DJIBOUTI July 2004 WHO Estimate of Number of People Requiring Treatment – End 2005: 1 200 Antiretroviral Therapy Target Declared by Country: 1 370 by 2005

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DJIBOUTI July 2004 WHO estimate of number of people requiring treatment – end 2005: 1 200 Antiretroviral therapy target declared by country: 1 370 by 2005

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�� Map data sources: �� WHO Country Office for Djibouti and Ministry of Health, Djibouti � �� Map production: WHO

1. Demographic and socioeconomic data 2. HIV indicators Date Estimate Source Date Estimate Source United WHO/ Total population (millions) 2004 0.7 Adult prevalence of HIV/AIDS (15–49 years) 2003 0.7 – 7.5% Nations UNAIDS United Estimated number of people living with 2 300 – WHO/ Population in urban areas (%) 2003 83.4 2003 Nations HIV/AIDS (0–49 years) 24 000 UNAIDS WHO/ Life expectancy at birth (years) 2002 49.6 WHO Cumulative number of reported AIDS cases 2001 1 783 UNAIDS Reported number of people receiving June Gross domestic product per capita (US$ ) 2001 835 IMF 94 WHO antiretroviral therapy (15–49 years) 2004 Estimated total number needing antiretroviral WHO/ Government budget spent on health care (%) 2001 13.7 WHO 2003 1 200 therapy in 2005 UNAIDS HIV testing and counselling sites: number of Ministry Per capita expenditure on health (US$) 2001 58 WHO 2003 8 sites of Health HIV testing and counselling sites: number of not Human Development Index 2001 0.462 UNDP people tested at all sites available Prevalence of HIV among adults with Ministry 2002 23% tuberculosis (15–49 years) of Health 3. Situation analysis

• Epidemic level and trend and gender data. Djibouti faces a generalized epidemic. and zidovudine + lamivudine + efavirenz or zidovudine + lamivudine + nevirapine According to Ministry of Health sources, a survey conducted in 2002 showed that the (for children 3 years or older). For people with tuberculosis, the first-line drug HIV prevalence in Djibouti was about 2.9%. The prevalence was estimated to be 3.3% regimen is zidovudine + lamivudine + abacavir. The average cost per person per in Djibouti City and 1.1% in other districts, including Obock, Tadjourah, Ali-Sabieh and year is estimated to be US$ 1680. Dikhil. The same survey indicated that women are more affected than men; in Djibouti • Assessment of overall health sector response and capacity. Djibouti’s health system is City, the prevalence is estimated to be 3.6% among women and 3.1% among men. In weak. Health services need to be strengthened to provide a more vigorous response to other districts, the HIV prevalence was estimated to be 1.7% among women and 0.3% the HIV/AIDS epidemic and to support scaling up antiretroviral therapy. Eight sites have among men. People 20–29 years old have a higher prevalence rate of about 6%. been identified as antiretroviral therapy centres. For outpatients, they are: Centre Yonis • Major vulnerable and affected groups. In Djibouti, in addition to the vulnerability of Toussaint, Health Centre of Einguela, Organisme de Protection Sociale, Health Centre youth and women, the major vulnerable groups are men in uniform, sex workers, for the Ministry of Defence and Health Centre for the Police. For inpatients, they are: dockworkers and truck drivers. Peltier General Hospital, Tuberculosis Centre (Paul Faure) and French military hospital • Policy on HIV testing and treatment. The policy on testing encourages people (Bouffard). All these antiretroviral treatment sites are located in Djibouti City. Testing and to undergo testing voluntarily. Before testing, pretest counselling is offered, counselling activities are fully functional but presently carried out only in the following and post-test counselling takes into account HIV status. A national antiretroviral antiretroviral therapy treatment sites: Centre Yonis Toussaint, Health Centre of Einguela, therapy protocol has been developed and is being revised in accordance with WHO Health Centre for the Ministry of Defence and Health Centre for the Police. simplified treatment guidelines. • Critical issues and major challenges. The major constraints to scaling up • Antiretroviral therapy: first-line drug regimen, cost per person per year. The first- antiretroviral therapy are the lack of human resources capacity and management line drug regimen for people without tuberculosis is zidovudine + lamivudine + skills. Drug procurement logistics systems are weak, and parallel procurement efavirenz (for men), zidovudine + lamivudine + abacavir (for women), zidovudine systems are run by various parties. The current system’s capacity for procurement + lamivudine + nevirapine (for pregnant women or children younger than 3 years) and stocking is very weak.

1 SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP

4. Resource requirements and funds committed for 7. WHO support for scaling up antiretroviral therapy scaling up antiretroviral therapy in 2004–2005 WHO’s response so far • WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the “3 by 5” treatment target of 600 people by the end of 2005 is • Conducting a scoping mission to assess the situation of antiretroviral between US$ 2.2 million and US$ 3.3 million. About US$ 226 000 is anticipated therapy in Djibouti and to identify opportunities and challenges for scaling up to be available from multilateral sources to fund scaling up antiretroviral therapy antiretroviral therapy provision and areas for WHO support during 2004–2005. Taking into account the funds committed to date, WHO • Reviewing and revising national antiretroviral therapy protocols and guidelines estimates that the total funding gap for Djibouti to scale up antiretroviral therapy to in accordance with WHO guidelines 600 people by the end of 2005 is between US$ 2.0 million and US$ 3.1 million. • Developing a Round 4 proposal submitted to the Global Fund to Fight AIDS, • Djibouti has been involved in a major process of health sector reform with financial Tuberculosis and Malaria with special focus on scaling up antiretroviral therapy support from the World Bank, which has committed US$ 15 million over a period • Supporting the development of an operational plan for scaling up antiretroviral of five years. The United States Agency for International Development is also therapy for 2004–2007 committing US$ 12 million. Other major supporters of the Ministry of Health include the French Cooperation, the African Development Bank, the Governments Key areas for WHO support in the future of Italy and Morocco and the Islamic Development Bank. • Establishing a “3 by 5” team in the WHO Country Office to support the government and other partners in scaling up antiretroviral therapy. The team is 5. Antiretroviral therapy coverage also expected to provide support to other Horn of Africa countries, including Somalia and Yemen • Developing a national human resource plan for scaling up antiretroviral • Djibouti’s total treatment need for 2005 is estimated to be 1200 people, and the therapy government has declared a national antiretroviral therapy target of 1370 people • Developing a monitoring and evaluation system by the end of 2005. • Supporting operational research including drug resistance, economic impact • Currently, an estimated 94 people are receiving antiretroviral therapy. and adherence to therapy • Supporting training of all levels of service providers 6. Implementation partners involved in scaling up Staffing input for scaling up antiretroviral therapy antiretroviral therapy and accelerating prevention • Leadership and management. The Executive Secretariat of the Intersectoral • Recruitment of a subregional “3 by 5” officer (Djibouti, Somalia and Yemen) is Committee against AIDS, Tuberculosis and Malaria coordinates all AIDS-related planned. activities. More than 11 ministerial departments and several nongovernmental organizations carry out AIDS control activities. In 2002, the Government developed a national strategy for preventing and controlling HIV/AIDS that serves as a reference for all partners who would like to contribute to the national response against HIV/ AIDS. The Ministry of Justice is involved in legal and policy-related issues. The Ministry of Finance is responsible for human resource planning. Other ministries play major roles such as the Ministries of Youth and Sports, Promotion of Women, Education, Interior, Labour, Information and Defence. United Nations agencies also support various components of the programme. • Antiretroviral therapy service delivery. The Ministry of Health in collaboration with other sectors is responsible for overall coordination and management of the national antiretroviral therapy programme, health system strengthening, laboratory services and capacity-building. The French Cooperation is especially involved in providing antiretroviral therapy services in hospitals, laboratory services and treating opportunistic infections. • Community mobilization. A community support unit has been established as part of the Executive Secretariat. Currently, key nongovernmental organizations are being identified to support the antiretroviral therapy programme. • Strategic information. The Ministry of Health coordinates the activities related to monitoring and evaluation with support from WHO.

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed “3 by 5” Help Desk in collaboration with national authorities, E-mail: [email protected] the WHO Country Office for Djibouti Tel.: +41 22 791 1565 and the WHO Regional Office for Fax: +41 22 791 1575 2 the Eastern Mediterranean. www.who.int/3by5