Sudan
Since independence in 1956, Sudan has suffered one of the longest civil wars in history (25 years) with brief interludes of peace between the north and south. In addition Sudan also experienced political unrest in the eastern and western regions during that period. A peace treaty was signed in 2002 in Nairobi, Kenya between the ruling northern national congress party and southern Sudan People Liberation army to dually govern Sudan. A year after the treaty, the conflict in the western region of Darfur re-ignited and still continues to date despite the signed peace agreement with the largest rebel group in 2006. The long civil strife has consumed much of Sudan's resources and left all public institutions and infrastructure weakened, including the health system.
HIV/AIDS Background
Sudan is the most severely HIV-affected country in the Middle East/North Africa region. Recent epidemiological data from the Sudan National AIDS Control Program's estimate indicate there are approximately 100,000 HIV-positive patients and, of those, 13,000 in need in antiretroviral therapy (ART) by 2009. More recent surveillance data and research findings indicate that the HIV epidemic is concentrated among most at-risk populations, such sex workers, tuberculosis patients (18% prevalence) and medical inpatients (3% prevalence), and in certain geographic regions, such as Southern and Eastern states. In addition, HIV prevalence has been found to be higher in health center settings; data from 26 of 285 Tuberculosis Management Units in 2008 showed an HIV prevalence of 18% among tuberculosis patients. Other data suggest that 3% of all medical admissions in Omdurman Teaching Hospital have an AIDS diagnosis in hospital registries. Exploratory data collection on HIV prevalence in hospital settings is showing a higher HIV prevalence among blood collected for medical investigations and will be followed by larger surveillance data to confirm this finding.
The Sudan National AIDS Control Program (SNAP) set a national target of provision of ART to 7,000 HIV positive patients by 2009. To date, there are about 30 ART sites and 127 voluntary counseling and testing (VCT) centers in Sudan and only about 2,000 registered HIV-positive patients in care (29% achievement of the target for 2009). There are no plans to expand these HIV testing and care sites as these sites have poor utilization rates and a low quality of care. The number of HIV patients on ART is one of the ten indicators selected by the Global Fund to score the Sudan's performance in HIV program. It is currently graded as a low performing indicator that can affect the overall performance of the program and result in non-eligibility for future funding in the HIV program.
The slow uptake of ART has been attributed to non-focused interventions to detect HIV-positive patients in need of ART and a non-integrated approach of HIV services within health settings. Currently, the main entry point for HIV care is from VCT centers based within hospital settings. About half of all HIV-positive patients detected in these centers are reported as hospital referrals.
Our Partnership with SNAP
Because of our experience in fragile states in Mozambique in the 1980s and ‘90s and Timor-Leste today, representatives of SNAP approached us in late 2006 to explore the possibility of partnership and support in scaling up HIV/AIDS services, including treatment and health systems research.
SNAP has recently revised its strategy, focusing HIV interventions on provider-initiated testing and counseling in hospital settings based on the lessons learned from the current PMTCT program. Together we worked on developing the National HIV/AIDS Strategic Plan for 2010-2014 that will continue to build off of SNAP sucesses and our partnership.