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SUDAN: Universal access still a long way off in the south

Photo: Kate Holt/IRIN
A health system overhaul is needed
Juba, 3 February 2010 (PlusNews) - Southern Sudan's poor infrastructure, largely illiterate population and dearth of health facilities and workers mean that despite five years of peace, HIV programmes are still in their infancy.

There are no national-level statistics on HIV prevalence or incidence, further hampering the fight against the pandemic, but a 2007 site-specific antenatal surveillance by the US Centres for Disease control found prevalence levels ranging from as low as 0.8 percent in Leer, Unity State, to as high as 11.5 percent in Tambura, Western Equatoria State.

"We use an estimate of 3.1 percent for the south, and we know that the epidemic is more concentrated in big towns and areas near the border with our neighbours who have higher prevalence, such as Kenya and Uganda, but so far we have not conducted a survey of HIV indicators," Bellario Ahoy Ngong, chairman of the South Sudan AIDS Commission (SSAC) told IRIN/PlusNews.

Ngong said HIV was spread mainly through heterosexual transmission, and was worse in the areas where trading opportunities had expanded since the Comprehensive peace Agreement with the north was signed in 2005.

"There has been a lot of movement of people since we attained peace, and in the big towns like Juba, Yei and Yambio, sex work has increased along with trade," he said. "Unfortunately, our people have very low knowledge of HIV transmission and prevention, so they are very vulnerable."

An HIV time-bomb

According to the SSAC, HIV awareness is below 10 percent; the UN Population Fund (UNFPA) puts literacy at 24 percent, making prevention literature - a staple in the HIV prevention plans of most countries - largely ineffective. The government and its partners depend mainly on health workers, community mobilizers and radio stations to disseminate information on HIV.

UNFPA described the situation in southern Sudan as "an HIV time-bomb" due to social and cultural issues like polygamy and widow inheritance, as well as misconceptions about the virus and a highly mobile population of internally displaced people, refugees, returnees and traders.

Nevertheless, Population Services International (PSI), a social marketing NGO, managed to sell or distribute more than a million condoms in 2009. "Condom promotion is difficult in southern Sudan because people want to reproduce to replace the sons lost during the 21- year north/south war," said Oksana Chikina, maternal and child health manager for PSI in the regional capital, Juba.

"Misconceptions still persist about condoms, including that they can break, are not reliable, and can make a man or woman infertile after prolonged use.
They are also associated with promiscuous people, and therefore create trust issues within relationships."

''Condom promotion is difficult in Southern Sudan because people want to replace the sons lost during the 21-year north/south war''
Other aspects of prevention, including HIV testing, are not doing much better; there are now 50 voluntary counselling and testing (VCT) centres in the south, but only one percent of the population has been tested for HIV.

"Low knowledge means a low perception of risk, so it is not easy to convince people to test," said SSAC's Ngong. "We also need many, many more VCT centres, as the ones we have are very far from some communities."

The tough, mountainous terrain, the sheer distance to remote areas in the vast region, and a very poor road network stand in the way of expanding VCT services and providing antiretroviral (ARV) treatment to those who need it.

Southern Sudan is also desperately short of physicians, with 0.22 doctors for every 1,000 people, according to the UN World Health Organization (WHO), while the government says just 25 percent of the population have access to health services.

A logistical nightmare

"ART [antiretroviral therapy] rollout is heavily dependent on functioning health systems - in the south we are dealing rebuilding health facilities destroyed during the war, but even before the war many areas simply had no health services," said Dr Rogers Busulwa, a medical officer with WHO's southern Sudan operations.

"Health worker salaries are often not paid on time, so retaining them is hard, especially since there is competition for them from the NGOs," he commented. "Working in the south is also a logistical nightmare ... there have been occasions when equipment, like refrigerators, has arrived damaged at the more remote areas due to the poor condition of the roads."

About 1,600 people are on ART in the south, up from only 200 when the programme started in 2006, but still far short of covering the estimated 23,250 who need the drugs.

Prevention of mother-to-child transmission [PMTCT] services have been set up at more than 20 sites. A national 2007 sero-behavioural survey noted that only 31.7 percent of Sudanese women aged between 15 and 49 knew that HIV could be transmitted from mother to child; a 2006 household health survey found that just 15 percent of women gave birth in formal health facilities.

"We have started a PMTCT programme in Upper Nile State, and while women in the community actively attend antenatal visits and agree to be tested for HIV, they still choose traditional birth attendants to deliver their babies," said Gladys Arika, health project manager for faith-based NGO, Tearfund. "We are encouraging pregnant women to come with their partners, [but] so far this is not happening."

Despite uncertain funding as global oil prices fluctuate, pockets of continued insecurity, and a shift in focus to a planned national election in May 2010 and a referendum in 2011, the government of South Sudan is going ahead with an ambitious health system reconstruction plan.

Read more
 Health workers report rise in HIV
 "At times we wear polythene bags in place of gloves to deliver babies"
 Funding woes continue to plague HIV fight
 Crafting prevention messages for the south
Health system reconstruction

Dr Samson Baba, director-general of the Ministry of Health's directorate of external assistance and coordination, said the plan would give 85 percent to 90 percent of people access to "acceptable levels of healthcare" within 10 years.

"Through the Multi-Donor Trust Fund [a World Bank mechanism to coordinate the reconstruction and development of Sudan], we are creating a basic healthcare package that stipulates the minimum standard of care that should be available at all health centres within the country," he told IRIN/PlusNews.

"We are also embarking on an ambitious training programme for health workers ... using NGOs to train local staff, sending locals abroad for training, and developing our own training institutions," he said. "At current training levels, it would take us 66 years to satisfy our midwife gap, but with our accelerated plan it should take 10 years."

The government intends scaling up its ART sites to at least 20 by the end of 2011, with at least one in each of the south's 10 states, and to double the number of people on ART.

"Achieving universal access will be a slow process because of all the difficulties," said WHO's Busulwa, "but there is strong political commitment and the government does want to take ownership of the programmes, so it will eventually happen."

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Theme(s): HIV/AIDS (PlusNews),

[This report does not necessarily reflect the views of the United Nations]

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