Health Action in Northern

Health Newsletter

W orld Health Organization–Health Action in Crisis Issue 3 May 2005 Editorial I NSIDE THIS The theme for this edition of ISSUE : E CHO a nd HIV/AIDS the newsletter is HIV/AIDS. Universal precautions 2 After consultations with Member States in the I n 2 0 0 2 , the AIDS Control in the Health Unit Humanitarian Aid Committee, the Directorate General Program (ACP) sentinel setting for Humanitarian Aid (ECHO) of the European s u r v e i llance site at Lacor Comprehensive HIV/ 2 Commission, has published a ‘Concept Paper’ and ‘Model Hospital indicated that the AIDS training Guidelines’ to be used as reference points for possible prevalence of HIV among ECHO financing of HIV/AIDS activities. This followed a mothers attending the ANC ECHO and AIDS 3 review by ECHO of its approach to the HIV/AIDS continued pandemic in response to a need to clearly articulate was between 10 and 12%, much lower than that of 1993; PMTCT in Kitgum/ 4 ECHO’s position in this respect. Pader 27.1% and higher than that of ECHO fully recognises that HIV/AIDS is a major factor 2001; 11.3%. Recent and Upcoming 5 of vulnerability in areas of humanitarian crises and events therefore, this is an important issue for ECHO to S o me may be quick to blame address. The ‘Concept Paper’, thus, recommends that this on the conflict situation- ECHO adopts a two-pronged strategy with an aim to: sexual violence and displacement– but this could ñ Mainstream do-no-harm measures, with a focus on be disproved. awareness and to avoid the spread of the virus by ( www.humanitarianinfo.org/ negligence wherever relevant; and iasc)

ñ Fund selected activities to mitigate the effects of HIV/The need for more HIV/AIDS AIDS in humanitarian emergency situation, as a services is still particularly big complementary component of already existing multi- in the IDP camps where most sector programmes. people have no access to VCT and therefore are ignorant of The ‘Model Guidelines’ set out vari- their sero status. ous activities for ECHO and its partners in the fight against HIV/Also important is the issue of AIDS – ranked from essential to prevention of new infection to; strongly recommended in addition health workers, caretakers, to various non-core activities that babies, partners, adolescents, should be undertaken only subject victims of rape/ defilement etc. to strict pre-conditions. The social aspect of HIV/AIDS It is, however, also reiterated that that includes planning of safe the issue of HIV/AIDS does not fall water points, safe camps and within ECHO’s specific mandate and others is another area that cannot per se become an entry/exit needs to be focused on. criteria for ECHO’s engagement in a country. The ‘Concept Paper’ places HIV/AIDS is vast area that ECHO’s position among other EC needs a consolidated effort for instruments combating the disease. any improvement to be seen. The principal EC contribution and This includes coordination at Staff at the ANC clinic funding aimed at fighting HIV/AIDS is made to ‘The all levels. at Referral Hospital Global Fund to Fight HIV/AIDS, TB and Malaria’. Continued on page 3 DDHS, Gulu Page 2 Volume 1 Issue 3

Training in Universal Precautions in Health Unit Setting

Universal precautions are essential to prevent transmission of HIV, Hepatitis B and other infectious diseases from patient to health worker, as they are to prevent patient to patient and health worker to patient transmission. And yet health workers have often depicted a perception of being invincible as exemplified by their misplaced readiness to work in environments that are strewn by blood spills and other body fluid spills that are potentially infectious

without making efforts to decontaminate and mop up the offending spills.

UNFPA sponsored a two week Life Saving-Skills course., which benefited 12 health workers from . The course had a big cross cutting topic on infection control; knowledge and skills on Universal Precautions against HIV

transmission.

More training that targets imparting skills and positive attitudes towards Universal Precautions are needed so as to protect our precious human resource from nosocomial transmission. This is so especially in circumstances where the patient loads are overwhelmingly as occurs in IDP units and referral hospitals in the north. People working un- der pressure are more likely to have work related accidents and to cut corners in sterilization techniques.

In addition the participants were able to perform five of the six signal functions of basic Emergency Obstetric Care

S (basic EmOC), namely; ability to administer parental antibiotics, anticonvulsants for eclampsia and pre-eclampsia,

D Oxytocics, ability to perform manual removal of the placenta and to perform assisted vaginal delivery-Vacuum ex- I

A traction. / V I This will improve upon the number of facilities that provide EmOC per 500,000 people and subsequently improve H

our met need for EmOC (proportion of women with obstetric complications delivering at EmOC facilities) in the n i

district. Met need for EmOC currently stands at a very low 23.9% nationally –it should be 100%. s p

o It is hoped that UNFPA will go ahead and sponsor the Post Abortion Care course as well so that participants get h

s the full components of Basic Emergency Obstetric Care. Source: UNFPA Gulu k r o Comprehensive HIV/AIDS training W

g In response to the global 3x5 initiative of providing Anti-Retroviral n i Drugs (ARVs) to 3 million People by the end of 2005, the Govern- n i

a ment of Uganda through the Ministry of Health, WHO and other r

T partners are scaling up comprehensive HIV/AIDS care including ART. Uganda is committed to having 60,000 HIV infected people on ARVs by the end of 2005. The delivery of the ARVs has now been inte- grated into the existing national health care system.

The first step in achieving this target is building capacity of the health service providers who are to handle the patients and the drugs. Capacity building of health service providers has been conducted in the 11 Regions including Masaka, Hoima, Arua, Gulu, Lira, , Mbale, Jinja, Kabale, Mbarara and Central Regions.

The training entails both classroom work and clinical sessions/ skills stations, which are facilitated by People Living With HIV/AIDS (PLWA) on ART have experience of living with the disease and drugs. The methods utilized are par- ticipatory in nature hence enhancing an atmosphere of knowledge sharing by the participants and facilitators.

Specifically health service providers were drawn from Hospitals and Health centre IV as clinical teams and trained to provide comprehensive HIV/AIDS care including ART. In Gulu and Lira Regions the following health facilities have trained teams: , Lacor Hospital, Anaka Hospital, , St Joseph’s Hospital Kitgum, Pajule HC IV, , Dokolo HC IV, Apac Hospital, Aber Hospital and other NGOs like TASO, Health Alert- Gulu and SOS.

The following health facilities have been accredited and are providing ART services: Gulu Hospital, Lacor Hospital, Anaka Hospital, Kitgum Hospital, St Jospeh’s Hospital Kitgum (by CRS), Pajule HC IV, Lira Hospital, Apac Hospital and Aber Hospital. Source: WHO Uganda Health Action in Northern Uganda Page 3

ECHO and AIDS continued As such, ECHO cannot become a frontline agency in the fight against HIV/AIDS, as this is a specific mandate of other organisations and, in addition, ECHO lacks the capacity and sufficient in-house technical expertise on HIV/AIDS.

Due to the wide variety of conditions existing in the field, the ‘Model Guidelines’ should be used by partners as a point of reference, rather than as universally mandatory. Electronic versions of the ‘Concept Paper’ and the ‘Model Guidelines’ can be found at: http://europa.eu.int/comm/echo/evaluation/thematic_en.html

ECHO Strongly recommended activities wherever appropriate and feasible: Objective: “to contribute to preventing any worsening in the impact of the crisis, saving and preserving life from the effects of HIV/AIDS during emergencies and their immediate aftermath”

Sectors Activities Objectives

Targeting in priority single, infected and/or elderly caretakers and orphans To ensure adapted and safe distribution mechanisms to Distributions (food Setting up distribution schemes adapted to weaker individuals (more frequent with the affected households/ aid, NFIs, etc) smaller packages) and design sites to minimise risk of rape communities in particular in Using school feeding, take-home rations for children if feasible high prevalence areas Using home-based care services, if no other solutions are available

Health Training staff on Syndromic approach for management of STIs To guarantee treatment of Sexually Transmitted Supplying drugs for treatment of STIs Infections (STIs) and Distributing condoms Opportunistic Infections Providing prophylaxis and treatment for opportunistic infections To ensure safe child deliveries Providing clean delivery and midwife delivery kits

Nutrition Targeting assistance to affected and at-risk households (infected, single and/or elderly To ensure that PLWHA and caretakers and orphans and communities orphans are included as beneficiaries in nutrition Using guidelines adapted to needs of People Living With HIV/AIDS (PLWHA) (see e.g, programmes Oxfam, SCF, WFP), focusing on women and children

Protection against Ensuring that protection activities are cross-cutting through all concerned sectors To contribute to the pre- sexual violence vention of sexual violence Detecting victims of sexual violence and providing counselling and to assist victims of rape Offering emergency contraception and post exposure prophylaxis

Rehabilitation and Rehabilitation/reconstructing e.g. essential health centres with adapted out- and in- To ensure that rehabilitation construction patients facilities for PLWHA e.g. of essential health cen- tres adapted with out and in-patient facilities for PLWHA Shelter and site Designing safe camp sites to minimise exposure to rape To adapt shelter and site planning design to specific needs of Employing female guards and logisticians PLWHA and to ensure their Placing PLWHA households close to camp facilities safety

Water and Sanitation Include HIV considerations in water and sanitation planning To adapt water and sanita- tion installations to specific Designing safe water point to minimise risks of rape needs of PLWHA and to ensure their safety

Workplace Additional training of staff on gender issues, sexual violence, special needs, stigma and To improve awareness and non-discrimination. Improving attitudes and dialogue skills. prevention among partner staff Source: ECHO Uganda Page 4 Volume 1 Issue 3

Prevention of mother-to-child transmission of HIV (PMTCT) programme in Kitgum and Pader districts: an example of holistic approach to pregnant mothers attending Ante Natal Clinic in two conflict affected districts

In Sub-Saharan Africa, Transmission of HIV from Mother to Child (MTCT) is the second major mode of HIV-spread (UNAIDS). According to preliminary findings from the 2004- 2005 Uganda HIV/AIDS Sero-Behavioural Survey, there has been an overall declining trend of HIV infection from 18% in 1992 to the current figure of 7% ( compared to 6.2% provided by the surveillance system of MoH). The prevalence rates vary in different : 9.2% in , 9% in north- central/central regions and 2.5% in W est Nile. The districts of Kitgum and Pader (Northern Uganda) have greatly suffered from the conflict over the last 19 years; insecu- rity has caused a massive displacement of more than 90% of the population in IDP camps and a breakdown of the socio-economic and health structure and preventing movements on the roads. This situation is matter for a great concern that the national declines of HIV seroprevalence might be reversed in the conflict affected areas. Despite insecurity, Kitgum and Pader districts have supported the fight against HIV/AIDS through the implementation of the activities in the main health facilities and at the community level with the collaboration of local and The Ante-Natal Clinic at Kalongo international NGOs and CBOs. The prevalence of HIV infection among pregnant women attending antenatal clinics in selected sites is the main tool util- ized in the surveillance system adopted in Uganda by the Aids Control Program (ACP) of the Ministry of Health. In Acholiland (districts of Pader, Kitgum and Gulu), the ACP surveillance site is located in Lacor hospital in Gulu, where the seroprevalence ranged in 2002 and 2003 between 11.9% and 11.5%. Kitgum and Pader districts have no sentinel surveillance sites, however, in the two districts a large number of mothers attend ANCs and with high coverage of the PMTCT programme, prevalence rates in the PMTC sites provide a fair estimate of the prevalence in the catchments population. The PMTCT programme has been running in the two districts since May 2002 in partnership with AVSI in two implementing sites in (Government Hospital and St Joseph’s Hospital) and in Dr Ambrosoli Memorial Hospital-Kalongo in and will open in six new peripheral sites: Namokora HC III, Padibe-St Peter and Paul HC III, Madi Opei HC III, Pajimo/Akwang HC III, Mucwini HC III in Kitgum district and in Pajule HC IV in Pader district. The partnership provides resources for hiring health workers (i.e. nurses or midwives); organizing trainings for assistant counsellors, TBAs and lab workers; delivering ANC drugs and testing equip- ment; supporting the logistic and the PMTCT-related activities like health/nutrition education; free medical assistance; nutritional support (more than 70 PMTCT babies are on replacement feeding); home visiting and support with food and non-food items; weekly/monthly meetings; Business Skill Training and Income Generating Activities to more than 100 PMTCT mothers. The wide range of PMTCT related activities are an entry point for the development of more integrated programmes of care and support, which facilitate the follow up of PMTCT mothers and babies and can improve PMTCT-indicators. Since 2002, 23,620 clients attending ANCs received improved services in the PMTCT-sites, 99% re- ceived pre-counseling, 97% accepted the HIV test and the post-counseling, 53% of women were en- rolled and 88% of these delivered in hospital. The overall HIV prevalence decreased from 7% (2002) to 6.3% (2004). The programme highlighted a great response by the community, as reflected in the Health Action in Northern Uganda Page 5

PM TCT i n Ki t gum /Pa d er Co nt d indicators of acceptance of counselling and testing. Enrolment rate is, C o n flict is conducive to a however relatively low (53%). Some mothers do not return for further ANC visits after testing positive; this highlights the importance of establishing a range of factors that durable trust with the clients, who otherwise will be lost to follow up. This could be established through a more efficient link between ANC, MoH i n c rease the risk of services and CBOs providing support services. Despite the insecurity 88% of infection with HIV (rape, the enrolled mothers return to deliver in the hospital. Offering support services to mothers before delivery and to mother and baby after delivery displacement, poverty, sex represents a formidable opportunity to monitor the pregnancy, encourage delivery at the health unit, monitor breastfeeding practices and create c o m mercialization, abuse opportunities of involvement of the partner (that currently remains among and coercion), but this is the greatest challenges). In conclusion, our experience shows that even in conflict situations, it is not necessarily translated possible to achieve good PMTCT results when the programme is integrating services by supporting mothers before delivery and mothers/babies after i nto higher prevalence delivery. Conflict is conducive to a range of factors that increase the risk of rates (4% in Pader and infection with HIV (rape, displacement, poverty, sex commercialization, abuse and coercion), but this is not necessarily translated into higher prevalence 7.9% in Kitgum districts). rates (4% in Pader and 7.9% in Kitgum districts). Moreover, PMTCT improved coverage could be achieved through scaling up the program to additional sites, taking into account the specific types of constraints already highlighted. After carrying out specific field-level assessments, AVSI is supporting the District Health Department in the scaling up of PMTCT sites in rural areas. This will guarantee a marked expansion of program coverage, enhancing the prevention, care, surveillance and treatment of PLW HAs in the districts. Comprehensive PMTCT-services, while helping to reduce HIV- transmission have also served as mechanism to spread awareness about health-care to women in Uganda and can help overcome the wall of isolation and discrimination behind which people living with HIV/AIDS are confined. Linkages between programmes and providers of medical assistance, psychosocial and nutritional support are being promoted, to reflect the holistic nature of interventions needed to prevent HIV/AIDS and to mitigate its effects. In the long-term, we envision a larger community participation in maternal care and a greater confidence in all health-care services. This is particularly important in rural areas and regions where the health-sector has been weakened by long-running conflict. Acceptance rates in Northern Uganda, that is undergoing 19-year old conflict, support this strategy. Source: AVSI Uganda

ecent and upcoming events: 3 May 2005: Sub-National UNICEF held a conference (9-11 Immunisation Days (SNIDs) planning meeting May) with the theme ‘Severe conflict as a major contributing R 7-9 May 2005: SNIDS round II factor to high prevalence of HIV/ 9-11 May 2005: UNICEF workshop on HIV/AIDS in Gulu AIDS among displaced people in 23–25 May 2005: Sensitisation of community leaders in Pabbo, Parabongo and Uganda’. Amuru IDP Camps on prevention of cholera and their role as leaders in it With 50 participants in the AIDS 26 May 2005: Meeting with the Swiss Ambassador sector, the common concern was the prolonged conflict (19 years) as a 26 May 2005: Health and Nutrition Coordination Meeting in Gulu contributing factor to the high 31 May 2005: Visit by the WHO Acting Country Representative prevalence of AIDS in the region.

Cholera Taskforce Meetings have been held on: 11, 13, 17, 19, 20, 24, and 30 May The workshop reviewed existing and 2005. The meetings have been held regularly to coordinate emergency response to possible interventions that could the cholera epidemic in Pabbo and Amuru. accelerate effectiveness in response to HIV/AIDS among displaced people in July 2005: A Mortality survey (UNICEF/WFP/WHO/UNFPA) will be carried out in Northern Uganda. Kitgum, Pader & Gulu. Health Statistics

More Facts on HIV/AIDS in Northern Uganda

ñ In Gulu district, WFP through World Vision, TASO and Gulu Regional Hospital, provide 27,400 people (on Anti Retroviral Treatment (ART), Prevention of Mother To Child Infection (PMTCT), CB Dots, TB ward In-patients and TB Caretakers). The food supplements are in form of oil, Corn Soy Blend, cereal and pulses.

ñ According to the results of the 2004/5 Uganda HIV/AIDS Sero-prevalence Survey, the North- All rights are reserved by the Central region prevalence is 9%, while North-West is 2.5% and North-east is 4.3%. organization. The document may, however, be freely ñ The AIDS Support Organisation (TASO) started work in Gulu 0n 5 January 2005 and opened as a reviewed, abstracted, Regional Centre on 26 February 2005. The centre initially offering counseling and testing services reproduced or translated in only, expanded on 30 May 2005, to include Anti Retroviral Therapy (ART) . 5092 clients are regis- part or whole, but not sold tered and are being re-screening for enrollment on the ART programme. Only those with a CD4 or used in conjunction with count below 200 will be enrolled. A social support programme that will include follow up visits commercial purposes. and provision of food supplements for clients on ART will begin soon. Sources: TASO, Gulu, WFP Gulu, The Newspaper This newsletter is not an official WHO publication. Number of people tested for HIV compared to those on Anti Retro-Virals (ARVs) at The views expressed in it do Gulu Regional Hospital May 2004-5 not necessarily represent

stated policy of WHO. Number of Adults & Children tested for HIV/AIDS compared to those on ARVs 568 For more information contact: 600 Ms. Ida-Marie Ameda 500 Gulu Sub-office 17 Eden Road, Gulu, 400 Adults Gulu Municipality Children PO Box 1054 – Uganda 300 224 236 Mb: +256-77-721963 189 200 Tel: +256-47132970 Tel/Fax: +256-471-32971 64 100 50 31 Email: [email protected] 8 12 1 4 3 [email protected] 0 No. Tested Registered Active Lost Dead Transferred In Kampala: Positive Ms. Helene Cunat WHO Kampala PO Box 24578 Kampala, Uganda Note: GRH refers to Gulu Referral Hospital– HIV/AIDS Counseling and Testing Centre (CTC). Tel: 256-41-335500/335582 Source: Gulu Referral Hospital May 2004-2005 Tel: 256-31-262071/6 Mob:256-77-721962 Fax:256-41-335569 PMTCT Statistics from Selected Hospitals 2002/4 Email: [email protected] PMTCT services at ANC sites in Kitgum (St Joseph & Kitgum Govt Hosp) and Pader (Dr Ambrosoli Memorial Hosp) Contributors to this issue: 25,000 99% 97% AVSI, Kitgum 20,000 88% ECHO Uganda 15,000 Gulu Regional Hospital 53% 10,000 Lacor Hospital UPHOLD Gulu 5,000 UNICEF Gulu 0 ANC No. No. tested No. enrolled Hosp UNFPA Gulu attendance counselled deliveries WFP Gulu WHO Uganda Note: The data from Kitgum/Pader is for years 2002 to 2004. Source: AVSI Kitgum