ANNUAL REPORT 2009 – WHO/HIV, Yemen
Introduction
HIV prevalence in Yemen is estimated between 0.14% and 0.2% of the total population,
according to WHO/UNAIDS Working Group Estimation. Though generally low HIV
prevalence, information from recent studies suggests that there are some populations with
relatively high levels of HIV or likely to be more at risk of infection these include commercial
sex workers, men having sex with other men, prisoners, migrants and refugees. Yemen uses
a number of strategies to track the HIV epidemic including case reporting of HIV & advanced
HIV through sentinel facilities, cross-sectional surveys of behavior and biological markers of
risk in sub-populations at high risk of STI/HIV and tracking HIV in donated blood. In 2008, the
first bio-behavioral survey in Yemen documented 1.3% HIV prevalence among female sex
work in Aden1, which is substantively higher than the HIV prevalence estimated among the
general population.
HIV & Advanced HIV
case reporting is part of
the Surveillance in
Yemen used to track the
HIV epidemic
1 HIV case reporting from sentinel facilities
With support from partners the National AIDS Programme has mounted a health sector
response to scale up a comprehensive package of HIV prevention, treatment and care, and
strengthening health care systems. The National AIDS Programme has its priority
interventions targeted at the marginalised populations and those most at risk of exposure to
infection. The service package that includes HIV prevention, treatment and care and support
provides referral linkages to reach people most-at-risk of infection and people living with
HIV. In Yemen HIV Response, prevention is emphasised to ensure the infection is kept below
1% in the general population and not exceeding 5% in MARPs and there is reduced mortality
and morbidity for people living with HIV.
1
NAP Study Reports, 2008
WHO with financial support of the Global Fund and with UNDP as Principal Recipient has the
primary responsibility for promoting and supporting health sector initiatives. WHO Yemen
provides technical support in line with its global established priorities under five strategies
for action towards achieving the universal access goals: Enabling people to know their HIV
status; Maximizing the health sector’s contribution to HIV prevention; Accelerating the
scale-up of HIV/AIDS treatment and care; Strengthening and expanding health systems and
Investing in strategic information to guide a more effective response.
HIV Testing and Counseling
According to available information, in Yemen less than 1% of the general population knows
their HIV status. Though the main mode for HIV testing and counseling in the country is
Client initiated; this strategy hasn’t been so successful in increasing numbers of people
accessing HIV testing and counseling, identifying vulnerable populations and expanding
services to most-at-risk-populations.
Through WHO technical support, an assessment of HIV T&C services was conducted in effort
to strengthen and map out a more appropriate strategy to scaling up services to those that
require them most. As a result of this assessment and Yemen having a low HIV epidemic, the
programmatic focus for the National Programme has shifted to increasing access and uptake
among most-at-risk populations and Provider Initiated Testing and Counseling (PITC)
approaches. In addition, training curricula has been reviewed and updated, refresher
courses for providers including hands-on (practical) training for HIV counselor trainees at
sites conducted, and technical assistance offered to establish functional linkages and
outreach programs to vulnerable and high risk populations.
2 Onsite training on reporting for HIV Testing and Counseling in Hodeida governorate
Preventing HIV among populations at high risk of HIV
Following the study conducted among Sex workers in Aden, a strategy has been put in place
for preventing HIV among those populations with high risk of HIV. Through support from
Global Fund and technical assistance provided by UNAIDS, a consultant was recruited to
assess and map populations most-at-risk of HIV. Preliminary results indicate MSM
populations exist and are also linked to other groups spread out especially in major cities of
the country. A Behaviour Change & Communication (BCC) strategy within a prevention
model program implemented with assistance of NGOs has been developed and tailored to
social needs for MARPs, advocating addressing stigma and discrimination and providing links
to nearby facilities for prevention (PMTCT) and care (Care/ART) services.
Blood Safety
The availability and safety of blood and blood products for transfusion is of major concern in
Yemen taking into consideration that blood transfusion could significantly lead to increased
transmission of HIV, hepatitis B, hepatitis C and syphilis. The National Blood Transfusion and
Research Centre (NBTRC) with support from partners including Italian Aid, Global Fund and
WHO, is working tirelessly to reduce unsafe blood transfusions and increasing availability of
safe blood.
In absence of conflict emergency situation, about 8,0002 blood donations are made through
NBTRC every year in Yemen. This represents about 27% of national needs for quality assured
blood donated units; implying a figure of 0.4 as measured by donations per 1000 population.
This number falls short of the estimated minimum per capita level of donation required to
meet a country’s most basic requirements for blood i.e. 1% of the population. About 0.12%
of screened blood units are infected with HIV
WHO supported recruitment of expert to conduct evaluation and provide technical
support to scale up quality blood transfusion services. The consultant reviewed the
organizational and management capacity of NBTRC; and conducted an inventory on
blood donations, distribution and availability of safe blood for transfusion in the
country and an assessment of quality assurance systems including monitoring and
evaluation systems and staff capacity. With help of this consultant an action plan
was developed to address gaps in service.
WHO is working alongside UNDP to support implementation of recommendations made
from the evaluation.
Treatment and Care for PLHIV
The National AIDS Program/Ministry of Public Health and Population has continued to
strengthen services in hospitals providing comprehensive HIV care including Antiretroviral
Therapy to PLHIV in Yemen. Integrating HIV within existing health care services and building
referral linkages to other non ART health care facilities has formed one of the areas of
emphasis. The hospitals have been equipped and health care teams trained and supported
through supervisory visits to sustain a good quality of care.
3Patient monitoring training for health providers at ART sites
2
This figure excludes Blood transfusions from Central and regional laboratories
With WHO technical support, teams mainly consisting of doctors, nurses, counselors,
pharmacists, laboratory technicians and record assistants were trained on specific tasks
related to their responsibilities in prevention, care and treatment of HIV using ‘WHO
Integrated Management of Adult Illnesses guidelines’. In this same training, People Living
With HIV (PLHIV) were trained into 'Expert Client Trainers' involved in training of health
workers on providing practical experiences in care as well as stigma reduction. They are now
recruited to work and support care at ART centres. WHO also recruited an expert (HIV
care/ART mentor) to support ongoing learning for health care providers at the 5 ART sites at
handling treatment, care, follow up and management of complicated cases. This support
was key in strengthening of health systems through strengthening HIV care/ART data
management, integration of HIV care into health care delivery; establishment of linkages
between antiretroviral therapy, HIV prevention programs, general health care services and
communities at governorate levels and capacity building of HIV clinical teams to identify and
suspect HIV in children and adults (PITC).
Through improved data quality systems, health care facilities are in better position to
monitor treatment outcomes, manage referrals, conduct support activities to other facilities
and plan quality improvement programs.
600
500
400
300
200
100
0
Cumulative enrolment
Cumulative started on ART
Total
589
330
Adults
549
314
40
16
Children
The ART coverage has risen from (189) 6% in the previous year to (268) 8% of those PLHIV in
need of treatment, representing a numerical increment of about 43% from previous year.
The current on ART represents 82% of our global fund target set for Yemen. A huge gap still
exists between those estimated to be in need and those that able to access treatment due
to difficulties reaching maginalised groups and populations with increased risk behavior such
as Men having Sex with Men, Commercial Sex Workers, migrants and akhdams.
Prevention, care and management of HIV/TB coinfection
TB is the most important co-infection in HIV. Proper identification and subsequent
management of TB clients with HIV and continuous assessment of TB infection in HIV
patients are core activities in this program. This year, 18 TB incidence cases in HIV were
identified and co-treated, representing about 3% of co-infected patients. A joint
collaborative study on 'HIV sero-survey among TB clients' has been conducted by the HIV&
TB programs. This study conducted in 4 governorates having highest incidence of TB, enables
the programs to obtain crucial information regarding the prevalence of co-morbidity in the
population. The information is essential in planning TB & HIV collaborative activities.
Preliminary results indicate xxx
Scaling up services for women and children
Women comprise about half of the total population in the country. The fact that 65% of HIV
infection is transmitted heterosexually, women and children may also be significantly
infected. Some women are also engaged in commercial sex whereas some are spouses of
bridging populations of men involved in high risk behavior hence victims as a result. Access
to health services for women is low in general and when it comes to HIV services access is
further limited due to stigma and discrimination. Females account for about one third
(35.1%) in HIV care and (33.3%) of those on ART. This number will improve by establishing
services that are gender sensitive and specifically target this vulnerable population.
WHO in collaboration with UNCEF have supported NAP to establish Prevention of Mother
To Child Transmission of HIV (PMTCT) services in the country. This programme aims at
preventing vertical transmission of HIV to the child; initially focusing on pregnant mothers in
high risk and vulnerable populations. PMTCT services were established in four hospitals in
Sana' (Qal al Olfy HC), Aden (Al Pasateen HC and Al Wehda hospital) and Lahaj (Ibn Khaldoun
hospital); implementation guidelines were developed, advocacy and sensitization of
communities conducted and capacity of staff built to implement the services. The program
has helped to identify HIV positive mothers who have successfully accessed ARV prophylaxis
to prevent HIV transmission to their newborns. HIV positive mothers are linked to nearby
sites providing ART services for continuity of treatment.
4 Counseling sesion at PMTCT site in Ibn Khalidun, Lahj governorate
By the end of 2009, about 4,211 ANC mothers had been counseled and tested for HIV in the
4 sites of whom 7 mothers were found HIV positive (representing about 0.17% prevalence in
pregnant women). 6 out of 7 mothers accessed ARVs for prophylaxis to prevent mother to
child transmission of HIV. 4 HIV positive mothers were referred from ART centres to PMTCT
sites. Establishment of PMTCT services has improved quality of ANC services by fostering
client education programs, ensuring availability of commodities and drugs and regular
monitoring of facilities.
Perspectives of 2010
WHO support will focus on the following:
1. Planning and resource mobilization: Development of National Operational Plan of the
NSF for STI&HIV. Support to proposal writing and costing the Round 10 Global Fund
country HIV grant application
2. Strengthening HIV/STI Surveillance: An international staff is being recruited to provide
technical assistance to national AIDS programme. Studies planned include HIV/STI
seroprevalence ANC study conducted among pregnant women; HIV risk assessment
study among incident cases; RDS among Female Sex Workers and Men Having Sex with
Men and formative assessment for IDU.
3. Care and treatment: HIV care and treatment clinical guidelines development in Adults
and Adolescents; strengthening ART monitoring and quality improvement in Care and
Treatment; HIV care and treatment clinical guidelines development in Children and
Infants; and Training of health providers
4. Prevention of Mother To Child Transmission of HIV: In collaboration with UNICEF and
with and with financial support of GFATM, provide technical support to development of
training curriculum for PMTCT , train national core trainers and support establishment
and monitoring of 4 new PMTCT sites
5. HIV Testing and Counseling (CITC and PITC): Support establishment of 7 VCT sites
targeted as priority at high risk populations, finalise HTC training curricular, strengthen
outreaches, monitoring and reporting
6. Post Exposure Prophylaxis: Development of guidelines for PEP, introducing the
guidelines and training health providers
7. HIV medicines and commodities management: Development of reporting tools,
electronic systems and capacity building of pharmacists and storekeepers
8. Blood safety: Management support to effect decentralization of quality services for
blood screening and transfusions