People’s Democratic Republic of Algeria Ministry of Public Health and Hospital Reform Department of Prevention National STI/HIV/AIDS Control Committee

Algerian Report on the monitoring of the Declaration of Commitment of the United Nations General Assembly Special Session on HIV/AIDS (UNGASS, 2001) in December 2005

Period covered: January 2003 – December 2005

WITH THE SUPPORT OF

Joint United Nations Programme on HIV/AIDS UNAIDS UNHCR-UNICEF-WFP-UNDP-UNFPA-UNODC- ILO-UNESCO-WHO-WORLD BANK TABLE OF CONTENTS

People’s Democratic Republic of Algeria...... 1 Ministry of Public Health and Hospital Reform...... 1 Department of Prevention...... 1 National STI/HIV/AIDS Control Committee...... 1 Algerian Report on the monitoring ...... 1 Period covered: January 2003 – December 2005 ...... 1 TABLE OF CONTENTS...... 2 The health system in Algeria: 5 health regions, 48 wilayas and 185 health sectors ..... 6 Table of indicators used for Algeria’s report on the monitoring of the Declaration of Commitment ...... 7 of the United Nations General Assembly Special Session on HIV/AIDS (UNGASS, 2001) in December 2005...... 7 2 – Overview of the HIV epidemic...... 11 3- National response to the AIDS epidemic ...... 22 5 – Support required from development partners in the country ...... 32 6 – Monitoring and Evaluation Framework ...... 37 The Multisectoral Monitoring and Evaluation unit ...... 38 Status of the monitoring and evaluation activities at the end of 2005 ...... 39 The growing under-reporting of HIV/AIDS in Algeria: the need for a uniform system ...... 41 Access to computerised databases for epidemiological surveillance and other surveys ...... 42 Bibliography...... 43 TEAM...... 48 METHODOLOGY...... 49 I – Strategic level...... 69 II – Political support...... 70 III – Prevention...... 70 IV – Treatment and support ...... 71 V – Monitoring - evaluation...... 72 I – Individual freedoms ...... 81 II – Participation of civil society...... 82 III– Prevention...... 82 IV– Treatment and support ...... 82

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APPENDIX 1: Process of consultation/ preparation for the national monitoring report on the Declaration of Commitment on HIV/AIDS APPENDIX 2: Questionnaire concerning the Composite Index for National Policies APPENDIX 3: National declaration forms for indicators relating to programmes, knowledge, behaviours and impacts

3 1 – Brief assessment of the situation

The available information shows that HIV infection in Algeria continues to spread, especially through unprotected sex. Injecting drug use, highlighted by the survey of knowledge and behaviours that was carried out in the north of the country in 2004, also represents a not insignificant method of contamination. The reporting data for HIV/AIDS concerning STI/HIV seroprevalence, in addition to the surveillance of knowledge and behaviour, indicate that Algeria is probably experiencing an epidemic that is concentrated in the highest risk population groups and within certain geographical regions, with the potential for a deterioration of the epidemiological situation unless precisely targeted and rigorous measures are implemented in response to the problems. Furthermore, all of the determinants required for infection to occur exist within the country and could trigger an epidemic process (Sex trade, sexually transmitted infections (STIs), mobility-migration, etc.).

A significant number of knowledge and behaviour surveys have been conducted in Algeria. However, very few of them have produced data enabling a comparison of the trends for knowledge and behaviour to be made over time and space, because they have not been conducted using a standardised methodology. Standardisation is also important, both for the serosurveillance of HIV infection via the sentinel network and the actions involved in the monitoring of interventions. The first disbursements from the Global Fund’s HIV Project in 2005 provide the opportunity to bolster the monitoring of the STI/HIV/AIDS control programme. All of the optimised and unified human resources must be used for the programme’s monitoring and evaluation activities. Biological surveillance and “risk surveillance” (STIs and behaviours) on the one hand, and the monitoring of the implementation of the programmes on the other, will not be successfully integrated unless data collection and analysis methods are standardised.

The analysis of resource and results indicators gathered from different government sectors and civil society organisations (NGOs) shows that in 2005, there was a significant increase in the speed of implementation of the response to the epidemic, thanks to the arrival of the first payments from the Global Fund. For certain sectors, such as Religious Affairs, Justice, Health, National Defence and Higher Education, along with civil society organisations, the increase observed in 2005 is a result of efforts committed over a period of several years. For other departments, 2005 marked the (new) beginning or the significant intensification of their interventions. The improvements observed can be illustrated by several encouraging figures:

- In 2005, 575 patients in advanced stages of the illness had access to an anti-retroviral treatment, in the health sector’s six reference treatment centres set up in 2001 in addition to those of the national defence sector. - Whilst the number of blood donations has continued to grow (from 174,405 donations in 1994 to 299,115 donations in 2003), the percentage of HIV-positive donations has fallen on a yearly basis, reaching the low and stable level of 0.01%. - In 2002, 99% of the 3,268 young, single people between the ages of 15 and 29 that were interviewed recognised that sex was a source of HIV contamination. - In 2005, 183 female sex workers were given prevention kits and 749 such workers in 12 wilayas (provinces) received awareness training to allow them to participate in a behavioural survey. - In 2005, 400 peer educators received awareness training on HIV prevention in prisons.

In 2006, in order to improve the impact of the resources used for controlling the illness, it will be necessary to invest in human and material resources, both of which are needed to integrate

4 monitoring and evaluation activities into the planning and implementation of routine interventions. In this way, it will be possible to make strategic decisions concerning the more accurate targeting of interventions in the areas where they will have the greatest possible impact.

The future challenges in the fight against STI/HIV/AIDS are underlined by the following data, derived from different surveys:

- 41% of injecting drug users have shared injecting equipment, according to a survey carried out in 2004 on the knowledge of problematic drug users (which included 50% of injecting drug users amongst the 285 participants). - In 2004, 65% of drug addicts did not know that the use of condoms can reduce the risk of HIV transmission. - In 2004, 44% of drug addicts acknowledged that they had had remunerated sex. - 15% of the drug addicts interviewed in 2004 had access to HIV counselling and screening. - When interviewed in 2004, 11% (5/45) of the drug addicts who had access to testing, declared that they were HIV-positive. - 19% (5/26) of the injecting drug users used safe injecting practices and had risk-free sexual behaviours. - 68% of the young soldiers interviewed in 1999 did not know that HIV transmission can be reduced by using condoms. - 71% of people with Sub-Saharan origins living in Tamanrasset in 2004 were unaware of the methods of preventing HIV infection. - The majority of HIV infections in Tamanrasset are detected within this non-native population

When compared to certain global objectives for 2007, namely…

- condoms to be available for 40% of high-risk sexual encounters; - 60% of female sex workers to have access to prevention programmes each year; - 50% of people in groups with risk behaviours to use counselling and the voluntary HIV test; - 75% of symptomatic STIs to be treated for patients with access to health-care structures;

… the data presented in this report for Algeria highlights the shortfalls illustrated by the available information. In order to have a genuine impact on the epidemic, there must be an urgent implementation of appropriate strategies in the field, in accordance with international recommendations (1, 2, 3).

Of all the North African countries, Algeria currently seems to be the hardest hit by the HIV/AIDS epidemic. As demonstrated by its international commitments in the fight against STIs/HIV/AIDS (African Union Summit on AIDS, Tuberculosis and Malaria [Abuja, 2001] and the United Nations General Assembly Special Session on HIV/AIDS [New York, 2001] on the one hand, and its international commitments (Commemoration of World AIDS Day

5 each year and the Regional Conference of People Living with HIV/AIDS in Algiers, 2005) on the other, in addition to the various successes of recent years, our country has shown that it is capable of implementing actions which can make a positive impact on the disease, thus helping to control STIs/HIV/AIDS. Taken as a whole, the various interventions in the different sectors and fields have had a considerable impact. The next stage in the response calls for the interventions to be more carefully targeted at the specific groups and in regions where the risks of transmission and the needs for care and treatments are the greatest, and where the available resources will have the maximum impact

For this stage, the setting up of a standardised and effective monitoring and evaluation system, the regular analysis of data collected from different sources and the triangulation of data during the analysis, along with the regular exchange of up-to-date knowledge, will certainly act as a catalyst and speed up progress in this field.

The health system in Algeria: 5 health regions, 48 wilayas and 185 health sectors

The health regions are: - Central Health Region (principal town: Algiers), grouping together 11 wilayas (“provinces”): Bejaia, Blida, Bouira, Tizi Ouzou, Algiers, Djelfa, Médéa, Bordj-Bou- Arriredj, Boumerdes, Tipaza and Ain Defla. - Western Health Region (principal town: Oran) consisting of 11 wilayas: Chlef, Tlemcen, Tiaret, Saida, Sidi Bel Abbes, Mostaganem, Mascara, Oran, Tissemsilt, Ain Temouchent and Relizane. - Eastern Health Region (principal town: Constantine) consisting of 14 wilayas: Oum El Bouaghi, Batna, Tébessa, Jijel, Setif, Skikda, Annaba, Guelma, Constantine, M’Sila, El Tarf, Khenchella, Soukh Ahras and Mila. - South-eastern Health Region (principal town: Ouargla) consisting of 7 wilayas: Biskra, Bechar, Tamanrasset, Ouargla, Illizi, El Oued, and Ghardaia. - South-western Health Region (principal town: Béchar) consisting of 5 wilayas: Adrar, Béchar, El Bayadh, Naama and Tindouf.

At the end of the year 2001, there were 185 health sectors in the 48 wilayas, each one covering a population of between 100,000 and 200,000 inhabitants. Each health sector is equipped with an Epidemiology and Preventive Medicine Department (Service d’Épidémiologie et de Médecine Préventive [SEMEP]) responsible for collecting epidemiological information about reportable diseases including STIs and for evaluating the health sector’s National Programmes. HIV/AIDS are subject to a specific system of reporting, in accordance with the Ministry of Public Health and Hospital Reform (Ministère de la Santé de la Population et de la Réforme Hospitalière [MSPRH]) Circular of 1990. Within each health region, the Regional Health Observatories (Observatoires Régionaux de la Santé), with their relatively small budget allocation, operate as the decentralised bodies of the National Institute of Public Health (Institut National de Santé Publique), which is itself responsible for providing epidemiological surveillance at the national level, shown in the Monthly Epidemiological Summary (Relevé Épidémiologique Mensuel). According to data provided by the National Statistics Office (Office National des Statistiques), the infant mortality rate in the 6 wilayas bordering the Sahara (in the south of the country) is higher than the Algerian average (34.97 per 100,000). The highest rate is found in the wilaya of Tamanrasset (48.83 per 100,000).

6 Table of indicators used for Algeria’s report on the monitoring of the Declaration of Commitment of the United Nations General Assembly Special Session on HIV/AIDS (UNGASS, 2001) in December 2005

Standard UNGASS indicators recommended for C/LPE countries 11,130,000 USD, (including 6,740,000 USD for the government’s contribution, National funding allocated to the HIV and AIDS C/LPE: 2,500,000 USD for the Global Fund’s HIV Project, response. (Total amount of national funding Ind. 1 950,000 USD for bi-lateral cooperation, committed by the government in 2005) 840,000 USD for the United Nations, and 100,000 USD for civil society organisations). C/LPE: National policies concerning HIV and AIDS See Appendix II Ind. 2 (Composite policy index) Drug addicts: 15% Female sex workers: unknown (to verify with sex workers in the qualitative C/LPE: HIV screening amongst the highest risk survey) ** Ind. 3 populations over the past 12 months Prison population: 3.2% of the 47,000 new inmates (127 institutions) per month Uniformed services (soldiers, police): unknown C/LPE: Prevention programmes aimed at the highest risk groups Ind. 4 1. Local education and peer education Female sex workers: 183 (have received prevention kits) & 749 in 12 of the 48 wilayas (educated for survey) Female sex workers, drug addicts, MSM: 3,158 (educated about HIV screening) Prison population: 400 peer educators trained (127 institutions) Uniformed services (soldiers, police): unknown Young people between 15 and 24 years: approximately 300 in 15 of the 48 wilayas Unspecified population: 31,100 (educated in use of condoms) 2. Access to targeted mass media Prison population: approximately 70% [30,000 leaflets & 10,000 posters & 35 videocassettes, one for each major detention centre] Young soldiers: AIDS information: 77% via television, 48% via newspapers, 42%

via the radio and 30% via information days Young, single people between the ages of 15 and 29 years: AIDS information: 92% via television, 25% via radio, 33% via newspapers and magazines, 30%

7 via friends/family, 29% via educational establishments (23% for boys, 37% for girls), 3% via mosques (5% for boys, 0.4% for girls) Unspecified population: 85,000 (printed materials) Unspecified population: in 2005, 1346 people used a free telephone helpline for information on HIV/AIDS (organised by SIDA INFO Service since 2003), 196 of whom (15%) called for information about screening General population: 17 million people attend 17 million mosques, led by 17,000 imams 3. Access to screening and/or treatment of Unknown (to verify with sex workers in the qualitative survey) sexually transmissible infections Non-single women aged between 15 and 49 years: 75% in total (63% doctor, 9% nurse or midwife, 3% pharmacist, 1% traditional healer, 2% self-medication) 4. Access to HIV counselling and screening Drug addicts: 15% (have used HIV screening in the course of the last 12 months) Female sex workers: unknown (to verify with sex workers in the qualitative survey) Prison population: 3.2% of the 47,000 new inmates (127 institutions) per month Uniformed services (soldiers, police) : (unknown) 5. Access to substitute treatments and risk-free Injecting drug users who use the Intermediate Treatment Centre for Drug Addicts

injecting practices (for IDUs) (Centre intermédiaire de soins pour toxicomanes [CIST]): 26 (December 2005) 6. Access to at least one HIV prevention unknown (to verify with sex workers in the qualitative survey) programme during the past 12 months C/LPE: Knowledge of HIV prevention within the highest See supplementary indicator A: Ind. 5b Ind. 5 risk groups C/LPE: Problematic drug users (44% of whom have indicated having had remunerated Condom use by sex workers Ind. 6 sex): 39 % (48% Algiers, 40% Annaba, 28% Oran) C/LPE: Risk-free injecting practices and sexual Injecting drug users: 5 [19%] out of 26 people questioned Ind. 8 behaviour in injecting drug users & See supplementary indicator A: Ind. 8b C/LPE: Reduction of HIV prevalence in the highest risk Drug addicts: 5 [11%] out of 45 people questioned (5 [31%] out of 16 in Algiers) in Ind. 9 groups 2004 * Sex workers: 3.8% in 5 towns (9% in Tamanrasset) in 2004 2.9% in 2 towns in 2000 1% in 2 other towns en 1988 2.9% in 2 other towns in 1984

8 STI patients: 1.2% in 4 towns in 2004 0.25% in 4 towns in 2000 0.25% in 2 other towns in 1984

* People interviewed who have not had HIV screening during a behavioural survey, but who were asked to give the result of their HIV screening, if available. ** The reporting of the results of the 2005 qualitative survey of female sex workers in three towns (Algiers, Oran and Tamanrasset) is planned for January 2006.

Modified (A)/ supplementary indicators A: Ind. 4b Prevention programmes aimed at the highest risk populations: - having undergone at least one detoxification treatment Drug addicts: 36% (28% Algiers, 53% Annaba, 27% Oran) in 2004 - benefiting from therapeutic education, People living with HIV and AIDS and undergoing treatment: approximately 10% in 2005 A: Ind. 5b Knowledge of HIV prevention within highest risk groups: - correct response for reduction of risk of transmission through sex with one faithful, Drug addicts: 21% (13% Algiers, 20% Annaba, and 29% Oran) in 2004 uninfected partner - correct response for reduction of risk of Drug addicts: 35 % (46% Algiers, 28% Annaba, and 31% Oran) in 2004 transmission through use of condoms Young soldiers: 32% in 1999 (* young, single 15-29 year-olds & non-single Young single people aged between 15 and 29: 8% of a national sample, in 2002 women between 15 and 49 years: those who Young 15-30 year-olds: 14% (20% from the north and 6% from the south, 5 indicated that a person can catch AIDS by not wilayas, in 2002 & 36% (49% from the north and 9% from the south), 3 wilayas, in using a condom) 1998-99 (* young 15-30year-olds: those who mentioned Non-single women between 15 and 49 years: 25% of a national sample, in 2002 the condom as a method of protection) - Response: those who mentioned abstinence as Young 15-30 year-olds: 42% (37% from the north and 48% from the south), 5 a method of reducing the risk of transmission wilayas, in 2002 & 39% (36% from the north and 43% from the south), 3 wilayas, in 1998-99. - Affirmative response to “know the methods for Young 16-20 year-old people in school system: 62% (Algiers, in 2000)

9 preventing HIV infection” People with Sub-Saharan origins (living in Tamanrasset): 29% in 2004 A: Ind. 8b Risk-free injecting practices and sexual behaviour in problematic drug users (also including IDUs) 1. who practise drug injection 50% of problematic drug users (PDU, which includes IDUs) 2. who have never shared injecting equipment 59% of injecting drug users (IDU) 3. who have sex 85% of PDUs (95% Algiers, 78% Annaba, 84% Oran) 4. who use condoms during sex 39% of PDUs (48% Algiers, 40% Annaba, 28% Oran) A: HIV treatment: number of patients undergoing 575 people undergoing ARV treatment, in 7 reference treatment centres Ind. 16b antiretroviral treatment, 1st October 2005

Other UNGASS supplementary indicators (not recommended for C/LPE countries) GE: Blood safety Ind. 9 (Percentage of transfused blood unit having 99.1% in Algeria (94.7% in the South-eastern Health Region) in 2000 undergone HIV screening) GE: HIV treatments: survival after 12 months for Ind. 16 patients undergoing antiretroviral treatment Survival after 12 months under antiretroviral treatment (Minimal): 71% (percentage of adults and children infected by (data from 3 reference treatment centres out of the 7) HIV still alive and undergoing antiretroviral treatment 12 months after the start of treatment.)

Standard UNGASS indicators not measured C/LPE: Condom use by men having sex with men Not measured Ind. 7

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2 – Overview of the HIV epidemic

The available information shows that HIV infection has continued to spread within Algeria since the detection of the first case in December 1985. The majority of the infections are due to unprotected sex, although injecting drug use is becoming an increasingly important factor. With the advent of systematic HIV screening for blood donors, blood-borne transmission has been virtually eradicated, to such an extent that sexual transmission (sexual contact with infected people) and syringe-borne transmission (for users of intravenous drugs) alone are responsible for maintaining the levels of infection. Taking account of the epidemiological data available up to 2004, the three countries of the Maghreb (Algeria, Morocco and Tunisia) have been ranked in the group of countries with a relatively low epidemic level. The prevalence of HIV infection in these three countries was estimated at between 0.01% and 0.10% by the WHO/UNAIDS organisations at the end of 2003 (4).

The epidemiological data for Algeria contained within this report, based on serological surveillance carried out via the sentinel network and specific surveys, support the arguments in favour reviewing the classification of the epidemic in Algeria.

Prevalence of HIV infection in the highest risk population groups

Nearly 3% of all female sex workers screened at the different sites in 2000, and 4% in 2004, (Tables 1 and 2) tested positive for HIV in the framework of sentinel serosurveillance surveys (5, 6).

Table 1: Prevalence rate of HIV infection per site and per study group. (Source: Serosurveillance Survey of 2000)

Wilayas/Sites Pregnant women STIs Female sex workers Total

Risk-free High risk Very high risk

No. + % No. + % No. + %

Tamanrasset 455 4 0.88 79 1 1.26 22 2 9.09 556 Constantine 156 0 156 Mustapha 462 0 0 52 0 514 University Hospital Maillot 216 0 06 0 222 Tizi-Ouzou 400 0 0 400 HCA 250 0 0 250 Oran 451 0 0 250 1 0.40 117 2 1.70 818 Total 1984 4 0.20 793 2 0.25 139 4 2.87 2916

However, the seropositivity within this population is unevenly distributed throughout the whole of Algeria. A seroprevalence of 9% was found amongst female sex workers interviewed in Tamanrasset, the only southern sentinel site in the first survey, in both 2000

11 and 2004. In the northern town of Oran, a seroprevalence of 1.7% was found in 2000. The two HIV-positive women screened in 2000 are included amongst the 22 clandestine female sex workers included in the group of 117 women screened.

The absence of HIV-positive results in Oran in 2004 can be explained by the fact that the sex workers screened were cared for at the public health centre (Centre de salubrité publique). A prevalence of 10% was found in the same group in the wilaya of Saida (in Orania). Algeria seems to have the highest percentage of HIV-infected female sex workers in the Maghreb.

Table 2: Prevalence rate of HIV infection per site and per study group. (Source: National Sentinel Serosurveillance Survey, 2004)

Wilayas/Sites Pregnant women STIs Female sex workers Total

Risk-free High risk Very high risk

No. + % No. + % No. + %

Tamanrasset 718 5 0.70 325 5 1.24 70 6 8.57 1113 Mustapha 560 0 0 560 University Hospital Tizi-Ouzou 550 0 0 16 1 6.25 566 Oran 400 1 0.25 250 2 0.80 45 0 695 Saida 646 0 0 10 1 10 656 Sétif 500 0 0 500 Sidi Bel Abbes 505 1 0.20 16 0 0 521 Skikda 600 0 0 44 0 0 644 Reggane 223 0 0 168 1 0.60 391 Adrar 410 0 0 410 Total 5112 7 0.14 759 9 1.19 185 7 3.78 6056

In the north of the country, a survey of the knowledge of problematic drug users (in which 50% of the 285 participants were injecting drug users) revealed that 5 out of the 45 people interviewed in Algiers (11%), who had access to screening, confirmed that they were infected by HIV (7). The 2004 survey had few participants, even fewer of whom had access to screening (45 out of 285, and all in the north of the country). Due to the absence of participants in the south of the country, it is not possible to suggest a rate of HIV prevalence at the national level for this group of people who are most at risk. Other sources of error result from the sampling methodology used and the absence of biological testing during the survey. This same survey illustrated the link between problematic drug use (PDU), remunerated sex (44% of PDUs interviewed) and unprotected sex (61%). Injecting drug use has increased in several countries in the Middle East and North Africa. It has been the source of significant HIV/AIDS epidemics in Libya and Iran (8).

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Thus, if the aforementioned data were to be confirmed by sentinel surveillance surveys on a larger scale, Algeria would probably be considered to form part of the group of countries with a concentrated HIV/AIDS epidemic. In fact, the infrastructure for epidemiological surveillance via the sentinel sites is currently incapable of providing a definitive assessment of the status of the epidemic within the country. The next stage involves using data validation surveys to confirm the high rates of prevalence in the two highest-risk population groups (female sex workers and injecting drug users). These high rates of prevalence have been detected firstly through the 2000 and 2004 sentinel serosurveillance surveys and secondly through the results of the drug addiction survey.

Prevalence of HIV infection within lower-risk populations

An understanding of HIV seroprevalence in the general Algerian population can be gained from the results of the HIV screening of blood donations, tuberculosis patients and women attending prenatal care departments.

The monitoring of HIV in blood donations is a general indication of the level of infection within the general population. However the selection of donors represents a source of error. The prevalence of HIV in blood donations remained relatively stable between 1994 and 1998 (between 0.01% and 0.02%). In 2000, a relatively high prevalence of 0.08% was observed, dropping back to 0.01% in 2002 and 2004 (9).

Between 1984 and 2002, between 0.2% and 0.3% of tuberculosis patients were HIV-positive (10).

During the course of the past ten (twenty?) years (from 1984 to 2004, and for five consecutive surveys), the average rate of HIV prevalence appears to be low, 0.1% - 0.2% for women attending prenatal care departments, apart from in 1984, when the prevalence was 0.4% in five unidentified healthcare facilities (5, 6, 11). The seroprevalence rates studied in the group of pregnant women were not collected from the same sites from one year to the next (see table for indicator 9 in Appendix 3), which makes it impossible to determine how the prevalence trend is evolving.

The Tamanrasset wilaya (the only sentinel site for the south of the country in the 2000 survey), which shows the highest prevalence rate amongst female sex workers, also has the highest seropositivity rate for pregnant women out of all of the sentinel sites (0.7% in 2004 and 0.9% in 2000), confirming the magnitude of the epidemic in the wilaya.

In 2000, there were no cases of seropositivity for women tested in the prenatal care departments of the three northern towns which participated in the seroprevalence survey (Algiers, Oran and Tizi-Ouzou). On the other hand, two pregnant women were found to be HIV-positive in two northern towns in 2004: one in Oran and the other in Sidi bel-Abbes. This new information shall be studied in more detail in the framework of the subsequent data validation and sentinel serosurveillance surveys.

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HIV/AIDS reporting and variability at the genomic level

The results of the sentinel serosurveillance survey are backed up by the findings of surveillance based on HIV/AIDS reporting. The primary approach to epidemiological surveillance in Algeria has consisted of incorporating the reporting of AIDS and HIV cases into the existing system for the routine reporting of contagious diseases. HIV/AIDS has been a reportable disease in Algeria since 1990. In addition to the inadequate level of HIV screening, under-reporting is another reason why the data emerging from the reporting fails to represent the total number of HIV-infected people or AIDS sufferers. For several years now, several University Hospitals (Centres Hospitalo-Universitaires [CHU]) have been confirming Western-blot HIV cases at their own level, thus failing to notify the National Reference Laboratory (Laboratoire national de référence [LNR]), which, according the current regulations, is the only authority qualified to carry out the confirmation and reporting (see Section 6 “Monitoring and evaluation framework”). Although it is subject to numerous sources of error, basing the epidemiological situation on the reporting nevertheless allows us to understand certain trends (Table 3). The total number of AIDS cases, confirmed by the National Reference Laboratory (LNR) between 1985 and 2005, reached 700 cases, including 58 new cases in 2005. Around 50 new AIDS cases are detected each year. Local heterosexual transmission has dominated the epidemiological landscape over recent years, in contrast to the early years when people were primarily contaminated by blood-borne transmission (drug addiction or blood transfusion) abroad. The primary transmission route is sexual, accounting for nearly half (45.71 %) of all modes of transmission, a figure which is constantly rising. Analysis of AIDS cases according to the place and mode of contamination shows that the local cases result essentially from heterosexual transmission and that women are increasingly infected by the sexual route when compared to men (57.67% against 40.50%). By analysing AIDS cases according to their geographical distribution, it can be seen that certain wilayas are at risk due to high numbers of citizens living abroad whose wives are often infected (Béjaia, Sétif, Tizi-Ouzou, etc.). Furthermore, the wilaya of Tamanrasset shows the highest average annual incidence, thus making it a veritable breeding ground for the virus.

Table 3: Breakdown of the total number of AIDS cases up to 30th December 2005, according to the mode of contamination. (Source: LNR –IPA -Sidi-Ferruch) Modes of Male Female Unspecified Total % contamination Heterosexuality 194 124 2 320 45.71

Homo and bisexuality 33 0 0 33 4.71 Drug addiction 89 5 0 94 13.43

Blood and blood by- 27 21 1 49 7.00 products Mother-child 7 8 0 16 2.29 Other known modes 1 3 0 2 0.29 Unspecified 128 54 3 186 26.57 Total 479 215 6 700 100

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2 Up to 31st December 2005, the total number of confirmed HIV-positive cases since 1985 stood at 1908, including 187 new cases during the year 2005. In 2004, Algeria reported a 67% increase in new cases of HIV infection (i.e. 266 HIV-positive cases) compared to the previous year (12). There are approximately just over 150 new HIV-positive cases each year. The number of HIV-positive cases is greatly underestimated (passive screening, most frequently for blood donors, and the results of a few isolated surveys carried out on groups with risk behaviours at the beginning of the epidemic). For 71.96% (1373 out of 1908) of the total number of HIV-positive cases reported up to 31st December 2005, the mode of contamination was unknown. The sexual route represents the primary mode of transmission and the sex ratio has dropped significantly, falling from 5.1 at the beginning of the epidemic to 1.01 in 2004, with the infection affecting both sexes in equal proportions. Most of the people infected by HIV are young (32% are under 30 years of age). The wilaya of Tamanrasset (South-eastern Health Region, 163,000 inhabitants in 2005) is the most severely affected by the HIV epidemic, with an incidence of 1.19 ‰ of HIV-positive cases reported, followed by Oran (0.18 ‰, Eastern Health Region, 1,344,000 inhabitants), Saida (0.15 ‰, Eastern Health Region, 310,000 inhabitants) and Algiers (0.13 ‰, Central Health Region, 2,810,000 inhabitants). Cases of HIV infection have been declared in 47 of the country’s 48 wilayas. The wilaya of Mila is the only one not to have reported any cases. The results of the reporting

In Algeria, HIV1 is the most commonly-found strain. However, around ten cases of HIV2 or mixed HIV1 – HIV2 infections have been reported within non-native populations in the south of the country. Out of the 17 sub-types discovered, sub-type B predominates in the north of Algeria. Sub-type C (seen most frequently in Sub-Saharan Africa) has been isolated in the south. In total, five different sub-types have been isolated in the samples taken in the wilaya of Tamanrasset (13).

Although the epidemiological situation cannot yet be described as alarming, an examination of certain epidemiological indices shows that an epidemic explosion cannot be ruled out. The predominance of the heterosexual mode of contamination in recent years, the emergence of local transmission, the increasing number of HIV-positive women, defective intra-hospital hygiene (around 15 new HIV-positive cases in the wilaya of Saida were caused by hemodialysis) and the epidemic in the wilaya of Tamanrasset, a point of convergence for the most infected areas, are all parameters which must not be ignored.

At the quantitative level, the data tend to underestimate the actual situation, due to the highly irregular collection system. The lack of a consistent and regular data collection system for the reporting of HIV/AIDS, combined with the absence of second generation surveillance studies, act as a genuine obstacle to improving knowledge of the epidemiological situation. This remains an essential requirement.

The HIV/AIDS reporting data, both for sexually transmitted infections and from knowledge and behaviour surveys, show trends that may support the hypothesis of an epidemic that is concentrated in certain population groups and within some of the highest-risk geographical regions of Algeria.

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Sexually transmitted infections: prevalence, reporting and treatment

According to Naim et al. in 2005, a survey of soldiers revealed a higher prevalence of urethritis in the south (7.95 ‰ in the Tamanrasset barracks) than in the north of the country (4.05 ‰, in Algiers and Oran). The prevalence of gonococcic urethritis was also higher in the south (2.11 ‰ in Tamanrasset) than in the north (0.83 ‰).

The geographical distribution of the prevalence of STIs is confirmed by HIV surveillance via the sentinel network (Tables 1 and 2). A prevalence of 1.26% of HIV-positive cases amongst patients being treated for STIs was noted in Tamanrasset in 2000, rising to 1.24% in 2004. This is higher than for other sentinel sites, which report a prevalence of below 1%, not including the wilaya of Tizi-Ouzou, whose prevalence cannot be considered, due to the small number of cases screened (5, 6).

In 2004, this same surveillance network also detected a higher prevalence of syphilis (diagnosis with TPHA+) amongst women attending prenatal care departments in Tamanrasset (3.6%) than in the eight other sentinel sites, underlining the significance of STIs in Algeria, especially in the south (Table 4).

Table 4: Syphilis prevalence rate per site and per study group. (Source: National 2004 Serosurveillance Survey)

Wilayas/Sites Pregnant women STIs Female sex workers Total

Risk-free High risk Very high risk

No. TPHA % No. TPHA % No. TPHA % + + +

Tamanrasset 718 26 3.62 325 10 3.07 70 6 8.57 1113 Mustapha 560 0 0 560 University Hospital Tizi-Ouzou 550 1 0.18 16 0 0 566 Oran 400 4 1.00 250 2 1.20 45 5 11.11 695 Saida 646 5 0.77 10 2 20 656 Sétif 500 6 1.20 500 Sidi Bel Abbes 505 2 0.40 16 5 31.25 521 Skikda 600 0 0 44 4 9.09 644 Reggane 223 1 0.45 168 6 3.57 391 Adrar 410 0 0 410 Total 5112 45 0.88 759 18 2.37 185 22 11.89 6056

16 In 2002, a national family health survey measured self-declared STIs: 1.3% of the non-single, 15 to 49 year-old women interviewed mentioned that they had suffered from mycosis, 0.4% from gonorrhoea and 0.1% from other types of sexually transmitted illnesses, though syphilis was not reported (14). The average annual incidence of reported gonococcal disease (syndromic diagnosis) is 2.44 p. 100 000, according to the system of declaration in force. STIs are greatly under-declared in Algeria, as in the majority of other countries. Between 1990 and 1995, 22% of STIs reported at the national level originated in the 12 wilayas to the south of the country (7 % syphilis and 30 % gonococcal disease) (15). According to the results of a survey carried out in Morocco, 40% of the STI cases reported affected young people between the ages of 15 and 29 (16).

It is currently estimated that over 60% of the strains of gonoccocal disease prevalent in Algeria are resistant to several courses of antibiotic treatment. Self-medication may be widespread within certain groups, according to preliminary information from a pilot survey of the pharmacies of Algiers and Tizi-Ouzou. On the other hand, non-single women between 15 and 49 years of age often seek treatment for a sexually transmitted illness: in total, 75% of sufferers over the past 12 months did so, including 63% who consulted a doctor, 9% a nurse or midwife, 3% a pharmacist and 1% a traditional healer. 2% treated themselves without any medical advice (14).

In conclusion, the incidence of STIs (including HIV) has been rising rapidly for around ten years, especially in the south of the country. However, measuring the current status of this epidemic calls for more recent standardised surveillance surveys. Sexually transmitted infections, a co-factor in HIV infection, represent a genuine public health problem that is currently excluded from the reporting-based surveillance system, since patients prefer to be treated in the private sector, which is not covered by this surveillance. Sexually transmitted infections are under-declared and there are insufficient resources for diagnosis and treatment.

Triangulation of data (STI/HIV prevalence, knowledge and behaviour studies)

Two structural elements shall contribute to any acceleration of the spreading of the epidemic: an unfavourable socio-economic environment which favours the emergence of risk behaviours amongst population groups in vulnerable positions on the one hand, and the geographical position of Algeria at the interface between two particularly hard-hit continents, on the other (Mediterranean Europe to the north and Sub-Saharan Africa to the south).

The results of many surveys evaluating HIV/AIDS-related knowledge and behaviours can be used to help target the different interventions. Thus, for example, a survey performed in 2002 on a national sample reveals that 92% of young, single people aged between 15 and 29 years of age receive information about AIDS from the television, 25% from the radio, 33% from newspapers and magazines, 30% from friends/parents, 29% from schools (23% boys and 37% girls), and 3% from mosques (5% boys, 0.4% girls) (14). Another survey, carried out by the National Foundation for Health Promotion and Development (Fondation Nationale pour la Promotion et le Développement de la Santé) [FOREM]), showed there to be significant levels of soft drug use amongst young people in schools (40% of the 1544 high school pupils interviewed used drugs on a daily basis and in their school environments). It is appropriate to note that the lack of standardised survey methods at these same sites prevents us from making comparisons of the evolution of knowledge and behaviour over time and space. Algeria is affected by an HIV epidemic which is mainly spreading through unprotected sex, especially in the south of the country. The intravenous injection of drugs seems to be

17 becoming an increasingly important factor, even if certain indices seem to show that the majority of these infections were acquired abroad. Nevertheless, HIV seroprevalence data and information about knowledge and behaviour show that there is a significant risk of transmission by this route in this country, regardless of where the contamination occurred, because there is the very real danger of it being introduced into the general population. Male and female sex workers, the uniformed services (army and police) and migrants are other population groups which seem to be particularly vulnerable.

Chart: Links between populations at risk from the transmission of HIV [source : Studies of HIV Seroprevalence in Algeria in 2000 & 2004 (from T. Brown)] 0- 9

Sex workers

Customers MSM IDUs .

Men at low or 0 -3 medium risk 1

Men and women at low or medium risk 0 - 0.9

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Supplementary data for the epidemic in the wilaya of Tamanrasset

The wilaya of Tamanrasset is home to 100,000 inhabitants, including around 30,000 refugees, the majority of whom come from the Sahel and other African countries: Mali, Niger, Mauritania, Chad, Burkina-Faso and Senegal. In total, more than 40 nationalities live side-by- side in the wilaya, with a sizeable Malian, Nigerian, Ghanaian and Algerian clandestine sex trade network. Algeria’s extensive sex trade is clandestine and multi-faceted, posing the problem of nucleus groups transmitting and spreading the infection. The wilaya of Tamanrasset and the other at-risk wilayas in contact with the national and international migrations pose problems caused by the triumvirate of migration, the sex trade and HIV/AIDS. Many of the people with an HIV infection in Tamanrasset are non-autochthonous (Table 5). The autochthonous Algerians who tested HIV-positive between 1992 and 1999 came from 24 different wilayas. Table 5: Breakdown of nationalities amongst people testing HIV-positive in 2000, Tamanrasset Laboratory, (note: these figures could include some false positive tests, as the results of the confirmation tests are not always known.)

Men Women Total Algeria 16 13 29 Niger 5 4 9 Mali 5 1 6 Ghana 2 1 3 Nigeria 1 1 2 Guinea 1 1 2 Senegal 1 1 2 Burkina Faso 1 - 1 Central African Rep. - 1 1 Congo 1 - 1 Benin 1 - 1 Unspecified foreigners 1 3 4 Total 35 26 61

The clear relationship between migration and HIV/AIDS in the town of Tamanrasset is shown by the fact that 52.45% of the reported cases of HIV infection shown in Table 5 were mobile people originating from Sub-Saharan Africa. The impact of the infection in Tamanrasset illustrates its uneven geographical distribution within the country and confirms the town’s vulnerability due to its location on the border with Sub-Saharan Africa.

The correlation between internal mobility and HIV/AIDS is explained by the close relationships that exist between the different groups involved in this movement. In fact, mobile people in Algeria belong to different categories: the cross-border population represented mainly by the Touareg who are constantly on the move, the working population originating from the north of the country, transporters who may or may not be involved in the grey market, soldiers, and finally, the female sex workers who often come from towns in the north of the country. This last group is a not insignificant source of the expansion of the HIV-AIDS epidemic between all of the different groups of mobile people in Algeria. Many autochthonous women and those originally from Sub- Saharan Africa ply their trade in places frequented by both young autochthonous adults and migrants. What is more, a mixed HIV1-HIV2 infection was detected in a female sex worker in Tamanrasset during the sentinel surveillance of 2004.

19

At the behaviour and knowledge level, a survey has shown that between 2001 and 2004, the percentage of young people at school in Tamanrasset who identified a relationship between drugs and AIDS increased from 63% to 83% (17). Although many other behaviour and knowledge evaluation surveys have been carried out in Algeria, they do not allow comparisons to be made over time, either because the sites participating in the surveys were changed or because the standardised sampling methodology was not observed in a consistent fashion. In 2004, a pilot survey revealed a significant lack of knowledge amongst people originating from Sub-Saharan Africa and living in Tamanrasset: only 29% of the 68 participants seemed to know the methods of preventing HIV infection (18).

20

Chart: Distribution of Health Regions and Sentinel Sites for the epidemiological surveillance of HIV in Algeria (operating in 1998, 2000 and 2004).

Health Regions 1998, 2000, 2004 Western Central 2004 Eastern South-western 2000 South-eastern

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3- National response to the AIDS epidemic

Governmental response

Algeria has endorsed all international AIDS commitments. Its national commitment involved implementing a coherent HIV/AIDS/STIs policy which goes hand in hand with the Algerian government’s political commitment to implement a decentralized health system, illustrated by the National HIV/AIDS/STIs Programme. It involves all the strategic measures, resources and structures the country implemented to stem the increase of these diseases, including HIV/AIDS/STIs, in the framework of the current health-care policy. The Regional Conference on people living with HIV (PLHIV), held in Algiers in November 2005 and during which the Minister of Religious Affairs reiterated his Department’s willingness to work towards the containment of ISTs/HIV/AIDS, was yet another example in the past year of the country’s political commitment.

Ministerial sector and civil society response

Institutional players and those from local community groups improved their medical and psychosocial interventions among people affected by HIV/AIDS; this may be among nationals, and in particular the impoverished populations, or migratory people from neighbouring countries of Sub-Saharan Africa that live in Algeria. All sectors have had elements of success. Certain resources were implemented notably in the areas of care and information, education and communication. A real commitment to combat HIV/AIDS is visible. Large-scale action in favour of vulnerable target populations has been taken, especially young people, prisoners and children at school. The communications (radio, television, press) and religious sectors have become involved in the programme. One inter-sectoral organization (NAC) is in charge of coordinating the various facilitators.

The various Ministries and civil society have deployed substantially more prevention and information-education-communication (IEC) efforts in the past two years after receiving financing for the HIV project from the Global Fund as well as the usual funds from UNAIDS cosponsors. Efforts implemented by these specific sectors form a large network for the transmission of IEC messages that reach several population groups.

We will mention efforts deployed by some ministerial sectors and NGOs to point out their activities which are no longer only limited to events on World AIDS day as was customary a few years ago. However, these efforts remain fragmented and unstructured. And we will draw attention to their efforts, above all, to highlight the impact of the programmes implemented, especially on prevention, care, knowledge and behavioural change. All these efforts combined can have an impact on the behaviour of the most-at-risk and most vulnerable population groups (prison inmates, sex workers, injecting drug users, young people, etc.) as well as on the prevalence of HIV.

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Ministerial sectors

The multi-sectoral nature of the national HIV/AIDS/STIs committee is an advantage and a source of strength in the fight to combat this disease as the various Ministries (Education, Health, Religious Affairs, National Defence, Youth and Sport, Justice, Culture and Communications, Posts and Telecommunications, Transport) have a large role to play because of their involvement with at-risk populations. The Youth Ministry is in charge of prison inmates that may pose a risk to the transmission of HIV/AIDS due to the following three parameters: the young age of prisoners, overcrowded prisons and the reality of men who sometimes have sex with men (MSM The Ministry of Defence is in charge of the military especially in the garrison forces and military bases. Young people are generally a vulnerable group, and thus HIV/AIDS targets, because of their young age, the risk posed by drugs and sex work. The Ministries of Higher Instruction, Education and Religious Affairs are particularly affected by this group.

The Ministry of Justice

As regards training, 250 doctors and 230 prison psychologists received HIV/AIDS/STIs training in 2004 (100% of doctors and 100% of psychologists) during 3- to 4-day sessions where 40 to 50 doctors were grouped together throughout the year. In 2005, 90 “trainers”, out of the 480 doctors and psychologists (0.18%), were trained on HIV testing for prison inmates. As regards the promotion of screening, in 2005, awareness of HIV testing was raised among 1,500 prison inmates, in one month, out of a possible 47,000 (in one month, awareness raised among 3.19% of inmates). As regards screening, 900 inmates were tested during the year, both in 2004 and 2005, out of a turnover of 60,000 to 80,000 incoming and outgoing prisoners. As regards IEC, in 2004, 10,000 posters and 30,000 pamphlets were printed for prison inmates. The same campaign was repeated in 2005 with 10,000 posters and 25,000 pamphlets.

The Ministry of Religious Affairs

In the past years, a training module on HIV/AIDS has been added to religious leaders’ curriculum. As a result, 100% of imams received training on basic AIDS awareness-creation techniques, mainly on modes of contamination. It is necessary to mention that there are 17,000 mosques throughout the country which are frequented by 17 million citizens every Friday, the day of prayer, which constitutes a powerful network of information transmission. A sermon on HIV/AIDS contamination and prevention is organized on World AIDS Day as part of the religious position that calls for faithfulness and abstinence. This illustrates the impact such sermons could have on the population. 20,000 copies of a guide on Islam and AIDS have also been published and especially targets religious leaders. It stands to reason that the lifting, even partial, of the religious taboo is a very big victory for the development of the AIDS programme. This Ministry, in addition, has an intra-sectoral committee but has also established committees at wilaya (provincial) level in the past few years.

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Ministry of Youth and Sport

Contrary to previous years during which drug-abuse was mainly limited to soft drugs, young people are now more and more inclined to abuse hard drugs requiring the use of injections, which increase the risk of HIV transmission. Added to that is the increased use of alcohol and psychotropic drugs that encourage drug use. Through the Ministry of Youth and Sport, the government opened Youth Activities and Information Centres (CIAJ) located in the country’s 48 wilayas; each CIAJ has a health-care section where doctors and psychologist offer:

- either one-on-one consultations with users of known injected drugs - or telephone consultations through a toll-free phone number (116).

Some hospitals have detoxification centres overseen by specialist doctors, social workers and psychologists. Their main aim is detoxification and combating dependency. These centres involve the addict’s family members in the decision-making process. Ministry of Population Health and Hospital Reform The recent measures taken by the Health-care Authorities on screening and the accreditation of new regional health-care centres mean that, thanks to the support received from the Global Fund, there will be a considerable increase in the number of people who regularly receive anti-retroviral treatment and overall health-care (up to then, health-care was fully paid for by National Authorities).

The reduction of the impact of HIV/AIDS on people living with HIV (PLHIV) through therapy and biological health care was illustrated by the establishment of anonymous and free testing centres (CDAG) within seven health-care reference centres for HIV-infected people and opportunistic infections (O.I.).

The introduction of anti-retroviral treatment caused a significant decrease in the mortality rate, a considerable reduction in the frequency and seriousness of opportunistic infections as well as the number and duration of hospital admissions. Patients who used to come to hospitals for the last days of their lives are now seen to in a more beneficial setting of a “Day Hospital” where they only spend a few hours every three months. In addition, there has been an improvement in patients’ quality of life; they can now attend to their business and retain their place in society without being forced to divulge their HIV status. The Doctor-Patient relationship has furthermore improved; they see each other periodically for clinical and biological monitoring of the treatment, for the proper observance of the treatment and the adaptation thereof, if required. This relationship also applies to the prevention of HIV transmission, whether by sexual contamination or mother-to-child transmission.

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The response analysis concentrated on three risk behaviour groups at whom efforts were aimed: drug addicts, prison inmates and sex workers. A situation study showed that there was an increase in the use of various types of drugs. Intermediate care centres for drug addicts (CIST) were opened for them. In rare tolerant companies, sex workers benefit from medical cover and psychological support in the event of HIV infection. Prisoners undergo regular medical check-ups in prisons and in medical penitentiary pavilions linked to some hospitals.

Civil society

In the past few years, civil society has played an important role in national programmes in spite of its belated involvement. Several theme group NGOs, including a local community group for people living with HIV (PLHIV), have implemented a significant number of activities centred on training, information and awareness-creation, the design of IEC materials, the promotion and distribution of condoms and some targeted activities. However some institutional or programme competency restrictions applied. The reduced transmission of and vulnerability to HIV/AIDS/STIs can be attributed to social communications efforts deployed by civil society which have increased notably over the past few years, owing, in particular, to financing received from the Global Fund. The efforts of local community groups are a great deal better structured thanks to the emergence of new NGOs outside of Algiers; a case in point is the group in the wilaya of Annaba, 400km from Algiers.

NGO ANISS in the wilaya of Annaba

There is one functional anonymous and free testing centre (CDAG) thanks to which 500 people were tested for HIV in 2004, especially most-at-risk population groups which include sex workers, MSM, and drug addicts. In 2005, awareness was created among 250 people with an operation carried out in night clubs and health-care centres for drug-addicts (CIST).

As regards prevention, ANISS organized a summer floating campaign that reached 6,000 people. In 2005, this campaign reached 300 people per day. In addition, 7,000 condoms were distributed in 2004 on beaches. In 2004, 6,000 pamphlets and 2,000 posters were distributed. In 2005, 60,000 pamphlets and 10,000 posters were printed which are currently being distributed. Awareness among students in 2004 resulted in 800 out of 40,000 students receiving care and in 2005, 1,000 students.

As regards training in 2004, 100 facilitators were trained by health-care professionals at a number of seminars. In addition, 20 midwives were trained in 2005 to conduct training in pairs. In addition, training workshops for penitentiary staff of the Annaba and Tarf wilayas were held during which 17 people received training (doctors, psychologists and dentists). Female leaders from local community groups and young students were trained as part of the training of mediators from local community groups from vulnerable population groups. ANISS also created several radio programmes, conducted interviews and held press conferences in 2004 and 2005.

Generally, civil society is in charge of dispensing two levels of training to facilitators: specific training of health-care practitioners, social workers and community agency professionals, and training of relief staff. Information efforts are aimed at:

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- Structured populations (young people at the level of socio-educational structures) - Unstructured populations (sexually active groups) AIDS-Algeria Experience, APCS Oran (summer special) and AIDS solidarity - Groups with risk behaviour (sex workers, young drug injectors, prisoners) through relief staff.

Designing, manufacturing and distributing IEC materials, counselling activities as well as condom distribution also form part of the efforts deployed by NGOs.

Advancement of knowledge and behavioural change At the end of 2005, risk behaviour warnings of the spread of HIV was not analysed with consecutive surveys conducted with the same methodology, in the same sentinel sites. However, a large number of localized and fragmented CAP (behaviour, attitudes and practices) surveys offer an indication of the level of knowledge of young Algerians. These various surveys showed a certain resistance to the use of condoms. National research conducted among young soldiers showed that barely a third (32%) of people surveyed in 1999 knew that condoms offered protection against the virus and only 50% would have agreed to use a condom with casual sex partners (19). But these results also prove that even though the awareness raised is still poor, it is the result of the various IEC campaigns conducted on this topic. A second survey conducted in 1997 among a higher-educated population group, in this instance 217 doctors-in-training, showed that 62% of students were in favour of using a condom; the result was the same for women and men (20). However, it should be noted that one student in four, especially women, in three out of four cases, refused to answer. This shows a group of very reserved doctors-to-be: a sure cause for concern. The actual use of condoms also seemed to raise some difficulties considering that 86% of surveyed people affirmed that they did not know how to use them properly. This raises a number of concerns, as the writers of the report pointed out, given that it involves doctors that should be able to recommend its use as part of their profession. A third survey conducted by the INSP among 266 young people revealed that 64% of young people did not mention (or did perhaps not want to mention?) condoms as a protective measure against AIDS (21). In conclusion, these results show that subsequent IEC campaigns should mainly focus on condom use. It is necessary to emphasize the infrequency with which the effectiveness of IEC messages is observed. The assessment of IEC messages and checking for behavioural change following an awareness campaign are not universally done.

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The impact of programmes

The indicators (Appendix 3) that measure the programme inputs (money, number of condoms, medicine to treat opportunistic infections, testing kit, training, etc. – resource indicators) and outputs (trained medical and paramedical staff, tested blood donations, adolescents educated on risk-free sexual practices, condom sales, etc. – results indicators) show that efforts are fragmented, spread-out, insufficient and without any real assessment.

The evaluation of the change in HIV prevalence trends among the surveyed groups means that the influence of programmes on the decrease of HIV rates can be determined. The inadequacy of HIV-sentinel surveillance surveys in Algeria, as regards the quantity (layout of country) and the reproductibility (perpetuation of surveys) means that the impact of the various efforts is not really visible. In fact the national HIV-sentinel surveillance survey in 2000 was only followed by another survey 4 years later, in 2004. It is consequently very difficult to evaluate the change in seroprevalence trends. However, it would seem like the epidemic is busy increasing: in 2000 the epidemic was not very wide-spread but it developed into a concentrated epidemic due to the sheer extent of certain risk behaviour groups severely affected by the infection (sex workers and young drug injectors). These population groups, whose knowledge level is very average according to the CAP (behaviour, attitudes and practices) surveys, and who often reject condom use, do not benefit from structured and assessed prevention programmes, as seen in the response. Therefore, it stands to reason that due to uncoordinated, fragmented efforts that do not really reach the identified risk behaviour groups (sex workers, young drug injectors with limited HIV/AIDS/ISTs knowledge), there is an increase in the epidemic among these groups because these efforts, that are not even assessed, have no real impact on them. In addition, the spread of the infection to the general population should be noted; the results of HIV-monitoring have brought this fact to light among pregnant women in a northern wilaya (Oran), a southern wilaya (Tamanrasset) and in the Sidi-Bel Abbes wilaya in Oranie, located 80km from Oran, and highlight the absence of any impact of these efforts on the general population. Through national and standardized indicators, it will be possible to evaluate the monitoring of changes on indictors over time and to see to what extent the national programme and the various efforts succeed in reaching their goals. An assessment of results could aim to prove that efforts have, in practice, decreased risk behaviour, while the evaluation of the impact could aim to prove that the behavioural change resulting from efforts has, in practice, had an impact from the point of view of less HIV transmission.

4 - Main challenges and necessary action to meet UNGASS objectives

Challenges

An external review of the process of the second mid-term plan (PMT2) in 2000 showed a series of strengths and weaknesses which remained consistent between 2003 and 2005.

The strong points to be highlighted are the Government programme in charge of the epidemic, the Ministry of Religious Affairs’ commitment to the programme – a deciding factor in the breaking of the taboo surrounding the disease – and an awareness of the reality of AIDS and its possible means of prevention and therapy.

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The main shortcomings are insufficiencies in the conception and gathering of resources, weak coordination, a fragmented implementation and a failure to follow up on the activities of the programme.

Achievements have been made in all aspects. Procedures have been implemented, mainly regarding coverage and IEC. There is visible determination to fight HIV/AIDS. However, key issues remain to which solutions need to be found. More specifically:

• The lack of professionalism of IEC workers • The difficult coordination between sectors • The inconsistency in the actions, which are often temporary • The absence of an adequate legal framework • Insufficient funds allocated and the absence of a special HIV/AIDS budget

Composite index number of national policies

It reveals several issues that remain partially, or not at all, addressed: individual rights, with existing laws that are still not enforced, the absence of monitoring and assessment, and the lack of appropriate strategies regarding groups with a high level of exposure on the field. Insufficient funding and the absence of a budget dedicated to STD/HIV/AIDS are concerns that should equally be pointed out.

Inadequate epidemiological surveillance and the absence of appraisal

Insufficiencies in the epidemiological surveillance system in Algeria have hindered accurate assessment of the epidemic and the implementation of an effective response. There is a lack of accurate data regarding HIV infection and behaviours, resources are scarce and the response to HIV/AIDS is almost exclusively concentrated in the medical field. Moreover, the absence of structures enabling an accurate estimation of cases of infection (few free, voluntary detection centres) combined with the lack of an HIV detection network (supported by microbiology laboratories rather than blood transfusion centres), are a definite obstacle in the assessment of the total figure of new infections.

The lack of an organisation in charge of coordination, of evaluation on a national scale and of the follow-up of the different activities of the sectoral programmes has resulted in the absence of monitoring regarding the programme’s activities. Appraisal of the activities in all sectors (public and private) remains a challenge in a context where a lack of training has hindered the creation of proper assessment indicators. The absence of coordination between these different sectors makes it impossible to assess the various actions on a national scale, in particular measures of detection and prevention.

The fact that surveillance surveys of HIV infection are not institutionalised or set on a long-term basis makes it impossible to study the evolutionary trend of the HIV infection.

Another factor hindering the appreciation of the scale of the epidemic is poor information management, in particular the lack of regular and coherent HIV/AIDS notification procedures and of second-generation surveillance studies. It is vital that these elements be improved in order to achieve better knowledge of the scale of the epidemic.

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Actions carried out on the field remain local, lacking coordination and appraisal, which adds to the difficulty in appreciating the impact of these interventions.

Behavioural monitoring and second-generation surveillance

On a qualitative level, the lack of socio-behavioural studies makes it impossible to have a clear vision of behaviours and their evolution, a vital element in second-generation monitoring.

Due to the shortage of behavioural surveys, it is impossible for the present system to monitor risky behaviour, an effective indicator in the tracking of HIV propagation. It is necessary to include the gathering of behavioural data into the monitoring system, for it is a valuable aid in the adequate targeting of preventive measures. The present system, based on information relative to actual HIV infection rather than risks of infection, makes it impossible for the alert to be raised early enough. Information relative to risky behaviour, such as non-protected sexual relations or multiple sexual partners can be provided by behavioural surveys or other biological markers (STD for non- protected sexual relations). It is necessary to adapt second-generation monitoring systems, providing information that helps to identify individuals at risk and behaviours exposing them to this risk.

The lack of behavioural monitoring, necessary to the implementation of second-generation monitoring, hinders the appreciation of behaviour evolution and the impact of the different measures. Implementing behavioural surveys and combining biological and behavioural data, which make up the second-generation monitoring systems, would enable a better appreciation of the epidemic.

The expected impact and problems inherent to the progress of the Programme have not been taken into account due to the lack of activity of the various actors on the epidemiological, technical and financial fronts. Moreover, there is no AIDS unit equipped with its own network and documentation and archive centre. Although a high number of health workers have been given training on HIV/AIDS, there has been insufficient follow-up, supervision and appraisal. Moreover, coordination within sectors and between sectors remains at a very low level.

Despite the increase in NGO activity in the fight against AIDS, there is still no available assessment of their impact. These organisations are too often confronted with institutional and programmatic hurdles preventing them from carrying out their mission efficiently. There is no measure of the impact of their actions. Finally, the various actors involved in prevention should be given substantial training in the elaboration of effective communication strategies.

Coordination between the CNLS and the various other actors

Due to the lack of clearly defined rights and duties for all members of the Comité National de Lutte contre le SIDA (CNLS), consistency in the scheduling of meetings and member attendance has often proven very weak. It is the mission of the CNLS to elaborate, plan and coordinate the PNLS. A clearly defined a plan of action would enable the CNLS to coordinate, monitor and evaluate the programmed actions in close collaboration with the different commissions and actors, with the degree of complete cooperation necessary to achieve these goals. In that respect, it is urgent to set up a technical and administrative coordination unit.

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Detection

Active detection has not been granted the particular attention it deserves. Indeed, the number of functioning free and anonymous detection centres is still very low. This situation is a serious issue which needs to be improved. Due to lack of information or misinformation, citizens are not aware of where to carry out tests for potential HIV or other STD infections. Sex workers or people having put themselves under risk are not offered detection, therefore increasing even more the number of people unaware of their own infection and posing a serious threat to people around them. This highly important aspect from an epidemiological point of view has not been taken into consideration. It is urgent for functioning free and anonymous detection centres to be set up, first of all in the main cities of the North of the country (Algiers, Oran, Constantine), in the Southern cities (Tamanrasset and Ouargala) and at a later date in other parts of the country. Counselling training is not carried out on a wide enough scale.

All studies of behaviour and awareness show a low level of condom use, as well as a lack of awareness of the use of condoms as a means of protection. What’s more, abandoned children (5,000 per year), the number of which is increasing at a disturbing pace, have revealed that sexual relations take place without the use of condoms. Improvements are to be made in the availability of condoms in places accessible to young people (sanitary units, youth houses, training organisations, army barracks, border stations), in making condoms more affordable and improving the distribution of condoms donated by different organisations.

Risky-behaviour groups

Users of injection drugs, who have so far never been targeted for specific programmes (in particular for disposable syringes), as well as sex workers for whom there is no appropriate strategy.

Biological surveillance

Biological surveillance of viral load treatments is available in Algiers, and will soon be in Oran. Proper dosage of CD/4 and CD/8 and many other parameters are not always provided. In 10% of cases, failures occur due to non-compliance, virus resistance or intolerance to the products.

Ineffective Information-Education-Communication (IEC)

The scarcity of IEC actions, as well as poor targeting of these actions, are among the existing obstacles to the implementation of better IEC. Due to the lack of thorough qualitative surveys, it is not possible to use the collected information to implement more specific preventive measures. Awareness campaigns must imperatively be tailored to the social and educational level of the targeted populations. These campaigns have so far mainly been aimed at populations with a medium or high level of education, which do not make up the bulk of AIDS victims.

Actions

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Regarding the reinforcement of epidemiological surveillance, qualitative information management and appraisal of the Programme

The HIV/AIDS and STD monitoring system needs to be strengthened in order to improve the national response to the epidemic. The reinforcement of this system requires an improvement of institutional competences. This will require revitalising first and second-generation epidemiological monitoring, extending the coverage of sentinel site surveillance, and the implementation of an effective information and appraisal management system, along with a high level of coordination between sectors.

It is urgent to set up the division in charge of collecting and centralising all information relative to the assessment of each different sector, of the effort made on epidemiological surveillance and of survey reports, as well as all other research results.

Training sessions must be organised regarding appraisal tools (procedure, result and impact indicators) for all people involved in the process in all sectors (public and private).

Regarding epidemiological surveillance, it is necessary to revise the STD/HIV/AIDS notification system in terms of circuit and of procedures in order to improve awareness of the scale of the epidemic.

HIV surveillance studies should be generalised and institutionalised for better geographical impact and more accurate appreciation of the epidemiological trend. These studies should not depend exclusively on outside partners but rather be under the aegis of the MSPRH.

Regarding behavioural surveillance

Behavioural surveillance must be based on repeated transversal studies of the population as a whole, or on repeated transversal studies of clearly defined population sub-groups, using behavioural indicators such as, for instance, the notion of sexual relations with non-regular partners in the previous twelve months, the use of a condom during the last sexual relation with a non-regular partner, and of course the age of the first sexual relation for young people. The sharing of used syringes for injection drug users, and the number of clients during the previous week for sex-workers are important questions to study.

Regarding the reinforcement of associative and community leader involvement

The objective is to reinforce the participation of the concerned audiences in prevention measures, through the principle of peer-education. Mediators, identified among vulnerable audiences, will be given training to help them intervene where health workers might not be able to. Genuine access to prevention for these audiences is required in the short or mid-term for a lasting change in behaviours towards health services to occur. Teacher and peer-educator training must be a priority in the implementation of the activities. It is essential that vulnerable individuals and social outcasts benefit from STD/HIV/AIDS preventive measures thanks to a proximity-based approach based on the involvement of associative mediators, who are familiar with both people at risk and health and social workers, and are therefore able to direct the audiences towards treatment or prevention centres.

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Regarding the reinforcement of global coverage for people living with HIV/AIDS

This aspect is essential because the programme will make it possible to continue the decentralisation of the coverage throughout the different regions. Patients will benefit from global coverage, as part of a continuum of treatments, including ARV treatments. Support and accompanying measures for people living with AIDS will be implemented in collaboration with local organisations. Particular attention will be paid to the problems of HIV/AIDS mother-to-child transmission, with affected women and their families, anti-viral treatment surveillance, and providing infected persons with psychological help and socio-professional reinsertion schemes. Individuals living with AIDS will also play an active role as mediators to facilitate access to treatment.

Training health professionals along with NGO workers and mediators must also be planned for as part of these activities, for people living with AIDS to be taken care of in both medical and psycho-social aspects. In order to ensure adequate and regular biological surveillance, funds will be used for laboratory equipment, which is currently lacking.

5 – Support required from development partners in the country Support by multilateral agencies for the Algerian response in combating HIV/AIDS through the UNAIDS Theme Group (UTG) 1996-2005 The UNAIDS Theme Group (UTG) Algeria was set up in 1996. Four co-sponsoring agencies of the United Nations already represented in Algeria at this time were members of the UTG: WHO, UNDP, UNFPA and UNICEF. In September 2000 − before it was included at international level by the ILO − the Algerian Office joined the UTG. Two other co-sponsoring agencies, UNESCO and UNODC, still did not have representatives in Algeria but contributed to regional projects. An example of involvement was the signing of a contract in 2003 between the UNODC and the Algerian Ministry for Higher Education and Scientific Research to investigate the possible link between drug abuse and HIV/AID. The study began in February 2004. Later in 2004 two other agencies involved in the UNAIDS programme at international level, the WFP and the UNHCR also signed up to the UNAIDS Theme Group. Between 1996 and 1999, the WHO provided all the support the Algerian government was receiving to combat STIs/HIV/AIDS, in spite of the fact that the UNAIDS Theme Group had been set up there in 1996. Following a suggestion by a WHO liaison officer during a meeting in 1998 it was decided by all the agencies that the presidency of the group would change annually. From 1996 onwards the UNAIDS Secretariat provided acceleration funds totalling $US80,000 to support the work in Algeria on a biennial basis. From 2003 this reduced to $US50,000. In 2004 Algeria was designated a country in greatest need by the Secretariat. When asked by the UTG, $US50,000 of the acceleration fund was allocated automatically at the start of the two-year period. The aim of these funds is to jump-start innovative STIs/HIV/AIDS prevention projects. They have to be used mainly to finance those programmes that the co-sponsoring agencies of UNAIDS do not cover. They can also be used to finance inter-agency (sponsors) initiatives. In addition to the joint projects that form the work of the UTG, each sponsoring agency supports various specific programmes as part of its own mission. In general the funding by the cosponsoring agencies that contribute to the national programme against AIDS is very limited. This is due to the reduced presence in Algeria by agencies as the country had not been perceived 32

as having a wide-spread AIDS problem. This established view has changed over the last few years, particularly since 2004 when a joint support plan was drawn up involving the agencies and a National Strategy Plan was introduced. Joint projects between the sponsoring agencies have since increased.

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Between 1996 and 2000, support by multilateral agencies for the Algerian programme on HIV/AIDS was made through a cooperation agreement drawn up between the Ministry for Health and WHO which, alone, had been supporting the AIDS programme during its initial years. The type of support provided at that time was mainly for emergency measures designed to allow the Algerian authorities the ability to control the epidemic by testing blood and blood by- products, monitoring the situation; training specialists to pick up opportunistic illnesses and several IEC campaigns aimed at the general public. In 2000, all the co-sponsoring agencies of UNIADS supported an evaluation of the second medium term plan (MTP2) which led to the recommendation that a STIs/HIV/AIDS National Strategy Plan should be set up as a priority. This plan would follow the procedures for Strategy Planning that the government had produced for 2002 to 2006 to combat STIs/HIV/AIDS. On 18 March 2002 this procedure, supported by the agencies, was approved by all those involved. At the 13th meeting of the UNAIDS Programme Coordinating Board (PCB) in 2002, it recognised the need for specific improvements in UNAIDS functioning at country level, including the importance of better and more coordinated support to expanded, multisector national responses. As a result, the PCB recommended intensified country action and support. It seemed obvious that since recommendations emanate from UNGASS resolutions, the indicators adopted to monitor the result were those of UNIGASS. The cross-cutting strategic objectives of UNAIDS Algeria that will act as support for the National Response between now and 2005 are: Strategic Objective 1: To empower leadership for an effective response at country level. Strategic Objective 2: To mobilize and empower country-level public, private and civil society partnerships. Strategic Objective 3: To promote and strengthen country management of strategic information. Strategic Objective 4: To build capacity to track, monitor and evaluate programmes to combat HIV/AIDS at country level. Strategic Objective 5: To facilitate access to technical and financial resources at country level. As a result of putting into practice the recommendation of the PCB, in 2003 the UTG Algeria supported the drawing up of sector-wide working plans to combat STIs/HIV/AIDS for the period 2004 to 2006. These involved nine government sectors and three NGOs. The plans were included when the National Strategy Plan, approved in 2002 by all those involved at national and international level, was implemented. At the same time as these two important contributions, the UTG also supported the mobilisation of funds by submitting an Algerian grant proposal to the GFATM second round. The Technical Review Panel issued 14 recommendations for Algeria to resubmit its proposal for the 3rd round. This application was then revised by the UNAIDS Experts Committee and was subsequently approved in October 2003. In March 2003, a team of three experts from UNAIDS helped the office of the Algerian resident Coordinator formulate a draft project for a HIV/AIDS initiative developed by seven countries bordering the Sahara (Algeria, Libya, Mali, Mauritania, Morocco, Niger and Tunisia) and was submitted to them in September 2003. Six of the countries approved and are now working to draw up country-level projects on Mobility and HIV/AIDS under the aegis of their respective UTGs.

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The Expert Committee is set to meet in March 2004 in Niamey, Niger to compile a regional project from the various country-level ones. UNICEF funded reagents for a nation-wide survey of sentinel sero-surveillance for HIV in 2000 to the tune of $US15,000. The UNFPA also contributed $US 5,000 for the 2004 survey and in doing so added to the support provided by the WHO of $US 30,000 for the purchase of reagents for HIV and syphilis. The UNAIDS secretariat then allocated $US12,000 to complete the survey whose results will be validated after December 2005. These results will form the basis for UNGASS’s impact indicators evaluation. In addition, the UTG has also facilitated, as part of the United Nations Programme against Drugs and Crime, the drawing up of terms of reference and the procedure for selecting an national institution to carry out a rapid situation assessment of the possible link between drug-taking and HIV/AIDS. This will be implemented by the Centre de Recherche en Anthropologie Sociale et Culturelle in Oran (Ministry of Higher Education and Scientific Research) from January 2004 onwards and its start-up will be funded by $US 20,000. The UTG Algeria has carried out a rapid assessment of the Mobility and HIV/AIDS situation using money from UNDP. Under the timetable of activities proposed as part of the Initiative, and on the basis of this rapid assessment, the UTG will have to draw up an Action Plan of urgent activities for the mobile population. However the necessary finance still has to be found so that the study can be completed using quality data. At the same time a country-wide project has to be established that takes into account the cross-referenced results from both studies. Finally, UNFPA, as part of a scheme to support an NGO AIDS campaign, is helping set up a system for HIV/AIDS second generation surveillance by working with the UNAIDS secretariat to finance a survey studying HIV and sexual behaviour among sex workers. This study should lead to the urgent local implementation of various actions among those behaviour groups that are at risk. The main thrust of these would be preventative measures developed by the NGO to encourage changes in behaviour.

The UNAIDS Programme Acceleration Fund (PAF) for 2002−2003 began in November 2003 with an overall sum of $US50,000, allocated for four projects run by the Ministry for Religious Affairs, the Justice Ministry, the Ministry of the Interior (Homeland) and the NGO, the El Hayet Association “People living with HIV and AIDS” (PLWHA). The project will be on-going until 31 December 2006 with financial support from UNDP and using the flexible mechanism of the Resident Coordinator to manage the finances. One of the UNIADS PAF projects, that of reinforcing the capability of the El Hayet Association has already found top-up finance from the UNDP. As to the others, the UNAIDS PAF project run by the Ministry of Religious Affairs will be topped-up by money from UNFPA to the tune of $US100,000 over three years. The project of prevention in prison will be topped-up by $30,000 from UNFPA and $US20,000 from UNDP. These four acceleration projects have enabled an effective multisector approach to be introduced through the implementation of working Action Plans using institutions others than the Ministry of Health.

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The UTG Algeria’s Integrated Support Plan (UN-ISP) for 2004-2005 covers the continuity of activities initiated to support the National Strategic Plan. The direction has been modified to meet the priorities defined in the UNGASS’s Declaration of Commitment dated June 2001 and cross- sector strategic focussing of UNAIDS and its cosponsors in 2002. The International Conference on AIDS and Sexually-transmitted infections in Africa (ICASA) held in September 2003 in Nairobi, Kenya was attended by top figures from national coordination groups and ministries involved across Africa. Important fund raising and awarding bodies, bilateral and multilateral institutions, NGOs and representatives from the private sector were also represented and everyone was able to discuss the principles that guide coordination at national level to combat HIV and AIDS. A series of guiding principles were defined beforehand as part of a procedure at world and country level set up by UNAIDS in conjunction with the World Bank and the Global Fund to fight AIDS, TB and Malaria. During discussions it was noted that various scenarios were provided by the growing diversity of funding methods and the challenges that this diversification engendered. The importance of choosing the right partners in working with HIV and AIDS was also discussed. Participants at the conference underlined the necessity of clarifying roles and relationships better and, in view of latest developments, insisted that local actions needed urgent attention. The audience was reminded that a policy of local care was the only one likely to succeed.

To carry this out, the support of all co-sponsoring agencies for 2004−2005 will be made through a Reinforcement of the National Council against AIDS by applying the “Three Ones”. A PAF proposal for 2005 to this effect was approved and allocated $US25,000. This action meets one of the guiding principles for the support of the UTG as part of the national response. Finance from the ILO should help consolidate the technical competences of the members of the tripartite committee combating HIV and AIDS that was set up by the Ministry of Work and Social Security. In 2004 the ILO was responsible for training the tripartite committee working to combat STIs, HIV and AIDS. Training on the codes of practice for AIDS − which will be offered to 30 members of the committee − will be developed in general by the ILO. Increasing the ability of people living with HIV and AIDS to get involved is considered a priority by UNAIDS and is crucial to their long-term empowerment in the fight against this scourge. In Algeria the El Hayet Association was founded in 1998. It has been operating ever since with considerable difficulty due to an absence of material and technical resources. A major obstacle in getting PLWHAs involved without fear of being stigmatised is the lack of a building to work from. The Association has produced a working Action Plan which includes activities for developing life skills for sufferers and their families; prevention methods, information and education as well as protecting the rights of PLWHAs. Organising and providing back-up for El Hayet is a prerequisite if the aims of its Action Plan are to be achieved. The support given by the UTG to improve the capacity of the NGO to respond to the HIV/AIDS situation, although considered a priority was made between 1996 and 2003 by several acceleration funds and particularly those that benefited specific associations related to AIDS (AIDS Algeria, Solidarity AIDS and El Hayet). These funds were also allocated to other organisations with a broader aim such as Santé Sidi El Houari and Le souk. These schemes were mostly preventative measures targeting young people as a priority and, in some cases, women. In 2003 in response to an initiative by UNFPA, the UTG funded the setting up of an Algerian network of NGOs working to combat AIDS, known by the initials ANAA (Algerian Network against Aids). This network will enable members to share and capitalise on the limited financial input by the UNAIDS cosponsoring agencies. The money was given both to make the NGO more

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secure financially and to enable it to apply the “Three Ones” so that coordination across the country will be improved. As part of the “Three Ones” strategy, Monitoring and Evaluation is the key to the long-term fight against the epidemic. As a result the UTG Algeria will be integrating its aid as part of its support for National Coordination and for the implementation of the “3 by 5” Initiative. A UNAIDS PAF is, in addition, available for this purpose up to $US 25,000. In 2006 all cosponsoring agencies will be working together as a priority to implement the Three Ones in Algeria. This will be illustrated by continuing to pursue existing actions and projects in a more coordinated fashion. A joint project will also be developed to speed up the implementation of the Three Ones, acknowledging that this is the only guarantee that everyone will have access to preventative measure, care and support. As to monitoring and evaluation, the country’s ability to carry these out should be improved to a great extent in the first instance by development partners and especially the HIV project financed by the Global Fund using the proposals of this report on monitoring UNGASS’s Declaration of Commitment on HIV/AIDS. In addition development partners need to get together to organise financing technical help on an international basis for the purpose of monitoring and evaluating schemes as well as epidemiological surveillance. Lastly, development partners can facilitate the analysis of available data by enabling the CNLS (the Algerian National HIV/AIDS Council) and the Commission Épidémiologie as well as the coordinating ministry’s dedicated unit, to have access to computerised databases from the various surveys that have taken place about understanding and behaviour in relation to HIV/AIDS. This should cover those carried out by any sector, no matter where the funding came from or whether it was externally or government-supplied. This will facilitate the responsible bodies’ ability to assess the indicators used to follow up UNGASS’s Declaration of Commitment on HIV/AIDS so that the level of response, the epidemic itself and especially behaviour patterns can be monitored better. (See Section 6 “Monitoring and Assessment Framework”)

6 – Monitoring and Evaluation Framework

For around ten years, Algeria has been engaged in the planning of a monitoring and evaluation system for the control of STI/HIV/AIDS (22), i.e.: 1986: Creation of a group of experts in charge of the epidemic 1988: Planning of the first Short-Term Programme (STP), including the creation of an epidemiological surveillance system and specific actions for prevention, treatment and the psycho-social environment 11th March 1988: The virology laboratory at the Algerian Pasteur Institute (Institut Pasteur d’Algérie) is designated as the National Reference Laboratory, confirmed by Ministerial Order (19th August 1995). 22nd June 1989: Creation of the National AIDS/HIV/STI Control Committee (Comité National de Lutte contre les IST, VIH/SIDA) [CNLS], with representatives from five ministries 17th November 1990: Ministerial Order drawing up the list of reportable diseases and reporting methods. HIV/AIDS benefits from a specific reporting status and circuit 1994: After the STP and the first Medium-Term Programme (MTP1, from 1990 to 1994), planning of the second Medium-Term Programme (MTP2), operating from 1995 to 1999) 2000: Evaluation of the second national Medium-Term Programme (MTP2)

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Mars 2002: Adoption of the Strategic Planning Process, 2002 – 2006 (in preparation since 2001) and the Sector-wide Operational Action Plans (plans for each of the nine ministries and for the three national NGOs for the period 2003 – 2006 2nd-3rd December 2003: Plan for the implementation of monitoring and evaluation activities, drawn up during a strategic planning, monitoring and evaluation workshop (Tunis) 2003: Proposal of a request to the Global Fund for the financing of an HIV project 2004: Updating of the Operational Action Plan for the Justice sector (2005 – 2008 period). 2005: First disbursements from the Global Fund for the HIV project

In 2000, the creation of an HIV/AIDS unit consisting of an epidemiologist, a biologist, an infectious diseases specialist and a medical examiner was proposed. The members of this unit were to be responsible for resolving problems relating to shortages of reagents and treatments and for managing and evaluating the programme. However, this unit had operational difficulties due to the lack of an administrative and regulatory process. In 2001, six reference treatment centres (Centres de soins de référence) were created by Ministerial Order (four had been set up in 1996, with budgeting for medication).

The epidemiological surveillance of STIs/HIV/AIDS has represented the corner stone of successive HIV/AIDS control programmes since the start of the epidemic, but the issue of the monitoring and evaluation strategy was not raised until the drafting of the Strategic Planning Process, 2002 – 2006. One of the five national objectives of the National Multisectoral Plan is the “Management of information for the epidemiological situation concerning STIs and HIV/AIDS” (23). The Operational Action Plan for the Health sector 2003 - 2006, explains that the STI/HIV/AIDS control programme “does not perform monitoring and evaluation activities due to the absence of a central surveillance structure equipped with human and material resources”.

The Multisectoral Monitoring and Evaluation unit

A plan for the implementation of monitoring and evaluation activities was drafted during a workshop organised in Tunis in 2003, on the basis of planning carried out in 2001 - 2002. This plan included a detailed schedule of monitoring and evaluation activities listed on a quarterly basis for 2004 and an annual budget proposal varying between 1.215 and 1.32 million USD. During the first quarter of 2004, it was suggested that monthly meetings should be held and that a Monitoring and Evaluation Unit should be set up, consisting of “two operational staff with one coordinator” (24). A quarterly or annual frequency was suggested for the collection and distribution of the different types of information proposed.

One of the first activities involved in the drafting of this Report on the Monitoring of the Declaration of Commitment on HIV/AIDS (UNGASS) was the compilation of a list of the biological and behavioural surveys and of information from the monitoring systems for the programmes. Most of the survey results presented in this report are not stored centrally. It is appropriate to note that up to now (end of 2005), the CNLS (National AIDS Control Committee), the Epidemiology Committee (Commission d’Épidémiologie) and the unit from the Ministry with responsibility for coordinating the monitoring of the STI/HIV/AIDS programme do not have a team of staff dedicated to monitoring and evaluation activities. These activities include compiling the results provided by surveys and monitoring systems for the programmes operating in all

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sectors of government and civil society, in addition to analysing regularly updated information and organising the exchange of information by different methods (reports, presentations, computerised databases, etc.). These activities also include the development of operational research, the identification of training needs, the provision of support for the creation of monitoring systems and the preparation of normative texts (directives, guides, instructions) and information collection tools, in addition to the management of computerised databases (including those managed by the CRIS software).

Following the drafting of this Report on the Monitoring of the Declaration of Commitment on HIV/AIDS (UNGASS) in December 2005, the setting up and development of a monitoring and evaluation unit have been planned for 2006. The elaboration of a programme of work for this unit and for the other participants in the monitoring and evaluation process shall take account of the proposals put forward in December 2003, in addition to the new needs that have been identified.

Status of the monitoring and evaluation activities at the end of 2005

Since 2000, the CNLS’s Epidemiology Committee (Commission Épidémiologique): the consultative body for monitoring and evaluation activities, has been organising serosurveillance surveys via the sentinel network and modifications to the reporting system. This has led to the creation of a new reporting circuit for AIDS and HIV-positive cases, along with new reporting forms. The Epidemiology Committee is one of the six committees which support the activities of the CNLS.

Different sectors (Health, Secondary Education, Justice, and others) have functional information systems. In 2005, the Health sector developed a system which, in future, will enable health data to be shared via the Internet on a regular basis. The Monthly Epidemiological Summary (Relevé Épidémiologique Mensuel), of the National Institute of Public Health (Institut National de Santé Publique), regularly publishes data for HIV/AIDS cases which have been confirmed by the National Reference Laboratory for HIV infection at the Algerian Pasteur Institute. On World Aids Day every year, the Department of Prevention of the Ministry of Public Health and Hospital Reform (MSPRH) also publishes the “Prevention Letter” (“la lettre de la prevention”), an information bulletin devoted entirely to AIDS. Papers on STIs /HIV/AIDS are regularly presented at conferences and publications appear in scientific journals. Furthermore, a report on epidemiological surveillance was carried out in 2002 (25). However, monitoring and evaluation reports are not published on a regular basis.

In Algeria, there have been no training programmes for the monitoring and evaluation of STI/HIV/AIDS control activities, apart from in December 2003 (24), when three people attended a training workshop on strategic planning, organised by UNAIDS in Tunis. In February 2003, the existing HIV/AIDS/STI surveillance system in Algeria was evaluated and a protocol for biological surveillance was developed (26).

In December 2003, seven people from Algeria (including one person from UNAIDS) took part in a training workshop on the strategic planning, monitoring and evaluation of HIV/AIDS programmes, organised by UNAIDS à Tunis (24). In February 2003, the existing HIV/AIDS/STI surveillance system in Algeria was evaluated with the aid of an international expert.

In May 2001, two people from Algeria (including one person from the WHO) took part in a meeting about the reinforcement of HIV surveillance in French and English-speaking countries in the African Region, organised by the WHO-AFRO in Ouagadougou, Burkina Faso.

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In February 2004, WHO-AFRO, in conjunction with the “Centres for Disease Control and Prevention/ Leadership in Fighting an Epidemic” (CDC/LIFE) initiative, organised a training workshop on the surveillance of HIV/AIDS/STIs for trainers from ten French speaking countries of the African Region in Bobo-Dioulasso, Burkina Faso. However, Algeria did not take part in this workshop. During this event, and at a similar workshop organised for 22 English-speaking countries of the African Region in Harare in January 2001, it was recommended that directives for the surveillance of HIV/AIDS/STIs should be issued to each country.

In June 2003, one person from Algeria took part in the fourth meeting of the Technical Network for the Surveillance of STIs/HIV/AIDS in the African Region, organised by the WHO-AFRO in Nairobi. Nobody from Algeria had participated in the three previous meetings of this Technical Network (in Accra in June 1998, Cotonou in September 1999 and Pretoria in October 2001).

Four sectors (National Defence, Justice, Higher Education and Health) in addition to civil society organisations have organised KAP surveys on HIV/AIDS within different population groups: 1) Young soldiers (at the national level, in 1999 [n=5 000]) (19) 2) Prison inmates (at the national level, in 2000) (27) 3) Problematic drug users (in 3 towns in the north of the country, in 2004) (7) 4) People originating from Sub-Saharan Africa (in Tamanrasset, in 2004) (18) 5) Female sex workers (in Algiers, Oran and Tamanrasset in 2005) 6) Medical students (in Algiers, in 1992 and 1997) (28, 29) 7) Young people in school aged between 16 and 20 years old (in Algiers, 2000 & Tamanrasset, 2004) (17, 18, 30) 8) Young 15-30 year-olds (in 3 Wilayas in 1998 and 5 Wilayas in 2002) (21, 31) 9) Young, single people aged between 15 and 29 years old (at the national level, in 2002 [n=3 268]) (14)

A standardised methodology such as that recommended by WHO/UNAIDS (32) must be implemented if comparisons of the levels of knowledge and behaviours of these risk groups are to be made over space and time and between the different populations studied (32). Standardised survey protocols should also be developed for the benefit of the staff in charge of the surveys.

The need for concordance and standardisation in the collection of information

Standardisation is not only recommended for behavioural surveys, but also for the management of process and results data. These allow us to analyse the implementation of the activities carried out by the different sectors responsible for the provision of services (Prevention, treatment, care, support and the psycho-social environment). It is therefore recommended that the CNLS or the coordinating ministry should take over the leadership and carry out the following activities:

(1) Compile a full list of the surveys carried out and of the monitoring systems for the functional programmes. (2) Identify the shortcomings in the data concerning the general population and vulnerable groups as well as at the level of the indicators used. (3) Identify the available skills (institutions and individuals).

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(4) Organise a consensus workshop on the methods needed to improve the system of monitoring and evaluation. The expected results concern the updating of the definitions for the indicators [main and supplementary] and for the monitoring and evaluation strategy, in addition to the evaluation of surveillance tools. (5) Support the drafting of directives, surveillance protocols and collection tools. (6) Organise training in data collection for operatives at the decentralised level. (7) Analyse data (8) Improve the use of data by providing feedback in the form of reports and provide information in other formats [presentations, Internet, electronic databases].

International technical support would be welcomed in this field, as it would allow Algeria to benefit fully from the experience of other countries. It will also be necessary to centralise the available human resources to the greatest possible extent. By the end of 2005, three organisations (the Department of Prevention, National Institute of Public Health and the National Reference Laboratory) were compiling HIV/AIDS reporting data on a more or less regular basis. The proposed management unit for the monitoring and implementation of activities financed by the Global Fund might become a fourth reservoir of information on HIV/AIDS. In the interests of greater efficiency, it would be advisable to group all of the different methods together. It is clear that if all of the monitoring and evaluation staff recruited by the different financial sources were to share the same place of work, this could only have beneficial effects on the integration of the different monitoring and evaluation activities, thus increasing cost efficiency.

The need to centralise the collection of data and set up a uniform system is inspired by the Global Application Framework for the consultation on the harmonisation of international financing in the fight against AIDS (Rio de Janeiro Conference, Brazil 2005). This calls for:

− A common national framework for the fight against AIDS into which the coordinated activities of all partners can be integrated. − A common national organisation with a wide and multisectoral representation to coordinate the AIDS response. − A common system of monitoring and evaluation on a national scale.

The growing under-reporting of HIV/AIDS in Algeria: the need for a uniform system

The reporting of HIV/AIDS, as described in Section 2 “Overview of the HIV epidemic”, concerns samples on which the National Reference Laboratory (LNR) for HIV/AIDS, based at the Algerian Pasteur Institute, has carried out the confirmation tests. The growing under-reporting of HIV- positive and AIDS cases, a practice which is unevenly distributed throughout Algeria, must be taken into consideration. By only examining data from the LNR, other confirmations carried out by different laboratories are not included in the figures. Indeed, there are no directives concerning the reporting of HIV-positive cases in the other laboratories. This under-declaration has been increasing due to the lack of a uniform, centralised system of reporting, based on a network of decentralised reference laboratories. Such a network, for which inspiration can be found in other countries, should be designed in such a way as to be capable of receiving data from all HIV confirmation tests. However, the beginnings of a uniform system already exist, as the other STIs (gonococcal disease, syphilis, hepatitis B and hepatitis C), are

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declared to the Department of Prevention at the Ministry of Public Health and Hospital Reform. Indeed, the Ministerial Order of 17th November 1990 lists HIV/AIDS reporting, along with syphilis and gonococcal disease, as reportable diseases. The private medical sector, which treats the majority of patients suffering from sexually transmitted infections, is not involved in the reporting procedure, which therefore means that this can only be a partial system.

Access to computerised databases for epidemiological surveillance and other surveys

The sharing of knowledge in the form of reports or other products is an essential part of epidemiological surveillance. A detailed analysis of the available data by those responsible for the surveillance report requires access to an electronic database. However, at the end of 2005, the National Reference Laboratory was still sending its HIV and AIDS reporting data to the Department of Prevention at the Ministry responsible for coordinating the STI/HIV/AIDS control programme and the Epidemiology Committee of the CNLS in a pre-compiled tabular format (26). The same applies to access to data from surveys evaluating knowledge, behaviour and the prevalence of STIs/HIV in different population groups. This access could have been helped to supplement the results of indicators used for the monitoring of the Declaration of Commitment on HIV/AIDS (UNGASS). These surveys are organised by different government organisations and/or with external financing.

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1. USAID, UNAIDS, WHO, UNICEF and the POLICY Project. Coverage of selected services for HIV/AIDS prevention, care and support in low and middle-income countries in 2003 (74 pages). Washington, USA, June 2004. (available from http://www.FuturesGroup.com). 2. Bertozzi S, Gutierrez JP, Opuni M, Walker N, and Schwartländer B. Estimating resource needs for HIV/AIDS health care services in low-income and middle-income countries. Health Policy 2004; 69: 189-200. 3. UNAIDS. Resource needs for an expanded response to AIDS in low- and middle-income countries. Geneva, Switzerland, August 2005 (available from http://www.unaids.org). 4 .UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance. UNAIDS/WHO Epidemiological Fact Sheet of Algeria, Morocco, Tunisia on HIV/AIDS and sexually transmitted infections, 2004 Update. (available from http://www.unaids.org and http://www.who.int/hiv/pub/epidemiology/pubfacts/en/index.html). 5 .Fares EG et coll . Epidemiological surveillance of HIV/AIDS in Algeria, North Africa, based on the sentinel sero-surveillance survey , 2000. XV International AIDS Conference. Abstract C10572. Bangkok. 11-16 July 2004. 6 .Fares EG et colll. Résultats de l’enquête sur la séro-surveillance sentinelle du VIH et de la syphilis réalisée en 2004 (Rapport à paraître, in French). Algiers, Algeria, Direction de la Prévention, Ministère de la Santé, de la Population et de la Réforme Hospitalière (MSPRH). December 2005. 7 .Mimouni B, Remaoun N, Abdalla T, Warner-Smith M. Etude du lien potentiel entre usage problématique de drogue et VIH/SIDA en Algérie (86 pages, in French). Algiers, Algeria, Centre de Recherche en Anthropologie Sociale et Culturelle (CRAS), Ministère de l’Enseignement Supérieur et de la Recherche Scientifique (MESRS), October 2005. 8 .Shepard BL & DeJong JL. Breaking the Silence and Saving Lives: Young People’s Sexual and Reproductive Health in the Arab States and Iran (245 pages). International Health and Human Rights Program, Francois-Xavier Bagnoud Center for Health and Human Rights, Harvard School of Public Health, 2005. 9 .La transfusion sanguine en Algérie pour l’année 2000 (in French). Algiers, Algeria, Agence National du Sang (ANS), 2001. 10. Khaled S, El-Hadj M, Touatioui Z, Mohammedi Z, Idri H, Missoum K, Chala M. Enquête de prévalence de l’infection par le VIH dans une population de malades tuberculeux en 1997 en Algérie. 13ème Conférence de la région Afrique de l’Union Internationale contre la tuberculose et les maladies respiratoires (UICT.MR). Conakry du 24-27 mai 2000. 11 .WHO, Regional Office for Africa. HIV Surveillance Report for Africa, 2000 (163 pages). Harare, Zimbabwe, No 2001 (available from http://www.afro.who.int/aids/surveillance/ resources/hiv_surveillance_report_2000.pdf). 12 .Institut Pasteur d’Algérie, Laboratoire National de Référence de l’Infection VIH/SIDA. Rapports 1985 – 2005. 13 .Mohammedi D, Laboratoire National de Référence de l’Infection VIH/SIDA, Institut Pasteur d’Algérie (personal communication, 2004).

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14 .Enquête algérienne sur la santé de la famille (in French, 375 pages). Algiers, Algeria, Ministère de la Santé, de la Population et de la Réforme Hospitalière & Office National des Statistiques & Ligue des États Arabes, July 2004. 15 .Institut National de Santé Publique. Rapports des maladies à déclaration obligatoire, 1990 - 1998. Algiers, Algeria, Ministère de la Santé, de la Population et de la Réforme Hospitalière. 16 .Worldbank/WHO/UNAIDS report, 2002. 17 .Sahraoui Tahar A, Akhamoukh I, Khiati M. Enquête sur l’infection VIH/SIDA chez les lycéens scolarisés à Tamanrasset. Santé Plus (journal de formation et d’informations médicales) N° 73 : pages 41-42. Algiers, Algeria, Fondation Nationale pour la Promotion de la Santé et le Développement de la Recherche Médicale (FOREM), Décembre 2004. 18 .Sahraoui Tahar A, Akhamoukh I, Khiati M. Enquête sur l’infection VIH/SIDA dans la population clandestine de Tamanrasset. Santé Plus (journal de formation et d’informations médicales) N° 73 : pages 43-44. Algiers, Algeria, Fondation Nationale pour la Promotion de la Santé et le Développement de la Recherche Médicale (FOREM), December 2004. 19 .Medjaoui et all. Etude des connaissances, attitudes et pratiques sur les maladies sexuellement transmissibles (MST/SIDA) auprès des jeunes militaires (in French). Algiers, Algeria, Ministère de la Défense Nationale, 1999. 20 .Belkaïd Rezki R, Graba MK. Sexualité chez les étudiants en médecine d’Alger (communication) à la Xème conférence internationale sur les MST/SIDA en Afrique, Abidjan, 7-11 December 1997. 21 .Meziane A et al. Enquête CAP SIDA 2002 (Alger, Khenchela, Oran, Ouargla, Tamanrasset) (15 pages, in French). Algiers, Algeria, Service de Communication Sociale, Institut National de Santé Publique (INSP), Ministère de la Santé, de la Population et de la Réforme Hospitalière (MSPRH), July 2002. 22 .Mokhtari L, Belkaid R, Belateche F. Situation épidémiologique de l’infection VIH/SIDA. Santé Plus (journal de formation et d’informations médicales) N° 73 : pages 9-12. Algiers, Algeria, Fondation Nationale pour la Promotion de la Santé et le Développement de la Recherche Médicale (FOREM), December 2004. 23 .Processus de planification stratégique de lutte contre les IST/VIH/SIDA, Algérie, 2002- 2006 (201 pages, in French). Algiers, Algeria, Direction de la Prévention, Ministère de la Santé, de la Population et de la Reforme Hospitalière, 2001. (available from http://www.ands.dz). 24 .ONUSIDA, Région pour l'Afrique du Nord et le Moyen Orient (MENA). Documents sur CD-Rom de «l’Atelier pour le Renforcement des Capacités de Planification Stratégique VIH/SIDA, Suivi et Evaluation, pour l'Afrique du Nord et le Moyen Orient», 3-6 décembre 2003, Tunis, Tunisie. 25. Fares EG. Rapport sur la surveillance épidémiologique en Algérie (30 pages, in French). Algiers, Algeria, Commission Épidémiologie du CNLS, 2002. 26. Adjovi C. Consultation pour le renforcement des activités de surveillance VIH/SIDA en Algérie (25 janvier – 8 février 2003) (30 pages, in French). Harare, Zimbabwe, WHO Regional Office for Africa, 2003.

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27 .Rapport d’activité du Comité Sectoriel de Lutte contre les IST/VIH/SIDA, 2005 (in rench, 2 pages). Algiers, Algeria, Direction Générale de l’Administration Pénitentiaire et de la Réinsertion, Ministère de la Justice, 2005. 28 .Belkaïd R, Aouchiche Y, Graba MK (SEMEP CHU Alger centre). Perceptions et connaissances sur le SIDA en 1992 chez les étudiants en médecine d’Alger (communication). Sétif 3/4 juin 1992 29 .Belkaïd Rezki R, Graba MK. Sexualité chez les étudiants en médecine d’Alger (communication) à la Xème conférence internationale sur les MST/SIDA en Afrique, Abidjan, 7-11 December 1997. 30.Khiati M. Rôle des ONGs dans la lutte contre le SIDA (pages 113-121). In : « L’infection VIH-SIDA, l’expérience algérienne. » (272 pages). Algiers, Algeria, Editions FOREM, 2004 (ISBN 9947-0-0294-2). 31 .Meziane A et al. Sondage Jeunes & SIDA 1998-99 (Alger, Biskra, Oran) (11 pages, in French). Algiers, Algeria, Service de Communication Sociale, Institut National de Santé Publique (INSP), Ministère de la Santé, de la Population et de la Réforme Hospitalière (MSPRH), February 1999. 32 .Behavioral Surveillance Surveys – Guidelines for Repeated Behavioral Surveys in Populations at Risk for HIV (350 pages). Arlington VA, USA, Family Health International, 2000. (available from http://www.fhi.org).

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APPENDIX 1

Consultation/preparation process for the National Report on monitoring the follow-up to the Declaration of commitment on HIV/AIDS

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Appendix 1. Consultation/preparation process for the National Report on monitoring the follow-up to the Declaration

1) Which institutions/entities were responsible for filling out the indicator forms?

a) NAC or equivalent xYes No b) NAP xYes No c) Others Yes No (Please specify)

2) With imputs from

Ministries: Yes No Education Yes No Health xYes No Labour Yes No Foreign Affairs Yes No Others (Please specify) Ministries of xYes No Justice, Religious Affairs, Defense Civil society organizations xYes No People living with HIV/AIDS xYes No Private sector Yes xNo United Nations organizations xYes No Bilaterals Yes xNo International NGOs Yes xNo Others (Please specify) Yes xNo

3) Was the report discussed in a large forum? Yes xNo 4) Are survey results stored centrally? Yes xNo 5) Are date available for public consultation? Yes xNo

Name / title: _Dr OUAHDI Director of Prevention of the Ministry of Population Health and Hospital Reform

Date: ______

Signature: ______

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Appendix 1. Consultation/preparation process for the National Report on monitoring the follow-up to the declaration of commitment on HIV/AIDS

The process required the use of an active methodology based on:

- Meetings with governmental sectors and civil society - A perpetual effort in partnership with the members of the NAC’s Epidemiology commission - Consultations as and when required with the various sectors (Ministries – NGOs) - Information gathering (Reports - surveys, etc)

TEAM

It is made up of:

1. An international expert, Mr YON FLEERACKERS, in charge of providing support to Algeria from 29 November to 7 December 2005, for drawing up the 2005 UNGASS report "United Nations declaration of commitment on HIV/AIDS”, adopted by 189 States including Algeria in June 2001.

2. Dr LOUNNAS, head of UNAIDS in Algiers

2. The NAC’s Epidemiology Commission with:

- The following members:

. Pr FARES, epidemiologist, head of the Commission . Dr CHERIET, biologist . Dr ZAIDI, epidemiologist . Dr CERBAH, infectious diseases specialist . Dr CERBAH, general practitioner who took part in all the work carried out from 29 November to 7 December 2005

- Les Profs. MOKHTARI (epidemiologist) and AMRANE (infectious diseases specialist) as well as Dr MESBAH were consulted during some working sessions

3. The Department of prevention

Drs AIT OUBELLI (AIDS programme) and MERBOUT (Deputy director of the Ministry of Population Health and Hospital Reform - MSPRH -) were involved in all work carried out

4. Sectors The sectors (Ministries and NGOs) were invited to participate in several meetings where all participants were gathered. During the first meeting, held on 30 November 2005 at the Ministry of Population Health and Hospital Reform, the international expert presented the mission goals as well as the the UNGASS report goals.

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The sectors were furthermore requested to submit their activity report at a meeting scheduled for Monday, 5 December at 2 pm with the members of the team, in order to draw up programme indicators. A restitution meeting was held on Wednesday, 7 December at the Ministry of Population Health and Hospital Reform during which Prof. FARES presented a draft of the Algerian UNGASS report and the international expert made a presentation on monitoring & evaluation, followed by a discussion. Some sectors and NGOs held several other working sessions with Prof. FARES to develop programme (prevention and testing) indicators. 5. Other people

Mr MEZIANE, charged with electronically capturing and using data obtained from the national 2004 HIV-sentinel surveillance.

METHODOLOGY

1. Working sessions, with some board members ensuring health-care for patients along with sector managers (Ministries and NGOs), were held to:

- Complete the 2006 national composite policy index especially the points relative to an individual’s right to take part in civil society: Prof. MEHDI (medical expert) in particular studied the section entitled “human rights”

- Develop some missing indicators relative to treatment

2. The members of the Epidemiology Commission drafted a section on comments of section A of the national composite policy index.

3. Contacts were made with institutions (National Institute of Public Health, National Statistics Office) and researchers to obtain the documents required to draw up the report

4. Prof. FARES (national expert) and Mr FLEERACKERS (international expert) continued to work on the various sections of the report by email for the drafting of the final UNGASS report.

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APPENDIX 2

Questionnaire on the national composite policy index (via the CRIS)

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Appendix 2. National composite policy index – 2006

Country: Algeria

Name of the National AIDS Committee officer in charge: Prof. A. DIF

Signed by: Name and title

Address: Specialized Hospital Institution (EHS) El-Kettar Algiers Algeria

TEL:

FAX: EMAIL:

DATE:

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Part A of the questionnaire on the national composite policy index

I. Strategic plan

1. Has your country developed a national multi-sectoral strategy/action framework to combat HIV/AIDS? (Multi-sectoral strategies should include, but not be limited to, those developed by Ministries such as the ones mentioned below.)

Yes No Not Applicable Period covered: 2002- (N/A) 2006

1.1 If YES, which sectors are included?

Sectors Strategy/Action Focal included framework point/Responsible Health Yes No Yes No Education Yes No Yes No Labour Yes No Yes No Transportation Yes No Yes No Military Yes No Yes No Women Yes No Yes No Youth Yes No Yes No Others to Yes No Yes No specify

Comments:

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1.2 If YES, does the national strategy/action framework address the following areas, target populations and cross-cutting issues? (Yes/No)

Programme a. ______oui ______a. Voluntary counselling and testing? b. ______oui +-______b. Condom promotion and distribution? c. ______oui +-______c. STI prevention and treatment? d. ______oui ______d. Blood safety? e. ______oui +-______e. Prevention of mother-to-child transmission? f. ______oui +- ______f. Breastfeeding? g. ______oui ______g. Care and treatment? h. ______oui +-______h. Migration?

Target populations

i. Women and girls? i. ______oui ______j. Youth? j. ______oui ______k. ______oui +-______k. Most-at-risk populations? l. ______non ______l. Orphans and other vulnerable children?

Cross-cutting issues

m. HIV/AIDS and poverty? n. Human rights? m. _____ oui +- o. PLHA involvement? ______n. ______oui ______o. ______oui ______

1.3 If YES, does it include an operational plan? Yes No

1.4 If YES, does the strategy/operational plan include: Yes No

a. formal programme goals? Yes No

b. detailed budget of costs? Yes No

c. indicators of funding sources?

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Yes No

1.5 Has your country ensured “full involvement and participation” of civil society in the planning phase? Yes No

1.6 Has the national strategy/action framework been Yes No

endorsed by key stakeholders?

Comments:

2. Has your country integrated HIV/AIDS into its general development plans such as: a) National Development Plans, b) United Nations Development Assistance Framework, c) Poverty Reduction Strategy Papers, and d) Common Country Assessments?

Yes No N/A

2.1 If YES, in which development plan? a)_yes_ b) _no_ c) _no_ d): yes other

Covering which of the following aspects? (Yes/No)

a) b) c) d) HIV Prevention yes yes Care and support yes yes HIV/AIDS impact alleviation yes +- yes +- Reduction of gender inequalities as yes yes relates to HIV prevention/care Reduction of income inequalities as yes yes relates to HIV prevention/care Others: no no

3. Has your country evaluated the impact of HIV and AIDS on its economic development for planning purposes ?

Yes No N/A

3.1 If YES, how much has it informed resource allocation decisions? (Low to High)

Low High 0 1 2 3 4 5 6 7 8 9 10

4. Does your country have a strategy/action framework for addressing HIV and AIDS issues among its national uniformed services

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military, peacekeepers and police?

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4.1 If YES, which of the following have been implemented?

HIV Prevention Yes No Care and support Yes No Voluntary HIV testing and counselling Yes No

Mandatory HIV testing and counselling Yes No Others to specify Yes No

Overall, how would you rate strategy planning efforts in the HIV and AIDS programmes?

2005 Poor Good

0 1 2 3 4 5 6 7 8 9 10

2003 Poor Good

0 1 2 3 4 5 6 7 8 9 10

In case of discrepancies between the 2003 and 2005 rating, please provide main reasons supporting such difference:

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II- Political support Political support

Strong political support includes government and political leaders who speak out often about AIDS and regularly chair important meetings, allocate national budgets to support the AIDS programmes and effectively use government and civil society organizations and processes to support effective AIDS programmes.

1. Does the head of the government and/or other high officials speak publicly and favourably about AIDS efforts at least twice a year?

Head of government Yes No Yes No Other high officials

2. Does your country have a multi-sectoral HIV and AIDS management/coordination body recognized in law? (National AIDS council or Commission)

Yes No N/A

2.1 If YES, when was it created? Year: 1989

2.2 Does it include?

Terms of reference Yes No Defined membership Including civil society People living with HIV Private sector Yes No Action plan Yes No Functional Secretariat Yes No Date of last meeting of the Secretariat Date: 23 November 2005

Comments:

3. Does your country have national HIV and AIDS body that promotes interaction between government, people living with HIV, the private sector and civil society for implementing HIV and AIDS strategies/programmes?

Yes No N/A

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3.1 If YES, does it include?

Terms of reference Yes No Defined membership Yes No Action plan Yes No Functional Secretariat Yes No Date of last meeting Date:

Comments:

4. Does your country have national HIV and AIDS body that is supporting coordination of HIV-related service delivery by civil-society organizations?

Yes No N/A

4.1 If YES, does it include?

Terms of reference Yes No Defined membership Yes No Action plan Yes No Functional Secretariat Yes No Date of last meeting Date:

Comments:

Overall, how would you rate strategy planning efforts in the HIV and AIDS programmes?

2005 Poor Good

0 1 2 3 4 5 6 7 8 9 10

2003 Poor Good

0 1 2 3 4 5 6 7 8 9 10

In case of discrepancies between the 2003 and 2005 rating, please provide main reasons supporting such difference:

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III. Prevention

1. Does your country have a policy or strategy to promote information, education and communication (IEC) on HIV and AIDS to the general population?

Yes No N/A

1.1 In the last year, did you implement an active programme to promote accurate HIV and AIDS reporting by the media?

X yes No

Comments:

2. Does your country have a policy or strategy promoting HIV and AIDS-related reproductive and sexual health education for young people?

Yes No N/A

2.1 Is HIV education part of the curriculum in:

primary schools? Yes No Yes No secondary schools?

2.2 Does the strategy/curriculum provide the same reproductive and sexual health education for young men and young women? Yes No

Comments:

3. Does your country have a policy or strategy to promote IEC and other preventive health interventions for most-at-risk populations?

Yes No N/A

10 Strategies/policies discussed under Prevention may be included in the national strategy/action framework discussed in I.1 or separate.

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3.1 Does your country have a policy or strategy for these most-at-risk populations?

Injecting drug users, including: - Risk reduction information, education and counselling? Yes NoNo N/A - Needle and syringe programmes? Yes No N/A - Treatment services? Yes No N/A - If yes, drug substitution treatment? Yes N/A Men who have sex with men? Yes No N/A Sex workers? Yes No N/A Prison inmates? Yes No N/A Cross-border migrants, mobile populations? Yes No N/A Refugees and/or displaced populations? Yes No N/A Other most-at-risk populations? Please specify Yes No N/A

Comments:

4. Does your country have a policy or strategy to expand access, including among most-at-risk populations, to essential preventative commodities? (These commodities include, but are not limited to, access to confidential voluntary counselling and testing, condoms, sterile needles and drugs to treat STIs.)

Yes No N/A

4.1 Do you have programmes in support of this policy or strategy?

A social-marketing programme for condoms? Yes No A blood-safety programme? Yes No A programme to ensure safe injections in Yes No health-care settings? A programme on antenatal syphilis screening? Yes No Other programmes Please specify Yes No

Comments:

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Overall, how would you rate policy efforts in support of prevention?

2005 Poor Good

0 1 2 3 4 5 6 7 8 9 10

2003 Poor Good

0 1 2 3 4 5 6 7 8 9 10

In case of discrepancies between the 2003 and 2005 rating, please provide main reasons supporting such difference:

5. Which of the following prevention activities have been implemented in 2003 and 2005 in support of the HIV-prevention policy/strategy? (Check all programmes that are implemented beyond the pilot stage to a significant portion in both the urban and rural populations).

2003 2005 a. A programme to promote accurate a Yes a Yes HIV and AIDS reporting by the media

b. A social-marketing programme for condoms? b No b No

b. School-based AIDS education for c Yes c Yes young people

d. Behaviour-change communications d No d No

e. Voluntary counselling and testing e No e No

f. Programmes for sex workers f. No f. No

g. Programmes for men who have g No g No sex with men

h. Programmes for injecting drug users, if applicable h Yes h Yes

i. Programmes for i No i No most-at-risk populations

j. Blood safety j Yes j Yes

k. Programmes to prevent mother-to-child transmission of k Yes k Yes HIV l Yes l Yes l. Programmes to ensure universal precautions in health-care settings m m

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m. Other (Please specify)

Overall, how would you rate the efforts in the implementation of HIV prevention programmes?

2005 Poor Good 0 1 2 3 4 5 6 7 8 9 10

2003 Poor Good

0 1 2 3 4 5 6 7 8 9 10

In case of discrepancies between the 2003 and 2005 rating, please provide main reasons supporting such difference:

V.

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Soins et appui11 IV. Care and support

1. Does your country have a policy or strategy to promote comprehensive HIV and AIDS care and support, with sufficient attention to barriers for women, children and most-at-risk populations? (Comprehensive care includes, but is not limited to, confidential voluntary counselling and testing, psychosocial care, psychosocial care, access to medicines, and home and community-based care.)

Yes No N/A

2. Which of the following activities have been implemented under the care and treatment of HIV and AIDS programmes?

2003 2005 a. HIV screening of blood transfusions a Yes a Yes

b. Universal precautions b Yes b Yes

c. Treatment of opportunistic infections c Yes c Yes

d. Antiretroviral therapy (ART) d Yes d Yes

e. Nutritional care e No e No

f. STI care f Yes f Yes

g. Family planning services g Yes g Yes

h. Psychosocial support for people living with HIV and h Yes h Yes their families

i. Home-based care i No i No

j. Palliative care and treatment of common j Yes j Yes HIV-related infections: pheumonia, oral thrush, vaginal candidiasis and pulmonary TB (DOTS) k Yes k Yes k. Cotrimoxazole prophylaxis among HIV-infected people l Yes l Yes l. Post exposure prophylasix (e.g. occupational exposures to HIV, rape) m m

m. Other (Please specify)

Comments:

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Overall, how would you rate the efforts in care and treatment of the HIV/AIDS programme?

2005 Poor Good 0 1 2 3 4 5 6 7 8 9 10

2003 Poor Good

0 1 2 3 4 5 6 7 8 9 10

3. Does your country have a policy or strategy to address the additional HIV and AIDS-related needs of orphans and other vulnerable children (OVC)?

Yes No N/A

3.1 If YES, Is there and operational definition for orphans and other vulnerable children in the country?

Yes No

If YES, please provide definition: ______

3.2 Which of the following activities have been implemented under orphan and vulnerable children programmes? 2003 2005 Payment of school fees for orphans and vulnerable children Community programmes Others: (Please specify)

Comments:

Overall, how would you rate the efforts to meet the needs of orphans and other vulnerable children?

2005 Poor Good 0 1 2 3 4 5 6 7 8 9 10

2003 Poor Good

0 1 2 3 4 5 6 7 8 9 10

In case of discrepancies between the 2003 and 2005 rating, please provide main reasons supporting

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such difference:

valuation V. Monitoring and evaluation

1. Does your country have a national monitoring and evaluation plan?

Yes No x In progress Years covered:

1.1 If YES, was it endorsed by key partners in evaluation? Yes No

Comments:

1.2 Was the monitoring and evaluation plan developed in consultation with civil society and people living with HIV?

Yes No

2. Does the Monitoring and Evaluation plan include?

a data collection and analysis strategy Yes No a well-defined standardized set of indicators Yes No guidelines on tools for data collections Yes No a strategy for assessing quality and accuracy of Yes No data a data dissemination and use strategy Yes No

3. Is there a budget for the monitoring and evaluation plan?

Yes No x In progress Years covered:

3.1 If YES, has funding been secured? Yes No

Yes No

4. Is there a monitoring and evaluation functional Unit or Department?

Yes No x In progress

If YES,

based on NAC or equivalent? based in Ministry of Health? elsewhere? Please specify Yes No Yes No

4.1 If YES, are there mechanisms in place to ensure that all major implementing partners

65

submit their reports to this Unit or Department? Yes No

Comments:

4.2 Is there a full-time officer responsible for monitoring and evaluation activities of the national programme?

Yes, full time Yes, part-time xNo monitoring and evaluation officer

4.3 If YES, since when? : Year ______

5. Is there a committee or working group that meets regularly coordinating monitoring and evaluation activities?

Yes, xYes, No Date of last meeting: 23/11/2005 irregular irregular

5.1 Does it include representation from civil society, people living with HIV? Yes No

6. Have individual agency programmes been reviewed to harmonize monitoring and evaluation indicators with those of your country?

Yes No N/A

7. To what degree (Low to High) are UN, bi-laterals, other institutions sharing monitoring and evaluation results?

Low High 0 1 2 3 4 x5 6 7 8 9 10

Comments:

8. Does the Monitoring and Evaluation Unit manage a central national database?

Yes No N/A

8.1 If YES, what type is it? ______

9. Is there a functional Health Information System? National level Yes No Yes No 66

Subnational*

(*reporting regularly data from health facilities aggregated at district level and sent to national level, analyzed, and used at different levels.)

Comments:

10. Is there a functional Education Information System? National level Yes No Yes No Subnational*

* If YES, please specify the level (e.g. district)

11. Does your country publish at least once a year an evaluation report on HIV and AIDS, including HIV surveillance reports?

Yes No N/A

12. To what extent (Low to High) is strategic information used in planning and implementation?

Comments:

13. In the last year, was training in monitoring and evaluation conducted?

At national level? Yes No At subnational level? Yes No Including civil society? Yes No

Overall, how would you rate the monitoring and evaluation efforts of the HIV and AIDS programmes?

2005 Poor Good 0 1 2 3 4 5 6 7 8 9 10

2003 Poor Good

0 1 2 3 4 5 6 7 8 9 10

In case of discrepancies between the 2003 and 2005 rating, please provide main reasons supporting such difference:

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COMMENTS ON APPENDIX II SECTION A

I – Strategic level

1.1 - Our country has developed a multisectoral framework of action for the control of STIs/HIV/AIDS. This includes the following sectors: Health, Education, Employment and Solidarity, Transport, National Defence, Youth and Sport, Culture, Communication, Religious Affairs, Justice, Higher Education, the Interior Ministry and Local Authorities, Post Office and Telecommunications and, finally, Tourism. Each of these ministerial sectors has a sector-wide committee for STI/HIV/AIDS control and a large number of them have Operational Action Plans (11 OAP).

1.2 – This framework of action covers the following areas:

- Counselling and voluntary testing - Promotion and distribution of condoms - Prevention and treatment of sexually transmitted infections (STIs) - Blood safety - Prevention of mother-to-child transmission through the application of the corresponding protocol - Care and treatments - Migration

This programme is aimed at the following population groups: - Women and girls - Young people - The highest risk populations (Injecting drug users -IDU- and female sex workers)

Issues relating to HIV/AIDS and poverty, individual freedoms and the participation of people living with HIV shall also be covered by these actions. With this in mind, an operational plan has been set in place, including the objectives of the official programme and a budget for the costs, in addition to indicators for the sources of finance, while ensuring that civil society is involved in the planning phase. This framework has been endorsed by all of the interested parties.

1.3 – Algeria has incorporated the HIV/AIDS question into its global development programmes and especially into the national development programmes and the Common Country Assessment.

The main aspects covered are as follows: : - HIV prevention - Treatment and support - Reducing the impact of HIV and AIDS

1.4 – Algeria has a strategy for tackling HIV/AIDS-related issues within its national services, uniformed services, armed forces and police. This includes the following aspects:

- HIV prevention - Treatment and support - Counselling and voluntary testing

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- Improved availability of ARV treatments - Availability of condoms - Identification of associations due to the Global Fund

In 2003 and 2005, efforts were made to improve the response to HIV/ AIDS, focussing on improving access to condoms and antiretroviral (ARV) treatments and increasing the involvement of associations, especially in the Information, Education and Communication (IEC) field.

1.6- There is no multisectoral monitoring-evaluation plan. Because of this, information is not sent to an identified central structure (monitoring-evaluation unit of the CNLS)

II – Political support

2 – The country’s higher authorities lend their support publicly and positively to the AIDS response efforts.

3 2.1 – Algeria’s National STI/HIV/AIDS Control Committee (Comité national de lutte contre les IST/HIV/AIDS [CNLS]) has been in existence since 1989. This committee was created by Ministerial Order. Its secretaryship is provided by the Department of Prevention of the Ministry of Public Health and Hospital Reform (Ministère de la santé de la population et de la réforme hospitalière [MSPRH]). In the beginning, the majority of the committee’s members came from the medical sector, with representatives from other departments such as the Ministries of Higher Education and Religious Affairs. Furthermore, there are no other national bodies with responsibility for HIV/AIDS in Algeria.

2.2- The last meeting of the CNLS took place on 23rd November 2005, when preparations were made for World AIDS DAY and the arrival of the international expert assisting with the drafting of the UNGASS report. Also on the agenda was the setting up of the monitoring-evaluation unit.

4. The improvement in scores between 2003 and 2005 may be explained by the financial support of the Global Fund, UNAIDS and bilateral cooperation, etc.

III – Prevention

1 –Algeria has a policy of promoting IEC activities. However, these activities only happen sporadically and mainly concern information. It should be noted that no evaluations have been carried out so far and that this activity lacks continuity.

2–HIV/AIDS-related education has captured the attention of our authorities and is thus included in study programmes in the mixed secondary schools.

3– For the highest risk populations, essentially injecting drug users (IDUs) and female sex workers, Algeria uses a strategy of IEC promotion.

The following activities are implemented for IDUs:

- Information, education and advice on reducing risks - Existence of treatment services; however, there is no available information on substitution therapy. This promotion of IEC concerns prison inmates and female sex workers in the

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places where they are based, following the example of the health centre in the wilaya of Oran. For cross-border migrants and mobile population groups, there is a treatment project based on reintegrating these people into their countries of origin.

4– Algeria has a strategy of facilitating access to the main prevention-related services, including for those people who belong to the highest risk population groups. These services include:

- Access to counselling and voluntary, confidential testing - Provision of condoms - Provision of medication for treating STIs - Guaranteeing blood safety - Prenatal syphilis screening programme - Provision of risk-free injections in treatment centres, although there is sometimes a shortage of disposable equipment.

There is no needle exchange programme for injecting drug users. Between 2003 and 2005, there was a clear improvement in blood safety (99.99 %) and improved access to condoms, thanks to the efforts of high-profile associations in the field. Free, Anonymous Treatment Centres (Centres de dépistage volontaire et anonyme [CDAG]) were set up with a view to encouraging voluntary, anonymous screening.

In addition, a programme for the prevention of mother-to-child HIV transmission (MTCT) has been established at the level of the Reference Centres.

The difference in scores for the two years may be explained by the following reasons:

- Improved organisation of the actions - Involvement of associations - Sectoral operational action plans

5- The difference between the two scores may be explained by an improved approach, combined with a blood safety of 99%.

IV – Treatment and support

1 – Algeria has a complete strategy for the promotion of treatment and support for HIV AIDS.

2– The evaluation of the actions undertaken can be described as “adequate”. The identification of all of the obstacles has not yet been carried out.

The following actions have been implemented in the framework of the HIV and AIDS treatment and care programme:

- HIV screening of all blood units destined for transfusion, with a clear improvement in 2005 - Systematic precautions in hospitals, featuring close cooperation with the Committee for the Control of Nosocomial Infections (Comité de lutte contre les infections nosocomiales [CLIN]) - Treatment for opportunist infections - Antiretroviral treatment - Treatment for STIs - Family planning activities

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- Psychosocial support for people living with HIV and their families - Palliative care and treatment for common HIV-related infections (pneumonia, buccal and vaginal candidiasis and pulmonary tuberculosis) - Post-exposure prophylaxis, essentially for blood exposure. The preventive treatment is administered no later than 48 hours after the exposure. The rare rape cases which are seen by the medical services are treated.

- Clear improvements have been observed in the treatment and care programme, thanks to the improved availability of ARV treatments, the acquisition of equipment providing improved immuno-virological monitoring (CD4 and viral load) and the development of a National Consensus on bioclinical treatment. Nothing has yet been done about the development of home-based care for AIDS sufferers.

V – Monitoring - evaluation

The creation of a national monitoring and evaluation plan is underway. A budget is being drawn up and a management body for the system is currently being established. At present, the monitoring and evaluation of STI/HIV/AIDS-related activities are the responsibility of the National STI/HIV/AIDS Control Committee, whose last meeting took place on 23rd November 2005. Our country also has a functional information system for education

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Part B of the questionnaire on the national composite policy index

I. Human rights I. Human rights 1. Does your country have laws and regulations that protect people living with HIV and AIDS against discrimination (such as general non-discrimination provisions or those that specifically mention HIV, that focus on schooling, housing employment, etc.) ?

Yes No N/A

Comments: contractualization, criminal law, social law that protects patients regardless of their disease

2. Does your country have non-discrimination laws and regulations that specify protections for certain groups of people identified as being especially vulnerable to HIV and AIDS discrimination (i.e., groups such as injecting drug users, men who have sex with men sex workers, young people, mobile populations and prison inmates)?

Yes No N/A

If YES, please list groups: contractualization, criminal law, social law that protects patients regardless of their disease

3. Does your country have laws and regulations that present obstacles to effective HIV prevention and care for most-at-risk groups?

Yes No N/A

If YES, please list groups:

4. Is the promotion and protection of human rights explicitly mentioned in any HIV and AIDS policy/strategy?

Yes No N/A

Comments: very high level political commitment

5. Has your government, through political and financial support, involved vulnerable populations in governmental HIV-policy design and programme implementation?

Yes No N/A 73

If YES, please list groups:

6. Does your country have a policy to ensure equal access, between men and women, to prevention and care?

Yes No N/A

Comments: vulnerable groups on the Commission throughout civil society MSM

7. Does your country have a policy to ensure equal access to prevention and care for most-at-risk populations?

Yes No N/A

Comments:

8. Does your country have a policy prohibiting HIV screening for general employment purposes (appointment, promotion, training benefits)?

Yes No N/A

9. Does your country have a policy to ensure that HIV and AIDS research protocols involving human subjects are reviewed and approved by a national/local ethical review committee?

Yes No N/A

9.1 If YES, does the ethical review committee include civil society and people living with HIV?

Yes No N/A

Comments: there is no representative for this policy

10. Does your country have the following monitoring and enforcement mechanisms?

Collection of information on human rights and HIV and AIDS Yes No issues and use of this information in policy and programme development reform Existence of independent national institutions for the promotion Yes No and protection of human rights, including human rights commissions, law reform commissions and ombudspersons which consider HIV-and AIDS-related issues within their work Establishment of focal points within governmental health and Yes No other departments to monitor HIV-related human rights abuses Development of performance indicators or benchmarks for Yes No compliance with human rights standards in the context of HIV and AIDS efforts

11. Have members of the judiciary been trained/sensitized

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to HIV and AIDS and human rights issues that may come up in the context of their work?

X Yes No N/A

12. Are the following legal support services available in your country?

Legal laid systems Yes No for HIV and AIDS casework State support to private sector law firms Yes No or university based centres to provide free pro bono legal services to people living with HIV and AIDS in areas such as discrimination Programmes to educate, raise awareness among people living Yes No with HIV and AIDS in areas such as discrimination

13. Are there programmes designed to change societal attitudes of discrimination and stigmatization associated with HIV and AIDS to understanding and acceptance?

Overall, how would you rate the policies, laws and regulations in place to promote and protect human rights in relation to HIV and AIDS?

2005 Poor Good 0 1 2 3 4 5 6 7 8 9 10

2003 Poor Good

0 1 2 3 4 5 6 7 8 9 10

In case of discrepancies between the 2003 and 2005 rating, please provide main reasons supporting such difference: civil society is more present in the field

Overall, how would you rate the effort to enforce the existing policies, laws and regulations?

2005 Poor Good 0 1 2 3 4 5 6 7 8 9 10

2003 Poor Good

0 1 2 3 4 5 6 7 8 9 10

In case of discrepancies between the 2003 and 2005 rating, please provide main reasons supporting such difference:

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II. Civil society involvement

1. To what extent (Low to High) has civil society made a significant contribution to strengthening the political commitment of top leaders and national policy formulation? Low High 0 1 2 3 4 5 6 7 8 9 10

2. To what extent (Low to High) have civil society representatives been involved in the planning and budgeting process for the National Strategic Plan on HIV and AIDS or for the current activity plan (attending planning meetings and reviewing drafts)? Low High 0 1 2 3 4 5 6 7 8 9 10

3. To what extent (Low to High) are the complimentary services provided by civil society to areas of prevention and care included in both the National Strategic plans and reports? Low High 0 1 2 3 4 5 6 7 8 9 10

4. Has your country conducted a National Periodic review of the Strategic Plan with the participation of civil society in:

Yes XNo N/A

Month __December ______Year _____2005______

5. To what extent (Low to High) does your country have a policy to ensure that HIV and AIDS research protocols involving human subjects are reviewed and approved by an independent national/local ethical review committee in which people living with HIV and caregivers participate?

Low High 0 1 2 3 4 5 6 7 8 9 10

Overall, how would you rate the efforts to increase civil-society participation?

2005 Poor Good

0 1 2 3 4 5 6 7 8 9 10

2003 Poor Good

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0 1 2 3 4 5 6 7 8 9 10

In case of discrepancies between the 2003 and 2005 rating, please provide main reasons supporting such difference: there are no clinical trials on HIV/AIDS

III. Prevention

1. Which of the following prevention activities have been implemented in 2003 and 2005 in support of HIV-prevention policy/strategy? (Check all programmes that are implemented beyond the pilot stage to a significant portion in both the urban and rural populations).

2003 2005 a. A programme to promote accurate a. Yes +- a. Oui +- HIV and AIDS reporting by the media

b. A social-marketing programme for condoms? b. No b.Non

b. School-based AIDS education for c Yes c Oui young people

d. Behaviour-change d. Yes +- d. Oui +- communications

e. Voluntary counselling and testing e Yes +- e Oui +-

f. Programmes for sex workers f. No f Non

g. Programmes for men who have sex g No g Non with men

h. Programmes for injecting drug users, if applicable h Yes+- h Oui+-

i. Programmes for other most-at-risk populations i No i Non (mobile populations)

j. Blood safety j Yes j Oui

k. Programmes to prevent mother-to-child k. Yes k. Oui transmission of HIV .l. Yes .l. Oui l. Programmes to ensure universal precautions in health-care settings

m. Other (Please specify)

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Overall, how would you rate the efforts in the implementation of HIV-prevention programmes?

2005 Poor Good

0 1 2 3 4 5 6 7 8 9 10

2003 Poor Good

0 1 2 3 4 5 6 7 8 9 10

In case of discrepancies between the 2003 and 2005 rating, please provide main reasons supporting such difference: duplication of society, multi-lateralness, political support

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IV Care and support

1. Which of the following activities have been implemented under the care and treatment of HIV and AIDS programmes?

2003 2005 a. HIV screening of blood transfusions a. Yes a. Yes

b. Universal precautions b. Yes b. Yes

c. Treatment of opportunistic infections c Yes c Yes

d. Antiretroviral therapy d. Yes d. Yes

e. Nutritional care e No e No

f. STI care f Yes f Yes

g. Family planning services g Yes g Yes

h. Psychosocial support for people living with HIV and h Yes+- h Yes+- their families

i. Home-based care i No i No

j. Palliative care and treatment of common j Yes j Yes HIV-related infections: pheumonia, oral thrush, vaginal candidiasis and pulmonary TB (DOTS) k. Yes k. Yes k. Cotrimoxazole prophylaxis among HIV-infected people l. Yes l. Yes l. Post exposure prophylasix (e.g. occupational exposures to HIV, rape) m m

m. Other (Please specify)

Overall, how would you rate the care and treatment efforts of the HIV and AIDS programme?

2005 Poor Good

0 1 2 3 4 5 6 7 8 9 10

2003 Poor Good

0 1 2 3 4 5 6 7 8 9 10

In case of discrepancies between the 2003 and 2005 rating, please provide main reasons supporting such difference:

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2. Does your country have a policy or strategy to address the additional HIV and AIDS-related needs of orphans and other vulnerable children?

Yes xNo N/A

2.1 Which of the following activities have been implemented under orphan and vulnerable children programmes? 2003 2005 Payment of school fees for orphans and Yes Yes vulnerable children Community programmes Others: (Please specify)

Overall, how would you rate the efforts to meet the needs of orphans and other vulnerable children? 2005 Poor Good

0 1 2 3 4 5 6 7 8 9 10

2003 Poor Good

0 1 2 3 4 5 6 7 8 9 10

In case of discrepancies between the 2003 and 2005 rating, please provide main reasons supporting such difference:

COMMENTS ON APPENDIX II SECTION B

I – Individual freedoms

- The constitution, penal law and social laws inform all patients regardless of their pathology.

- The constitution, penal law and social laws inform all patients regardless of their pathology.

1.4- A commitment exists at a very high level; an association for people living with HIV has been set up and access to care and treatments is provided.

1.5- Vulnerable groups are represented on the national committee through civil society: including men who have sex with men – MSM, sex workers and injecting drug users – IDUs.

1.6- The constitution, penal law and social laws inform all patients regardless of their pathology.

1.7- The constitution, penal law and social laws inform all patients regardless of their pathology.

1.8- This is a general law

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9.1 – There are no representatives for this particular pathology, but a patients’ representative sits on the National Ethics Committee (Comité national de l’Ethique) for all patients

1.3- With regard to HIV and AIDS, have any programmes been created with the aim of changing discriminatory and disparaging attitudes within society, thus encouraging greater understanding and tolerance? Explain the difference in scores between 2003 and 2005.

Civil society has a higher profile in the field. There are a large number of awareness-raising campaigns. The involvement of the authorities is “political”.

Globally, what score would you allocate to the efforts devoted to ensuring the application of the policies, law and existing regulations? Explain the difference in scores between 2003 and 2005. Civil society has a higher profile in the field. There are a large number of awareness-raising campaigns. The involvement of the authorities is “political”

II – Participation of civil society

4- Two national experts will begin the periodic national examination of the Strategic Plan in late December 2005 and January 2006.

5. There are no clinical trials on HIV/AIDS. A common Ethics Committee (Comité d’éthique) exists for all clinical trials.

III– Prevention

The difference between 2003 and 2004 can be put down to the contributions made by civil society, the involvement of multiple sectors and political support

IV– Treatment and support

2.1 The lack of resources available to NGOs should be noted

APPENDIX 3

National Return Forms for programme, knowledge, behaviour and impact indicators

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APPENDIX 3: National Return Forms for programme, knowledge, behaviour and impact indicators

C/LPE: Indicator 1 Government funding for HIV/AIDS

Data sources (name): 1. Proposal entitled “Appui à l’initiative algérienne pour la mise en œuvre du Plan d’action multisectoriel de lutte contre le VIH/SIDA” to the Global Fund to Fight AIDS, TB and Malaria (97 pages, in French). Algiers, Algeria, National Coordinating Committee for Algeria (CCM Algeria), May 2003 (available from http://www.theglobalfund.org). 2. Global Fund to Fight AIDS Activity report 2005 (2 first quarters). Data source (type): 1. Proposal for external funding 2. Information system (data base) – Program monitoring Data collection period 1. From : September 2000 1. To : December 2003 (day/month/year): 2. From : June 2005 2. To : November 2005 Required data US$11,130,000 (including US$6,740,000 from Government funding, US$2,500,000 from the Global Fund to fight AIDS project [3 quarters in 2005, of which US$1,559,344 for Q1 + Q2], US$950,000 for bilateral cooperation, US$840,000 from the United Nations, and US$100,000 from civil society organisations [NGOs],

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C/LPE: Indicator 3 Most-at-risk populations: HIV testing

Data sources (name): 1. Mimouni B, Remaoun N, Abdalla T, Warner-Smith M. Etude du lien potentiel entre usage problématique de drogue et VIH/SIDA en Algérie (86 pages, in French). Algiers, Algeria, Centre de Recherche en Anthropologie Sociale et Culturelle (CRASC), Ministère de l’Enseignement Supérieur et de la Recherche Scientifique (MESRS), October 2005. 2. Rapport d’activité du Comité Sectoriel de Lutte contre les IST/VIH/SIDA, 2005 (in French, 2 pages). Algiers, Algeria, Direction Générale de l’Administration Pénitentiaire et de la Réinsertion, Ministère de la Justice, 2005. 3. Enquête qualitative auprès des professionnelles du sexe (Alger, Oran, Tamanrasset), 2005. ** 4. Données sur le dépistage VIH parmi les patients avec tuberculose Data source (type): 1. Quantitative behavioural survey Report (Rapport d’enquête comportementale quantitative) 2. Information system (data base) – Program monitoring 3. Qualitative behavioural survey Report (Rapport d’enquête comportementale qualitative) 4. Information system (data base) – Program monitoring Data collection period 1. From : September 2004 1. To : December 2004 (day/month/year): 2. From : ? 2. To : ? 3. From: ? 3. To : ? 4. From: ? 4. To : ?

Most-at-risk populations [1.] addicted drug users [2.] People in [3.] Sex workers in [4.] TB infected (including detention PART I: Required data Algiers, Oran, people injecting drug users) (prison population) Tamanrasset in Algeria in Algiers, Annaba, and Oran in Algeria NUMERATOR 1. Number [among the most-at-risk population group] who received 45 Between 200 and 700 ? ? HIV testing in the 12 last months. 2. Number who know the results of 43 ? ? ? this HIV testing. 3. Number who received HIV testing and who know the 43 ? ? ? results. DENOMINATOR 285 problematic users of drugs, Between 4,000 and 4. Total number of [most-at-risk with 142 making injections Between 38,000 and 30 5,000 (89 Algiers, 94 Annaba, 102 42,000 population] Oran) PART II: Calculation of the indicator INDICATOR’S RESULTS BY GROUP OF MOST-AT-RISK POPULATIONS (who 15 % About 1 % ? ? received HIV testing)

* [1. & 3.] Algeria is divided into 5 medical areas: 3 in the North (West, Centre, East) et 2 in the South (South-West, South-East). In north we find the Cities of Oran (Western medical area, Wilaya of Oran), Algiers (Centre medical area, Wilaya of Algiers) and Annaba (Eastern medical area, Wilaya of Annaba). The city of Tamanrasset is located in the southern part of the country (South-Eastern medical area, Wilaya of Tamanrasset).

** [3.] The reporting of the results of the qualitative survey conducted in 2005 among sex workers in 3 cities (Algiers, Oran, Tamanrasset) is planned for January 2006.

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C/LPE: Indicator 4 Most-at-risk populations: prevention programmes

Data sources (name): 1. Mimouni B, Remaoun N, Abdalla T, Warner-Smith M. Etude du lien potentiel entre usage problématique de drogue et VIH/SIDA en Algérie (86 pages, in French). Algiers, Algeria, Centre de Recherche en Anthropologie Sociale et Culturelle (CRASC), Ministère de l’Enseignement Supérieur et de la Recherche Scientifique (MESRS), October 2005. 2. Rapport d’activité du Comité Sectoriel de Lutte contre les IST/VIH/SIDA, 2005 (in French, 2 pages). Algiers, Algeria, Direction Générale de l’Administration Pénitentiaire et de la Réinsertion, Ministère de la Justice, 2005. 3. Enquête qualitative auprès des professionnelles du sexe (Alger, Oran, Tamanrasset), 2005. * 4. Données sur le dépistage VIH parmi les patients avec tuberculose Data source (type): 1. Quantitative behavioural survey Report (Rapport d’enquête comportementale quantitative) 2. Information system (data base) – Program monitoring 3. Qualitative behavioural survey Report (Rapport d’enquête comportementale qualitative) 4. Information system (data base) – Program monitoring Data collection period 1. From : September 2004 1. To : December 2004 (day/month/year): 2. From : ? 2. To : ? 3. From: ? 3. To : ? 4. From: ? 4. To : ? * [3.] The reporting of the results of the qualitative survey conducted in 2005 among sex workers in 3 cities (Algiers, Oran, Tamanrasset) is planned for January 2006. Most-at-risk populations [1.] Problematic users of drug [2.] People in detention [3.] Sex workers in [4.] TB infected (including PART I: Required data (prison population) Algiers, Oran, people injecting drug users) in Algeria Tamanrasset in Algeria in Algiers, Annaba, and Oran NUMERATOR 1. Number (of surveyed people) 400 peer educators trained who had access to outreach and ?? & training of 12 trainers and ? peer education, 90 prison staff 30,000 flyers & 10,000 2. Number (of surveyed people) posters & 35 videocassettes who have access to targeted mass ? (one for each of the biggest media, detention institutions) 3. Number of respondents who have been tested and/or cured for a ? ? STI, 45 ?? 4. Number of respondents who (who have been tested for HIV 900 ? (who have been benefited advice and HIV testing, in the last 12 months) tested for HIV) 20 IDUs surveyed (26 in Dec. 5. Number of responding IDUs 2005) [who have access to who have substitution therapy and CIST safer injection practices, (centres intermédiaires de soins pour toxicomanes)] 6. Number of respondents who One-month sensitization of have been reached by at least on 1,500 prison inmates to ?? ? ? HIV-prevention programme testing during the last 12 months (=18,000 in 12 months) DENOMINATOR 285 drug users, of which 142 From 80,000 to 90,000 Between 4,000 7. Total number of [most-at-risk injecting drug users (89 in prisoners (in & out) per year 30 and 5,000 population] Algiers, 94 in Annab, 102 in & 47,000 monthly Oran) PART II: Calculation of the indicator INDICATOR’S RESULT 4 “having been tested for HIV” 15 % ? ? INDICATOR’S RESULTS 6 “who have been sensitized for HIV testing” 3.2% 14% (20 out of 142 INDICATOR for IDUs “who have substitution therapy” respondents)

C/LPE: Indicaor 4 Most-at-risk populations: prevention programmes (continued)

Data sources (name): 5. Rapport d’activité de la lutte contre le SIDA (6 pages, in French). Algiers, Algeria, Fondation Nationale pour la Promotion de la Santé et le Développement de la Recherche Médicale (FOREM), 2005. 85

6. Medjaoui A et al. Etude des connaissances, attitudes et pratiques sur les maladies sexuellement transmissibles (MST/SIDA) auprès des jeunes militaires (in French). Algiers, Algeria, Ministère de la Défense Nationale, 1999. 7. Rapport d’activités du programme IST/VIH/SIDA du Ministère de la Défense Nationale (in French). Data source (type): 5. Information system (data base) – Program monitoring 6. Quantitative behavioural survey Report (Rapport d’enquête comportementale quantitative) 7. Information system (data base) – Program monitoring Data collection period 5. From : 1 July 2005 5. To : 31 December 2005 (day/month/year): 6. From : ? 6. To : ?

Most-at-risk populations [5.] Sex workers in 12 out [6.] Young military [7.] Military [7a.] Military [7b.] Military PART I: Required data of 48 Wilayas in Algeria in Algeria in area A in area B NUMERATOR 749 1. Number (of surveyed people) (sensitized for who had access to outreach and ? ? ? ? survey of “at-risk” peer education, women) 2. Number of respondents who had exposure to targeted mass media [mention the source of ? ? ? ? information received on AIDS]

3. Number of respondents who have been tested and/or cured for ? ? ? ? a STI, 4. Number of respondents who benefited advice and HIV ? ? ? ? testing, 5. Number of responding IDUs who have substitution therapy ? ? ? ? and safer injection practices, 6. Number of respondents who have been reached by at least on HIV-prevention 5 000 ? ? ? programme during the last 12 months DENOMINATOR 7. Total number of [most-at- ? ? ? ? ? risk population] PART II: Calculation of the indicator 77% by TV, 48% by INDICATOR’S RESULTS 2 “exposure to newspapers, 42% by targeted mass media: which source of information on AIDS?” BY MOST-AT- ? radio broadcasting, ? ? ? RISK MEN & WOMEN 30% by sensitization days

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C/LPE: Indicaor 4 Total population (including the Most-at-risk populations): (continued) prevention programmes

Data sources (name): 8. & 9. Enquête algérienne sur la santé de la famille (in French, 375 pages). Algiers, Algeria, Ministère de la Santé, de la Population et de la Réforme Hospitalière & Office National des Statistiques & Ligue des Etats Arabes, July 2004. 10. Rapport d’activités du programme IST/VIH/SIDA organisé par le Ministère des Affaires Religieuses et des Wakfs (MARW), 2005. Data source (type): 8. & 9. Quantitative survey Report (Rapport d’enquête quantitative) 9. Programmes monitoring Data collection period 8. & 9. From : 21 September 2002 8. & 9. To : 30 November 2002 (day/month/year): 10. From : 2000 10. To : 2005

Total population [10.] People who attend places of [8.] Non-single women [9.] Young singles worship (mosques), as well as coranic PART I: Required data aged from 15 to 49 years aged from 15 to 29 years schools “zaouias”, and the Islamic cultural centres affiliated NUMERATOR 17 million people go to the mosques every Friday (and to other worship 2. Number of respondents who places) through 22,705 men of had exposure to targeted mass religion (including 17,000 imams), ? ? media [mention the source of who all were trained with the information received on AIDS] rudimentary techniques of sensitizing on AIDS, In particular on the modes of contamination. 3. Number of respondents who have been tested and/or cured for ? a STI, DENOMINATOR 17 million people attend 7. Total number of [most-at- Around 7,500 3 268 mosques, coranic schools et the risk population] (in 10,200 households) (in 2550 households) affiliated cultural Centres PART II: Calculation of the indicator 92% by TV, 25% by the radio, 33% 94% on TV 100% by religious activities, by the newspaper and magazines, 40% over radio including the prayer on Friday, and INDICATOR’S RESULTS 2 “exposure to 30% by friends/parents, 29% by targeted mass media: which source of 27% by newspapers and other activities organised in the school institutions (23% for boys, information on AIDS?” magazines, coranic schools (zaouias) and the 37% for girls), 3% by the mosques 25% by friends/parents Islamic Arts Centres (5% for boys, 0,4% for girls) 75% total INDICATOR’S RESULT 3 “sexually (63% medical doctor, 9% nurse or transmitted infection screening and/or midwife, 3% pharmacist, treatment?” 1% traditional healer, 2% self-treatment)

* [8.] & [9.] For the extended sample 20,400 households were planned for the investigation, while for the master sample 10,200 households were planned. Questions to non-single women aged 15 to 49 years formed part of the questionnaire for the master sample (planned: 10 200 households), while questions to young single women aged 15 to 29 years were requested only from the women - 1 out of 4 of the households of the master sample (planned: 2,550 households). 19,233 households were observed during the execution of the investigation on the health of the family in Algeria, that is to say 121 153 people. The number of the women of the eligible samples was 15 156 (the rate for all answers was 97,4%; of which 97,2% in rural area and 97,6% in rural zone). 3,268 young single people aged 15 to 29 years were surveyed (1,767 boys and 1,501 girls; 1,927 young people resident in urban environment and 1,341 in rural zone); that making a rate of total response of 73,8%.

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Indicator 4b Most-at-risk populations: prevention programmes (other indicators) (additional)

Data sources (name): 1. Mimouni B, Remaoun N, Abdalla T, Warner-Smith M. Etude du lien potentiel entre usage problématique de drogue et VIH/SIDA en Algérie (86 pages, in French). Algiers, Algeria, Centre de Recherche en Anthropologie Sociale et Culturelle (CRASC), Ministère de l’Enseignement Supérieur et de la Recherche Scientifique (MESRS), October 2005. 2. & 3. & 4. Global Fund to Fight AIDS Activity report 2005 (2 first quarters). 5. Compte rendu des activités AAPF, IST/VIH/SIDA – 2001 / 2005. Algiers, Algeria, Association Algérienne pour la Planification Familiale (AAPF), 2005. Data source (type): 1. Quantitative behavioural survey Report (Rapport d’enquête comportementale quantitative) 2. & 3. & 4. Information system (data base) – Program monitoring 5. Information system (data base) – Program monitoring Data collection period 1. From : September 2004 1. To : December 2004 (day/month/year): 2. & 3. & 4. From : June 2005 2. & 3. & 4. To : November 2005 5. From: ? 5. To : ?

Most-at-risk populations [5.] Young men & [4.] People [1.] addicted drug users women aged [2.] Sex workers, drug [3.] Unknown infected with (including 15 to 24 PART I: Required data addicts, & most-at-risk HIV/AIDS on injecting drug users) years in 15 homosexuals population therapy in Algiers, Annaba, and Oran of the 48 in Algeria Algerian wilayas NUMERATOR 1. Number of men & women 31,100 sensitized on condom use 85,000 2. Number of people with (printed exposure to information supports support, ) 3. Number of people sensitized 3,158 on HIV testing, (all 3 groups) 4. Number of young people Around 300 aged 15-24 who had access to peer outreach and peer education, educators 5. Number of sex workers who 183 have been given a prevention (Sex workers ? kit (including outreach ) education), 6. Number of PLHIV who have access to therapeutic 64 education, 7. Number of drug users 103 (36%) respondents who underwent at [25 (28%) Algiers, least one treatment for drug 50 (53%) Annaba, addiction, 28 (27%) Oran] DENOMINATOR 285 addicted drug users of 7. Total number of [most-at- whom 142 making injections ? ? Around 600 ? risk population] (89 in Algiers), 94 Annaba, 102 Oran) PART II: Calculation of the indicator 36 % INDICATOR’S RESULT BY GROUP OF MEN & WOMEN THE MOST-AT-RISK (28% Algiers, 53% Annaba, ? ? About 10 % ? 27% Oran)

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Indicator 4b Most-at-risk populations: prevention programmes (other indicators) (additional/continued)

Data sources (name): 6. Medjaoui A et al. Etude des connaissances, attitudes et pratiques sur les maladies sexuellement transmissibles (MST/SIDA) auprès des jeunes militaires (in French). Algiers, Algeria, Ministère de la Défense Nationale, 1999. 7. Rapport d’activités du programme VIH du Ministère de la Défense Nationale (in French). 8. Rapport d’activité du Comité Sectoriel de Lutte contre les IST/VIH/SIDA, 2005 (in French, 2 pages). Algiers, Algeria, Direction Générale de l’Administration Pénitentiaire et de la Réinsertion, Ministère de la Justice, 2005. Data source (type): 6. Quantitative behavioural survey Report (Rapport d’enquête comportementale quantitative) 7. Information system (data base) – Program monitoring 8. Information system (data base) – Program monitoring Data collection period 6. From: ? 6. To : ? (day/month/year): 7. From : ? 7. To : ? 8. From : ? 8. To : ?

Most-at-risk populations [6.] Young military [7.] Military [7a.] Military [7b.] Military [8.] Prison PART I: Required data in Algeria in Algeria in area A in area B population NUMERATOR 1. Number of men & women ? ? ? ? sensitized on condom use 2. Number of people with exposure to information ? ? ? ? support, One-month sensitization of 1,500 prison 3. Number of people sensitized ? ? ? ? inmates to testing on HIV testing, in 2005 (=18,000 in 12 months) 4. Number of young people aged 15-24 who had access to ? ? ? ? outreach and peer education,

6. Number of PLHIV who have access to therapeutic ? ? ? ? education, 7. Number of drug users respondents who underwent at ? ? ? ? least one treatment for drug addiction, DENOMINATOR From 80,000 to 90,000 prisoners 7. Total number of [most-at- 5 000 ? ? ? (in & out) per risk population] year & 47,000 monthly PART II: Calculation of the indicator INDICATOR’S RESULT BY GROUP OF MEN & WOMEN THE MOST-AT-RISK ? ? ? ? 3.2%

In 2004, 250 doctors and 230 psychologists working in 127 prison establishments were trained with the rudimentary techniques of awareness on AIDS. In 2005, 90 of them were trained for sensitization to HIV testing.

89

Indicator 5b Most-at-risk populations: knowledge about HIV prevention (additional)

Data sources (name): 1. Mimouni B, Remaoun N, Abdalla T, Warner-Smith M. Etude du lien potentiel entre usage problématique de drogue et VIH/SIDA en Algérie (86 pages, in French). Algiers, Algeria, Centre de Recherche en Anthropologie Sociale et Culturelle (CRASC), Ministère de l’Enseignement Supérieur et de la Recherche Scientifique (MESRS), October 2005. 2. Medjaoui A et al. Etude des connaissances, attitudes et pratiques sur les maladies sexuellement transmissibles (MST/SIDA) auprès des jeunes militaires (in French). Algiers, Algeria, Ministère de la Défense Nationale, 1999. 3. Meziane A et al. Enquête CAP SIDA 2002 (Alger, Khenchela, Oran, Ouargla, Tamanrasset) (15 pages, in French). Algiers, Algeria, Service de Communication Sociale, Institut National de Santé Publique (INSP), Ministère de la Santé, de la Population et de la Réforme Hospitalière (MSPRH), July 2002. 4. Meziane A et al. Sondage Jeunes & SIDA 1998-99 (Alger, Biskra, Oran) (11 pages, in French). Algiers, Algeria, Service de Communication Sociale, Institut National de Santé Publique (INSP), Ministère de la Santé, de la Population et de la Réforme Hospitalière (MSPRH), February 1999. Data source (type): 1. Quantitative behavioural survey Report (Rapport d’enquête comportementale quantitative) 2. Quantitative behavioural survey Report (Rapport d’enquête comportementale quantitative) 3. Quantitative behavioural survey Report (Rapport d’enquête comportementale quantitative) 4. Quantitative behavioural survey Report (Rapport d’enquête comportementale quantitative) Data collection period 1. From : September 2004 1. To : December 2004 (day/month/year): 2. From : ? 2. To : ? 3. From : January 2002 3. To : July 2002 4. From : September 1998 4. To : February 1999

Most-at-risk populations [2.] [3.] Young men & [4.] Young men & [1.] Addicted drug users (including Young women aged 15-30 women aged 15-30 PART I: Required data injecting drug users) military from 5 wilayas from 3 wilayas (in in Algiers, Annaba, and Oran in (in 2002) 1998-99) Algeria NUMERATOR: Number of respondents with a right answer/ (for surveys [3.] & [4.]: who mentioned a protection) 1. Can having sex with only one faithful, uninfected partner reduce the 61 ? risk of HIV transmission? 60 96 2. Can using condoms reduce the risk of (50 in the North (87 in the North 100 ? HIV transmission? and and 10 in the South) 9 in the South) 181 100 3. Can abstinence reduce the risk of (93 in the North (64 in the North ? HIV transmission? and and 88 in the South) 36 in the South) 4. Is there any relationship between drug and AIDS? Other knowledge indicators (to survey ? young military)?? DENOMINATOR 431 266 7. Number of respondents who gave 285 problematic users of drugs, with 142 (249 from the (178 in the North answers, including “don’t know", to making injections 5 000 North and 182 and questions above. (89 Algiers, 94 Annaba, 102 Oran) from the South) 88 in the South) PART II: Calculation of the indicator 21% (13% Algiers, INDICATOR 1 RESULT ON “FAITHFULNESS” 20% Annaba, & 29% Oran) 14% (20% from 36% (49% from 35 % (46% Algiers, INDICATOR 2 RESULTS 32% the North & 6% the North & 9% ON “CONDOM USE” 28% Annaba, & 31% Oran) from the South) from the South) 42% (37% from 39% (36% from INDICATOR 3 RESULT ON “ABSTINENCE ” the North & 48% the North & 43% from the South) from the South)

* [1.] Algeria is divided into 5 medical areas: 3 in the North (West, Centre, East) & 2 in the South (South-West, South-East). Cities of Oran (Western Health Region), of Algiers (Centre Health Region), et Annaba (Eastern Health Region). [3. & 4.] There are 48 wilayas in Algeria. The 2002 survey included young men and women surveyed in 5 wilayas: 3 in the North (Algiers,Khenchela, Oran), and 2 in the South (Ouargla, Tamanrasset). The 1998-99 survey included young men and women surveyed in 3 wilayas: 2 in the North (Algiers, Oran) and 1 in the South (Biskra).

90

Indicator 5b Most-at-risk populations: knowledge about HIV prevention (additional/continued)

Data sources (name): 5. & 6. Sahraoui Tahar A, Akhamoukh I, Khiati M. Enquête sur l’infection VIH/SIDA chez les lycéens scolarisés à Tamanrasset. (in French) Santé Plus (journal de formation et d’informations médicales) N° 73 : (in French) Algiers, Algeria, Fondation Nationale pour la Promotion de la Santé et le Développement de la Recherche Médicale (FOREM). December 2004, pages 41-42. 7. Khiati M. Rôle des ONGs dans la lutte contre le SIDA (pages 113-121). (in French). In : « L’infection VIH- SIDA, l’expérience algérienne. » (272 pages). Algiers, Algeria, Editions FOREM, 2004 (ISBN 9947-0-0294- 2). 8. Sahraoui Tahar A, Akhamoukh I, Khiati M. Enquête sur l’infection VIH/SIDA chez les lycéens scolarisés à Tamanrasset. (in French) Santé Plus (journal de formation et d’informations médicales) N° 73 : (in French) Algiers, Algeria, Fondation Nationale pour la Promotion de la Santé et le Développement de la Recherche Médicale (FOREM). December 2004, pages 43-44. 9. Belkaïd Rezki R, Graba MK. Sexualité chez les étudiants en médecine d’Alger (communication) à la Xème conférence internationale sur les MST/SIDA en Afrique, Abidjan, 7-11 décembre 1997. (in French). 10. Belkaïd R, Aouchiche Y, Graba MK (SEMEP CHU Alger centre). (in French). Perceptions et connaissances sur le SIDA en 1992 chez les étudiants en médecine d’Alger (communication). (in French). Sétif 3/4 june 1992. 11. Soukhal A, Guenoune A. Connaissances et attitudes des jeunes face aux MST/SIDA; Enquête par sondage auprès des lycéens de la Daïra de Sidi M’Hamed (Alger). (communication) Algiers, April 13th-14th 1988. Data source (type): From 5 to 11 (all) Behavioural Quantitative Survey Report Data collection period 5. From : 15 October 2004 5. To : 30 October 2004 (day/month/year): 6. From : 2001 6. To : 2001 7. From : 2000 7. To : 2000 8. From : 15 October 2004 8. To : 30 October 2004 9. From : 1997 9. To : 1997

Most-at-risk populations [6.] Young [7.] Young [8.] Men & women [5.] Young people people attending people from [9.] Medical attending school school attending Sub-Sahara Africa, students of PART I: Required data Aged 16-20, Aged 16-20, school living in Algiers from Tamanrasset from Aged 16-20, Tamanrasset (in (in 1997) (in 2004) Tamanrasset from Algiers 2004) (in 2001) (in 2000) NUMERATOR: Number of respondents with a positive response 1A. Do you know AIDS? ? 1B. Do you have precise knowledge on ? infection HIV? 1C. Do you know how the infection ? with HIV happens? 2. Do you know means of prevention? ? ? 3. Do you know how to use condom? ? 4. Is there any relationship between ? ? drug and AIDS? 5. Do you have a nearest and dearest ? ? infected with AIDS? DENOMINATOR 6. Number of respondents who gave 68 (of which 63% answers, including “don’t know", to 461 ? 1972 from Niger and 217 questions above. Mali) PART II: Calculation of the indicator INDICATOR 1A RESULTS “KNOWING AIDS” 95% INDICATOR 1B RESULTS “PRECISE KNOWLEDGE” 22% INDICATOR 1C RESULTS “HOW DOES INFECTION OCCUR” 50% INDICATOR 2 RESULTS “KNOWLEDGE OF THE MEANS OF PREVENTION” 62% 29% INDICATOR 3 RESULTS “CONDOM USE KNOWLEDGE" 14% INDICATOR 4 RESULTS “RELATIONSHIP BETWEEN DRUG AND AIDS” 83% 63% INDICATOR 5 RESULTS “HAVING A NEAREST AND DEAREST INFECTED 0.43% 13% WITH AIDS”

91

Indicator 5b Total population (including the Most-at-risk populations): knowledge about (additional/continued) HIV prevention

Data sources (name): 10. & 11. Enquête algérienne sur la santé de la famille (in French, 375 pages). Algiers, Algeria, Ministère de la Santé, de la Population et de la Réforme Hospitalière & Office National des Statistiques & Ligue des Etats Arabes, July 2004. Data source (type): 10. & 11. Quantitative household survey Report (Rapport d’enquête ménage quantitative) Data collection period 10. & 11. From : 21 September 2002 10. & 11. To : 30 November 2002 (day/month/year):

Low-risk populations PART I: Required data [10.] Non-single women aged 15-49 [11.] Young single women aged 15-29 Total Urban area Rural area Total Urban area Rural area NUMERATOR: Number of respondents with a positive response 1A. Have you already heart about ? ? ? ? ? ? AIDS? 1B. How can one get infected with ? ? ? ? AIDS: sexual relationships? 1C. id.: Injections? ? ? ? ? 1D. id.: blood transfusions? ? ? ? ? 1E. id.: Not using condom? ? ? ? ? 1F. id.: Mosquito bites? ? ? ? ? 2A. What can one do to avoid AIDS: ? ? ? protected sexual relationship? 2B. id.: avoiding blood transfusions? ? ? ? 2C. id.: using condom? ? ? ? 2D. id.: avoiding syringes already used? ? ? ? 2E. id.: avoiding injections? ? ? ? 2F. id.: testing blood prior to ? ? ? transfusion? DENOMINATOR 6. Number of respondents who gave Around 7,500 3 268 answers, including “don’t know", to (in 10,200 ? ? (in 2550 ? ? questions above. households) households) PART II: Calculation of the indicator INDICATOR 1A RESULTS “KNOWING AIDS” 68% 77% 56% 97% 98% 95% INDICATOR 1B RESULTS 89% 91% 85% 99% “sexual relationships” INDICATOR 1C RESULTS 39% 44% 30% 33% “Injections” INDICATOR 1D RESULTS “blood transfusions” 36% 42% 24% 34% INDICATOR 1E RESULTS Not using condom? 17% 21% 10% 8% INDICATOR 1F RESULTS “Mosquito bites” ? ? ? ? INDICATOR 2A RESULTS “Safe sexual relations” 78% 80% 74% INDICATOR 2B RESULTS “avoiding blood transfusions” 31% 37% 21% INDICATOR 2C RESULTS “using condom” 25% 30% 15% INDICATOR 2D RESULTS “avoiding syringes already used” ? ? ? INDICATOR 2C RESULTS “avoiding injections” ? ? ? INDICATOR 2F RESULTS “testing blood prior to transfusion” ? ? ?

* For the extended sample 20,400 households were planned for the investigation, while for the master sample 10,200 households were planned. Questions to non-single women aged 15 to 49 years formed part of the questionnaire for the master sample (planned: 10 200 households), while questions to young single women aged 15 to 29 years were requested only from the women - 1 out of 4 of the households of the master sample (planned: 2,550 households). 19,233 households were observed during the execution of the investigation on the health of the family in Algeria, that is to say 121 153 people. The number of the women of the eligible samples was 15 156 (the rate for all answers was 97,4%; of which 97,2% in rural area and 97,6% in rural zone). 3,268 young single people aged 15 to 29 years were surveyed (1,767 boys and 1,501 girls; 1,927 young people resident in urban environment and 1,341 in rural zone); that making a rate of total response of 73,8%.

92

C/LPE: Indicator 6 Sex workers: using condom?

Data sources (name): 1. Mimouni B, Remaoun N, Abdalla T, Warner-Smith M. Etude du lien potentiel entre usage problématique de drogue et VIH/SIDA en Algérie (86 pages, in French). Algiers, Algeria, Centre de Recherche en Anthropologie Sociale et Culturelle (CRASC), Ministère de l’Enseignement Supérieur et de la Recherche Scientifique (MESRS), October 2005. 2. Enquête qualitative auprès des professionnelles du sexe (Alger, Oran, Tamanrasset), 2005. ** Data source (type): 1. Quantitative behavioural survey Report (Rapport d’enquête comportementale quantitative) 2. Qualitative behavioural survey Report (Rapport d’enquête comportementale qualitative) Data collection period 1. From : September 2004 1. To : December 2004 (day/month/year): 2. From : ? 2. To : ?

[1.] addicted drug users [2.] Sex workers PART I: Required data (including sex workers in Algiers, Oran, Tamanrasset in Algiers, Annaba, and Oran NUMERATOR 1. Number of respondents who admitted having used condom with ? their last client in the last 12 months 2. Number of respondents who said 110 they use condom (43 Algiers, 38 Annaba, 29 Oran) DENOMINATOR 285 addicted drug users 3. Number of respondents who of whom 142 have injection practice, and 125 reported admitted having had commercial 30 having commercial sex sex in the last 12 months (89 Algiers, 94 Annaba, 102 Oran) PART II: Calculation of the indicator INDICATOR’S RESULT ON “USE OF CONDOM WITH THE LAST CLIENT” ? 39 % INDICATOR RESULTS “CONDOM USE" (48% Algiers, 40% Annaba, 28% Oran)

* [1. & 2.] Algeria is divided into 5 medical areas: 3 in the North (West, Centre, East) et 2 in the South (South-West, South-East). Cities of Oran (Western Health Region), of Algiers (Centre Health Region), et Annaba (Eastern Health Region). The city of Tamanrasset is located in the southern part of the country (South-Eastern medical area).

** [2.] The reporting of the results of the qualitative survey conducted in 2005 among sex workers in 3 cities (Algiers, Oran, Tamanrasset) is planned for January 2006.

93

C/LPE: Indicator 8 Injecting drug users: safe injecting and sexual practices

Data sources (name): 1. Mimouni B, Remaoun N, Abdalla T, Warner-Smith M. Etude du lien potentiel entre usage problématique de drogue et VIH/SIDA en Algérie (86 pages, in French). Algiers, Algeria, Centre de Recherche en Anthropologie Sociale et Culturelle (CRASC), Ministère de l’Enseignement Supérieur et de la Recherche Scientifique (MESRS), October 2005. 2. Enquête qualitative auprès des professionnelles du sexe (Alger, Oran, Tamanrasset), 2005. ** Data source (type): 1. Quantitative behavioural survey Report (Rapport d’enquête comportementale quantitative) 2. Qualitative behavioural survey Report (Rapport d’enquête comportementale qualitative) Data collection period 1. From : September 2004 1. To : December 2004 (day/month/year): 2. From : ? 2. To : ?

[1.] addicted drug users [2.] Sex workers PART I: Required data (including injecting drug users) in Algiers, in Algiers, Oran, Tamanrasset Annaba, and Oran NUMERATOR 45 of whom 1. Have you injected drug to yourself in the last month? <25 years old: 10 men and 1 woman <25 years old: 29 men and 5 woman 18 of whom 2. Have you shared a injecting tool in the last month? [for <25 years old: 1 man and 1 woman those who answer “yes” to question 1] <25 years old: 12 men and 4 woman 26 of whom 3a. Did you have sex in the last month? [for those who <25 years old: 5 men and 1 woman answer “yes” to question 1] <25 years old: 16 men and 4 woman 16 of whom 3b. Did you have sex in the last month? [for those who <25 years old: 2 men and 1 woman answer “yes” to both questions 1 and 2] <25 years old: 8 men and 5 woman 4a. Did you/your partner use condom during your last sexual 3 of whom relationship? [for those who answer “yes” to both questions <25 years old: 3 men 1 and 3a] 4b. Did you/your partner use condom during your last sexual 3 of whom relationship? [for those who answer “yes” to all questions 1, <25 years old: 3 men 2 and 3a] 5. Number of respondents who reported having never shared 8 of whom a injecting material in the last month et also report having <25 years old: 1 men ? used condom during their last sexual relationship. (= row 4b) <25 years old: 6 men 6. Number of respondents who reported having never shared a injecting material in the last month et also report having either used condom during their last sexual relationship or 5 ? avoided sexual relationship in the last month. (= row 2 – row 3b + row 4b) DENOMINATOR 26 used injecting drug and had sex with peer, Number of respondents who report having injected drugs among the 285 addicted drug users, of whom in the last month and having had sexual relationship 30 142 are injecting drug users during the same period. (89 Algiers, 94 Annaba, 102 Oran) PART II: Calculation of the indicator INDICATOR’S RESULT BY GENDER AND AGE GROUPS (<25; 25+, ALL AGES) 19% ?

* [1. & 2.] Algeria is divided into 5 medical areas: 3 in the North (West, Centre, East) et 2 in the South (South-West, South-East). Cities of Oran (Western Health Region), of Algiers (Centre Health Region), et Annaba (Eastern Health Region) are located in the North. The city of Tamanrasset is located in the southern part of the country (South-Eastern medical area).

** [2.] The reporting of the results of the qualitative survey conducted in 2005 among sex workers in 3 cities (Algiers, Oran, Tamanrasset) is planned for January 2006.

94

Indicator 8b addicted drug users: safe injecting and sexual practices (additional)

Data sources (name): 1. Mimouni B, Remaoun N, Abdalla T, Warner-Smith M. Etude du lien potentiel entre usage problématique de drogue et VIH/SIDA en Algérie (86 pages, in French). Algiers, Algeria, Centre de Recherche en Anthropologie Sociale et Culturelle (CRASC), Ministère de l’Enseignement Supérieur et de la Recherche Scientifique (MESRS), October 2005. Data source (type): 1. Quantitative behavioural survey Report (Rapport d’enquête comportementale quantitative) Data collection period 1. From : September 2004 1. To : December 2004 (day/month/year):

[1.] addicted drug users PART I: Required data (including injecting drug users) in Algiers, Annaba, and Oran NUMERATOR 1. Have you injected drug to yourself at any time? 142 (50%) 2. Have you shared an injecting tool at any time? [for those who 84 (59%) answer “yes” to question 1] 242 (85%) 3. Do you have sexual relationship? (95% Algiers, 78% Annaba, 84% Oran) 110 (39%) 4. Do you use condom during sexual relationships? (43 [48%] Algiers, 38 [40%] Annaba, 29 [28%] Oran) DENOMINATOR Number of respondents who report having injected drugs in 285 addicted drug users the last month and having had sexual relationship during of whom 142 are drug injecting users the same period. (89 Algiers, 94 Annaba, 102 Oran) PART II: Calculation of the indicator INDICATOR RESULTS (see above)

* [1.] Algeria is divided into 5 medical areas: 3 in the North (West, Centre, East) et 2 in the South (South-West, So uth-East). Cities of Oran (Western Health Region), of Algiers (Centre Health Region), et Annaba (Eastern Health Region).

95

C/LPE: Indicator 9 Most-at-risk populations: Reduction in HIV prevalence

Data sources (name): 1. Mimouni B, Remaoun N, Abdalla T, Warner-Smith M. Etude du lien potentiel entre usage problématique de drogue et VIH/SIDA en Algérie (86 pages, in French). Algiers, Algeria, Centre de Recherche en Anthropologie Sociale et Culturelle (CRASC), Ministère de l’Enseignement Supérieur et de la Recherche Scientifique (MESRS), October 2005. 2. Fares EG. Enquêtes de séro-prévalence VIH/SIDA en Algérie 2000 & 2004 (various reports and personal communications/ presentations, in French). Algiers, Algeria, Commission Epidémiologie du Comité National de Lutte contre les IST/VIH/SIDA (CNLS), Ministère de la Santé, de la Population et de la Réforme Hospitalière (MSPRH), 2002 - 2005. & Fares EG et al. (2004). Epidemiological surveillance of HIV/AIDS in Algeria, North Africa, based on the sentinel sero-surveillance survey. XV International AIDS Conference. Abstract C10572. Bangkok. 11-16 July. 3. Fares EG. Rapport du séminaire d’évaluation de l’enquête réalisée en 2004 sur la séro-surveillance sentinelle du VIH et de la syphilis (Zéralda, 18 septembre 2005, 17 pages, in French). Algiers, Algeria, Direction de la Prévention, Ministère de la Santé, de la Population et de la Réforme Hospitalière (MSPRH), September 2005. 4. La transfusion sanguine en Algérie pour l’année 2000 (in French). Algiers, Algeria, Agence National du Sang (ANS), 2001. 5. Données sur le dépistage VIH parmi les patients avec tuberculose & Khaled S, El-Hadj M, Touatioui Z, Mohammedi Z, Idri H, Missoum K, Chala M. Enquête de prévalence de l’infection par le VIH dans une population de malades tuberculeux en 1997 en Algérie. 13ème Conférence de la région Afrique de l’Union Internationale contre la tuberculose et les maladies respiratoires (UICT.MR). (in French) Conakry, 24-27 may 2000. 6. Institut Pasteur d’Algérie, Laboratoire National de Référence de l’Infection VIH/SIDA. (in French) 1985 – 2005 Reports . 7. UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance. UNAIDS/WHO Epidemiological Fact Sheet of Algeria on HIV/AIDS and sexually transmitted infections, 2004 Update. (available from http://www.unaids.org and http://www.who.int/hiv/pub/epidemiology/pubfacts/en/index.html). 8. AFRO (WHO Regional Office for Africa) Surveillance épidémiologique VIH/SIDA: mise à jour pour la Région Afrique de l’OMS 2002 (77 pages & 222 pages [Country Profiles]). Harare, Zimbabwe, September 2003 (available from http://www.afro.who.int/aids/). 9. WHO, Regional Office for Africa. HIV Surveillance Report for Africa, 2000 (163 pages). Harare, Zimbabwe, Nov. 2001 (http://www.afro.who.int/aids/surveillance/resources/hiv_surveillance_report_2000.pdf). 10. Grara MK. Séro-surveillance épidémiologique de l’infection à VIH par réseau sentinelle. Département de Médicine, the University of Algiers, June 1999. 11. R. Belkaid. Séro-surveillance épidémiologique de l’infection à VIH par réseau sentinelle. Département de Médicine, the University of Algiers, June 1999. Thesis. 12. Mokhtari L, Belkaid R, Belateche F. Situation épidémiologique de l’infection VIH/SIDA. (in French) Santé Plus (journal de formation et d’informations médicales) N° 73 : (in French) Algiers, Algeria, Fondation Nationale pour la Promotion de la Santé et le Développement de la Recherche Médicale (FOREM). December 2004, pages 9-12. 13. Processus de planification stratégique de lutte contre les IST/VIH/SIDA, Algérie, 2002-2006 (201 pages, in French). Algiers, Algeria, Direction de la Prévention, Ministère de la Santé, de la Population et de la Reforme Hospitalière, 2001. (available from http://www.ands.dz) 14. Khaled S, El Hadj M, Mohamedi D, Touatiou Z, Idri H, Missoum K, Chala L. Enquête de prévalence de l’infection par le VIH dans une population de malades tuberculeux en 1997 en Algérie. Direction de la Prévention, Ministère de la Santé, de la Population et de la Reforme Hospitalière, & Institut National de Santé Publique. 15. Zidouni N, Belkaïd R, Missoum A (INSP), Khaled S (EHS El Hadi Flici), (personal communication, 2005). Data source (type): 1. Quantitative behavioural survey Report (Rapport d’enquête comportementale quantitative) [note: surveyed people who have not been tested for HIV during the survey, but who are asked to reveal the result of their test if available] from 1. to 13. (all) Information system (data base) – Program monitoring Data collection period 1. From : September 2004 1. To : December 2004 (day/month/year): 2. From : 2000 2. To : 2004 3. From : 2004 3. To : 2004 4. From : 2000 4. To : 2000 5. From : ?? 5. To : ?? 6. From : 1985 6. To : 2005 7. From : 1988 7. To : 2001 8. From : 1990 8. To : 2002 9. From : 1984 9. To : 2000 10. From : 1984 10. To : 1998 11. From : 1984 11. To : 1998 12. From : 1996 12. To : 1996 13. From : 1996 13. To : 1996 14. From : 1997 14. To : 1997 15. From : 2002 15. To : 2002 (3 months)

Most-at-risk populations

96

Testing Name & Type Period Geographical localization HIV+ HIV+% Required data done 1. Problematic users of drug [1.] Behavioural 3 cities 2004 5 45 11% (including injecting drug users) survey (Algiers, Annaba, and Oran) 2004 Algiers 5 16 31% 2004 Annaba 0 15 0% 2004 Oran 0 14 0%

[3.] Sentinel 5 cities (Oran, Saida, Sidi bel- 2. Sex workers 2004 7 185 3.78% surveillance Abbes, Skikda, Tamanrasset) 2004 Oran 0 45 0% 2004 Saida 1 10 10% 2004 Sidi bel-Abbes 0 16 0% 2004 Skikda 0 44 0% 2004 Tamanrasset 6 70 8.57% [2.] Sentinel 2000 2 cities (Oran, Tamanrasset) 4 139 2.88% surveillance 2000 Oran 2 117 1.7% 2000 Tamanrasset 2 22 9% [2.] Sentinel 3 cities (Algiers, Oran, 1998 ? ? ? surveillance Tamanrasset) 1998 Algiers (structure xx ??) ? ? ? 1998 Oran ? ? ? 1998 Tamanrasset ? ? ? [9.] Sentinel 4 cities (Blida, Constantine, 1988 ? ? ? surveillance Oran, Tlemcen) [7.] Sentinel 1988 2 cities (Constantine, Oran) ? ? 1% surveillance 1988 Blida 0 ? 0% 1988 Constantine ? ? 0.42% 1988 Oran ? ? 1.92% 1988 Tlemcen 0 ? 0% [9.] Sentinel 1984 2 cities (Oran, Tamanrasset) ? ? 2.9% surveillance 1984 Oran ? ? ? 1984 Tamanrasset ? ? ?

[3.] Sentinel 4 cities (Oran, Tamanrasset, 3. STI Expert(s) 2004 9 759 1.19% surveillance Tizi-Ouzou, Reggane) 2004 Oran 2 250 0.80% 2004 Tamanrasset 5 325 1.24% 2004 Reggane 1 168 0.60% 2004 Tizi-Ouzou 1 16 6.25% [2.] Sentinel 4 cities (Algiers, Constantine, 2000 2 793 0.25% surveillance Oran, Tamanrasset) Algiers (Army’s Central 2000 0 250 0% Hospital) 2000 Algiers (CHU Maillot) 0 6 0% 2000 Algiers (CHU Mustapha) 0 52 0% 2000 Constantine 0 156 0% 2000 Oran 1 250 0.40% 2000 Tamanrasset 1 79 1.23% [2.] Sentinel 3 cities (Algiers, Oran, 1998 ? ? ? surveillance Tamanrasset) 1998 Algiers (structure xx ??) ? ? ? 1998 Oran ? ? ? 1998 Tamanrasset ? ? ? [10.] Sentinel 2 cities, 6 medical structures 1984 ? ? 0.25% surveillance (not specified) 1984 City A, Structure a ? ? ? 1984 City A, Structure b ? ? ? 1984 City B, Structure c ? ? ? 1984 City B, Structure d ? ? ?

97

Low-risk population Testing Name & Type Period Geographical localization HIV+ HIV+% Required data done [5.] Programmes 4000 - 4. TB infected people 2004 Algeria (5 medical regions ? ? monitoring 6000 2004 Western Medical Region ? ? ? 2004 Centre Medical Region ? ? ? 2004 Eastern Medical Region ? ? ? South-Western Medical 2004 ? ? ? Region South-Eastern Medical 2004 ? ? ? Region 2003 Algeria (5 medical regions ? ? 0.2% 2003 Western Medical Region ? ? ? 2003 Centre Medical Region ? ? ? 2003 Eastern Medical Region ? ? ? South-Western Medical 2003 ? ? ? Region South-Eastern Medical 2003 ? ? ? Region [12. & 15.] Programmes 2002 Algeria (5 medical regions 8 3346 0.22% monitoring 2002 Western Medical Region 3 ? ? 2002 Centre Medical Region 1 ? ? 2002 Eastern Medical Region 0 ? ? South-Western Medical 2002 0 ? ? Region South-Eastern Medical 2002 4 ? ? Region [7.] Programmes 1998 Algeria (5 medical regions ? ? 0.29% monitoring 1998 Western Medical Region ? ? ? 1998 Centre Medical Region ? ? ? 1998 Eastern Medical Region ? ? ? South-Western Medical 1998 ? ? ? Region South-Eastern Medical 1998 ? ? ? Region [8. & 14.] Programmes 1997 Algeria (5 medical regions 0 1460 0% monitoring 1997 Western Medical Region 0 ? 0% 1997 Centre Medical Region 0 ? 0% 1997 Eastern Medical Region 0 ? 0% South-Western Medical 1997 0 ? 0% Region South-Eastern Medical 1997 0 ? 0% Region [10.] Programmes 1984 Algeria (5 medical regions ? ? 0.29% monitoring 1984 Western Medical Region ? ? ? 1984 Centre Medical Region ? ? ? 1984 Eastern Medical Region ? ? ? South-Western Medical 1984 ? ? ? Region South-Eastern Medical 1984 ? ? ? Region

5. Blood donations 2004 Algeria (5 medical regions ? ? ? 2004 Western Medical Region ? ? ? 2004 Centre Medical Region ? ? ?

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Low-risk population Testing Name & Type Period Geographical localization HIV+ HIV+% Required data done 2004 Eastern Medical Region ? ? ? South-Western Medical 2004 ? ? ? Region South-Eastern Medical 2004 ? ? ? Region [12.] Programmes 2002 Algeria (5 medical regions 18 176 532 0.01% monitoring 2002 Western Medical Region ? ? ? 2002 Centre Medical Region ? ? ? 2002 Eastern Medical Region ? ? ? South-Western Medical 2002 ? ? ? Region South-Eastern Medical 2002 ? ? ? Region [4.] Programmes 2000 Algeria (5 medical regions 204 255 354 0.080% monitoring 2000 Western Medical Region 35 57 316 0.061% 2000 Centre Medical Region 87 100 558 0.087% 2000 Eastern Medical Region 73 77 788 0.094% South-Western Medical 2000 1 5 546 0.018% Region South-Eastern Medical 2000 8 14 146 0.057% Region [8.] Programmes 1998 Algeria (5 medical regions ? ? 0.014% monitoring 1996 Western Medical Region ? ? ? 1996 Centre Medical Region ? ? ? 1996 Eastern Medical Region ? ? ? South-Western Medical 1996 ? ? ? Region South-Eastern Medical 1996 ? ? ? Region [9.] Programmes 1996 Algeria (5 medical regions 7 70 468 0.009% monitoring 1996 Western Medical Region ? ? ? 1996 Centre Medical Region ? ? ? 1996 Eastern Medical Region ? ? ? South-Western Medical 1996 ? ? ? Region South-Eastern Medical 1996 ? ? ? Region [9.] Programmes 1994 Algeria (5 medical regions ? ? 0.021% monitoring 1994 Western Medical Region ? ? ? 1994 Centre Medical Region ? ? ? 1994 Eastern Medical Region ? ? ? South-Western Medical 1994 ? ? ? Region South-Eastern Medical 1994 ? ? ? Region

9 cities (Adrar, Alger, Oran, 6. Women who have access to [3.] Sentinel Reggane, Saida, Setif, Sidi bel- 2004 7 5112 0.14% antenatal clinic services surveillance Abbes, Skikda, Tamanrasset, Tizi- Ouzou) 2004 Adrar 0 410 0% 2004 Reggane 0 223 0% 2004 Algiers (CHU Mustapha) 0 560 0% 2004 Oran 1 400 0.25% 2004 Saida 0 646 0% 2004 Sétif 0 500 0% 2004 Sidi bel-Abbes 1 505 0.20%

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Low-risk population Testing Name & Type Period Geographical localization HIV+ HIV+% Required data done 2004 Skikda 0 600 0% 2004 Tamanrasset 5 718 0.70% 2004 Tizi-Ouzou 0 550 0% [2.] Sentinel 4 cities (Algiers, Oran, 2000 4 1984 0.20% surveillance Tamanrasset, Tizi-Ouzou) 2000 Algiers (CHU Maillot) 0 216 0% 2000 Algiers (CHU Mustapha) 0 462 0% 2000 Oran 0 451 0% 2000 Tamanrasset 4 455 0.88% 2000 Tizi-Ouzou 0 400 0% [2.] Sentinel 3 cities (Algiers, Oran, 1998 ? ? ? surveillance Tamanrasset) 1998 Algiers (structure xx ??) ? ? ? 1998 Oran ? ? ? 1998 Tamanrasset ? ? ? [6. & 12. & 13.] Sentinel 1996 Number of cities not specified 0 8000 0% surveillance 1996 City A ? ? ? 1996 City B ? ? ? 1996 City C ? ? ? [9.] Sentinel 5 medical structures 1984 ? ? 0.4% surveillance (not specified) 1984 Structure a ? ? ? 1984 Structure b ? ? ? 1984 Structure c ? ? ? 1984 Structure d ? ? ? 1984 Structure e ? ? ?

* Algeria is divided into 5 medical areas: 3 in the North (West, Centre, East) et 2 in the South (South-West, South-East). Cities of Oran (Western Health Region), of Algiers (Centre Health Region), et Annaba (Eastern Health Region) are located in the North. The city of Tamanrasset is located in the southern part of the country (South-Eastern medical area, Wilaya of Tamanrasset).

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Additional data on Prevalence of syphilis: TPHA+ Diagnosis surveillance

Data sources (name): 1. Fares E.G. Enquêtes de séro-prévalence VIH/SIDA en Algérie 2000 & 2004 (various reports and personal communications/ presentations, in French). Algiers, Algeria, Commission Epidémiologie du Comité National de Lutte contre les IST/VIH/SIDA (CNLS), Ministère de la Santé, de la Population et de la RéformeHospitalière (MSPRH), 2002 - 2005. & Fares E. G. et al. Epidemiological surveillance of HIV/AIDS in Algeria, North Africa, based on the sentinel sero-surveillance survey, 2000. XV International AIDS Conference. Abstract C10572. Bangkok. 11-16 July.2004 &Fares E G. et al. Rapport du séminaire d’évaluation de l’enquête réalisée en 2004 sur la séro-surveillance sentinelle du VIH et de la syphilis (Zéralda, 18 septembre 2005, 17 pages, in French). Algiers, Algeria, Direction de la Prévention, Ministère de la Santé, de la Population et de la Réforme Hospitalière (MSPRH), September 2005. Data source (type): 1. Information system (data base) – Program monitoring Data collection period 1. From : 2004 1. To : 2004 (day/month/year):

Prevalence of syphilis Most-at-risk populations & Low-risk population Testing Name & Type Period Geographical localization TPHA+ TPHA+% Required data done

1. Sex workers [1.] Sentinel 5 cities (Oran, Saida, Sidi bel- 2004 22 185 11.89% surveillance Abbes, Skikda, Tamanrasset) 2004 Oran 5 45 11.11% 2004 Saida 2 10 20% 2004 Sidi bel-Abbes 5 16 31.25% 2004 Skikda 4 44 9.09% 2004 Tamanrasset 6 70 8.57%

2. STI Expert(s) [1.] Sentinel 4 cities (Oran, Tamanrasset, 2004 18 759 2.37% surveillance Tizi-Ouzou, Reggane) 2004 Oran 2 250 0.80% 2004 Reggane 6 168 3.57% 2004 Tamanrasset 10 325 3.07% 2004 Tizi-Ouzou 0 16 0%

9 cities – 10 sites (Adrar, Alger, 3. Women who have access to [1.] Sentinel 2004 Oran, Reggane, Saida, Setif, Sidi 45 5112 0.88% surveillance antenatal clinic services bel-Abbes, Skikda, Tamanrasset) 2004 Reggane 1 223 0.45% 2004 Adrar 0 410 0% 2004 Algiers (CHU Mustapha) 0 560 0% 2004 Oran 4 400 1.00% 2004 Saida 5 646 0.77% 2004 Sétif 6 500 1.20% 2004 Sidi bel-Abbes 2 505 0.40% 2004 Skikda 0 600 0% 2004 Tamanrasset 26 718 3.62% 2004 Tizi-Ouzou 1 550 0.18%

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Chart: Distribution of medical regions and the sentinels surveillance sites for the epidemiologic monitoring of the HIV in Algeria (functional in 1998, 2000, 2004).

Medical Regions 1998, 2000, 2004 West Centre 2004 East South-West 2000 South-East

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GE: Indicator 9 Blood safety

Data sources (name): La transfusion sanguine en Algérie pour l’année 2000 (in French). Algiers, Algeria, Agence National du Sang (ANS), 2001. Data source (type): Information system (data base) – Program monitoring Data collection period From : 1 January 2000 To : 31 December 2000 (day/month/year):

Centre Medical Eastern Medical Western South-Eastern South-Western Algeria PART I: Required data Region Region Medical Region Medical Region Medical Region (5 medical regions NUMERATOR Number of blood units tested for HIV in the last 100 558 77 788 57 316 14 146 5 546 255 354 12 months meeting WHO standards or national's DENOMINATOR Number of blood units transfused in the last 12 101 715 78 050 57 928 14 943 5 566 258 202 months PART II: Calculation of the indicator INDICATOR RESULTS BY MEDICAL REGION 98.96% 99.66% 98.94% 94.67% 99.64% 99.05%

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GE: Indicator 16 HIV Treatment: survival after 12 months on antiretroviral therapy

Data sources (name): 7 reference centres of care for people infected with HIV/AIDS (6 belonging to the medical sector of activity and 1 managed by the Ministry of National Defence) Data source (type): Information system (data base) – Program monitoring Data collection period From : 1 December 2004 To : 1 December 2005 (day/month/year):

Algiers (3 centres Algeria Army’s Algiers for (7 health- PART I: Required data Annaba Constantine Oran Sétif Tamanrasset Central (El Kettar) health- care Hospital care) centres) NUMERATOR 1. Number of adults and children initiating ? ? ? 1 ? 14 4 19 ? antiretroviral therapy in the last 12 months 2. Number of people who have stopped antiretroviral therapy, including those ? ? ? 1 ? 3 8 12 ? who have transferred out, those lost to follow-up and those who have died 3. Number of adults and children continuously on antiretroviral therapy at ? ? ? 0 ? 20 9 29 ? 12 months after initiating treatment (=row 4 – row 2) DENOMINATOR 4. Total number of adults and children who initiated ? ? ? 1 ? 23 17 41 ? antiretroviral therapy 12 month ago (including "2") 5. Total number of adults and children who initiated antiretroviral therapy 12 ? ? ? ? ? ? ? ? ? month ago (excluding "2") PART II: Calculation of the indicator INDICATOR’S RESULT BY GENDER AND AGE GROUPS (<15, 15+, any age) ? ? ? 0% ? 87% 53% 71% ? / MINIMUM SURVIVAL INDICATOR’S RESULT BY GENDER AND AGE GROUPS (<15, 15+, any age) ? ? ? ? ? ? ? ? ? / MAXIMUM SURVIVAL = Percentage of infected adults and children still alive on antiretroviral therapy at 12 months after initiating treatment

104

Indicator 16b HIV Treatment: patients on antiretroviral therapy (additional)

Data sources (name): Dr Ait-oubelli (personal communication). Direction de la Prévention, Ministère de la Santé, de la Population et de la Réforme Hospitalière (MSPRH), December 2005. Data source (type): Information system (data base) – Program monitoring Data collection period From : 1 October 2005 To : 1 October 2005 (day/month/year):

Algiers Algeria Army’s Algiers PART I: Required data Annaba Constantine Oran Sétif Tamanrasset (7 health-care Central (El Kettar) centres) Hospital NUMERATOR Number of adults and children on antiretroviral ? ? ? ? ? ? ? 575 therapy on 1st October 2005 DENOMINATOR Total number of adults and children who initiated ? ? ? ? ? ? ? ? antiretroviral therapy 12 month ago PART II: Calculation of the indicator INDICATOR RESULTS BY ? ? ? ? ? ? ? ? HEALTH CARE CENTRE

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