Pamela E. Mukaire, ME.d , MPH, Dr.PH (c) APHA Annual Meeting & Exposition November 2013

1. Increasing acceptance of HIV/AIDS prevention, treatment practices through religious leaders and institutions Pamela E. Mukaire, ME.d, MPH, Dr.PH (c)APHA Annual Meeting & Exposition November 2013

2. Presenters Disclosure I have no relationships to disclose

3. South Sudan • Independence – July 9th 2011 • Scared by more than 40 years of conflict (1955-1972 & 1983 to 2005) • Over half of the 8.26 million is under age 18, & 72% of SS population are less than 30 years old. • A history of underdevelopment

4. HIV/AIDS in South Sudan • HIV prevalance among 15-49 year olds estimated at 2.7% (UNAIDS 2013) • South Sudan borders countries with high rates of HIV/AIDS (Uganda 6.5%, Kenya, 6.3%, DRC 3.4%, Central African Republic 4.9%) • Epidemic is generalized as low although there are “hot spots” • highest rates with Western (6.8%), Eastern (3.4%), and Central Equatoria (2.6%) and Lakes (2.3%)

5. HIV/AIDS Prevalence by State

6. HIV/AIDS Prevalence by State

7. Key Determinants of the Epidemic • Low knowledge of HIV transmission and risky sexual behavior • Only 11% of women 15-24 years knew about 3 ways of preventing transmission of HIV (Sudan HS 2010). • Only 53.8% women 15-49 years have heard of HIV/AIDS • 41.1% of women and 58.1% of men knew how to avoid the HIV virus by using a condom correctly every time

8. Key Determinants of the Epidemic • Multiple concurrent sexual partners coupled with low levels of condom use • High HIV stigma - discrimination, and denial • Cultural norms: • like tribal marking practices, • polygamy and • widow inheritance

9. Vulnerability in South Sudan • Massive population movements • IDPs relocation • refugees influx • Repatriation • ex-combatants transition to civilian life • commercial transporters • Gender inequality factors that expose women to HIV infection

10. Statement on the Challenge Hon. Dr. Hussein Michael Milli, Minister of Health, Republic of South Sudan Dec 2011 Dakar meeting “The legacy of the more than two decades of gruesome war for the independence of the Republic of South Sudan is more evident in the health sector, where there is almost total collapse of the health system”

11. Innovative and Strategic Partnerships Government, FBOs and community groups • Structures and systems of FBO’s add value to effective service delivery or programming in SS difficult terrain • Access to RH services is low, • health service user rates are estimated at 0.2 contacts per person per year. • Gov.SS AIDS commission joint venture with FBO’s and CBO’s to plan, develop and deliver comprehensive HIV/AIDS services

12. The South Sudan HIV/AIDS Project Development Objectives: • Strengthen the capacity of the SSAC to plan, coordinate and monitor the GoSS response to HIV/AIDS • Increase community access to comprehensive HIV/AIDS services, and • Create awareness and measurable behavior change regarding HIV/AIDS. GoSS – Government of South Sudan SSMHA-South Sudan HIV/AIDS Project SSAC- South Sudan AIDS Commission

13. Christian Health Association of Sudan Shared Vision: • Anetwork of Christian health organizations, with 72 members drawn from: • Diverse Christian faiths, • Muslim faith groups • PLHIV groups • “All CHAS member organizations visibly and effectively participating in health service delivery and contributing to the attainment of health outcomes for South Sudan”

14. CHAS Partnerships • Awarded a service agreement to provide technical leadership and management of SSMHA Project (supported by Multi Donor Trust Fund) • Two states: Western Equatoria and Lakes States • Sub-contracted and strengthened capacity of 35 implementing partners Western EquotoriaLakes • 15 FBO 7 8 • 6 CBO 3 2 • 11 PLHIV Associations 10 1 • 2 Local government departments 1 1 SSMHA-South Sudan HIV/AIDS Project

15. CHAS Strategies to FBO Health Promotion and Service Delivery • Religious institutions as community mobilisers • Religious facilities providing HIV related services • Religious leaders and church groups as service providers • Religious owned business and individuals as lead participants in awareness activities • Religious leaders engagement in community assessments • Religious leaders as advocates for policy development and implementation

16. CHAS Approach: Engaging Religious Leaders & Institutions • LQAs – Lot Quality Community Assessment: • processes that enable targeted communities to become actively and genuinely involved in defining the issues of concern to them; • making decisions about factors that affect their lives; • formulating and implementing policies meant to improve their conditions; • planning, developing and delivering services, and taking action to achieve change

17. CHAS Approach: Engaging Religious Leaders & Institutions • Religious Institutions/ Leaders Training and Service Delivery Strengthening: LINKAGE of traditional and modern systems • Trained 929 religious leaders and workers in WE& L States • Trained church service groups as service providers – youth clubs, mother union, catechists • Introduced HIV related services at FBO owned health facilities – VCT, PMTCT, treatment of opportunistic infections • Attracting 80 – 100 clients per session once a month • Established outreach service centers at FBO compounds • Integrated HIV educational messages in weekly sermons/services – and all other religious events • Engaged FBO owned and managed FM radios

18. CHAS Approach: Engaging Religious Leaders & Institutions • Religious Leaders as Advocates and Change Agents: • advocate for a supportive social cultural environment for HIV care, treatment and prevention • Addressing high HIV stigma and tough social norms • how to utilize religious gatherings, and activities to mobilize community action, • raise awareness and educate on multifaceted issues of gender inequalities and HIV – delayed marriages, not to older men, increased male involvement, maternal referrals and follow-ups

19. FBO’s Contribution to SSMHA :LQAs Baseline – End line Results • Men's knowledge on HIV transmission and prevention increased by: • 5% in Western Equatorial (Yambia County KAP Survey) • 68% in Lakes state (Rumbek County KAP Survey) . • Women' perceived risk of contracting HIV/AIDS increased by: • 17.8% in Western Equatoria and • 10.7% in Lakes state. • The number of women seeking HIV counseling and testing services increased by: • 21.5% in Western Equatoria and • 21% in Lakes state.

20. Faith Communities and HIV in Humanitarian Settings • Why FBO’s are critical partners? • Faith-Based Communities and NGOs together provide an estimated 90% of all health services (40% to 50% - FBO – greatly contribute to HIV responses) • 1 in 5 orgs working in HIV programs are FB • First port of call for vast humanitarian human development needs for over 40 years • Filled long-term displacement needs - food, water, poverty and HIV/AIDS related vulnerabilities • Bridging communities, AID organizations and government health agencies/ programs • Partnership with traditional health care systems to increase access to PMTCT

21. Implications for PH Practice • Religious leaders have contributed to scaling-up community HIV response by collectively implementing an innovative community health information system to increase the flow of information for effective community mobilization. • Interfaith program activities have highlighted the differences in message packaging between the different faiths in ways that are culturally accessible and acceptable to the diverse cultural belief systems influencing infectious disease acquisition, response and prevention in this population.

22. Thank you for your interest and for listening SHUKRAN!