Chad

One year ago, on 15 April 2023, armed conflict broke out in Sudan between the Sudanese Armed Forces and the Sudanese Rapid Support Forces. Since then, the situation has worsened. The hostilities, which were initially centred in Khartoum State, have intensified and rendered over half the country inaccessible.

The impact of this conflict has been devastating. Some 8.6 million Sudanese have been forced to flee their homes, 6.8 million are displaced with in the country and 1.8 million have sought refuge in neighbouring countries – Chad, Egypt and South Sudan.

The severity of the humanitarian emergency has been compounded by a deepening famine crisis, with 17.7 million Sudanese facing acute food insecurity, close to 5 million of whom are on the verge of starvation, as reported by OCHA and the Integrated Food Security Phase Classification.

In addition to the humanitarian crisis, the conflict has severely disrupted the healthcare infrastructure. The central depot, which stored all the antiretroviral treatment for people living with HIV in the country is inaccessible and the stock that it holds has since expired.

Before the conflict erupted, 11,000 people living with HIV in Sudan were on HIV treatment, 4000 of whom were lost to follow-up when the war broke out. All HIV prevention and testing services were suspended.

“We are adapting the HIV response in Sudan to the situation in the country. Our priority has been to get anti-retroviral treatment to those who need it, in whatever way we can,” said Elsheikh Ali, UNAIDS Country Director for Sudan.

Despite these challenges, there are unsung heroes who are working tirelessly to ensure that the HIV response continues uninterrupted.

Amidst active war, the displacement of critical partners in the HIV response, poor internet connectivity and communications, sporadic electricity and growing food insecurity, the HIV national response team, with UNAIDS’ support, were able to reconsider, plan and raise resources for this new, national context of the HIV response in the country. The team was able to submit a funding application to the Global Fund to Fight AIDS, TB and Malaria (Global Fund) and to finalize the Global Fund Grant Making process. This secured critical financial support to HIV, TB and Malaria for the next three years. The funds received from previous Global Fund cycles have been used to replace stocks of antiretroviral treatment (ARVs) as well as to establish new HIV treatment storage facilities in safer regions.

During the COVID pandemic, Sudan established a ‘Search and Rescue’ system to track people living with HIV who had  their treatment interrupted. Once the conflict in the country escalated, the HIV national response team were able to draw on the ‘Search and Rescue’ system to locate most of the 4000 people living with HIV who were lost to follow-up because of the war and to re-enrol them again to receive HIV treatment services.

“We have heroes here in Sudan, including networks of people living with HIV, who are working in very difficult circumstances, traveling tens of kilometres and risking their safety, to personally deliver ARVs to the people who need it,” said Elsheikh Ali, UNAIDS Country Director, Sudan. “These are the people we should be applauding; they are the ones keeping the HIV response going in the middle of a war and famine.”

The Ministry of Health, whose infrastructure has been significantly disrupted, is trying to provide critical HIV services including treatment and PEP (emergency medicine for HIV taken to prevent the virus in case of potential exposure to the virus) in regions of the country where there is active warfare. In more stable areas, more comprehensive HIV services are now being offered to those who need them.

In the face of the escalating humanitarian crisis in Sudan, there are dedicated people who remain steadfast in their commitment and working selflessly to mitigate the impact of the conflict on the HIV response.

“The HIV national response team exemplify the resilience  the AIDS response,” said Anne Githuku-Shongwe, UNAIDS Regional Director Eastern and Southern Africa. “In the face of adversity – war, displacement, famine – and against all odds, they have found a way to continue collaborating to uphold the HIV response.” She adds, “They have completed a successful Global Fund grant in the middle of an active war. They have made sure that people living with HIV across Sudan are not being left behind, that they are found, there is treatment available for them and that they receive it.  That is resilience, commitment and leadership.”

Home to 5 million people living with HIV, western and central Africa is not on track to ending AIDS by 2030. Every day, more than 760 people become newly infected with HIV in the region and only 2.6 million of the 5 million people living with HIV are on treatment.

Insufficient political will, frail health systems and weak support for community organizations―as well as barriers such as HIV-related criminalization―are the most significant obstacles to progress. A regional acceleration plan aims to put the region on track to reaching the target of tripling the number of people on antiretroviral therapy by 2020 and achieving epidemic control. While progress has been made, that progress is not coming fast enough. Children are of particular concern―only 28% of under-15-year-olds living with HIV in the region have access to antiretroviral therapy.

“We need policies and programmes that focus on people not diseases, ensuring that communities are fully engaged from the outset in designing, shaping and delivering health strategies,” said Gunilla Carlsson, UNAIDS Executive Director, a.i., speaking at the Global Fund to Fight AIDS, Tuberculosis and Malaria Sixth Replenishment Conference, taking place in Lyon, France, on 9 and 10 October.

There are many examples of how investing in communities can make a difference. “The response is faster and more efficient if it is run by those who are most concerned,” said Jeanne Gapiya, who has been living with HIV for many years and runs the ANSS nongovernmental organization in Burundi.

Community-led HIV testing and prevention is effective, particularly for marginalized groups. “Most of the people tested by communities were never reached before and this shows how community organizations are unique and essential,” said Aliou Sylla, Director of Coalition Plus Afrique.

Reducing the number of new HIV infections among children and ensuring that women have access to the services they need remains one of the biggest challenges in the region. Networks of mothers living with HIV who support each other to stay healthy and help their child to be born HIV-free have been shown to be an effective way of improving the health of both mothers and children.

“Our community-based approach works. In the sites where we work we have reached the target of zero new HIV infections among children and all children who come to us are on treatment,” said Rejane Zio from Sidaction.

Financing remains a concern and although total resources for the AIDS response have increased, and HIV remains the single largest focus area for development assistance for health, domestic investments account for only 38% of total HIV resources available in western and central Africa, compared to 57% worldwide. Greater national investments reinforced by stronger support from international donors are needed to Fast-Track the regional response. Bintou Dembele, Executive Director of ARCAD-Sida, Mali, said, “We have community expertise, but we lack the funds to meet the need.”

Support is growing for community-based approaches in the region. Recognizing the importance of community-led work, Expertise France and the Civil Society Institute for Health and HIV in Western and Central Africa announced a new partnership on 9 October. “The institute brings together 81 organizations from 19 countries aiming to ensure better political influence at the global and country levels and to galvanize civil society expertise in programme delivery. This partnership is a recognition of our essential contribution,” said Daouda Diouf, Director of Enda Sante and head of the steering committee of the institute. “The situation in western and central Africa remains a priority. It is clear that community-based approaches are agile and appropriate for responding to pandemics,” said Jeremie Pellet from Expertise France.

Shifting to a people-centred approach has been at the core of reforms in the region. A growing regional resolve to accelerate the response and to strengthen community-led approaches that have been proved to work provides hope for the future of the HIV epidemic in western and central Africa.

The First Lady of Chad, Hinda Déby Itno, has been appointed as the UNAIDS Special Ambassador for the Prevention of HIV and the Protection and Health of Adolescents by the Executive Director of UNAIDS, Michel Sidibé.

During the appointment ceremony, which took place on 21 November at the Presidential Palace in N’Djamena, Chad, Mr Sidibé highlighted the many initiatives that the First Lady had put in place as a member of the Organisation of African First Ladies against HIV/AIDS. He urged her to continue her leadership in the response to HIV in areas as diverse as the elimination of mother-to-child transmission of HIV, gender equality and access to sexual and reproductive health services. He also noted that the personal involvement of the First Lady had helped in the passing of a law promoting sexual and reproductive health issues and the outlawing of female genital mutilation.

“Every child deserves a life without HIV,” said Ms Itno.

During his two-day visit to Chad, Mr Sidibé also met with the President of Chad, Idriss Déby Itno, during which they spoke about health and HIV, the challenges of the response to HIV in the country and the role of African youth in the AIDS response.

Mr Sidibé also met with civil society in Chad, who he congratulated for the campaign to reduce of cost of HIV treatment in the country. Mr Sidibé said that civil society has a role to play in ensuring that the resources invested in the responses against malaria, tuberculosis and HIV are used efficiently, considering the shortage of such resources.

Only 1.8 million people of the 6.5 million people living with HIV in western and central Africa were on antiretroviral therapy at the end of 2015. This 28% treatment coverage of people living with HIV in the region contrasts with the 54% coverage in eastern and southern Africa in the same year.

In response to this HIV treatment shortfall in western and central Africa, UNAIDS, the World Health Organization (WHO) and other partners in the region have developed country emergency catch-up plans to accelerate the AIDS response. These plans call for tripling HIV treatment coverage within the next three years.

At a meeting on the sidelines of the 70th World Health Assembly to support the catch-up plan, health ministers and other representatives of countries in the region vowed to strengthen government leadership, make structural changes in their health systems and strengthen accountability.

The meeting, which was organized by the WHO Regional Office for Africa and UNAIDS, was attended by the health ministers of Benin, Burkina Faso, the Central Africa Republic, Chad, Côte d’Ivoire, Gabon, Liberia and Nigeria and representatives of Cameroon, Guinea and Sierra Leone. They all collectively agreed to put in place strong measures to accelerate HIV treatment in their countries.

All the participants agreed that health-service delivery models had to be transformed, notably by community health workers taking a bigger role in health-care delivery. WHO and UNAIDS will continue to work with the countries as they implement their plans for increasing access to HIV treatment.

UNAIDS is working with countries to achieve the commitment in the 2016 United Nations Political Declaration on Ending AIDS of ensuring that 30 million people living with HIV have access to treatment through meeting the 90–90–90 targets by 2020.

Strategic partners in the response to AIDS came together from 28 to 30 September in N'Djamena, Chad to develop a common strategy and an HIV advocacy plan for the UN system.

Participants acknowledged that political leadership and commitment at the highest level, including from the Head of State and the First Lady, has played a critical role in the response to AIDS. The country provides free access to HIV treatment for people living with HIV and 46% of its health facilities offer HIV services to prevent mother-to-child transmission of HIV. 

Despite progress made in the country—the HIV prevalence rate has declined from 3.3% in 2005 to 2.5% in 2014—challenges still remain. According to participants, the major obstacles to the national AIDS response are the lack of resources, coordination of health activities at community level, and the management of health supplies. 

The workshop proceedings and the strategic document will be presented at the meeting of the UN Country Team for Heads of Agencies’ approval. This is a unique approach epitomizing the One UN approach.

Participants

Funded by UNFPA, participants included representatives from all UN agencies working in the country and the core of national stakeholders (CCM, NAC, PMTCT, RNTAP+, France Expertise, PSLS, Ministry of Women’s Affairs, FOSAP, AMASOT, TB, etc.).

Miss Chad 2015 took part in the workshop where she made a presentation on the forum she is organizing in November 2015 to address the issues of youth’s and young women’s education on HIV.

Key messages

Based on the situation analysis, participants identified the following main areas of advocacy where the UN system should focus its efforts:

• Contribute to the scale up of HIV services to prevent mother-to-child transmission.
• Contribute to the improvement of the data input management system
• Contribute to the extension of the delegation of tasks in all health facilities and official community structures.
• Support the implementation of AIDS programmes among youth and adolescents.
• Support the increased involvement of civil society in the national AIDS response.
• Help reduce stigma and discrimination among people living with HIV.
• Help mobilize financial resources to support the national AIDS response. 

The Executive Director of UNAIDS Michel Sidibé has congratulated Chad for its progress in responding to HIV and urged the country to adopt the UNAIDS Fast-Track approach to end the AIDS epidemic in Chad by 2030.

Mr Sidibé was on country visit to Chad from 2 to 4 August 2015 where he met with many senior officials including the Prime Minister, the Minister of Health, the Minister of Planning and International Cooperation, the First Lady and civil society to discuss national achievements and global HIV treatment targets set for 2020.

The percentage of people accessing lifesaving antiretroviral treatment in Chad remains low at 30% and more needs to be done to scale up access. Mr Sidibé spoke about the importance of increasing HIV testing as a first step towards giving people living with HIV a chance to access treatment for their own health and to prevent new HIV infections. Globally, it is estimated that only 54% of the 36.9 million people living with HIV know that they are living with the virus.

He also called for universal access to health care and to address the stigma and discrimination marginalized populations, people living with HIV and their families face.

There are an estimated 210 000 people living with HIV in Chad and HIV prevalence has remained stable at 2.5% since 2013. UNAIDS estimates that last year there were 12 000 AIDS-related deaths and 14 000 new HIV infections in the country.

During a courtesy call to First Lady Hinda Deby Itno, Mr Sidibé congratulated her for the work she did as the President of the Organisation of First Ladies against HIV/AIDS. 

How to realize Africa’s potential for the future of all its peoples and build international support for the continent’s development were key questions explored in the first session of the Africa Rising Forum held this week in New York.

Taking place at the Africa Center and organized by the Mo Ibrahim Foundation, the 22 September event brought together a number of African heads of state, United Nations partners, and leaders from African civil society and the business community.

They examined how to move beyond simply talking about the need for broad-based economic transformation and sustainable development to taking concrete steps to make them a reality, especially with regard to the post-2015 development agenda. 

A session on ensuring shared prosperity looked at ways to improve investment and resource mobilization, champion entrepreneurship and ensure social protection. Another stressed that development cannot be achieved without the existence of good governance, peace, security and respect for human rights.

It was agreed that ensuring health for all was a critical facet of Africa’s rise, and that ending the AIDS epidemic as a public health threat by 2030 now a realistic goal. There was also a consensus that the continent’s rise should not only be measured in terms of overall wealth generated but by the inclusiveness of socioeconomic progress that leaves no one behind.

UNAIDS Executive Director Michel Sidibé receives a national honour from the President of Chad, Idriss Deby Itno. L to R: Fritz Lherisson, Acting Director, Regional Support Team for West and Central Africa, Mr Sidibé and President Deby Itno. 30 May 2012. Ndjamena, Chad.
Credit: UNAIDS

UNAIDS Executive Director Michel Sidibé concluded his official visit to Chad on 31 May after meeting with President Idriss Deby Itno, First Lady Hinda Deby Itno, senior government officials and civil society to highlight the country’s progress in the AIDS response.

Mr Sidibé met with President Deby Itno to discuss opportunities and challenges in Chad’s AIDS response. One area of the national AIDS response that has seen progress is access to antiretroviral treatment. Since 2007, the provision of HIV treatment has been offered by the state free of charge. According to the Progress report 2011: Global HIV/AIDS response, issued jointly by UNAIDS, WHO and UNICEF, an estimated 32 000 people were receiving antiretroviral treatment at the end of 2010, covering 39% of people who are eligible for treatment.

President Deby Itno highlighted that Chad finances more than half (53%) of the resources required for treatment. He stressed that the AIDS response has enabled Chad to place people at the centre of the country’s development agenda.

Chad has a national adult HIV prevalence of 3.4%. The rate of HIV infection is particularly high among sex workers, estimated at 25.5% in the capital city of Ndjamena.

Mr Sidibé shared with the President his concern over the high levels of stigma and discrimination in the country, especially among people living in rural areas. He emphasized that stigma and discrimination drive people living with HIV underground, away from much-needed HIV services, and if left unaddressed could undermine the effectiveness of the country’s recent gains.

Promoting national ownership

In view of the upcoming African Union Summit in Malawi, Mr. Sidibé encouraged President Deby Itno to support and promote the agenda for country ownership and shared responsibility among the other African Heads of State. He underscored that Chad has an unprecedented opportunity to contribute greater domestic resources to complement HIV investments from international partners. Currently, Chad relies on external sources to finance more than 85% of its national AIDS programmes.

“Chad has demonstrated remarkable progress in expanding treatment access, in fighting stigma and discrimination and in ensuring the rights of people living with HIV are protected. The AIDS response presents an important opportunity to change the development paradigm,” said Mr Sidibé.

Eliminating new HIV infections among children

In their discussions, President Deby Itno and Mr Sidibé agreed that greater momentum is needed to increase services to prevent mother to child transmission of HIV (PMTCT). Although the number of PMTCT sites across the country has increased from 93 in 2009 to 140 in 2011, coverage remains low, at 10%. One of the main bottlenecks is the lack of coordination and integration between PMTCT and maternal and reproductive health programmes.

Mr Sidibé joined President Deby Into at an event on 31 May to launch the national plan to eliminate new HIV infections among children. Chad is one of 22 countries included in the Global Plan towards the elimination of new HIV infections among children and keeping their mothers alive by 2015.

As part of his visit, Mr Sidibé held bilateral meetings with Chad’s Prime Minister, Emmanuel Nadingar, the Minister of Public Health, Mamouth Nahor Ngawara, and the Minister of Finance, Christian Georges Dinguimbaye.

Before concluding his two-day trip, Mr Sidibé met with the First Lady of Chad, Hinda Deby Itno, to discuss her work with the Campaign for Accelerated Reduction of Maternal Mortality in Africa (CARMMA). He also took the opportunity to interact with the national network of people living with HIV (RNTAP+) and participate in a forum on human rights and HIV, hosted by the Ministry of Foreign Affairs.

During the visit, President Deby Itno awarded Mr Sidibé one of the country’s highest decorations—the Grand Chancelier de l'ordre National du Tchad—in recognition of his commitment and contribution to the global AIDS response.