Country Progress Report 2006 Peru

United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

United Nations General Assembly Special Sessions on HIV/AIDS

REPORT ON MONITORING THE DECLARATION OF COMMITMENT ON HIV/AIDS 2005*

Written by:

Dr. Lourdes Kusunoki Dr. Juan Gunaira Economist Carmen Navarro Dr. Carlos Velásquez

Lima, December 2005

• (Preliminary Version, may be amended)

1 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

REPORT ON MONITORING THE DECLARATION OF COMMITMENT ON HIV/AIDS 2005

INTRODUCTION

AIDS is a public health problem and one of the most serious challenges to the life and dignity of human beings. It affects everyone, regardless of their financial situation, age, sex or race, and it is noticeable that the populations of developing countries are the most affected, where the women, young people and children, particularly girls are very vulnerable. In Latin America some vulnerabilities result in the most affected groups being found in socially excluded populations, such as injecting drug users, male and female sex workers, men who have sex with men, prison inmates, boys, girls and adolescents in conditions of social exclusion (on the street, workers, sexually exploited, MSM), amongst others.

Poverty, underdevelopment and illiteracy are amongst the main factors that contribute to the spread of HIV/AIDS, and this in turn has had an adverse effect by worsening poverty and hindering development in many countries1. From the social demographic point of view, Peru has around 26.7 million inhabitants in 20052, with a population growth range of 1.7% in the same year3. The urban population is around 73.9%; infant mortality for the year 2005 was 26 per 1,000 live births and the maternal mortality rate is 185 per 100,000 live births4.

Measure Peru Population (millions) 2005 26.7 Rural population (%) (1) 26.1 Urban population (%) (1) 73.9 Population growth (%) (1) 1.7 Maternal mortality x 100,000 Live Births (3) 185 Infant mortality x 1,000 Live Births (1) 26 Chronic malnutrition (%) (2) 25 Source:

(1) PNUD [UN Development Programme] Global Report on Human Development http://hdr.undp.org/reports/global/2005/espanol/pdf/HDR05_sp_HDI.pdf (2) CEPAL, Statistics Yearbook for Latin America and the Caribbean 2004 http://www.eclac.cl/publicaciones/Estadisticas/4/LCG2264PB/p1_1.pdf (3) INEI [National Statistics & IT Institute Peru] ENDES 2004

There is no uniform approach to defining, identifying and measuring poverty, which in turn also implies differences with regard to what “reduction of poverty” means. The first Development Objective for the Millennium (ODM), “Reduce by half the proportion of the population who

1 UNAIDS. Declaration of commitment on HIV/AIDS “World Crisis – World Action”, New York 25-27 June 2001. 2 2005 Census INEI [National Inst. For Statistics & IT of Peru] Web page www.inei.gob.pe 3 PNUD [UN Development Programme] Global Report on Human Development 2005 (http://hdr.undp.org/reports/global/2005/espanol/pdf/HDR05_sp_HDI.pdf) 4 INEI: ENDES 2004

2 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 live on less than one dollar a day and reduce by half the proportion of the population suffering from hunger, between 1990 and 2015”, is one of the most important current challenges. Government policies to reduce poverty have not turned out as hoped, and worse still, is that some countries have not developed any policies in this respect as they did not wish to fall into the World Bank category of “low income” countries, due to having a GDP per capita classified as “medium income”.

The country classifies the population according to levels of poverty and of abject or extreme poverty based on the measurement of the cost of meeting basic needs, both food and non- food; such as the lack of a minimum level of resources for access to goods and services available to society, and on the basis of information obtained from surveys in homes and about family budgets.

Poverty can also be defined from a human rights approach as proposed by Amartya Sen, who defines poverty as the absence or inadequate fulfilment of certain basic liberties. Respect for human rights is vital for a person’s dignity and poverty threatens this dignity. From the gender aspect, it is poverty based on the socio-cultural and historical connotations that have brought about sexual differences in discrimination and which have become clear in the sexual divide of work and a differential and hierarchical access to material and symbolic resources.5

54.1% of the country’s total population is below the poverty line, with incomes less than those necessary to meet their basic needs; 20% of the population cannot meet their basic food needs6, meaning that they are in the extreme poverty band7.

The proportion of the population in the country who live with inappropriate basic conditions is high in rural areas, as well as in the border areas. The unemployment rate reached 10.2% in 2000 and underemployment reached 50.8%. In spite of the proportion of the population in poverty declining from 57.4% to 50.7% between 1991 And 1997, it increased to 54.1% in 2004.

The policies that were solely intended to reduce poverty in absolute terms may be limited for a society where there are parallel processes of exclusion, stigma and discrimination amongst groups, especially those which are intensely involved in the HIV/AIDS epidemic. Often, in these population groups, these factors contribute to perpetuating many of the social exclusion conditions which probably led to acquiring the disease. Reducing poverty may be understood as an increase in a person’s monetary income, or as having better access to education, health, social protection and other social services, in order for their rights to be met and to increase their abilities.

5 A.Minujin, E. Delamonica & Others. Children Living in Poverty: A Review of Child Poverty Definitions, Measurements and Policy 6 The Andes Community: “Hacia una estrategia Humanitaria para el desarrollo Social” 2002[Towards a Humanitarian Strategy for Social Development] 7 INEI: ENAHO 2004-IV Peru

3 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 In general, the health of the Peruvian population is a reflection of their social reality. A major improvement has been reached in some of the country’s health indicators; however, the great differences disguising the national averages hide inequalities in health. A greater or lesser probability of falling ill, or dying, is related to factors such as socioeconomic strata, ruralism condition, educational type and level of persons and communities.

Health cover in the country is currently provided in the following manner: MINSA [Ministry of Health] 59%, EsSALUD [Social Security] 26%, personal 12%, Armed Forces and police 3%. The Seguro Integral de Salud (SIS) part of the MINSA, administers the funds for the financing of individual health care, in accordance with the Sector Policies and, within the Universal Insurance Policy, guarantees that health care is provided to the vulnerable population in circumstances of extreme poverty and poverty. This contributes to protection for non-insured Peruvians through a non-contributory health insurance policy. It has different schemes according to age; these are Plans A, B, C D and E, with “care of the child born with HIV/AIDS” explicitly in the first two.

26% of the total population is registered and covered by EsSALUD, who are assuring us that, of the total number of PLWHA [People Living with Aids] who need AVR Therapy, approximately one quarter of the population affected would be covered by EsSALUD:

Total population cover, by sex and age

Age/Sex Total Insured % Cover Both sexes 27,308,177 7,093,535 26.0 Men 13,733,780 3,416,098 24.9 Women 13,574,397 3,677,437 27.1

All ages 27,308,177 7,093,535 26.0 Under 15 8,928,046 2,496,002 28.0 15 to 59 16,315,867 3,776,402 23.1 Source: Author’s estimates based on figures from EsSalud and ENAHO 2003.

According to the UNAIDS 2005 Report, the AIDS epidemic claimed the lives of around three million people that year, and it estimates that five million people will contract HIV throughout the year. The cumulative number of people living with HIV/AIDS (PLWHA) is 40 million worldwide (36.7-45.3 million) and 1.8 million in Latin America (1.4-2.4 million)8.

For October 2005, the Ministry of Health in Peru has reported that, apart from the 23,657 persons with HIV, there are 17,678 persons with AIDS9. There are 7,000 PLWHAs needing treatment, of whom approximately 6,298 (89.97%) are already receiving AVR Therapy as at November 200510. This is due to a great effort made by the country over the last few months,

8 UNAIDS. Global summary of the HIV/AIDS epidemic, 2005 9 Ministry of Health. Office of Epidemiology Gazette October 2005. Aids cases by year of diagnosis. Peru 1983-2005. 10 Information provided by the ESN PCITS/HIV/AIDS. Ministry of Health Peru.

4 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 with the technical and financial support of the Proyecto Fortalecimiento de la Prevención y Control del SIDA y la Tuberculosis [Project for Reinforcement of the Prevention and Control of AIDS and Tuberculosis] in Peru, financed by the Global Fund to fight AIDS, Tuberculosis and Malaria.

However, it is possible to understand the true magnitude and spread of the HIV/AIDS epidemic through the seroprevalence studies being made on certain population groups. Following the classification of the state of the epidemic proposed by the World Bank in 1997, the information available up to now indicates that the epidemic in Peru continues to be CONCENTRATED. This means that the prevalence of the infection by HIV in high risk behaviour groups, such as men who have sex with men, patients with sexually transmitted diseases (STDs), is greater than 5%, but is less than 1% in women who have attended for an antenatal examination, who are considered as low risk behaviour population group, and who therefore represent the general population.

In accordance with the stage of the epidemic in which the country finds itself, there are certain recommendations for prevention and control, which are universally recognised, by which the epidemic could be maintained in such a stage and not allowed to progress.

The fight against AIDS is also a fight for the right to health, which in the case of the PLWHAs is closely tied to AVR Therapy. The proposal to provide AVR Therapy should be seen as an investment rather than as a cost, and should be part of the State’s political agenda, with objectives, strategies and deadlines for its implementation. The cost implication of AVR Therapies is outweighed by the favourable results obtained in the reduction of costs for hospital care and by the incorporation of many HIV persons into productive activities.

In our country, the tendency for access to AVR Therapy, which is going to be widespread in the coming years with the country’s strong commitment channelled through the Ministry of Health, is based on the existing legal framework and on the following agreements adopted by the Government:

• At the Millennium Summit held within the framework of the United Nations General Assembly on 8th September 2000, 189 state representatives, amongst them representatives from the Andean Subregion, signed the Millennium Declaration. The commitment is to achieve a series of quantifiable goals, aimed at being a basic agenda for action towards the year 2015. 8 goals, 18 targets and 48 indicators were set, with the base reference point as the year 199011.

Goal 6: Combat HIV/AIDS, malaria and other diseases12, with target 7: to have halted by 2015 and begun to reverse, the incidence of HIV/AIDS, with the following indicators:

11 The Netherlands Co-operation for Development Service. Andean Subregional Conference. The objectives of the Millennium Development from the Latin-American perspective. Lima September 2005. 12 http://millenniumindicators.un.org/unsd/mispa/mi_goals.aspx?

5 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

Indicators

18. HIV prevalence among pregnant women aged 15-24 years (UNAIDS-WHO-UNICEF) 19. Condom use rate as a percentage of the contraceptive prevalence rate (UN Population Division)C 19a. Condom use at the last high-risk sex (UNICEF-WHO) 19b. Percentage of population aged 15-25 years with comprehensive correct knowledge of HIV/AIDS (UNICEF-WHO)D 19c. Contraceptive prevalence rate (UN Population Division)C 20. Ratio of school-attendance of orphans to school attendance of non-orphans aged 10-14 years (UNICEF-UNAIDS-WHO)

C. Among contraceptive methods, only condoms are effective in preventing HIV transmission. Because the contraceptive use rate is only measured among women in a union, it is supplemented by an indicator on condom use in high-risk situations (indicator 19a) and with an indicator of knowledge regarding HIV/AIDS (indicator 19b) Indicator 19c (contraceptive prevalence rate) is also useful in monitoring progress made towards other health, gender and poverty goals.

D. This indicator corresponds to the Percentage of the population age 15-24, who correctly identify the two major ways of preventing the sexual transmission of HIV (using condoms and limiting sex to one faithful, uninfected partner), who reject the two most common local misconceptions in the country regarding the transmission of HIV, and who know that a healthy looking person can transmit HIV.

However, as a sufficient number of surveys is not currently available to calculate the above defined indicator, the United Nations Children’s Fund (UNICEF), in collaboration with the Joint United Nations AIDS Programme (UNAIDS) and the World Health Organisation (WHO), have written two substitute indicators representing two components of the actual indicator. These components are: (a) the percentage of women and men age 15-24 who know that a person can protect themselves against infection from HIV by “consistent condom use”; (b) the percentage of women and men age 15-24 who know that a healthy looking person can transmit HIV. Only data referring to women is available in the report for the current year.

• The Declaration of Commitment was approved in the United Nations General Assembly Special Sessions on HIV/AIDS held in June 2001 in New York. This event can be the dividing line between the past and the future in the history of the HIV/AIDS epidemic, the most important part being the monitoring of the goals outlined in that Commitment. Following the evaluation made in the country in 2003, it was noted that the achievements have been limited; it is therefore important that the achievement of the goals for this year 2005 are measured, and which are presented in this document. It is appropriate to stress that this Declaration of Commitment is very wide ranging in the fight against the HIV/AIDS epidemic, and not just that regarding Antiretroviral Treatment since it embraces various areas such as: leadership, prevention, care support, treatment and human rights.

It is essential to acknowledge that in spite of the proven effectiveness of the preventive measures for transmission in recent years, these have been inadequate to stop the increase in the numbers of cases of AIDS at the global level. There are various theories for this, such as the lack of understanding outside the health sector to face up to the epidemic; the

6 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 “denial or playing down” of the epidemic; poor access to preventative methods; our population’s cultural beliefs or patterns (taboos and myths); the poor effect of educational campaigns, independent of their low coverage and association with the socio-psychological pattern of adolescents and youth invulnerability.

I.- STATE OF THE EPIDEMIC IN PERU

CURRENT SITUATION

The first case of AIDS was reported in Peru in 1983, and between then and October 2005 23.657 people have been reported as HIV positive and 17.678 people as having AIDS13, of whom 7,000 PLHIV are estimated to need treatment in 200514. We should add to these figures more than 50,000 people who do not know their serological status and who have therefore not yet been reported to the health service (figure based on sentinel surveillance studies carried out in 2002 which found a prevalence of 0.21% among pregnant women). This adds up to between 57,258 and 144,328 Peruvians affected by the epidemic15. This is the average estimate, which seems to give the most plausible projection of the population affected by AIDS, according to the assumptions on which the 2002 estimate was based. These did not vary significantly, and so they give us an idea of the current national situation16. 70% of those infected came from Lima and Callao and the greatest accumulated incidence was centred on coastal regions (Ica, Ancash, La Libertad, Arequipa) and Amazonian jungle regions (Iquitos, Ucayali, San Martín)17.

The sentinel surveillance studies carried out by the Ministry of Health Surveillance Comittee (the General Office of Epidemiology, the National Instititute of Health, the National Health Strategy for the Prevention and Control of STDs, HIV and AIDS) found that the Peruvian epidemic is concentrated among the population of men who have sex with men (MSM) who constitute 13.9% of the estimated national total, according to the findings of the Sentinel Surveillance Survey 2002-2003, whereas the incidence among pregnant women is between 0.02 and 0.03%, a figure which has remained constant between 1996 and 2002 according to sentinel surveillance studies carried out on this population during that period18. In the case of sex workers (SW) the prevalence of HIV has remained at a level of less than 1% over the last few years. Among people deprived of their liberty, who are also seen as a vulnerable group and who have been the subject of sentinel surveillance studies, the incidence of HIV is 1.1% according to studies carried out in 199919, and is now 0.87% according to preliminary reports from the same source produced in 200520.

13 Ministry of Health. OGE.Bulletin of Epidemiology. October 2005. Cases of HIV by year of diagnosis. Peru, 1983-2005 14 Information compiled by ESN PC ITS/VIH/SIDA. Ministry of Health. Novermber 2005. 15 Surveillance studies 2002-2003 16 Ministry of Health. OGE. Report on Core Indicators for the Application of the Declaration of Commitment Data Presentation UNGASS- 2006 17 MINSA.OGE Bulletin of Epidemiology. October 2002 18 Ministry of Health. OGE. Report on Core Indicators for the Application of the Declaration of Commitment Data Presentation UNGASS- 2006 19 Surveillance study of persons deprived of their liberty carried out in 1999 by the Committee on Surveillance Studies. Ministry of Health 20 Surveillance study of persons deprived of their liberty carried out in 1999 by the Committee on Surveillance Studies. Ministry of Health in the framework of Objective 2, TB component of the World Fund Project for the Support of AIDS and TB Prevention and Control in Peru.

7 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

The epidemic in Peru, as in the rest of the world, has tended increasingly to affect young people and women, hence the male/female ratio has shifted from 27/1 to 2.6/1, confirming the biological and social vulnerability of the female population21. However, the epidemic continues to affect mainly men.

70% of PLHIV are aged between 20 and 39. The mode of transmission is predominantly sexual (97%), 2% is vertical (mother-to-child) transmission and 1% is via blood transfusion. According to the estimates of the General Office of Epidemiology, 584 children are HIV positive and 230 have full-blown AIDS, of whom 184 are receiving TARGA as of Novenber 200522. There is no accurate figure for the number of children orphaned as a result of HIV/AIDS but, taking account of the figures supplied by institutions that work with children affected by HIV/AIDS, it has been calculated that 20% of children affected by and 60% of those living with AIDS are orphans23.

As of November 2005, approximately 6298 PLHIV are in TARGA, 3752 are receiving treatment from MINSA, 213 from COPRECOS and 2333 from ESSALUD24.

The following section shows available national information on the indicators for the concentrated epidemic and some indicators for the generalised epidemic.

21 MINSA. OGE. Bulletin of Epidemiology October 2005. 22 Ministry of Health. ESN PCITS/VIH/SIDA. Total TARGA National Report, 07 November 2005. 23 Vía Libre Association and San Camilo Home 24 Ministry of Health ESN PCITS/VIH/SIDA. TARGA consolidated, 28 November 2005

8 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

9 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 Indicators used in Monitoring the Declaration of Commitment on HIV/AIDS

Area Concentrated Generalised Indicator 3 Percentage of the most Indicator 3. Percentage of schools with at-risk population who received HIV teachers who have been trained in life- testing in the last 12 months and skills based HIV/AIDS education and know the results who taught it during the last academic year Indicator 6: Percentage of pregnant Prevention Indicator 4. Percentage of the most women with HIV infection who have at-risk population reached by received a course of antiretroviral HIV/AIDS prevention programmes prophylaxis to cut the risk of mother-to- child transmission Indicator 9. Percentage of transfused blood units screened for HIV

Indicator 5. Percentage (of most at- Indicator 10. Percentage of men and risk population) who correctly identify women aged 15 to 24 who correctly ways of preventing the sexual identify ways of preventing the sexual transmission of HIV and who reject transmission of HIV and who reject major misconcenptions about HIV major misconcenptions about HIV transmission transmission (Goals: 90% by 2005 and Indicator 6. Percentage of female and 95% by 2010) Knowledge and male sex workers reporting the use of Indicator 11. Percentage of young Behaviour a comdom with their last client women and men who have had sex Indicator 7. Percentage of men before the age of 15 reporting use of a condom last time Indicator 12. Percentage de young they had anal sex with a male partner women and men aged 15 to 24 who have had sex with a non-marital, non- cohabiting partner in the last 12 months

Indicator 9. Percentage of most at- risk (most exposed) population Indicator 15. Percentage of women and Impact infected with HIV young men infected with HIV (Goals: 25% reduction in worst affected countries by 2005; 25% global reduction by 2010)

Indicator 16. Percentage of adults and children with HIV still alive and known to be in treatment 12 months after Treatment and initiation of antiretroviral ttreatment Support Indicator 17. Percentage of nursing infants born with HIV infection to infected mothers (Goal: 20% reduction by 2005 and 50% reduction by 2010) Indicator 5: Percentage of men and women with STDs who have received appropriate diagnosis, treatment and assessment in a health centre Indicator 7. Percentage of men and women with advanced HIV infection receiving combined retroviral treatment Indicator 8: Percentage of orphan and vulnerable children whose households received free basic external support in care for the child

10 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

II. – GENERAL OVERVIEW OF THE AIDS EPIDEMIC

According to the 2005 UNAIDS report, the AIDS epidemic has already cost more than three million lives this year; it is estimated that five million persons contracted HIV over the same period, bringing the estimate of PLWA to 40.3 million worldwide. In western Europe and central Asia, the number of persons living with HIV in 2005 increased to 1.6 million. HIV/AIDS continues to spread rapidly in the Baltic States, the Russian Federation and various republics in central Asia.

In Asia and the Pacific region, more than 8.3 million persons now live with HIV. The progress of HIV/AIDS in this region is for the large part due to the increase of the epidemic in China, Vietnam and Indonesia, principally as a result of the use of intravenous drugs and the sex trade; official estimates calculate that the number of infected persons will multiply inexorably during the next decade. Africa continues to be the continent most affected by the HIV epidemic; in Sub-Saharan Africa alone, 25.8 million persons are infected by HIV. The infection level for HIV among pregnant women stands at 20% or more in six South African countries (Botswana, Lesotho, Namibia, South Africa, Swaziland and Zimbabwe).

In Latin America there are 1.8 million PLWA, 300,000 in the Caribbean and 1.2 million in North America. In some Caribbean and Central American countries, the prevalence of HIV is greater than 1% of the general population, whereas in North and South America this rate is less than 1%, with the epidemic concentrated in high-risk groups, namely men who have sex with other men (MSM), injecting drug users and male and female sex workers.

Over the last few years, access to antiretroviral therapy has increased; many countries which did not consider antiretroviral therapy for patients as an option are now in a position to offer this treatment. In order to ensure universal access, radically different approaches will be needed. The objectives of preventing, treating, monitoring and alleviating the impact of the epidemic have to advance simultaneously, not consecutively or in isolation from one another. Countries must concentrate on implementing programmes, including strengthening human and institutional resources and applying strategies that enable services to be integrated as far as possible25.

In Peru, the main means of transmitting the HIV epidemic is through sex; almost 50% of cases are a result of homosexual or bisexual transmission among men26. The epidemic in Peru is concentrated in the MSM population.

11 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 revealed an HIV prevalence in the general population of 0.2% (0.4% for men and 0.1% for women)28. If we include the percentage obtained for women, we see that half of the value obtained in the sentinel surveillance is attributed to expectant mothers, which could be explained by the fact that this figure includes Lima where 33% of the Peruvian population is concentrated and where close to 68% of accumulated AIDS cases have been reported in the country since 1983.

The prevalence of HIV infection among sex workers stands at between 1% and 2% across the country, which is one of the lowest figures in Latin America. Consecutive sentinel surveillances on MSM have revealed that the prevalence of HIV is at least 14.5%29. Various methods have been used to monitor the HIV epidemic among MSM in Peruvian cities.

Between 1998 and 2002 Alaska undertook the first cohort of seronegative HIV patients in Lima, in which 2,061 high-risk MSM participated. From the 971 persons who took part in the observation year, 34 men contracted the HIV infection giving an incidence rate of 3.5 infections for every 100 persons/year (95% CI 2.3 - 4.7)30. In the second cohort of seronegatives, the HPTN 03631 project involved and monitored 254 participants between April 2002 and October 2003. From the 244 persons from the follow-up year, the incidence of HIV in this cohort was 6.2 for every 100 persons/year (95% CI 3.5 – 9.9).

In 2000 and 2002, men who were at least 18 years old and who had had at least one sexual relationship with another man during the previous year were invited to participate in the HIV sentinel surveillance. This study was undertaken in several Peruvian cities for a duration of 3 months in each city. The ELISA test was used to detect early HIV32, resulting in an HIV incidence estimate of 5.12 for every 100 persons/year; Lima, Iquitos and Arequipa were the cities with the highest incidence. The wide-ranging inclusion criteria for these studies and the absence of a focus on the high-risk MSM sub-populations would suggest that this incidence estimate could be a general trend in the MSM population. The incidence of HIV is likely to be greater in the high-risk MSM sub-population. The incidence level reported indicates that the prevention methods implemented for MSM have not produced the desired results, as between 3% and 5% of MSM contract the HIV infection every year and they may potentially transmit HIV to their female partners.

28 Cayetano Heredia Peruvian University, Home-based study of STDs and sexual conduct (“Encuesta domiciliaria de ETS y conducta sexual”). 2002: Lima. 29 Guanira, J., et al. Second generation of HIV sentinel surveillance among men who have sex with men in Peru during 2002. XV International AIDS Conference. 2002. Bangkok, Thailand. 30 Sanchez, J., et al., Incident HIV infections is associated with anogenital ulcer diseases among men who have sex with men in Peru. 2002. 31 Sponsored by the AIDS Division of the United States Health Institute, entitled “Prevalence and incidence of HIV and prevalence of HSV-2 among high-risk MSM in Lima, Peru”. (“Prevalencia e incidencia de VIH y Prevalencia de HSV-2 entre HSH de alto riesgo en Lima Perú”). 32 Janssen, R.S., et al., New testing strategy to detect early HIV-1 infection for use in incidence estimates and for clinical and prevention purposes. Jama, 1998. 280 (1): p. 42-8.

12 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 had had sex with a woman during the past year. As such, these men are classed as possible “bridges”. In addition, a small proportion of these men regularly used condoms with partners of both sexes, highlighting the potential of MSM to transmit STIs and HIV to their female partners; these men are acting as infection “bridges” among the heterosexual population33. As a consequence the man/woman relationship has decreased, as mentioned previously, confirming that the female population is more vulnerable on a biological and social level. It also highlights the relevance of an approach to analyse trends in the epidemic in the medium term34, including intensive widespread preventative actions for “bridges” that are transmitting HIV to their female partners.

In the current environment, where all affected persons requiring antiretroviral therapy are now gaining access to this treatment, the number of persons living with HIV is increasing as a result of the reduction in HIV mortality rates. In turn, this will increase HIV prevalence, which is not related to a worsening of the epidemic but to the fact that infected persons are living longer. Prevalence may no longer be one the most appropriate indicators for monitoring the epidemic; incidence rates should be the new indicator since they reflect the appearance of new cases. This indicator would provide a more objective view of the dynamics of the epidemic in Peru.

33 Tabet, S., et al., HIV, syphilis and heterosexual bridging among Peruvian men who have sex with men. Aids, 2002. 16 (9): p. 1271-7. 34 “Strengthening of the Prevention and Control of AIDS and Tuberculosis in Peru” (“Fortalecimiento de la Prevención y Control del SIDA y la Tuberculosis en el Perú”), presented at the World Fund in September 2002.

13 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

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

If YES, please list groups:

14 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 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

15 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 11. Have members of the judiciary been trained/sensitized 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:

16 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

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

0 1 2 3 4 5 6 7 8 9 10

17 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 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. 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 d. Yes +- d. Yes +- communications

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

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

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

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

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

j. Blood safety j Yes j Yes

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

m. Other (Please specify)

18 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

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

19 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 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

20 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 supporting such difference:

21 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 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:

II. – GENERAL OVERVIEW OF THE AIDS EPIDEMIC

22 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 In Latin America there are 1.8 million PLWA, 300,000 in the Caribbean and 1.2 million in North America. In some Caribbean and Central American countries, the prevalence of HIV is greater than 1% of the general population, whereas in North and South America this rate is less than 1%, with the epidemic concentrated in high-risk groups, namely men who have sex with other men (MSM), injecting drug users and male and female sex workers.

In the general population the epidemic is at a nascent stage. Results from the 2002 sentinel surveillance point to a prevalence of 0.21% among pregnant women27. The 2002 population based survey (PREVEN), conducted in Peruvian cities with populations of over 50,000 inhabitants (excluding the capital, Lima), revealed an HIV prevalence in the general population of 0.2% (0.4% for men and 0.1% for women)28. If we include the percentage obtained for women, we see that half of the value obtained in the sentinel surveillance is attributed to expectant mothers, which could be explained by the fact that this figure includes Lima where 33% of the Peruvian population is concentrated and where close to 68% of accumulated AIDS cases have been reported in the country since 1983.

25 UNAIDS, Global summary of the HIV/AIDS epidemic, December 2005. 26 Epidemiology, OGD, Statistics from the report of AIDS cases. 2004: Lima. 27 Epidemiology, OGD, Statistics from the report of AIDS cases. 2004: Lima. 28 Cayetano Heredia Peruvian University, Home-based study of STDs and sexual conduct (“Encuesta domiciliaria de ETS y conducta sexual”). 2002: Lima. 29 Guanira, J., et al. Second generation of HIV sentinel surveillance among men who have sex with men in Peru during 2002. XV International AIDS Conference. 2002. Bangkok, Thailand.

23 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 (95% CI 2.3 - 4.7)30. In the second cohort of seronegatives, the HPTN 03631 project involved and monitored 254 participants between April 2002 and October 2003. From the 244 persons from the follow-up year, the incidence of HIV in this cohort was 6.2 for every 100 persons/year (95% CI 3.5 – 9.9).

In 2000 and 2002, men who were at least 18 years old and who had had at least one sexual relationship with another man during the previous year were invited to participate in the HIV sentinel surveillance. This study was undertaken in several Peruvian cities for a duration of 3 months in each city. The ELISA test was used to detect early HIV32, resulting in an HIV incidence estimate of 5.12 for every 100 persons/year; Lima, Iquitos and Arequipa were the cities with the highest incidence. The wide-ranging inclusion criteria for these studies and the absence of a focus on the high-risk MSM sub- populations would suggest that this incidence estimate could be a general trend in the MSM population. The incidence of HIV is likely to be greater in the high-risk MSM sub-population. The incidence level reported indicates that the prevention methods implemented for MSM have not produced the desired results, as between 3% and 5% of MSM contract the HIV infection every year and they may potentially transmit HIV to their female partners.

In 1996 a transversal study was undertaken in Lima on the MSM population aimed at calculating precisely the risk factors associated with seropositivity for HIV and syphilis. It also characterised the behaviour of men who reported having sex with men and women (also known as “bridges”). In this study 47.1% of men reported having had sex at some time with a woman and 26.5% stated that they had had sex with a woman during the past year. As such, these men are classed as possible “bridges”. In addition, a small proportion of these men regularly used condoms with partners of both sexes, highlighting the potential of MSM to transmit STIs and HIV to their female partners; these men are acting as infection “bridges” among the heterosexual population33. As a consequence the man/woman relationship has decreased, as mentioned previously, confirming that the female population is more vulnerable on a biological and social level. It also highlights the relevance of an approach to analyse trends in the epidemic in the medium term34, including intensive widespread preventative actions for “bridges” that are transmitting HIV to their female partners.

In the current environment, where all affected persons requiring antiretroviral therapy are now gaining access to this treatment, the number of persons

30 Sanchez, J., et al., Incident HIV infections is associated with anogenital ulcer diseases among men who have sex with men in Peru. 2002. 31 Sponsored by the AIDS Division of the United States Health Institute, entitled “Prevalence and incidence of HIV and prevalence of HSV-2 among high-risk MSM in Lima, Peru”. (“Prevalencia e incidencia de VIH y Prevalencia de HSV-2 entre HSH de alto riesgo en Lima Perú”). 32 Janssen, R.S., et al., New testing strategy to detect early HIV-1 infection for use in incidence estimates and for clinical and prevention purposes. Jama, 1998. 280 (1): p. 42-8. 33 Tabet, S., et al., HIV, syphilis and heterosexual bridging among Peruvian men who have sex with men. Aids, 2002. 16 (9): p. 1271-7. 34 “Strengthening of the Prevention and Control of AIDS and Tuberculosis in Peru” (“Fortalecimiento de la Prevención y Control del SIDA y la Tuberculosis en el Perú”), presented at the World Fund in September 2002.

24 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 living with HIV is increasing as a result of the reduction in HIV mortality rates. In turn, this will increase HIV prevalence, which is not related to a worsening of the epidemic but to the fact that infected persons are living longer. Prevalence may no longer be one the most appropriate indicators for monitoring the epidemic; incidence rates should be the new indicator since they reflect the appearance of new cases. This indicator would provide a more objective view of the dynamics of the epidemic in Peru.

III. – NATIONAL RESPONSE TO THE AIDS EPIDEMIC

The Ministry of Health is the country’s governing body in respect of health and makes the regulations for action against HIV/AIDS, which are the same as those applied to other sub- sector activities. The General Department for Health of the People is the source of activities in the fight against HIV and AIDS, for which it has had the Estrategias Sanitarias Nacionales (ESN) [National Health Strategies] since 27th July 2004 (RM. 721-2004/MINSA), one of which is the Prevention and Control of Sexually Transmitted Diseases, HIV and AIDS. The transition from dismantling the Programme for Control of Sexually Transmitted Diseases and AIDS (PROCETSS) to the current National Strategy led to some processes taking longer to adapt to the change; for example the information system, which is a very important element for a diagnosis of the situation and decision making.

In this sense, the execution of Phase I of the Project to Strengthen Prevention and Control of AIDS and Tuberculosis25, has allowed the start of prevention and control activities, such as AVR Therapy, to which we have to add the great effort displayed by the country in the introduction of fast track diagnosis of HIV in expectant mothers and others, the impact of which we shall be able to see in the evolution of the epidemic in the coming years. The Project is run with contributions from the Ministry of Health and the bodies that make up CONAMUSA – Coordinadora Nacional Multisectorial en Salud [Multisector National Co- ordinator for Health) that encompasses government sectors, civil society and international cooperation.

The Instituto Nacional de Salud (INS) comes under the Ministry of Health and plays a very important role in the diagnosis of persons with HIV by improving the population’s access to treatment. It has a network of decentralised MINSA recommended laboratories that are responsible for the diagnosis and laboratory confirmation of HIV. It is also responsible for studies into genotyping, resistance to the virus and others, studies that will have greater significance in the future given the initiation of AVR Therapy.

One of the advisory bodies to MINSA is the General Epidemiology Office (OGE), which has epidemiology units nationwide, both in the Direcciones de Salud [Health Departments] as well as in the Direcciones Regionales de Salud (DIRESAs) [Regional Health Departments] which are locally responsible for the constant and sentinel monitoring of HIV/AIDS cases. The latest activity of sentinel monitoring was carried out between 2002 and 2003 in the MSM, sexual workers and expectant mothers groups.

In connection with the decentralisation and increase in cover of treatment, we should mention the Peruvian Social Security (EsSalud), which amongst its regular services provides AVR Therapy to member PLWHAs. Also the Armed Forces and the Police have a Comité de Prevención y Control del SIDA [Committee for the Prevention and Control of AIDS] (COPRECOS) for the Armed Forces (FFAA) and the Peruvian National Police Force (PNP), which proposes the regulations, co-ordinates diagnosis and treatment given by these

25 The main beneficiary of which is CARE Peru

25 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

26 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 institutions, and has a central laboratory. 3.3% of the country’s PWLHAs under AVR Therapy belong to the Armed Forces and the Police. Likewise, given the need to increase availability, the Ministry of Health has approved some civil society organisations (Médicos sin Fronteras, Asociación Vía Libre, Hogar San Camilo, Asociación Civil Impacta Salud y Educación) to deliver AVR Therapy to PLWHAs.

The Instituto Nacional Penitenciario (INPE) [National Prisons Institute] also carries out HIV prevention activities in prisons at the national level, and has an agreement with the Ministry of Health to deliver AVR Therapy to HIV-positive prison inmates. In executing Objective 226, which is the TB element of the Project to Strengthen the Prevention and Control of AIDS and Tuberculosis, the INPE health centres were improved in order to develop prevention activities and, jointly with the MINSA Sentinel Committee, an HIV Sentinel campaign was run in 2005.

In addition, other state sectors such as the Ministry of Education (MINEDU) and the Ministry for Women and Social Development (MIMDES) have programmes directed at educating and protecting adolescents and children, including the topic of preventing HIV/AIDS through promotion of healthy life-styles and sex education. In the last two years MINEDU has actively participated as technical contributor to Objective 127 of the FM Project, both in going along with the revision of the secondary school curriculum, as well as training of teachers, students (trained as peers) in seven cities around the country chosen for their higher prevalence of HIV.

Above all, the activities of the National and Private Universities are, in one way or another, aimed at research work into changing behaviour in vulnerable populations, antiretroviral interventions and treatments, and into opportunistic diseases. In the last two years (2004- 2005) through their respective Faculties, the Universidad Nacional Mayor de San Marcos (UNMSM) and the Universidad Peruana Catetano Heredia (UPCH) have participated with the consortium to implement Phase I of the World Aids Fund Project28.

Civil society has a series of institutions for their actions either in the areas of promotion or prevention, such as caring for the sick, and research. They have a network, the AIDS Network of Peru, which works for unifying efforts for the management of knowledge, generation of proposals and promoting actions to contribute to the fight against HIV-AIDS.

The organisations for people living with HIV and AIDS (PWLHAs) have consolidated to form community groups generating recognised leaderships in different areas of intervention, as well as participating very actively (either as an integral part of the activities or social

26 Objective 2. TB. Reduce the percentage of occurrence of baciloscopic-positive tuberculosis cases from more than 2,364 per 100,000 prison inmates to less than 1,000 per 100,000 in the country’s 9 largest prisons. 27 Objective 1. HIV. Promote healthy life-styles in adolescents and young people in matters of STDs/HIV/AIDS 28 UNMSM (Objective 3, Objective 5); UPCH (Objective 1, Objective 4)

27 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 monitoring) in the execution of programmes such as the one financed by the World Fund, as an example of the application of the principal “greater involvement of people living with and affected by HIV/AIDS”, also known by its initials in English and Castilian Spanish of GIPA or MIPA.

The Church or Interconfessional Communities, and the Peruvian Episcopal Conference (Roman Catholic Church), through Pastoral Care in Health, have raised awareness about PLWHAs and their families. Through the activities under Objective 529, led by the Centro Parroquial Ecuménico Rosa Blanca de la Iglesia Anglicana, [Anglican Church] the PLWHAs organisations have been reinforced so that they take an active part in the country’s fight against HIV/AIDS.

A National Strategic Plan 2001-2004 closely linked to the available services, was written by the Ministry of Health, without taking account of the capacity which civil society and persons affected by HIV have to make suggestions. It is therefore necessary to have a Multisector Plan in order to integrate the above mentioned initiatives, and this is in fact in hand, led by the Ministry of Health and supported by the Peruvian United Nations HIV/AIDS Subject Group. Since 2002, based on the need to apply to the World Fund, the Country Coordination Mechanism was formed (a fundamental requirement of the World Fund), and which locally adopted the name of Multisector National Co-ordinator for Health (CONAMUSA) which encompasses the government sectors, civil society and international co-operation. This group creates synergies between the designed strategies and the methods for their implementation. CONAMUSA presented the Project to Strengthen Prevention and Control of AIDS and Tuberculosis in Peru, which was accepted in 2003 with an approximate budget of US$ 23.6 million for AIDS over 5 years.

29 Objective 5. HIV: Strengthen the inter-institutional civil society and state response to the World Fund HIV/AIDS Project.

28 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

Core Indicators for Monitoring the Declaration of Commitment on HIV/AIDS

In order to monitor the Declaration of Commitment, the Joint United Nations Programme and associates have developed a set of core indicators to allow for the monitoring of the measurable aspects of the different international actions, of the national programme results and of the national impact of the goals.

Given that the epidemic in our country is concentrated, a fundamental part of this report is the analysis of the indicators of a Concentrated Epidemic. However, in addition, due to the high importance of outlining the epidemic’s trends, analysis of some indicators is included on the Generalised Epidemic for which some information is available.

PREVENTION

Concentrated Epidemic Indicator 3 Analysis over the last 12 months and for which the results are known on the percentage of the population most-at-risk30.

Measurement Tool: Specially designed surveys, programme monitoring.

Number interviewed (of the population most-at-risk) subjected to HIV screening during the last 12 months, and for which the results of the study are known ------x 100 Number (population most-at-risk) included in the sample or methods of estimation to determine the percentage of the population most-at-risk for the denominator.

Information was not found in the Monitoring Sheets of the National Health Strategy for STDs/HIV/AIDS, or in the Sentinel Study made between the years 2002-2003, which would allow us to determine the indicator elements for MSM and Sex Workers.

30 The term “population or populations most-at-risk” included in the above-mentioned indicators was replaced by a specific population sector (for example, female and male sex workers, injecting drug users, men who have sex with men, prison inmates, street kids, etc.) who are being evaluated as typical for above average prevalence of HIV (usually measured in pregnant women). It was also reported in Peru for men who have sex with men (MSM), female and male sex workers and prison inmates.

29 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 However, in the Sentinel Study survey of the MSM group, there is information on those MSMs who have sometimes been screened, who do not meet the measurement objective of the Indicator Incidence:

● MSM: 1857/3228 x 100 = 57.53% (% of MSM who have sometimes been screened for HIV) (**)

(**) Sentinel Surveillance 2002-2003

In the case of Sex Workers, there are no sources for calculating this indicator. The information regarding cover of Atención Médica Periódica (AMP [Periodical Medical Care] by the National Health Strategy for Prevention & Control of Sexually Transmitted Diseases/HIV/AIDS is not adequate since this activity, in accordance with the current guidelines, does not involve HIV screening during the consultation.

● Sex Workers: Indicator exists in the form of a register in the operational levels.

There is a study on Prison Inmates (considered as an at-risk population) which was conducted by Médicos Sin Fronteras which indicates how many Prison Inmates have had an HIV screening in the last 12 months and were given post-screening counselling:

● Prison Inmates: 1483/8600 x 100 = 17.24% (% of Prison Inmates with post- screening HIV) (*)

(*) Médicos Sin Fronteras 2004

It has emerged from the above that it is necessary to systematically measure vulnerable populations’ access to HIV screening with pre and post-screening counselling.

In the case of Sex Workers, it is necessary to approve the new Regulation to include taking a sample for serological screening for detection of HIV, with prior informed consent in order to have the necessary elements to evaluate the indicator in this population group.

Indicator 4

Percentage of the most-at-risk population who manage to attend prevention programmes.

Measurement tools: Specially designed surveys, programme surveillance.

Key Questions: 1. Peer-to-peer social and education promotion. 2. Exposure to specialised media 3. Detection and treatment of STDs 4. Counselling and HIV screening 5. Replacement Treatment and safer injection practices for intravenous drug users.

30 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 In the 2002-2003 Sentinel Surveillance Campaign, the latest HIV survey carried out at the national level amongst MSMs, the key questions needed for calculating this Indicator were not included. The following were amongst the questions asked which may give some idea of the survey’s value:

9 distribution of condoms 9 receive lubricants 9 receive face-to-face information on prevention (peers)

Using this information we are able to calculate the following indicators:

Numbers interviewed (MSM/Sex Workers) who have had access to HIV prevention programmes during the last 12 months ------x 100 No. of (MSM/Sex Workers) interviewed

● MSM: 2151/3280 x 100 = 2151/3280x100 = 65.58% (answered that they had been contacted by some of the three)

●MSM: 622/3280x100 = 18% (answered that they receive condoms and face-to-face information (*) (*) Sentinel surveillance 2002-2003

Sex Workers: Women who provide sex in exchange for money, making up approximately 2% of the population. MSM: men who have had sex with another man in the last year, making up approximately 6% of the population.

In the case of Sex Workers, the information found was the cover of Atención Médica Periódica (AMP) [Periodical Medical Care] by the National Health Strategy for Prevention & Control of STDs/HIV/AIDS, although this does not confirm that the key points required for the Indicator have been applied:

●Sex Worker = 22,051/56,000 to 132,000x100 = 39.3% - 16.7% (Sex Workers with access to AMP) (*) (*) Monitoring Sheet Strategy for Prevention & Control of STDs/HIV/AIDS

What is certain is that there is no data on the surveillance of the Programme which differentiates the vulnerable populations who attend the prevention programmes.

31 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

Other Government Institutions do not have data on this point. Some work done, such as that by the Universidad Cayetano Heredia (the PREVEN study), can give us evidence on the target population, for example, they find 2.6% of women age 18 to 29 in 24 towns are Sex Workers and 6% of the MSM population, which can give us an idea of the gap in the cover of the Programme’s activities across these populations.

Regarding the Ministry of Health’s Periodical Medical Care for the period 2000-2004, we see a growing curve of the female and male sex workers who attend Periodical Medical Care, although the extent of lack of attention to these vulnerable groups is unknown, especially if these activities do not involve MSMs who are not Sex Workers, as we see in the following chart.

Sex Workers, by sex, seen for the first time in the MINSA Periodical Medical Care System Peru 2000 to 2004

Total TS Atendidos = Total Sex Workers Seen. Varones=Men. Mujeres= Women. Años = Years

Source: Information from National Health Strategy for Control of Sexually Transmitted Diseases Peru 2000-2004 By: UNAIDS/Policy. Evaluation of the Strategic and Multisectorial Plan 2001-2004.

Generalised Epidemic

Indicator 3 Percentage of schools with trained teachers to deliver education on HIV/AIDS, based on life-skills given by this education in the last academic year.

Measurement tools: School survey or study plan review

Number of schools with teachers trained on HIV/AIDS based on life-sills and delivered regularly x 100 Number of schools interviewed

Peru classifies the HIV epidemic as concentrated, but the actions to prevent its spread to a generalised epidemic involve various lines of action, amongst which is the role of teachers to

32 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 provide prevention awareness to students in their educational centres.

The execution of the World Fund Project during the years 2004 and 2005 through the consortium formed by the Instituto de Educación y Salud (IES), the Consortium leader, Pathfinder, Calandria, PROSA and the Universidad Peruana Cayetano Heredia enabled: a) the review of the national studies plan on sex education in co-ordination with MINEUD; b) training in HIV prevention of 1807 teachers from 165 educational centres in the cities of Lima, Callao, Piura, Iquitos, Huancayo, Ica and Chimbote.

●No. of schools with personnel trained in HIV:

No. of schools (165) x 100 = 2.5% (*) Total No. of schools (6512)

(*) Objective 1. Project to Strengthen Prevention and Control of HIV and TB 2004-2005. Secondary schools (1807 teachers trained in 165 schools)

This Indicator, as distinct from the one requested, measures a preliminary stage, since we do not yet have sufficient information to verify that the teachers who have received training are using what they have learned to pass this on to students during the school year.

Indicator 6 Percentage of pregnant women infected by HIV who have received a course of antiretroviral prophylaxis to reduce the risk of mother-to-child transmission

Measurement tool: Surveillance of the programme

No. of HIV (+) expectant mothers who received a full course of antiretroviral prophylaxis to reduce the risk of MTCT in accordance with the national treatment protocol approved in the last 12 months ------x 100 Estimated number of HIV (+) expectant mothers

During the years 2002 to 2004 the management was based on the 002-1998 Programme to Control STDs Guideline, which determines the use of Zidovudine (AZT) from 36 weeks gestation, at the time of delivery and to the child up to 45 days. From February 2005, the Technical Standard for the Prevention of Mother-to-Child Transmission approved through RM No. 024-2005 MINSA/DGSP V.01 takes account of management based on the background and the delivery of AVR Therapy, Zidovudine or Nevirapine as appropriate.

The Monitoring Sheet for the National Strategy for Prevention & Control of Sexually Transmitted Diseases/HIV/AIDS was used to measure this Indicator, the evolution of which has been as follows during these years:

(2002) 177/474x100 = 37.34%

33 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 (2003) 482/982x100 = 49.08% (2004) 161/339x100 = 47.49% (*)

(*) Monitoring Sheet of activities for the National Health Strategy for Prevention & Control of Sexually Transmitted Diseases/HIV/AIDS MIN. HEALTH

There is no data from other Institutions regarding the management of antiretrovirals in expectant mothers.

Expectant mothers screened for HIV in antenatal control

anticipated expectant mothers expectant mothers attending health control Expectant mothers screened

Source: Monitoring Sheet Strategy for Prevention & Control of STDs/HIV/AIDS. MINSA

HIV Expectant Mothers receiving prophylaxis to prevent mother-to-child transmission

Blue = HIV Expectant Mothers Purple = HIV Expectant mothers receiving prophylaxis Source: Monitoring Sheet Strategy for Prevention & Control of STDs/HIV/AIDS. MINSA

34 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 Mother-to-child transmission of HIV is the cause of approximately 99% of infections in children. The extent of screening of expectant mothers for HIV reaches 31% of the population who attend antenatal clinics and 21% if the number of anticipated pregnant mothers during the year is taken into account, which is due to various factors, amongst which are the lack of medical supplies and equipment. Of the group diagnosed, only 37.4%-47.4% received antiretroviral prophylaxis during the years 2002 to 2004. The explanation for these figures possibly stems from the fact that the expectant mothers were diagnosed postpartum and did not therefore receive treatment.

It is hoped that with the execution of Phase II of the World Fund Project – which is concerned with reducing the Mother-to-Child Transmission by rapid screenings for diagnosis – the number of HIV expectant mothers diagnosed will increase, both during antenatal controls and at the time of delivery. It is therefore necessary for the Ministry of Health to improve access to prophylactic treatment.

It is worth mentioning that at the present time there are other protocols for the prevention of mother-to-child transmission of HIV in expectant mothers, which include combinations of more than one antiretroviral drug, thereby reducing the mother-to-child transmission of HIV to less than 2%. For the time being this standard is not applied in Peru.

Indicator 9 Percentage of blood units for transfusion that are screened for HIV.

Measurement Tool: Evaluation Blood Safety Protocol

Peru has the Programa Nacional de Hemoterapia y Bancos de Sangre [National Haemotherapy and Blood Banks], which is the governing body since 1995 and carries out safety surveillance of blood transfusions in the public sector.

The indicator is as follows:

No. of units of blood screened for HIV in the last 12 months in accordance with the WHO or national standards 135.979 ------x 100 = ------x 100 = 100% (*) No. of units of blood transfused in the 135.979 Last 12 months

Year No. of units transfused % of units screened 2003 145,665 99.35 2004 135,979 100.0

(*) PRONAHEBAS

35 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

CHANGE IN BEHAVIOUR

Concentrated epidemic

Indicator 5 Percentage (of the population most-at-risk) who correctly identify the methods to prevent sexual transmission of HIV and reject the most common misconceptions on the transmission of HIV.

Measurement Tool: Specially designed surveys

No. interviewed (age 15 to 24) who correctly answered the 5 questions No. interviewed (of the population most-at-risk) who answered “don’t know” to the 5 questions

The key questions of this indicator are:

1. Can you reduce the risk of HIV transmission by limiting sex to one faithful and non- infected partner? 2. Can you reduce the risk of HIV transmission by using condoms? 3. Can a healthy looking person have HIV? 4, Can you get HIV from mosquito bites? 5, Can you get HIV from sharing food with an infected person?

The MSM Sentinel Surveillance Campaign of 2002-2003 did not include all the above questions. In an attempt to obtain a result approaching the Indicator objective, 3 of the questions included in the document were considered:

• Can you reduce the risk of HIV transmission by using condoms? • Can you reduce the risk of HIV transmission by limiting sex to one faithful and non- infected partner? • Can you get HIV from mosquito bites?

The results for the MSM population were as follows:

●MSM: 2020/3280 x 100 = 61.59 ●Age under 24 = 1049/1646x100 = 63.73 (*)

(*) Sentinel Surveillance Campaign (2002-2003)

36 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

These results show us that more than 50% of the population interviewed have inadequate information on the transmission of HIV/AIDS. However, it also corroborates that knowledge differs from behaviour, since there is a very high prevalence of HIV in this population and their potential to transmit HIV to women in the general population is also high.

Indicator 6 Percentage of female and male sex workers who say they used a condom with their latest client.

Measurement tool: Specially designed surveys

No. interviewed who say they used a condom with their latest client In the last 12 months ------x 100 No. interviewed who say they have had commercial sex in the last 12 months

The Indicator components for MSM who do sex work are included in the MSM Sentinel Surveillance Campaign for 2002-2003; the findings were:

●MSM-Sex Workers=142/284x100=50% ●Age under 25 47.7% (*)

(*) Sentinel Surveillance Campaign 2002-2003

The Indicator shows us a low percentage of condom use, in spite of the fact that knowledge of the prevention methods are referred to by the vast majority of MSM who are sex workers, as observed in the previous Indicator. The risk of infection continues and intervention strategies must be re-evaluated in order to improve the acquired preventive knowledge being put into practice.

In the case of female sex workers, up to date information regarding the use of condoms with their clients was not found.

Indicator 7 Percentage of males who say they used a condom the last time they had anal sex with a male partner

Measurement Tool: Specially designed surveys

In the MSM Sentinel Surveillance Campaign for 2002-2003 we find:

●MSM age25: 511/1122x100=45.54% (*) (*) Sentinel Surveillance Campaign 2002-2003

37 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 In spite of the fact that there is no up to date data for this Indicator, the low percentage rate of condom use in MSMs who have anal sex explains this population group’s high risk of acquiring HIV. The same as for the previous indicators, it explains the need to draw up more aggressive strategies for the vulnerable populations in order for them to successfully acquire protection in the most effective way.

Generalised Epidemic

Indicator 10. Percentage of women and men age 15-24 who correctly identify the ways of preventing the sexual transmission of HIV and reject the most common misconceptions about HIV transmission (Targets: 90% for 2005 and 95% for 2010)

Measurement tool: Specially designed surveys

No. interviewed (age 15 to 24) who correctly answered the 5 questions ------x 100 No. interviewed (age 15 to 24) who answered (including “don’t know”) all questions

The survey should include the following key questions:

Key questions:

1. Can you reduce the risk of HIV transmission by limiting sex to one faithful and non- infected partner? 2. Can you reduce the risk of HIV transmission by using condoms? 3. Can a healthy looking person have HIV? 4. Can you get HIV from mosquito bites? 5. Can you get HIV by sharing food with an infected person?

The 5 key questions were not included in research conducted during the years evaluated. The ENDES population survey of 2004 introduced one of the questions related to awareness that a person may look healthy but may have the HIV AIDS virus. However, this survey was amongst women and therefore it would be necessary to have this same information for young men.

38 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 Percentage interviewed who know that a healthy looking person may have the AIDS virus.

Age

ENDES 2004. Dr. Cárcamo’s presentation

The chart shows us that 70% of women surveyed age between 15 and 24 acknowledge that appearing to look healthy does not rule out the possibility of infection by HIV. There is still a worrying 30% who are unaware of this possibility, which therefore increases their vulnerability.

Indicator 11 Percentage of young women and men who have had sex before the age of 15.

Measurement tool: Population based surveys

No. interviewed (age 15 to 24) who say they had their first sexual relationship before the age of 15 ------x 100 No. interviewed age 15 to 24.

The ENDES 2004 population based survey does not have a target male population; however, it does manage to show us that of the 4,686 interviewed, 23.4% of the women answered that they had Sexual Relations (SR) before age 15.

Indicator 12 Percentage of women and men age 15 to 24 who have sex with a non-marital, non- cohabiting sexual partner in the last 12 months.

Measurement tool: Population based survey There is no data to calculate this indicator.

Indicator 13 Percentage of women and men age 15 to 24 reporting the use of a condom the last time they had sex with a non-marital, non-cohabiting sexual partner in the last year.

39 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 Measurement tool: Population based survey

No. interviewed (age 15 to 24) who report having had a casual sex partner in the last 12 months and who also say they used a condom the last time they had sex with this casual partner. ------x 100 No. interviewed (age 15 to 24) who indicate they have had a casual sex partner in the last 12 months

This Indicator is from the ENDES population based survey 2004 cannot be used either as a measure for men since it was carried out on the female population.

The Development Survey we find the following data:

Uses condom with Uses condom with Uses condom with any AGE husband or partner person she does not live partner with % No. % No. % No. Women Women Women

15-19 9.9 115 24.5 108 17.2 220

20-24 8.1 393 24.5 191 13.2 581

We can see from the chart that there is a low percentage of women who acknowledge that they used condoms with their last casual partner (who they do not live with), which illustrates their vulnerability to the HIV epidemic.

Percentage interviewed who report having had sex recently with casual partners and using a condom

Age Green = Report having casual partners Blue = Report use of a condom with casual partners

40 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

ENDES 2004 Peru

We can see from the same population based survey that amongst the women interviewed age 15-24, 17% report having had casual partners, and of them, 19% confirm having used a condom in this relationship. The same as in the previous chart, there is clear evidence of the woman’s vulnerability to HIV due to the low use of the condom.

IMPACT Concentrated Epidemic

Indicator 9 Percentage of a population (most-at-risk) infected by HIV Measurement tool: Surveillance of second generation in the capital

No. (MSM/Prison Inmates/Sex Workers) with positive results to the HIV screening ------x 100 No. (MSM/Prison Inmates/Sex Workers) who have taken an HIV screening

The information obtained from the MSM Sentinel Surveillance 2002-2003 and the Prison Inmates Sentinel Surveillance 2005 was taken to measure this Indicator. According to the Indicator features, the figures obtained must be those found in the country’s capital so as to avoid the bias that it may present in rural areas, especially when the majority of HIV/AIDS cases reported in Peru are in urban areas.

●MSM: age 25 = 227/750x100 = 30.27% (*)

●Prison Inmates: 47/4364x100=1.07 (**)

National 68/7761 x 100 = 0.87 (**)

(*) Sentinel surveillance 2002-2003 (**) Sentinel surveillance (2005) Prison population of Lima

HIV prevalence is high, and easily surpasses the minimum established by the World Bank for a concentrated epidemic. This organisation also mentions that efforts to reduce the impact of HIV should be given high priority in populations such as this one.

From the beginning of the country’s Sentinel Surveillance studies, the prison inmate population was considered as an exposed population or at risk of acquiring HIV due to

41 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 overcrowding conditions, homosexual relationships due to circumstances, unprotected male sex workers, and the lack of preventative actions against STDs/HIV/AIDS. As soon as they are released they become carriers of these diseases to the general population. Up to 2004, Médicos Sin Fronteras undertook preventative activities in prisons, and these have been carried on under the Consortia Project both with the HIV and TB Components financed by the World Fund.

Sex Workers If any. No studies have been made in the country capital, but sentinel surveillance studies have been made in the Peru’s interior provinces.

Generalised Epidemic

Indicator 15 Percentage of women and men age 15 to 24 who are infected by HIV (Targets: 25% reduction for 2005 in countries most affected; reduction of 25% for 2010 globally) Measurement tool: Second generation surveillance

No. of pregnant women (age 15-24) who attend antenatal clinic with HIV-positive screening results 24 ------x100 = ------x 100 = 0.21%(*) No. of pregnant women (age 15-24) screened for HIV 10202

(*) Sentinel surveillance 2002-2003

Source: General Epidemiology Office

Evolution of HIV Prevalence in Pregnant Women From 1996 to 2002

Years Blue = National Prevalence Pink = Prevalence in Lima

42 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 The prevalence amongst pregnant women remains constant at 0.2 to 0.3% nationally in the Sentinel Surveillance studies of the last 6 years, and is higher in the Peruvian capital where 70% of HIV diagnoses are concentrated. For several years now this indicator places us as a country with concentrated epidemic.

In the following chart, drawn up by the General Epidemiology Office, we show the evaluation of the HIV impact on our country, from which we can see 3 scenarios reporting of the supposed percentage of the MSM population, which based on this assumption can provide an approximation of the total PLWHA population in Peru.

IMPACT OF HIV IN PERU

*MSM Population estimated at 3% of Men age between 15 and 49. ** MSM population estimated at 7% of Men age between 15 and 49 *** MSM Population estimated at 10% of Men age between 15 and 49 1 MSM Sentinel Surveillance 2000 PROCETSS-MINSA 2 Prevalence estimated from Sentinel Surveillance studies on Pregnant Women. PROCETSS/OGE/INS/MINSA 2000 3 Prevalence in female sex workers was estimated based on the Sentinel Surveillance in Sex Workers PROCETSS/MINSA 2000 The estimated female sex worker population taken as a denominator is based on ENDES 1996

Total MSM Heterosexua Heterosexua Female Sex Population l l Women 2 Workers 3 Men 2 Cases Prev Cases Preval Case Prev Case Prev Case Prev al 1 s al s al s al Minimu 57258 0.23 9242* 12 3047 0.24 1732 0.14 219 0.5% m 7 % 0 % Scenari o Mediu 76633 0.30 29258 12 2977 0.24 1732 0.14 276 0.7% m ** 9 % 0 % Scenari o High 14432 0.57 99312 12 2733 0.22 1732 0.14 362 1% Scenari 8 *** 4 % 0 % o

43 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 Indicator 16 Percentage of HIV adults and children still alive 12 months after initiation of antiretroviral treatment. Measurement tool: Surveillance of the programme

No. of adults and children still in antiretroviral therapy 12 months after Initiation of treatment ------x 100 (a) Minimum survival: total adults and children who began initial therapy 12 months previously, including those whose treatment has been suspended, transferred to other groups and those lost track of (b) Maximum survival: total adults and children who began initial therapy 12 months previously, except for those whose treatment has been Suspended, transferred to other groups and those lost track of

● Maximum survival: 1069/1148x100=93.11% ● Minimum survival: 1069/1176x100=90.90%

The start of antiretroviral therapy has changed the scenario in the fight against HIV in Peru; the indicator shows high survival rates. The information became rapidly available due to the Ministry of Health’s efficient database, with the support of the Project financed by the World Fund.

Indicator 17 Percentage of babies born with HIV to infected mothers (Target: 20% reduction for 2005 and 50% reduction for 2010)

No. of babies born with HIV to HIV (+) mothers ------x 100 Total No. of babies born to HIV (+) mothers

It is difficult to calculate the percentage of infants born with HIV to HIV mothers due to the fact that no specific studies have been carried out. Therefore, to ascertain the extent of mother-to-child transmission we have used the following formula:

INDICATOR SCORE: T* (i-e) + (1-T)*v • T: proportion of seropositive pregnant women receiving antiviral therapy • v: percentage of mother-to-child transmission without treatment • e: effectiveness of treatment given • v is equal to 25% and e is equal to 50%

44 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 Applying this formula we obtain

2002: 0.37(1-0.5)+(1-0.37)x0.25= 0.20 20% 2003: 0.49(1-0.5)+(1-0.49)x0.25=0.18 18% 2004: 0.47(1-0.5)+(1-0.47)x0.25=0.19 19%

2002 2003 2004

% HIV pregnant mothers under 37.34 49.08 47.49 ARV treatment % of infants still on milk infected 20 18.8 19 by HIV

The extent of mother-to-child transmission has remained the same for the last three years, although it is now hoped that coverage will be increased for HIV (+) pregnant women under ARV prophylaxis treatment and consequently the reduction in the percentage of infants infected by HIV. The World Fund provided impetus for this goal in 2004 and in 2005, including: training in carrying out rapid screening; availability of rapid screening for pregnant women who go into labour without prior diagnosis and campaigns to increase demand. This was coupled with the approval of the Technical Standard and the supply of medicines for prophylaxis both for the mother and the child.

HEALTH CARE

Generalised Epidemic

Indicator 5 Percentage of men and women with STDs in health-care facilities who have received, diagnosis, treatment and appropriate counselling

Measurement tool: survey in healthcare facility. Surveillance of Programmes

No. of patients with STDs for whom correct procedures have been followed for: a) obtaining medical history; b)examination; c) diagnosis and treatment; d) effective counselling about notifying their partner, use of condoms and HIV screening ------x 100 No. of patients with STDs where interactions have been observed between provider and client

45 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 To calculate this indicator information has been taken from care of patients with STDs regarding urethral discharge and vaginal discharge which are contained in the National Health Strategy Monitoring Sheet

STDs 2002 2003 2004 Urethral discharge 96% 95.5% 95.4% Vaginal discharge

(*) Monitoring Sheet Strategy for Prevention & Control of STDs/HIV/AIDS.

Vaginal Discharge with syndromic case management in Ministry of Health types I and II facilities. Peru 2000

Source: National Health Strategy for Control of Sexually Transmitted Diseases and AIDS (PROCETSS) Casos = Cases Vaginitis Tratadas = Treated Vaginitis

In spite of an increase of 51% being observed in the access to care of vaginal discharge, there is a fall of 20% in treatments administered, which should be considered when planning new intervention strategies.

46 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

Males age 15-49 with Urethral Discharge consulting Ministry of Health clinics Peru 2000-2004

Years Source: National Health Strategy for Control of Sexually Transmitted Diseases and AIDS (PROCETSS)

In the case of urethral discharge, there is evidence of a drop in access to health care, which is much greater if we consider that according to ENDES 1996 it was calculated that there were around 40,000 men with urethral discharge, and only 15% of them reached Ministry of Health care facilities.

Syndromic management of STDs is a proven strategy for the prevention of infection by HIV, and should therefore be reviewed and strengthened.

Indicator 7 Percentage of men and women with advanced HIV infection who receive combination antiretroviral therapy

Measurement tool: Surveillance of programme

No. of persons living with advanced HIV who receive combination ARV Therapy in accordance with the national approved treatment protocol. ------x 100 No. of persons living with advanced HIV infection

47 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 AVR Therapy by Institution. November 2005 Institutions No. of PLWHAs receiving Treatment MINSA 3752 [Ministry of Health] COPRECOS 213 [Committee for the Prevention and Control of AIDS – Armed Forces & Police] ESSALUD 2333 [Social Security] Total 6298

According to the Ministry of Health database of AVR Therapy surveillance, we have:

AVR Therapy by ethereal groups. MINSA November 2005

Ethereal Groups Total [0-9] [10-19] [20-59] Over 60 Total 122 (3.7%) 63 (2.14%) 2967 (92.2%) 64 (1.9%) 3216

SOURCE: Based on Epi-Info, *Format Manual National Health Strategy HIV-AIDS-MINSA

AVR Therapy by sex. MINSA November 2005 Female Male Total 1078 (34%) 2138 (66%) 3216 SOURCE: Base EpiInfo, * Format Manual National Health Strategy HIV-AIDS – MINSA

SUPPORT

Indicator 8 Percentage of orphans and vulnerable children whose families received free external basic support for child care

Measurement tool:

Key Questions: 1. Has this household received medical support, including medical care and/or medical supplies within the last 12 months? 2. Has this household received school-related assistance, including school fees within the last 12 months? 3. Has this household received emotional or psychological support, including counselling from a trained counsellor, and/or emotional or spiritual support /companionship within the last 3 months? 4. Has this household received other social support forms including socioeconomic and/or instrumental support within the last 3 months?

48 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 Being orphaned is another of the ways in which HIV impacts on the child population. This indicator cannot be measured locally as surveys have not been conducted that include the necessary questionnaire for its measurement. However, it is necessary to recognise some of the activities carried out by NGOs and parish groups who work to support children made vulnerable by HIV in Peru.

In its programme “Niños y Niñas por la vida creando un entorno favorable en VIH/SIDA” [Boys and Girls for life creating a favourable HIV/AIDS environment”, the NGO Vía Libre has made information available on an approximation of the HIV impact on creating orphans. Out of 102 children living with HIV, 61.7% are without a father or mother, or both.

Orphaned children living with HIV

Relationship Boys/Girls % Mother 7 6.8 Father 19 18.6 Both parents 37 36.27 TOTAL 63 61.76

Source: Vía Libre, Boys and Girls for life creating a favourable HIV/AIDS environment

In the same way, “Hogar San Camilo” has provided food and assistance to mothers since 1998. This year, 2005, 10% of 120 children of HIV mothers who are not infected are orphans, whilst with Vía Libre, 116 children affected by HIV/AIDS (not-infected) 22% are orphans.

Orphaned children affected by HIV

Relationship Boys/Girls % Mother 5 3.38 Father 23 15.54 Both parents 4 2.7 TOTAL 32 22.62

Source: Vía Libre, Boys and Girls for life creating a favourable HIV/AIDS environment

Comparative chart: Orphaned children affected by HIV Vía Libre – Hogar San Camilo

Vía Libre Hogar San Camilo TOTAL Children of HIV (+) 116 120 236 mothers not infected by HIV No. of Orphans 25 12 37 Percentage of Orphans 22 10 15.6

49 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 Although there is no exact idea of how many HIV orphans there are in Peru, it can be deduced from the previous data on the number of reported cases of expectant mothers infected in the last three years, and the extent of mother-to-child transmission, that there are around 580 children orphaned by HIV. Nevertheless, the difficulties and the lack of regulations for their early diagnosis could result in their deaths.

There are also other Institutions providing support to HIV orphans, these are * La “Posadita del Buen Pastor” and the *Casa de Acogida “San Juan Diego”, Huancayo.

4. Some organizations of civil society maintain the vulnerable populations within their spectrum of work, with most of their activities focused on promoting prevention and training peer educators (Impacta, Doctors Without Borders, the PREVEN Project from the Univeridad Peruana Cayetano Heredia, CPESJU among others), as compared to public health activities. With the initiation of the Project funded by the Global Fund, civil society has involved itself in public health activities in coordination with the Ministry of Health, constituting a strength whose results should come to fruition in a few years. 5. In the surveys administered to key actors in vulnerable groups, it was found that that they request a larger role in the design and implementation of the projects and activities targeted at them, complimentary to the principle involving more people who live with and are affected by HIV (MIPA or GIPA). It is hoped that upon initiation of the second phase of the Project funded by the Global Fund that the decision-making role of these groups will be larger. 6. RMA coverage for SW’s increased 51% in 2004 compared to 2002 due to activities by a particular project, PREVEN Project and localized to the ten cities where they are active. However, the RMA activities have unevenly lost strength in some regions and the information system that it uses does not identify duplicate SW in the new consultation records. The RMA goal is very important, which is to control the epidemic in vulnerable groups, above all in SW’s, which is why it is necessary to obtain a standard quality level of services in the different regions of the country. Regrettably, the sentinel sexual workers surveillance data from 2002-2003 is not available. 7. The peer education strategy obtains RMA coverage in MSM. Nevertheless, preventative activities through CERETS and URMAS for MSM are not completely registered by current systems and coverage cannot be calculated, especially when you consider that based on computer-generated models there should be more than 240,000 MSM in the country. Redesigning the data purging methods so as to not lose this information is necessary. The Ministry of Health has plans to customize the services according to each vulnerable group, which would facilitate reliance upon more precise information and at the same time, reevaluate the public health activities directed towards the most prone populations in a customized manner, which would increase the coverage and better the availability of services. 8. Current legal guidelines limit STD and HIV containment activities directed to sexually exploited adolescents, MSM and other vulnerable adolescents. So long as the legal guidelines do not change, serving these populations will be difficult. Civil society should remain alert in order to bring about these changes. 9. Sentinel HIV surveillance on MSM to support the report is from 2003. This work reports on the prevalence of HIV in this population, however, in reality, the incidence is the best means to evaluate the epidemic in the country due to

50 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 access to RMA to HAART. Said information serve as one of the inputs in decision-making, and it should therefore be available for all levels at the appropriate moment. The MSM incident rates in the studies presented in this report are high and very alarming. However, not all of the information is available regarding the sentinel MSM surveillance for 2002-2003. 10. HIV prevention work in schools is in its initial phases; research studies are necessary to see the impact of training students in HIV by their professors. MINEDU should contribute to this. The current legal guidelines makes autonomous access to preventative and STD and HIV services difficult for adolescents and should be reviewed. 11. With regard to vertical HIV transmission prevention there have been lost opportunities in the timely diagnosis in pregnant women that use Health Center services, to the effect of 70%, and in the preventative treatment in those that are diagnosed, to the effect of 52%. This gap is much larger when the estimated annual number of pregnant women is taken into account. The Project, funded by the Global Fund, includes an introduction to quick tests during prenatal care as well as at the moment of giving birth, the training of those health care professionals and the availability of antiretroviral for the prevention of the transmission of HIV from the mother to child, by which, it is expected in the following years to dramatically reduce lost opportunities, and therefore, the impact that HIV has on the child population. 12. The epidemiological reports that exist do not lend themselves to entirely evaluate the knowledge and behavior regarding HIV. 13. Timely studies mention some interesting tendencies, such as women’s low use of condoms, early sexual activity and more than one partner. It is necessary for the state institutions of civil society to include in their questionnaires the information required in order to comply with the requested Evaluation. 14. ENDES 2004 gives evidence of the low percentage of women that use condom with casual sex partners, which increases their vulnerability to HIV. This demographic survey should not be limited in population to women, but should also include men, especially having precedent, having previously completed a study of both sexes in 1996. This would give us a clearer idea concerning our youth’s behavior and the HIV vulnerability rate. 15. The information available regarding the handling of STDs can be found on the NSS PCITS/HIV/AIDS Monitoring Sheet, which shows that there was a reduction in the appropriate processing of vaginal fluids in 2004, going from 97.9% in 2002 Comment [DF1]: I can't tell from the context if they mean treatment, as in to 76.61% in 2004. Coverage by MINSA is even higher in cases of urethral medical treatment or "processing " or discharge. The handling of the STD syndromes as an HIV prevention strategy "handling" such as for the purposes of deserves more attention on the part of the NGO’s and MINSA for the purposes of testing. bettering the services and increasing coverage and access to appropriate treatment. 16. The PLWHA’s receiving HAART in the entire country can be classified as a major event in the struggle against HIV in Peru. There is an increase in people receiving HAART by more than 500% in 2003 to 2005. Currently, there are efforts to guarantee sustainability and the quality of care. 17. There is no systematic register of the impact of the epidemic on the children of people living with or that have died with HIV. The efforts by civil society, and in specific cases by the State, in supporting orphans and children vulnerable due to HIV are not sufficient, making an explicit protection policy for these populations necessary. MIMDES can contribute in this regard. In order to have a clearer idea of the infected and affected children, securing the implementation of the standardization of early diagnosis for children with HIV is an urgent task.

51 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 18. The projections of the epidemic signal the need to shore up prevention programs for MSM taking the cross-over groups (bisexuals) into account, continuing the work started with SW and broadening prevention coverage in PVHIV (prevention of positive HIV results), design prevention programs for non- pregnant women and heterosexual men, including the “cross-overs”. V.- NEEDED SUPPORT FOR THE COUNTRY’S DEVELOPMENT PARTNERS The fundamental activities that the development partners should undertake with the vision to reach the country’s goals and objectives are the following: 1.- Support the Strategic Multisectoral Plan and a National Monitoring and Evaluation Plan that will allow the evaluation of the national response to HIV/AIDS: Develop a national monitoring and evaluation strategy (the third one); Design sustainable monitoring and evaluation systems based on proven, successful models that can be used to report the results and the impact during the stages of implementation. Implement and execute quality control on the monitoring and evaluation systems; Evaluate, examine and improve the monitoring and evaluation systems in the long-term to the extent that the activities are broadened in order to reduce the morbidity and mortality associated with HIV/AIDS. 2.- Support activities related to Epidemiological Monitoring. This includes strengthening of compilation systems, analysis of data and dissemination of the information. The information currently generated by the Strategy via the Monitoring Sheets is incomplete and the Sentinel Surveillance is not executed or disseminated in a timely manner. Likewise, support is needed to bring up to standard the data collection tools. The HIV epidemic in the country is concentrated but the monitoring systems do not generate sufficient information regarding the populations most affected (MSM, SW). 3.- Support in redefining Regular Medical Attention (RMA) and the populations it should serve. RMA has a very important objective: to control the epidemic in vulnerable groups, above all SW, making securing a quality of level of service in the country’s different regions necessary. Evaluating the provision of some form of RMA to MSM’s, above all taking into account the high prevalence and incidences and the proven effectiveness of some strategies included in RMA, such as the diagnosis and treatment of STD’s, education on the use and predisposition to the use of condoms and the voluntary testing for HIV with counseling is additionally necessary. 4.- Support for large-scale training of educators in sex education, following the healthy lifestyle guidelines and the systematic evaluation of habits picked up by students. 5.- Support in measuring the Economic Impact of HIV/AIDS in the country, as a foundation for the steps towards Universal Access to HIV prevention, treatment and attention. VI.- EVALUATION AND MONITORING SYSTEM Indicators are divided into two subgroups: national and global indicators. In this document we dedicate ourselves to the latter. 1. Does your country have a national Monitoring and Evaluation Plan? It is not explicit, since it is not a consideration in the ITS/HIV/AIDS 2001 – 2004 Prevention and Control Strategic Plan: although operationally, on a national level there are NSS PCITS/HIV/AIDS evaluation events, i.e. supervisory visits and monitoring the HIV epidemiological surveillance and sentinel. 2. Does the Monitoring and Evaluation Plan include the following?

52 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 A compilation and analysis of data strategy YES A well-defined group and standardized indicators YES Directives for the data compilation tools YES A strategy to evaluate the data quality and precision No A dissemination strategy for the use of data No The Monitoring and Evaluation Plan is in effect, but there are activities being carried out that are not part of a plan. The designing and implementation of a strategy to evaluate the quality, precision and dissemination and timely use of data is needed. 3. Is there a Monitoring and Evaluation Plan budget? Per the Ministry of Health’s own structure, the monitoring and evaluation budget is not administered by the ESN; there is a budget for annual Evaluation Meetings and for supervisory/monitoring visits. The General Office of Epidemiology has a budget for epidemiological monitoring, which is somewhat limited to sentinel monitoring, although it is considered within the Activities Plan. 4. Is there a unit or department dedicated to monitoring and evaluation? Within the Ministry of Health’s structure the Integral Care Administration is tasked with multiple supervisions: the evaluation is under the NSS and the HIV sentinel epidemiological surveillance is through the General Office of Epidemiology. 4.1 Are there mechanisms to ensure that all important operational entities submit their reports to said unit or department? There are established Ministry of Health internal mechanisms for the sharing of information and reporting of activities, with there being difficulties in some occasions with the speed of the sharing of information. 4.2 Is there a full-time official responsible for the National Program’s monitoring and evaluation activities? There is no one exclusively dedicated to it, since most of the members of the NSS team have multiple duties and responsibilities. With respect to the General Office of Epidemiology, there is a person dedicated to the monitoring of HIV in the country. 5. Is there a working group or committee that meets regularly and coordinates monitoring and evaluation activities? Within the Ministry, there is a Sentinel Surveillance Committee that meets to implement the Country Monitoring Plan and to see to it as to what time of the year and which populations are to start being monitored. This Committee participates by representation at NSS PCITS/HIV/AIDS, OGE, National Health Institute, Reproductive Health ESN. In the case of people deprived of their freedom, the respective person in charge from the INPE is suggested to participate.

At the Ministry of Health level there is also a Medication Committee constituted by the Coordinator; the Chemical Pharmacist; a respective personnel from HAART of NSS PCITS/HIV/AIDS; the representative from the Directorate General of Human Health; the representative from the Executive Secretary of the CONAMUSA; the representative from the Principal Beneficiary (Peru CARE) of the FM Project; and the representative of PROVIDA (the institute that represents IDA – Holand, the provider of the antiretroviral medication). The meetings are held regularly with the last one having been held on the 7th of December, 2005.

6. Have the programs of each entity been revised in order to correlate the monitoring and evaluation indicators with those of your country? NO

53 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 7. To what degree do the United Nations, bilateral organizations and other institutes share the monitoring and evaluation results?

The monitoring data is disseminated through epidemiological bulletins issued by the OGE; press releases made by the Ministry of Health’s Communications Office where knowledge is imparted not only on the results of the evaluation but also on the status of the country’s epidemic; around World AIDS Day this dissemination is much greater or in situations of reporting demands, such as this UNGASS Follow-up Report. 8. Does the monitoring and evaluation unit maintain a national, central database? The monitoring and evaluation unit maintains a centralized database. The GOE maintains the epidemiological and sentinel monitoring database and that of the ESN PCITS/HIV/AIDS evaluations. 9. Do you have a functional health information system? There is a system for dissemination of information that stems from health institutions and reaches a central level, making reinforcing the entering of quality data and analysis in each of those levels. Currently, in the country, alongside the Global Funds Project, an HIV informations system is being designed at the Ministry of Health level which combines all of the parties that participate in the dissemination of information. 10. Is there a functional informations system regarding education? The functional information system regarding education is in its initial stages. 11. Does your country publish at least once a year an evaluation report regarding HIV/AIDS that includes HIV monitoring reports? YES. Information is regularly disseminated through the Ministry of Health’s GOE, and is located on its website. (www.minsa.gob.pe) 12 To what degree is strategic information used in the planning and execution? 4th Degree. Because some of this information data is not available during the planning process this cannot be considered. 13. During the last year was there monitoring and evaluation training? At a national level, YES At a subnational level, YES Did it include civil society? YES Training has been provided through the Ministry of Health on evaluation through the NSS PCITS/HIV/AIDS in national and subnational levels. Training insofar as monitoring has been at a subnational level by private entities to complete the Sentinel Surveillence in Sex Workers and MSM. How would you, in general, rate the efforts of the HIV and AIDS monitoring and evaluation program? The HIV/AIDS monitoring and evaluation program efforts have not changed since 2003. It is important to highlight that beginning 2005 with the FM funding, the Sentinel Surveillance of People Deprived of Their Freedom; likewise, with funding from other Projects, Sentinel Surveillance on pregnant women in provinces is being considered for January of 2006.

NATIONAL LEVEL NATIONAL ACTION AND COMMITTMENT National action and committment Data compilation method Spending

54 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 1. Amount of national funds provided by the governments of low and medium income countries The most appropriate, according to the petition and country funding Evaluation of national spending on HIV/AIDS. Status of development and the implementation of policies 2. National Composite Policy Index *Areas covered; prevention, care and support, human rights, civil society participation, monitoring and evaluation. *Target Groups: people who live with HIV/AIDS; women; youth; orphans and prone populations Biennial Study theoretic and interviews with key sources

1. AMOUNT OF NATIONAL FUNDS DISBURSED BY GOVERNMENTS IN LOW- AND MIDDLE-INCOME COUNTRIES

A. GOVERNMENT FUNDING FOR HIV/AIDS31

Amount of national funds disbursed by governments in low- and middle- income countries

The amount of national funds disbursed is calculated on the basis of the financial resource Flow of Public Funds spent on the prevention, care and/or treatment of HIV/AIDS according to information available in the Ministry reports for the years 2003 and 2004.

The Sectors32 for which there is information are: o Health: the Ministry of Health, the National Institute of Health and Integral Health Insurance o Education: the Ministry of Education o Interior: the Ministry of the Interior o Economy and Finance: the Ministry of Economy and Finance o Defence: the Ministry of Defence o Justice: the National Prisons Institute o Labour and Employment Promotion: the Ministry of Labour and Employment Promotion

Public Funds are Public Treasury Income33 derived from contributary income and other concepts which constitute the main financial flow of state organization

31 Information obtained from: Strengthening Project for the Prevention and Control of AIDS and Tuberculosis in Peru. Object 5. Component HIV. Survey of Multi-Sector Budgetary Information 2003 and Survey of Multi- Sector Budgetary Information 2004. 32 In accordance with pre-existing legal norms, Ministers are Heads of the Sector to which they belong. Each Sector may have one or more budgetary specifications. For example, the Interior Sector consists only of the Budgetary Specification of the Ministry of the Interior. The Justice Sector’s budgetary specification is the National Prisons Institute – INPE. 33 In 2004 Public Funds constituted 60.8% of the Public Sector Budget. If contribution to other Public Funds were to be added to this, the figure would rise to 71.3%. In 2003 this financial flow constituted 69.1% of the Public Sector budget.

55 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 activities, the destination of which is decided annually in the Annual Budget Laws. Budget Allocation for the Control of HIV-AIDS increased between 2003 and 2004 by 99.2% as we will see in the following table:

HIV Budget Allocation by Ministries 2003-2004 1/ (US Dollars) Public Organization 2003 2004 Increase Ministry of Justice 123,112.9 137,656.2 11.8% National Prisons Institute 123,112.9 137,656.2 11.8% Ministry of the Interior 179,533.5 494,356.5 175.4% Ministry of Education 97,970.1 203,859.4 108.1% Ministry of Health 1,468,165.4 2,905,928.4 100.0% DIGEMID 703,198.0 100.0% Management Agreements Administration Programme 1,086,421.0 1,427,775.0 31.4% National Institute of Health 97,032.6 506,599.7 422.1% Integral Health System 284,711.8 268,355.6 -5.7% Ministry of Defence 254,483.2 100.0% COPRECOS 275,751.8 275,751.8 0.0% Total 2,144,533.7 4,272,035.3 99.2% 1/ Does not include budget allocation for EsSalud – Social Security Health, which reached 5.4 million US Dollars in 2003. Information for 2004 is unavailable. Exchange rate 3.4 Nuevos Soles to the US Dollar.

The information above shows what has been allocated to the Control of HIV/AIDS by officials of Public Sector organizations. This information does not represent the financial cost to the Government of Peru for the Control of HIV/AIDS, as it does not include all spending designated to healthcare (which falls under personal spending).

As far as the Ministry of Health’s main source of information was concerned, it was difficult to centralize information due to the implementation of the Model of Integrated Healthcare and the de-activation of the Programme for the Control of STI/HIV/AIDS. There is information available on the ESN PCITS HIV/AIDS programme itself but none about its budget because this information formed part of the standard planning for the (de-activated) Programme.

The following table shows the Ministry of Health’s allocated budget through PROCETSS, between 1998 and 2002. For the 2003 budget the Management Agreements Administration Programme began to operate under the new Model of Integral Healthcare, which is why it is not possible to disaggregate by spending lines34.

PROCETSS/CETSS Ministry of Health Year Annual Budget Allocation (US$) 1998 3,295,337.90 1999 2,493,112.90 2000 2,584,401.20 2001 2,795,793.50

34 Kusunoki L; Access to the Integral Care of People with HIV/AIDS; FOROSALUD-CIES, Cuadernos de Trabajo Series; No5; Lima 2003

56 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 2002 1,737,751.50

Ministry of Justice

The Mission of the Ministry of Justice is to provide legal advice to the Executive Power in general and especially to the Cabinet so they can strengthen the country’s democratic institutions; and drive a policy of promotion and protection of human rights, and Extrajudicial conciliation as an alternative means to conflict resolution, in order to achieve a culture of peace.35

35 Source: Government of Peru webpage

57 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 The Ministry of Justice does not have an assigned budget specification for health spending. One of the Ministry of Justice’s Decentralized Public Organizations – OPD – is the National Prisons Institute (INPE) which is responsible for healthcare in the prison population.

National Prisons Institute

In all its prisons the INPE runs activities relating to the Programme for the Control of Sexually Transmitted Diseases and AIDS.

Ministry of the Interior

The mission of the Ministry of the Interior – MININTER – is to guarantee, maintain and establish internal order; provide protection and help to individuals and the community; guarantee adherence to laws and the safety of public and private property; prevent, investigate and combat crime; guard and control borders; participate in national defence, as well as the economic and social development of the country and civil defence, according to Law; through the National Police. It must also perform the duties of Interior Government.36

The Ministry of the Interior has an allocated budget for Healthcare through the State National Police of Peru – PNP. Not all the budget concepts concerning the Control of HIV/AIDS are identified within the programme structure but it was possible to obtain the following information:

Budget Allocation 2003 (US Dollars) 1/ Budget concept Amount Antiretrovirals 137,884 Viral load 3,769 CD4 count 3,959 Total 179,534 1/In 2004 spending reached 494,356 US Dollars.

As well as the purchase of drugs and laboratory costs outlined in the table above, the Ministry of the Interior held meetings and talks, which were carried out by its own staff, which is why they have not been assessed and included in the investment figures for MININTER.

Ministry of Economy and Finance - MEF

36 Source: Government of Peru webpage

58 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 The Ministry of Economy and Finance’s Mission is to develop, propose and implement economic and financial policy which will benefit economic growth for the general well-being of the population.37

It is responsible for budget allocation to different specifications for carrying out the activities of prevention, diagnosis and treatment of HIV/AIDS. In this Institution there is no disaggregated data available concerning spending allocated to the control of HIV/AIDS.

Ministry of Education

The Mission of the Ministry of Education is part of the restructuring tasks proposed by the Peruvian State, which aims to become a modern, flexible instrument, suited to the needs of an emerging nation, one which is preparing to take on the enormous challenges that come with growth. The Ministry of Education has defined its strategic mission as the task of encouraging personal development.38

In this Ministry it was possible to identify, through the programme structure, the part which was linked to Control of HIV/AIDS and this was allocated to the Office of Integral Education and Prevention through sex education. According to the detail provided in the operational Plan, the main activities carried out were related to sex education training, specialists and technical teams.

There now follows information for 2003 and 2004. In 2003 the two financial resource flows used in the programme were: public funds and revenue from privatization and franchises (whose denominations were only used in 2003) and which can only strictly be classified as Public Treasury resource flows. In 2004 resources were only allocated to the Financial Resource Flow of Public Funds.

Budget Allocation – Ministry of Education (US Dollars) Financial Resource Flow 2003 2004 Source: Public Funds 203,859 January to September 74,895 Source: Revenue from privatization and franchises October to December 23,075 Total 97,970 203,859

Ministry of Health

37 Source: Government of Peru webpage 38 Source: Government of Peru webpage

59 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 The Ministry of Health’s Mission is to promote and guarantee the integral health of the population of Peru.39 In the Ministry of Health the following have been identified for the allocation of resources for the control of HIV/AIDS40:

o State Office for Individual Health through the National Health Strategy for Prevention and Control of Sexually Transmitted Diseases and HIV/AIDS o State Office for Medicine, Supplies and Drugs o Management Agreements Administration Programme - PAAG o Integral Health Insurance – SIS; and o The National Institute of Health

General Directorate for People’s Health The spending allocation of the General Directorate for People’s Health, the organization responsible for the aforementioned National Health Strategy, is mainly for personal (and operational) costs.

State Office for Medicine, Supplies and Drugs The spending allocation is for Public Tender Nº 006-2003-MINSA carried out as National Counterpart of the World Fund Project. It consisted of the acquisition of antiretroviral drugs to treat 1,000 adults and 100 children for a period of 6 months. The purchase was initiated in June 2003 and delivered in 2004. 11 drugs were obtained, at a cost of S./2,390,873.20 (US$ 703,198.00 Exchange rate 3.40 Nuevos Soles per US Dollar)

Antiretroviral Drugs – Public Tender Nº 006-2003 (MINSA)41

Nº Description Price of Reference price Unit price Supplier Combined per unit obtained Negotiation S/. S/. (t.c.=3.5)

Management Agreements Administration Programme – PAAG

This is a MINSA Programme which offers funding to help improve fairness, efficiency and transparency in the allocation of financial resources for priority health measures, ensuring that the objectives of each sector are met.

One of PAAG’s investment paths is Health Priorities to which it provides the finances for the development of health activities, and preventative and recuperative care; it also funds the acquisition of strategic Supplies and Drugs for Basic Service Benefits concerning collective healthcare, such as transmissible diseases and other prevalent or emerging health problems.

As well as providing financial resources for the purchase of drugs for the control of HIV/AIDS, PAAG also offers support to Care for Communities at Risk. The

39 Source: Government of Peru webpage 40 The reference is taken from the organic structure of MINSA approved by Supreme Decree No 014- 2002-SA organization ruling and duties of MINSA 41 DIGEMID Report on the evaluation of Post Negotiation Impact of Antiretroviral Drugs, 2004

60 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 participation of Collective Health in the prevention and control of sexually transmitted diseases – AIDS – is through PARES’ (PEPs) health strategy; 350 PARES peer group educators are employed in the development of preventative and control measures in popular places where they interact with communities at risk of sexually transmitted diseases.

Human resources allocated to the Control of STDs/HIV/SIDA amount to 1.1 and 1.4 million US Dollars for 2003 and 2004 respectively.

Spending on human resources corresponds as much to the hiring of personnel (for HIV/AIDS) as it does to payments42 from PAAG to the Executive Bodies of the Health Regions at national level, such as the DISAS in Lima (Callao, South Lima, North Lima, East Lima and Lima City).

The information for 2003 is as follows:

MINISTRY OF HEALTH – UE 035 MANAGEMENT AGREEMENTS ADMINISTRATION PROGRAMME INFORMATION ON DISTRIBUTION TO DISAS 2003 (in Nuevos Soles) MATERIAL HUMAN RESOURCES TOTAL RESOURCES Amount Remittance 1/. RESOURCES ALLOCATED STDs HIV AIDS 1,006,831 350 2,627,000 3,693,831

This is followed by the information for 2004:

MINISTRY OF HEALTH – UE 035 MANAGEMENT AGREEMENTS ADMINISTRATION PROGRAMME INFORMATION ON DISTRIBUTION TO DISAS 2004 (in Nuevos Soles) MATERIAL HUMAN RESOURCES TOTAL RESOURCES Amount Remittance 1/. RESOURCES ALLOCATED

42 Including travel expenses

61 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

STDs HIV AIDS 1,975,994 350 2,878,441 4,854,435 1/ The relative weight of each problem presented, in respect of the total financial resources allocated to Health Priorities, is STDs-HIV-AIDS (3%). The total amount in payments made to Health Priorities in 2003 was 32 million Nuevos Soles.

Integral Health Insurance – SIS

This is a decentralized, public body which is part of MINSA. Its purpose is to administer funds for financing individual health benefits in accordance with Health Sector policy. One of its main objectives is to promote equal access for the uninsured population to quality health benefits, with priority given to vulnerable groups, those in poverty and those in extreme poverty.

The SIS is currently in its implementation stage, mainly in terms of mechanisms for the identification and incorporation of beneficiaries, mechanisms for the consolidation of financial paths to include those populations who have the characteristics mentioned above, and control mechanisms for ensuring the correct use of funds.

The SIS Benefits Plan, approved in DS N 003-2002-SA and its amendments, relies on financing from public fiscal funds approved in the annual budgets. It offers a range of Benefits Plans for recuperative and preventative care, which are granted to the population at no cost to the population in poverty or extreme poverty.

The Benefits plans include Plan A: Infants between 0 and 4 years, Plan B: children and adolescents between 5 and 17 years, Plan C: pregnant women whose requirements for this group include: prophylaxis treatment for HIV positive mothers and their newborns, and HIV/AIDS treatment for children.

The following table shows the total cost for the SIS for antiretroviral treatment between 2002 and 2005. It should be noted that it includes all types of tests and treatments given to people living with HIV/AIDS.

Also, 2,226 diagnostic tests were carried out in 2004 and in 2003 there were 1,810.

BUDGET ALLOCATION – INTEGRAL HEALTH INSURANCE (in Nuevos Soles)

Plan 2002 2003 2004 2005 ANTIRETROVIRALS A B Total VIRAL LOAD A B Total BREAST MILK A Overall total

62 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

Plan A: Infants from 0 to 4 years Plan B: Children and Adolescents from 5 to 17 years

National Institute of Health

The purpose of the National Institute of Health is the development of scientific and technological advances in the rigorous field of science applied to health, nutrition, food, the manufacture of biological products for human and veterinarian use, quality control of food and pharmaceutical products and so on; also, the control of transmissible and non-transmissible diseases, health and safety in the workplace and environment, focussing on the health of individuals and intercultural health, thereby contributing with creative responsibility and MISTICA (Methodology and Social Impact of Information and Communication Technologies in America) to the social aspect which the health of the Peruvian community demands.

The National Institute of Health is organized into the following Centres:

The National Centre for Health and Safety at Work and in the Environment (CENSOPAS) The National Centre for Public Health (CNSP) The National Food and Nutrition Centre (CENAN) The National Centre of Biological Products (CNPB) The National Centre for Intercultural Health (CENSI) The National Centre for Quality Control (CNCC)

The National Centre of Public Health Laboratories is the standard technical agency of the National Institute of Health, and its function is to investigate, standardize, develop and fully assess investigations into the development of new technologies, those which are applicable to transmissible and non-transmissible diseases; their aim is to deliver technical and scientific data that facilitates the formulation of policies guiding public healthcare.

One of the National Centre of Public Health Laboratories’ main services is the Laboratory Diagnosis of Viral, Bacterial, Parasitic and Mycotic diseases. Currently, the Laboratory Network comprises 16 Regional Laboratories: Apurímac, Arequipa, Ayacucho, Cajamarca, Cuzco, Huancavelica, Junín, Lambayeque, Lima, Loreto, Madre de Dios, Piura, Puno, Dan Martín, Tacna y Tumbes: there are also 4 laboratories planned in Ancash, Amazonas and Ucayali. In Lima Metropolitana there is Lima Este.

The following shows the estimated cost of Investment from the INS towards the control of HIV/AIDS.

63 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 The information about tests performed is based on information from the INS database and is in accordance with the unit costs of tests43.

COST OF TESTS CARRIED OUT BY INS – HIV/AIDS 2003 (in Nuevos Soles) HIV NUMBER OF TESTS UNIT COST TOTAL ELISA IFI* WESTERN TOTAL COST (1) * IFI tests must be preceded by ELISA tests. AIDS NUMBER OF TESTS UNIT COST TOTAL VIRAL LOAD CD4 TOTAL COST (2) TOTAL (1+2)

COST OF TESTS CARRIED OUT BY INS – HIV/AIDS 2004 (in Nuevos Soles) HIV NUMBER OF TESTS COSTS ** TOTAL ELISA IFI* WESTERN TOTAL COST (1) * IFI tests must be preceded by ELISA tests. AIDS NUMBER OF TESTS COSTS TOTAL VIRAL LOAD CD4 TOTAL COST (2) TOTAL (1+2)

Ministry of Defence

The Mission of the Ministry of Defence is to ensure Independence, Sovereignty and the Territorial Integrity of the Republic; to participate in the socio-economic development of the country and in Civil Defence; to assume control of internal order in exceptional circumstances.44

43 In order to estimate budgetary spending by the INS, and using information about the cost of tests, further information was requested on how many of each of the services mentioned was carried out by the INS. 44 Source: Government of Peru webpage

64 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 The Ministry of Defence has an allocated budget for Health through Armed Forces, Army, Navy and Air Force Hospitals.

In the specific case of the Armed Forces, which are part of the Ministry of Defence, the only information available was from the Navy of Peru. In 2004 their annual expenditure for a total of 49 patients, according to protocol, was 222,555 Nuevos Soles on reactives for HIV/AIDS treatment and 642,687 Nuevos Soles for drugs, their total cost amounting to 865,242 Nuevos Soles.

COPRECOS

The control of HIV/AIDS is the responsibility of COPRECOS – Committee for the Prevention of HIV/AIDS in the Armed Forces and National Police – a collaboration between representatives of the Air Force, Navy and Army and the National Police of Peru. COPRECOS activities are targeted towards the prevention of HIV infection among members of these institutions; however, they have greater success because of the prevention activities they carry out.45

The total expenditure for COPRECOS in 2003 amounted to 937,556 Nuevos Soles for the Armed Forces (Ministry of Defence) and Police (Ministry of the Interior). This amount includes treatment costs, leaflets, condom costs, and so on.

Ministry of Labour and Employment Promotion

The Ministry of Labour and Employment Promotion is one of the Management Agreements Administration Programme’s leading Institutions, which has developed capabilities for overseeing the implementation of policies and generation programmes, improving employment levels, aiding development of small and big businesses, encouraging pension funds and professional training; it also ensures the fulfilment of Legal Standards and improvement of working conditions through dialogue and consensus between social representatives and the State.46

The Ministry of Labour and Employment Promotion has not incurred costs for the Control of HIV/AIDS and Tuberculosis. However, according to Law 27056, the Social Health Insurance – ESSALUD (formerly Peruvian Institute of Social Security) is a Decentralized Public Body assigned to the Labour and Social Promotion Sector and it has technical, administrative, financial, budgetary and accountancy autonomy.

Its resources come from national insurance contributions, according to Law 26790, articles 2 and 8 – Law of Social Security Modernization.

45 Quote from Teresa Mendoza in the National Reports on HIV/AIDS for 1999 46 Source: Government of Peru webpage

65 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 ESSALUD does not receive its income from Treasury-sourced Public Funds, which means that costs incurred in the control of HIV/AIDS are not included in the summary table. Their budgetary allocation corresponds to the number of people with HIV/AIDS who pay contributions to ESSALUD, as the latter are responsible for providing them with complete Cover.47

ESSALUD estimates48 the average, annual cost of antiretroviral treatment per patient by taking into the consideration external consultation, auxiliary tests and Antiretroviral drugs a patient receives on average each year.

The average estimated cost for 1999 was 90.9 Nuevos Soles a day and 33,167.0 Nuevos Soles a year. The average cost for 2003 was 26.9 Nuevos Soles a day and 9,813 Nuevos Soles a year. According to these figures, the cost of antiretroviral treatment per patient has decreased by 70% since 1999, basically through reduction of drug costs and the unification of antiretroviral treatment through established protocols. This has allowed the number of patients being treated to increase from 400 in 1999 to 1,874 in 2003.

The estimated cost of HIV/AIDS care for ESSALUD amounted to 13.2 million Nuevos Soles in 1999 and 18.4 million Nuevos Soles in 2003.

Ministry of Women and Social Development

The Mission of the MIMDES is to ensure – with the cooperation of public and private sectors such as the Civil Society and International Cooperation - complete care for those living in situations of serious social risk, poverty and extreme poverty, violence, discrimination and social exclusion, and to help in the fight against poverty; to contribute to social development and improvement of the population’s quality of life; with investment in social capital and the promotion of equal opportunities and fairness.

No budget concept has been identified for the Control of HIV/AIDS by this Ministry. Although in the study of National Reports on HIV/AIDS for 1999 Teresa Mendoza states: “The Ministry of Health… has been developing preventative measures for AIDS in children and adolescents with the Ministry for the Promotion of Women and Human Development (PROMUDEH). They have been working on two projects: one of them is called Sexual and Reproductive Health Among Adolescent Leaders and the other, Sexual and Reproductive Health in the Protection of Children and Adolescents in the Community”. In 2003 the State Office for the Protection of Children and Adolescents, on which the Office for Child and Adolescent Protection depended, existed in the MIMDES; however, it was not possible to identify any cost allocated to the Control of HIV/AIDS.

B. Government policies on HIV/AIDS

National composite policies indexes

47 Sentence G, article 2, Supreme Decree 009-97-SA 48 Epidemiology and operational report on HIV/AIDS - Essalud 2003

66 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

I. Strategic Plan

1. Has your country developed a national multi-sectoral strategy/action framework to combat HIV/AIDS?

Since 1996 the 1996-2000 Anti-Aids Plan was drawn up, aiming to become a weapon for the whole of the country to fight with. Civil society barely participated in the preparation of the plan. Later on the 2001-2004 Strategic Plan was drawn up, it was based on the previous Plan but from 2002 an effort was made to devise a Multisectoral Plan with active participation from civil society. This Plan worked on the goals and specific objectives, the development of activities and commitments by sectors were pending. The Plan wasn’t completed, but it served as a base for the drawing up of the project that was presented and approved by the World Fund, Phase II of which is currently being implemented.

From the multisectoral point of view, our country has a Country Coordinator Mechanism, called the National Multisectoral Coordinating Committee for Health (CONAMUSA), which was formed immediately after the request made by the World Fund for the presentation of Projects. This Coordinating Committee is not only working on HIV/AIDS, but on Tuberculosis as well. It has a 2004-2007 Strategic Plan that was devised in November 2004.

1.1 Which sectors are included?

Sectors included Strategy/Action Framework Focal point/Responsible Health YES YES Education YES YES Labour YES NO Transportation NO NO Military YES NO Women YES (Ministry of Women) NO Youth NO NO Law YES YES Defence YES YES Universities YES YES Civil Society YES YES People living with YES YES HIV/AIDS Church YES YES

1.2 Does the national strategy/action framework address the following areas: target populations and cross-cutting issues?

Programme a. Voluntary counselling and testing? NO b. Condom promotion and distribution? Is there a promotion of condoms above all in most-at-risk populations (HSH, TS, PPL) both in the strategy of couples as well as in the care at STD Reference Centres.

67 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 c. Sexually transmitted infection prevention and treatment? YES, via the Syndromic management in health establishments. d. Blood safety? YES. There is a National Programme for Haemotherapy and Blood Banks, its’ mission is to ensure blood safety. e. Prevention of mother-to-child transmission? YES. There is a Programme to Diminish Vertical Transmission, for both HIV and syphilis. f. Breastfeeding? NO. The administration of artificial milk to children of HIV positive mothers is considered within the Programme to Diminish Vertical Transmission. g. Care and treatment? YES. The integral care of PLHA is in the process of being improved; the TARGA from the Ministry of Health in our country began in 2004. In previous years EsSALUD and the military had supplied TARGA in our country. h. Migration? NO

Target populations i. Women and girls? YES j. Youth? YES k. Most-at-risk populations? YES (HSH, TS and PPL) l. Orphans and other vulnerable children? The state doesn’t intervene directly in issues regarding orphans. There are other specific entities such as the Vía Libre Association, the San Camilo Home, the Buen Pastor hospitality inn that have Support Programmes for orphans with HIV.

Cross-cutting issues m. HIV/AIDS and poverty? HIV and poverty are subjects that are considered in the majority of speeches, they are due to be incorporated into the policy to combat poverty in our country. n. Human rights? It’s one of the transversal issues considered as much for the ESN, in the FM Project and in the Strategic Plan of the CONAMUSA. o. PLHA involvement? The PLHA are represented in the CONAMUSA.

1.3 Does it include an operational plan? NO

1.5 Has your country ensured ‘full involvement and participation’ of civil society in the planning phase? The drawing up of the Multisectoral Plan relied on the participation of the PLHA organisations.

1.6 Has the national strategy/action framework been endorsed by key stakeholders? YES

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)? NO

There are sectoral initiatives within Programmes created in order to combat poverty, but there isn’t an articulated and explicit national response to HIV within the Plan to

68 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 combat Poverty.60 HIV/AIDS is specified in the United Nations Development Assistance Framework (UNDAF).

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

3.1 How much has it informed resource allocation decisions?

At the Ministry of Health’s request the study ‘Recommendations for the Implementation of an Antiretroviral Therapy Programme for HIV/AIDS in Peru’61 has been carried out.

The quality of information has been adequate (7). The purpose of this report is to enable the Ministry of Health to place within its’ priorities the sustainability of the TARGA programme, to increase access to the treatment of PLHA and to increase the budget of the health sector to combat HIV/AIDS.

4. Does your country have a strategy/action framework for addressing HIV and AIDS issues among its national uniformed services, military, peacekeepers and police? YES

The Prevention of AIDS Committee for the military and the national police of Peru (COPRECOS) was created in May 1992. It is a coordinating committee authority made up of four military representatives: the Air Force, Navy and Army, as well as the National Police of Peru62. This guided the encouragement of actions of an epidemiological surveillance and the promotion of healthy sexual lifestyles with fewer risks of contracting infections by HIV/AIDS. It consists of the following areas:

HIV Prevention YES Care and support YES Voluntary HIV testing and counselling YES Mandatory HIV testing and counselling Antiretroviral treatment YES

The military and the National Police of Peru have been the institutions that have initiated the TARGA among their people before the Ministry of Health did (1999).

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

60 http://www.delper.cec.eu.int/es/eu_and_country/coop_CO2.htm: Programa Marco de Lucha Contra la Pobreza. 2001 61 Study carried out by the Cayetano Heredia University, Acción Internacional para la Salud y con los fondos del Projecto Vigía (MINSA –USAID). 2004 62 Ministry of Health, ONUSIDA. Estado de Situación: EL SIDA al año 2000. 2001

69 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

2005 2003 5 3 There are efforts to plan the strategies in In 2003, most of the strategies weren’t the National Programme (ESN undertaken with the same dynamism than PCITS/HIV/AIDS) and to draw up the in previous years, which meant less Multisectoral Plan in 2006. coverage in some strategic areas such as vulnerable people and syndromic management.

II. Political Support

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 The President of the Republic mentioned the CONAMUSA during a Speech on 28th July 2004 (anniversary of the homeland) Other high officials The Economy and Finances Minister and the Prime Minister of Peru mentioned the support that the government is going to give for access to the antiretroviral treatment of PLHA in a speech on 28th July 2005.

2. Does your country have a national multisectoral HIV and AIDS management/coordination body recognised in law? (National AIDS Council or Commission) YES

2.1 When was it created? We have the CONAMUSA that is recognised by the DS. 007- 2004-SA of 21st May 2004. It has a Regulation that was passed on 18th March 2005.

2.2 Does it include the following?

Terms of reference YES Defined membership Including civil society YES People living with HIV/AIDS YES Private sector NO Action Plan YES Functional Secretariat YES Date of the last meeting of the Secretariat 05/12/05

3. Does your country have a 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

There is the Ministry of Health’s National Sanitary Strategy for the Control and Prevention of STIs/HIV/AIDS in our country that belongs to the Executive

70 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 Management for the Integral Health Care of the General Management for the Health of the People. There is an objective dedicated to the multisectoral work and it’s in the process of being implemented within the 2001-2004 National Strategic Plan. Among its features we have:

Terms of reference YES Defined membership YES Action Plan YES Functional Secretariat YES Date of last meeting

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

We have the National Multisectoral Coordinating Committee for Health that helps civil society organisations to coordinate the provision of HIV-related services. Also there are articulated organisations (collectives/networks) at civil society level concerning this field such as: the Peruvian Coordinating Committee for PLHA; the Peru AIDS network; Collective for Life, the Peruvian network for Women living with HIV, among others.

Overall, how would you rate the political support for the HIV/AIDS programme?

2005 2003 8 3 This year we have a lot of direct support In 2003, the fight against the HIV/AIDS from the Ministry of Health, which chairs epidemic in the country was relegated the CONAMUSA and heads many legal and political support couldn’t be relied processes, while there is an increase in upon for the implementation of strategies; the health sector budget, where one of the but it’s possible to recognise that in this biggest components is the budget same year Peru headed the Negotiation designated to combat HIV/AIDS that Process for the Coordination of includes antiretroviral treatment. Antiretroviral medication in the Andean Sub region with the incorporation of Argentina, Mexico, Paraguay and Uruguay. This Negotiation tried to reduce the price of medicine and therefore increase the coverage of people living with HIV and their access to antiretroviral treatment.

III. Prevention

1. Does your country have an established policy or strategy to promote information, education and communication (IEC) about HIV/AIDS among the general population? NO

71 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 Although the country does not have a clearly defined strategy for the promotion of IEC among the general population, it is worth considering that during 2004 and particularly 2005, there has been greater media coverage focusing on access to HAART, both on television and in the written press.

With the budget from the Global Fund (Objective 3, component HIV), there have been campaigns for the Reduction of Vertical Transmission on a national scale and campaigns to increase the demand for information, but with an emphasis on local measures in the towns and cities involved. In this instance there were nine cities involved in the Global Fund Project and three cities in the Project funded by UNICEF. These cities were chosen for their greater prevalence of PLWHA as well as high maternal death rates.

Around World AIDS Day a television campaign on the prevention of HIV/AIDS was broadcast, aimed at young people and with an emphasis on delaying the onset of sexual activity and on responsible sex.

2. Does your country have an established policy or strategy to promote education on reproductive and sexual health with regard to HIV and AIDS among young people? YES

Within the Ministry of Education is the office of Tutoría de Prevencion Integral (OTUPI), which is responsible for overseeing the implementation of courses on sexual and reproductive health for young people.

In 2004 a pilot curriculum for secondary education was devised (National Strategic Programme for Curricular Development. Level: The Secondary Education of Minors. Ministerial Resolution No. 0019- 2004-ED). The area of the curriculum entitled Person, Family and Human Relations, which in the previous curriculum corresponds to the area entitled Social Development, examines issues relating to adolescence and sexuality (STI/HIV/AIDS are not mentioned explicitly) and gender. The programme covers all five grades of secondary education and has been implemented in all state secondary schools in the country since March 2005. (6512 schools)

2.1 Indicate whether education about HIV forms part of the curriculum in Primary Schools NO Secondary Schools YES

2.2 Does the curriculum and education strategy provide education on sexual and reproductive health for young men and women? YES

Through the Global Fund Project63 1807 teachers from the regions involved (Lima, Callao, Piura, Huancayo, Chimbote, Ica and Iquitos) have been trained to teach sex education in accordance with the modified curriculum, that is, in the management of the new school curriculum.

3. Does your country have an established policy or strategy for the promotion of information, education and communication and other preventative measures with regard to health, to meet the needs of the most exposed populations? YES

3.1 Does your country have an established policy or strategy to meet the needs of the most exposed populations?

Injecting Drug Users Not applicable Men who have sex with men YES Sex workers YES Prison inmates YES Cross-border emigrants and mobile populations NO Refugees and Displaced Populations NO

63 CARE. Quarterly Report. Reinforcement Programme for the prevention and control of AIDS and Tuberculosis in Peru. September 2005

72 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 The Ministry of Health has specific measures and trained personnel, for groups where there is a high prevalence of STI, such as sex workers and MSM. Within the ‘Tackling AIDS’ Plan (CONTRASIDA), 1996 – 2000 and the National Strategic Plan 2001 – 2004, one of the strategic objectives is the Reduction of Sexual Transmission, the expected outcomes of which are as follows: • System of periodic medical assessments for Groups with a high prevalence of STI. To meet this objective there are STD Clinics (CERETS) which provide Periodic Medical Assessments consisting of: medical advice, periodic clinical assessments, clinical tests, distribution of condoms and respective treatment for the sex workers and MSM who are sex workers. The system has 34 health-care facilities that provide periodic medical assessments; 71% (24) are accredited by CERETS while 29% (10) are accredited by the Periodic Medical Assessment Unit (UAMP). In 2004 only 58% of the facilities had the required kits for carrying out RPRs, 70% of the facilities did not have Benzedrine Penicillin, 23% did not have Doxicicline, 15% did not have Azitromicine and a similar figure did not have condoms.64 There is no standard practice of Periodic Medical Assessments for MSM who are not sex workers. • Adoption of behaviours that reduce the risk of contracting STD/HIV In the first stage measures were established aimed at changing behaviour through the Peer Educators strategy – PEP – (MSM, sex workers, young people joining in 2001, peer advisers for HIV positive women; advice in its different forms (pre-test, post test, advice for vulnerable populations, advice on support). Up to 2001 these Peer Educators were in some way involved in the health-care system. By 2004 there were 133 MSM Peer Educators and 127 sex worker Peer Educators nationally. This year, 2005, there are plans to involve more Peer Educators in the Ministry of Health (MINSA) system in order to carry the peer strategy forward and thus contribute towards the objective the country is pursuing with regard to the epidemic.

In these two areas, with the budget from the Global Fund, the following has been achieved:65

1. Reinforcement of Health-Care Facilities aimed at vulnerable populations through in-service training on the Periodic Medical Assessment system, received by 103 teams from 94 health-care facilities (CERETS and UAMPs) of which 97 teams from 86 CERETS received training on Periodic Medical Assessments (AMP) from a human rights perspective. The strategy for this training involved an initial stage of training through workshops and a second stage of consolidation of what had been learned through in-service training. These teams were in general composed of a clinical physician, an adviser and a clinician.

2. Between 2004 and 2005 a total of 1191 Peer Educators for vulnerable populations were trained, of which 492 were Peer Educators working with sex workers and 580 Peer Educators working with MSM and 123 Peer Educators working with people in prison (PPL).

Since the year 2000 the number of male and female sex workers seen for the first time through the AMP system has increased by 29%, from 22,376 to 31,252 (2004), whilst the number of health assessments received per person in the first year was 2.79 per year and by 2004 this had reduced to 2.29 assessments (it should be noted that, as part of the standard practice, periodic medical assessments should be received every 28 days, that is, thirteen assessments per year).

64 UNAIDS, POLCY, MINSA: Evaluation of the MINSA Strategic Plan, 2001 – 2004 for the prevention and control of HIV/AIDS in Peru. Maria Rosa Garate, Percy Minsaya, Manuel Vargas, Rosa Ines Bejar. October 2005 65 CARE: Quarterly Report. Reinforcement Programme for the prevention and control of AIDS and Tuberculosis in Peru. September 2005.

73 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 Within civil society there have been great advances: in the sex worker population we have the formation of the Association Miluska: Life and Dignity, which has been recognized since 29th October 2002, though as an association in the recent public register, since 2004. It is an organization comprised of sex workers and was set up in response to the repression and stigma they face from society, reflected in its institutions, since sex work is viewed as a criminal activity. They develop workshops on the subject of rights, round tables, awareness workshops and forums involving authorities and the general public to help achieve acceptance of sex workers in society and to ensure they are not discriminated against for carrying out their activities. In Lima there are more than 100 female associates of which around 25 work as health workers and educators with their colleagues in the street and other places where sex work is carried out. Nationally there are now more than 500.66

The Lima Homosexual Movement (MOHL) and the Angel Azul association, a coalition made up of transsexual, transgender and transvestite populations, are working very actively from a Human Rights point of view in the process of devising and endorsing the National Plan for Human Rights and they run a national project on equal health rights.

With regard to People in Prison (PPL), Doctors without Borders were working in the EPERCO Lurigancho up until the end of 2003; an experience which has ensured that the budget from the Global Fund in 2004 and 2005 was used to carry on this work, leading to the training of Peer Educators and the training of health-care personnel in HIV and co-infection TB-HIV, in the prisons of Lima and in the provinces. Training on the subject of biosafety and HIV/AIDS was carried out for health-care personnel from the INPE from the 1st to the 3rd August. 46 members of health-care teams from a number of prisons around the country took part.

4.Does your country have an established policy or strategy to increase access to basic preventative products, including for the most exposed populations? (these products include, among others, access to counselling and confidential, voluntary tests, condoms, sterile needles and drugs for the treatment of sexually transmitted infections)?

4.1 Do you have programmes that support the policy or strategy?

A social marketing programme for condoms? NO A Blood Safety Programme? YES A programme for the administration of safe injections in Health Care Facilities? N/A A progamme for the prenatal diagnosis of syphilis YES Reduction of the vertical transmission of HIV YES

For expectant mothers, there is Regulation No. 024-2005 MINSA/DGSP “For the prevention of vertical transmission of HIV from mother to child” from which an amendment relating to the mandatory diagnosis of HIV has been withdrawn. According to Article 28243, modified from Article 26626, there are considered to be exceptions to the voluntary HIV diagnostic test for expectant mothers.

In 2004 and 2005, through the Global Fund, the strategy for the reduction of the vertical transmission of HIV has been reinforced; health-care professionals have been trained to carry out quick HIV screening tests and the IEC has worked to increase the demand for information.

Vulnerable populations have access to free screening within the framework of the studies of Sentinel Surveillance; condoms are given free of charge during the periodic medical assessments and during contact with Peer Educators and are given to the general population who come for a consultation when they suspect they have, or indeed they have, an STI.67

The treatment of STI is one of the strategies in need of reinforcement. As a result of budget cuts, the quantity of drugs needed to treat STIs free of charge for both the general population and in the CERETS for highly exposed populations have not been made available. In 2004 alone, approximately 143,000 people who were diagnosed with Vaginal Discharge and who should have received syndromic

66 Project: “Towards a commitment to the Empowering of the Human Rights of Sex Workers” Opening Roads. Year 1 No.3 December 2004. Information Leaflet. 67 Dirctive No. 007-98-PROCETSS. Outline for Advice Service for STD and HIV/AIDS

74 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 management went untreated. 68With regard to professionals trained in syndromic management, in the years 2000 – 2001 it is likely that many of them changed jobs or moved to other facilities. As a result it is necessary to carry out a new round of training in order to carry the strategy forward.

In general how would you mark the efforts of policies aimed at supporting prevention?

2005 2003 5 3 In 2005, through the Global Fund Project the peer Preventative action both among the general strategy for the most exposed populations (MSM, population and among the most exposed SW, People in Prison) was reinforced, but the populations was not maintained as in previous measures fall short since the CERETS, the years. The peer educator strategy in these treatment of STI and investment in diagnosis do populations, access to condoms and health care in not meet demand. The work of school peers and the CERETS were all disjointed, with little local youth peers was also reinforced; the reinforcment. curriculum for sex education in secondary schools was modified; secondary education teachers were trained.

5. Of the following Prevention activities, which have taken place in 2003 and 2005 in support of the policy and strategy for the prevention of HIV?

2003 2005 A programme to promote accurate information about HIV and AIDS in the media A programme for the social marketing of condoms AIDS education for young people in schools x Information on changing behaviour Counselling and voluntary tests A Programme for sex workers x x A programme for men who have sex with men x x Programmes for injecting drug users, if applicable Promgrammes for other highly exposed populations x Blood Safety x x Programmes to prevent mother to child transmission of HIV x x Programmes to ensure standard precautions taken in all x x Health care facilities

In general, how would you mark efforts in the application of programmes for HIV prevention?

2005 2003 6 4 In 2005, through the Global Fund Project, Activities for prevention, both among the general prevention strategies were reinforced, as was the population and among the most exposed peer strategy, both in the most exposed populations were established in the last decade: populations (MSM, Sex Workers, People in however from 2002-2003, due to various Prison) and among young people. However this is problems and budget priorities, these strategies not enough and there is a need for a Multisectoral began to deteriorate. Strategic Plan that incorporates the strategies for HIV prevention.

68 UNAIDS, POLCY, MINSA, 2001-2004 for the prevention and control of HIV/AIDS in Peru. Maria Rosa Garate, Percy Minsaya, Manuel Vargas, Rosa Ines Bejar. October 2005

75 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

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, access to medicines and home and community-based care).

There is an AVR Therapy and a comprehensive care programme which are in the process of implementation in the country. The authorities are working at the community level to reduce the barriers to access to care for the most-at-risk populations such as the PLWHAs.

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

2003 2005 HIV screening of blood transfusion x x Universal precautions x x Treatment of opportunistic infections (OI) Antiretroviral therapy (ART) x Nutritional care x Sexually transmitted infection care x* x Family planning services Psychological support for persons living with HIV and their x x families Home-based care Palliative care and treatment of common to HIV related infections: x** pneumonia, oral thrush, vaginal thrush and pulmonary TB (DOTS) Cotrimoxazol prophylaxis among HIV-infected people x x Post exposure prophylaxis (e.g. occupational exposures to HIV, rape) * Drugs for the treatment of STDs were limited ** Only deals with pulmonary TB (DOTS)

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

2005 2003 7 2 Thanks to the WF budget there has been a The care and treatment of PLWHAs this year great deal of progress. With the coverage has been carried out by ESSALUD, the provided to PLWHAs by AVR through Armed Forces and Police and some NGOs. ESSALUD, Armed Forces and Police and the The Ministry of Health only had 40 children Ministry of Health, numbers have increased on AVR Therapy and provided care and from 1050 PLWHAs in 2002 to support counselling to PWLWHAs. approximately 6200 PLWHAs. This is progress, although some support strategies

76 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 have still to be implemented in the care and treatment of HIV/AIDS

77 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 3. Does your country have a policy or strategy to address the additional HIV/AIDS- related needs of orphans and other vulnerable children?

There is no policy specifically for orphans affected or infected by HIV/AIDS, but there are civil society organisations which take in orphans.

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

2005 2003 3 1 Peru does not have a policy for HIV/AIDS There were not many organisations dedicated orphans, but there are organisations working to orphans affected and infected by with this population group, and they are: Vía HIV/AIDS. Libre, Hogar San Camilo, La Posadita del Buen Pastor.

B: 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

Comments: Article 2 of the Country’s Political Constitution protects against any kind of discrimination, and if PLWHAs are specifically referred to, by Law 26626 and the Modification 28243.

The problem is not whether there are or are not any Laws, the greatest problem is whether these are adequately enforced. There are no mechanisms for surveillance of enforcement, nor any penalties specified for breach thereof.

Law 26626 Article 6 deals with employment and HIV/AIDS: People with HIV/AIDS may continue to work whilst they are able to do their job. Dismissal due to discrimination as an HIV/AIDS carrier is invalid.

Control of Law 26626. Article 15. A test for HIV should not be set as a condition to begin or maintain a working, educational or social relationship. This article does not change the Supreme decree No.011-73-CCFFAA, added to by the Supreme Decrees No 005-85-CCFFAA and No. 072-94-DE/CCFFAA49

49 Supreme Decree No. 004-97-SA. Control of Law 26626 referring to achievement of the National Plan AGAINST AIDS objectives 1997

78 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

2. Does your country have non-discrimination laws or regulations which 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, youth, mobile populations and prison inmates)?

NO There is no specific non-discrimination law which provides for the vulnerable populations as described.

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

NO There are no laws that present obstacles to effective HIV prevention and care. The greatest problem stems from the attitude of the people providing the services.

There are contradictory regulations, for example, despite the fact that the National Youth Plan provides for prevention and care for youths, in practice this is not feasible.

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

YES Comments: In the Law 26626 AGAINSTAIDS, in the Modifying Law 28243, but they are not adequately applied.

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

YES, through the Ministry of Health Consultative Committee on National Health Strategy (ESN) for the Prevention and Control of HIV/AIDS, in which civil society participates. This Committee meets periodically to evaluate some of the ESN intervention strategies. However, in the surveys carried out amongst key players, it was found that organised vulnerable groups call for greater participation in the design and implementation of projects and interventions aimed at them, in accordance with the principal of greater involvement of people living with and affected by HIV (MIPA in Spanish or GIPA in English).

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

NO. There is no policy on this aspect. All the Regulations and Guidelines are more directed at care for women.

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

YES. There are Ministry of Health guidelines for care of sex workers at CERETS [STD Clinics] and UAMPSs [Periodical Medical Attention Clinics]. The 2001-2004 Strategic Plan has a strategic objective oriented to most-at-risk populations that addresses Peer Strategy. There are no specific policies for MSMs who are not sex workers.

79 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 8. Does your country have a policy prohibiting HIV screening for general employment purposes (appointment, promotion, training, benefits)?

Yes. Law 26626 and the Modifying Law 28243, but there are difficulties in its enforcement.

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. The Instituto Nacional de Salud has a National Ethical Committee, which has also approved other local ethical committees. This responsibility is designated to the Instituto Nacional de Salud, in accordance with Law 27657 of 17th January 200250.

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

All the local Committees have civil society representatives and some local Committees have a PWLHA amongst their members.

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

Collection of information on human rights and HIV and AIDS issues and use of this information in policy and programme development reform.

NO. There is no institution that collects information on human rights and HIV/AIDS.

Existence of independent national institutions for the promotion and protection of human rights, including human rights commissions, law reform commissions and ombudspersons which consider HIV-and AIDS-related issues within their work.

YES. The Ombudsperson, Ministry of Health Transparency Office, Legal Department of some public institutions. These do not necessarily cover HIV/AIDS related issues.

Establishment of focal points within governmental health and other departments to monitor HIV-related human rights abuses.

YES. Some governmental departments, such as the Ministry of Health, the Ombudsman have focal points to monitor violations of HIV-related human rights.

50 Law No. 27657. Ministry of Health Law. 2002

80 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005

Development of performance indicators or benchmarks for compliance with human rights standards in the context of HIV and AIDS efforts.

11. Have members of the judiciary been trained/sensitized to HIV and AIDS and human rights issues that may come up in the context of their work?

YES. The prosecutors have been sensitized as far as the most-at-risk populations (Sex workers) are concerned, by the NGO (CEPESJU), which is working with Sex Workers in the capital.

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

Legal aid systems for HIV and AIDS casework YES. There are governmental legal support centres, that have court appointed lawyers who are paid by the state, for individual cases, but they are not experts on HIV/AIDS.

State support to private sector law firms or university based centres to provide free pro bono legal services to people living with HIV and AIDS in areas such as discrimination NO

Programmes to educate, raise awareness among people living with HIV and AIDS concerning their rights. YES. We have NGOs that are specialising in this aspect: Vía Libre, Agora

13. Are there programmes designed to change attitudes in society of discrimination and stigmatisation 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: 4 2003: 2 There is a bias in the Regulations in that the focus is conservative. Vulnerable populations are not incorporated. There are regulations for pregnant mothers and not necessarily for women.

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

2005: 4 2003: 2

81 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 The effort is coming more from civil society, although not very well organised. The ONGs are the ones fighting for human rights (collective Networks for life rights). There is no commitment from those who make the laws. There are laws without approved Regulations (Modifying Law 28243). Many times laws are neither enforced, communicated, nor promoted.

II. Civil society participation

1. To what extent has civil society made a significant contribution to strengthening the political commitment of top leaders and national policy formulation? Level 5. There are civil society initiatives which have been considered in the public agenda. The role played by civil society is one of support and surveillance of the processes.

2. To what extend have civil society representatives been involved in the planning and budgeting process for the National Strategic Plan of HIV and AIDS or for the current activity plan (attending planning meetings and reviewing drafts)? Level 4: Civil society participated in writing the Strategic Plan which was not officially recognised, but one of the important things is that this Plan was useful for drawing up the World Fund Project, which is now entering Phase II.

3. To what extent are the complimentary services provided by civil society to areas of prevention and care included in both the National Strategic plans and reports? Not included.

4. Has your country conducted a National Periodic review of the Strategic Plan with the participation of civil society, and when: YES. This was conducted in 2005, but civil society’s participation was limited.

5. To what extent 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? Level 7

Overall, how would you rate the efforts to increase civil-society participation? 2005: 7 2003: 6 Civil society is incorporated into CONAMUSA [Multi-sector National Co-ordinator for Health], and in an attempt to implement social awareness.

82 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 III. Prevention

1. Which of the following prevention activities have been implemented in 2003 and 2005 with the support of the HIV-prevention policy/strategy?

2003 2005 A programme to promote accurate HIV and AIDS reporting by the media A social marketing programme for condoms School-based AIDS education for youth x Behaviour change communications x x Voluntary counselling and testing Programmes for sex workers x x Programmes for men who have sex with men x x Programmes for injecting drug users, if applicable Programmes for other most-at-risk populations x Blood safety x x Programmes to prevent mother-to-child transmission of HIV x x Programmes to ensure safe injections in health care settings

Overall how would you rate the efforts in the implementation of the HIV prevention programmes? 2005: 5 2003: 2 The improvement is due to the input of the World Fund budget

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 HIV screening of blood transfusion x x Universal precautions Treatment of opportunistic infections (OI) Antiretroviral therapy (ART) x Nutritional care Sexually transmitted infection care x Family planning services Psychological support for persons living with HIV and their families Home-based care x* x* Palliative care and treatment of common to HIV related infections: pneumonia, oral thrush, vaginal thrush and pulmonary TB (DOTS) TB Cotrimoxazol prophylaxis among HIV-infected people x** x** Post exposure prophylaxis (e.g. occupational exposures to HIV, rape)

*some NGOs do this ** There is usually a shortage of supplies

83 United Nations General Assembly Special Sessions on HIV/AIDS Monitoring of the Declaration of Commitment on HIV/AIDS Peru - 2005 Overall, how would you rate the efforts of the care and treatment of HIV and AIDS programmes? 2005: 5 2003: 3

The significant difference between 2003 and 2005 is the initiation of AVR Therapy and the 6200 PWLHAs on AVR Therapy at the national level.

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

NO. There are no defined policies; that related to orphans is being handled by Associations and some NGOs.

How would you rate the efforts to meet the needs of orphans and other vulnerable children? 2005: 3 2003: 3 There has been no change in this period.