—one in district hospital (SHARP), four in health centres

MOHS

Eastern Region

a. Kono District


MOHS

b. Kenema

District 0 5 new—one in district hospital

(SHARP), four in health centres MOHS

1new-Hospital CHASL

c. Kailahun 0 5 new—one in district hospital (SHARP), four in health centres

MoHS

1new-Hospital CHASL 0 1 in district hospital IMC

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TABLE 5. SERVICE PROVIDERS AND SUPPORT STAFF TO BE TRAINED

BY MOHS AND PARTNERS

Personnel MRC IMC MOHS CHASL MSSSL PPASL ARC Total Resp.

146

7. Doctors 0 2 95 6 3 2 4 112 MOHS

Nurses 15 2 951 40 40 7 20 1075 MOHSMidwives 8 0 108 20 25 6 10 177 MOHS

Regional VCCT Supervisors 0 0 11 0 0 0 0 11 MOHSMCH Aides 0 0 1,590 0 0 1 15 1,606 MOHS

TBAs 57 10 1,5763 40 120 20 20 16,020 MOHSLaboratory Technicians/

Assistants7 2 12 11 3 2 2 39 MOHS

Counsellors 14 2 50 24 4 9 10 113 MOHSSupport staff 30 0 490 60 20 10 4 614 MOHS

Community promoters 29 0 0 50 40 10 10 139 MSSSL PPASL

147

148

TABLE 6.

EQUIPMENT REQUIRED TO ENSURE BLOOD SAFETY NATIONWIDE

No. ITEM QUANTITY 1. ELISA machine 1 2. ELISA Reader 1 3. ELISA Printer 1 4. Water distilling plant 12 5. Deep Freezer for Plasma storage 1 6. Scale for plasma production 1 7. Refrigerator (electrical) storage of reagents 1 8. Binocular microscope 2 9. Table-top Centrifuge for cross-matching 12 10. Solar powered/gas refrigerator for storage of blood (1 per district

hospital) 12

11. Solar powered/gas refrigerator for storage of reagents (1 per district hospital)

12

12. Water bath 13 13. Incubator 10

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i. PROFILE OF NGO-1 ii.

iii. THE SOCIETY FOR WOMEN AND AIDS IN AFRICA, SIERRA LEONE CHAPTER (SWAASL)

150

8.

Society for Women and AIDS in Africa, Sierra Leone chapter (SWAASL) is one of 40 branches of Society for Women and AIDS in Africa (SWAA). SWAA is an African regional movement committed to fight HIV and AIDS, and is currently based in Dakar, Senegal. The National AIDS Control Program (NACP) of the Ministry of Health launched the Sierra Leone chapter in 1990 after the first international conference of SWAA International. SWAA was set up primarily to address the constraints faced by African women in responding positively to information on the HIV/AIDS pandemic. It is registered as a community-based organization, with a current membership of 51. A five-member executive board leads the organization. MEMBERSHIP is open to persons and groups interested in HIV/AIDS and related issues. It comprises men and women of diverse professional backgrounds including housewives, nurses, nutritionists, social scientists, theologians, lawyers, etc. Although our primary objective is to educate, inform and empower our target population on HIV/AIDS, issues such as socio-cultural, reproductive health, economic, advocacy and human right, skills training, agriculture, food and nutrition have been addressed in many SWAASL activities. Very recently, care and support for Persons Living With HIV and AIDS (PLWHAs) have featured prominently on our program of activities. Primary target are women but we encourage the participation of men. Youth and children are also welcome. Men could be elected to the executive board, become volunteers and fully participate in country programs. RESOURCES/INSTITUTIONAL CAPACITY SWAASL’s office in Freetown consists of a resource center, a library and a training/conference room. Prior to the rebel incursion into Freetown in January 1999, SWAASL had one of the largest up-to-date resource materials on HIV/AIDS in the country. Most of this was destroyed or stolen. There is a plan to replenish the materials. Being semi-autonomous, the society must generate its own funds. Fund raising drives include: developing proposals for funding, sponsored walks, dash cards, small support grants from partners and fees from training/workshops for staff/members of some organizations, groups and businesses. SWAASL has a pool of resource persons from among its membership to meet its training needs. Services provided for its target groups are usually free. SWAASL has received financial and material support from:

-Catholic Relief Services – CRS -United Nations Fund for Population Activities - UNFPA -United Nations Fund for Women – UNIFEM -The British Council -The Urgent Action Fund – UAF

COLLABORATION AND COOPERATION In the face of limited resources, SWAASL attaches great importance to collaboration with groups and partners. This serves to avoid duplication of efforts and also help us draw on the experiences and expertise of these groups. We collaborate and cooperate with several organizations and groups nationally and internationally. Some of these include: Nationally:

-Young Women Christian Association - YWCA

151

-Marie Stopes Society – Sierra Leone -Ministry of Social Welfare, Gender and Children’s Affairs -United Nations Fund for Women - UNIFEM -United Nations Fund for Population Activities - UNFPA -National AIDS Control Program – NACP

Internationally, SWAASL collaborates with: -SWAA International and all SWAA branches in the sub-region -Christian Children’s Fund based in London -School of Public Health of the University of South Carolina, USA.

SWAASL’S PAST ACTIVITIES AND ACHIEVEMENTS Despite several interruptions during the ten-year long civil war, SWAASL successfully organized, developed and implemented many HIV/AIDS programs targeting various segments of the population. Between 1994 and 2003, SWAASL conducted massive sensitization, awareness campaigns and/or skills training, targeting groups such as:

-Female Parliamentarians and Paramount chiefs -Commercial sex workers -Youth in and out of school -Women traumatized by the war who testified before the Truth and Reconciliation Commission -Persons living with HIV/AIDS

a. COMMERCIAL SEX WORKERS (CSWs)

Between 1994 and 2003, SWAASL organized and conducted HIV/AIDS awareness and sensitization training targeting about 300 commercial sex workers in the Government Wharf, Kanikay and Kroo Bay areas of Freetown. Over 60% of these were referred to the Marie Stopes clinic for STI management. About 50% were linked up with vocational training centers for skills training for alternative income generation. Close to 90% accepted the use of condoms in their work.

SWAASL also organized and successfully conducted training workshops for peer educators and staff of organizations including:

-The United Nations Country Team in Sierra Leone -FORUT -Médecins Sans Frontières – MSF Belgium -National Commission for Social Action - NaCSA -The Sierra Leone Commercial Bank -The United States Embassy, Sierra Leone

Current activities involve conducting workshops for PLWHAs focusing on health/hygiene, food/nutrition, positive living and peer group counseling.

152

i.

ii. PROFILE OF NGO –2

THE SHEPHERD’S HOSPICE SIERRA LEONE

43A Bai Bureh Road, Lower Allen Town, Freetown The Shepherd’s Hospice Sierra Leone is a recognized NGO with a paid-up registration with the Ministry of Development and Economic Planning. It was founded in 1995 and is a member of Christian Health Association of Sierra Leone (CHASL). It is a non-denominational Christian movement with members from the Catholic Church of Sierra Leone, the United Methodist Church and other Protestant churches. However the responsive nature of the hospice to the needs of HIV infected and affected has transformed the hospice into a collaborative effort between the Government of Sierra Leone and the community affected. The purpose is to combat a crisis and mitigate its impact on individuals and families. The World Bank recently granted funds to build a six-bed facility to provide short-term admission to terminal cases of AIDS and cancer. As the only hospice in Sierra Leone providing palliative care, Shepherd’s Hospice has always emphasised community-based care through trained volunteers who may be infected or affected. Family members are also trained to give practical patient care and to serve as childcare givers to OVCs. This approach has fostered a partnership between the hospice and St. Edward’s Catholic Seminary in Freetown, where the hospice is training student-priests in HIV/AIDS prevention and care, with an emphasis on counselling for young adults and infected persons. Such volunteers are recruited from churches and the community. The Hospice Centre is located in Lower Allen Town along Bai Bureh Road which is the main highway leading to Freetown from the rest of the country The Shepherd’s Hospice Sierra Leone has a long-standing experience in HIV/AIDS prevention and care. It provides competent and compassionate care for HIV/AIDS patients. In addition, the Hospice is implementing a project that builds the capacity of 23 Health Care providers in Sierra Leone, so as to enable them to respond adequately to the HIV/AIDS crisis. The objective of the capacity building project is to integrate HIV/AIDS prevention into services. The Hospice has conducted the following activities:

Training of community volunteers in HIV/AIDS prevention and home-based care.

Training of nurses, midwives and Community Health Officers in HIV/AIDS from 23 health care institutions in HIV/AIDS prevention and care. Training is also provided

153

for people at work including factory workers, Church leaders, and recently CRS workers in Sierra Leone.

HIV/AIDS needs assessment survey in 1997

Survey on the needs of AIDS orphans and vulnerable children in 2002.

Providing educational, medical and legal support for AIDS orphans registered with

the institution. These children stay with foster parents that are identified with the community to serve as caregivers. Regular visits are made to the home of these children by the social work team to maintain a follow-up on their progress in the home and school. Children of chronically ill parents benefit especially in the area of making will to facilitate inheritance of property.

Providing palliative care for HIV/AIDS and cancer patients. This aspect of our

work emphasizes pain relief and symptom control at the respite centre of six beds. The hospice care team is multidisciplinary comprising of the social worker; nurse and medical officer. Training is now provided for priests at the St Edwards seminary in Freetown to enhance their knowledge on HIV/AIDS as counsellors on the home care program. This network of volunteers can reach wider target on HIV and AIDS issues.

Advocacy on human rights issues pertaining to HIV/AIDS. The Hospice has

organised an Association of persons living with HIV/AIDS and encouraged them to speak out for themselves on stigma and discrimination.

Resource centre development to enhance information dissemination on HIV/AIDS

and STIs.

154

PROFILE OF NGO-3

KAKUA HOSPICE, BACKGROUND, RATIONALE AND JUSTIFICATION, AS

PROVIDED BY A COMMUNITY MEMBER (UNEDITED) There are many NGOs, CBOs and Government institutions engaged in the fight against HIV/AIDS but virtually all of them are engaged in IEC/BCC activities. Consequently, their activities are centered around prevention or slowing down the incidence of the AIDS pandemic. Only SWAASL, Sierra Leone Red Cross, Women in Crisis Movement, Community Animation and Development Organisation, HIV/AIDS Care and Support Association, and Shepherd’s Hospice have components for the treatment of STIs and other Opportunistic Infections. The only Institution which provides palliative care for particularly AIDS patients is the Shepherd’s Hospice whose activities are confined to Freetown. The others are engaged in limited home-based care and psychosocial support. Even in Districts where they are operating, they cover few chiefdoms. This project, the Kakua Community Hospice, will fill in the huge gap that remains particularly in the 8 districts that it will cover. It is the need to fill in the huge gap in the areas of treatment, palliative and psychosocial care for both AIDS and terminally ill TB patients that necessitated the quest for a Hospice in the Provinces. This project, therefore will not only provide the much needed treatment, palliative and psychosocial care for terminally ill patients, outside Freetown, but also give them the opportunity of dying in dignity, Given the stigmatization and isolation People Living with HIV/AIDS (PLWHAs) suffer from throughout the country, we will encourage and facilitate home-based care for our patients. But in a country just emerging from ten years of one of the most barbaric civil wars in recorded history, which left many people without homes/extended families, it is absolutely necessary to also make provisions for those patients who, because of the scenario described above, cannot benefit from home care facilities. Unfortunately,

155

people are not willing to lease out their buildings to us for the treatment particularly of AIDS patients due to the stigma associated with the disease. The unwillingness of people to lease out their buildings, for the treatment and care for PLWHAs has made it impossible for the project to take off. Therefore, the community has provided five acres of land for the construction of our own structures specifically for looking after terminally ill AIDS and TB patients while at the same time treating those that could be treated. Our aim therefore is to put up structures using local materials that are not very expensive. Infact, free labour will be provided by the community, but would need food for work. Because of the stigma and the Agricultural Component, the Hospice will be located about ten kilometers from the center of Bo Town. The need for at least one ambulance to ferry patients to and from the regional referral Hospital in Bo and to convey corpses to their homes will therefore not be over emphasized. Also because of its out of town location, it will be absolutely necessary for essential staff to reside on Hospice premise. Therefore the need for staff quarters. Two buildings of two apartments each will be constructed in the second year. Due to the scenario described above, it will take nothing less than four to five years to rebuild community structures and traditional sources of income such as cash crop plantations, therefore, the Kakua community mandated the interim committee hereafter referred to as the Executive Committee to write Project Proposals to Donors for assistance to make this project a success story. It is hoped that at the end of the five-year period of assistance from the Donor Community, when it is hoped our traditional sources of income would have been completely rehabilitated, the Kakua Community would to a great extent, rely on its own resources for the sustenance of this project. With land already provided by the community, we hope to go into vegetable farming and animal husbandry (piggery and poultry) to provide a steady source of protein for in-mates as well as much-needed funds to run the institution when donor support would have ended. The manager of the health Component of the Sierra Leone HIV/AIDS Response Project, SHARP, has consented to help with drugs for palliative care, similarly, the Extension Services Wing of the Ministry of Agriculture and Food Security has agreed to give technical assistance to the Animal Husbandry component of this project. The Ministry of health has also consented to provide training for our care givers while our counsellors will be trained by the American NGO the American Relief Council ARC and SHARP will provide training for our counsellors. i UNAIDS (2003) HIV and UN Peacekeeping operations, AIDS. ii ARC (2001) Strengthening AIDS Prevention in Port Loko, Baseline Survey Report – KAP among commercial sec workers, military and youth in Port Loko, Sierra Leone. iii Central Statistics Office / UNICEF (2002) Adolescents’ Knowledge, Attitude and Practice concerning HIV/AIDS in Sierra Leone, Survey Report. iv GoSL/UNICEF (2002), Adolescents and HIV/AIDS in Sierra Leone, facts and figures. v CSO / GoSL (2000) The status of women and children in Sierra Leone, A Household Survey Report (Multi-Indicator Cluster Survey MICS2). vi MSSL (2002), Report of Knowledge, attitude and Practice Survey on Basic Health and Sexual Reproductive Health.

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