Saturday 6 December 2008.
By El-Sadig El-Mardi
December 5, 2008 — As the Government of Sudan (GOS) and the Sudan People’s Liberation Movement/Army (SPLM/A) signed the comprehensive peace agreement on January 9, 2005 a new era began in the history of the largest country in Africa, which has been troubled by more than two decades of civil war . Many people are hoping that the new post-conflict administration works hard to find peaceful resolution to the crisis of Darfur.
Even though Sudan’s long civil war with its devastating consequences represented the country’s national emergency crisis, yet the potential of the HIV/AIDS prevalence to increase is another monster in the absence of sufficient political will to deal with the epidemic.
The geographic location of the country, the refugee and displacement crisis, famine, economic collapse, insufficient commitment to public health education and the weak testing capabilities have all contributed to the current situation in which the reported cases represent only the visible part of the epidemic.
The weak commitment to public health education in general, and HIV/AIDS education in particular, has resulted in the great stigmatization of people living with the infection, lack of awareness with regard to the disease symptoms, signs and mode of transmission, increase of sexual practices and resistance to condom use.
Some countries in the region, such as Uganda, Kenya and Senegal, were able to demonstrate sufficient political will in dealing with the AIDS crisis, which was the key to some positive reduction in the HIV/AIDS prevalence .These countries interventions and experiences are of great benefit to the effort aimed to control the HIV/AIDS epidemic in Sudan.
The full implementation of the south peace agreement and the fair resolution of the Darfur crisis will indeed create a better environment for the campaign against the AIDS crisis. However there is an urgent need for a strong political will from the post-conflict administration in dealing with the epidemic. This can help in better accessing external fund, mobilizing the internal resource, building the coalition and developing comprehensive national strategic plan for the HIV/AIDS control in Sudan.
BACKGROUND
Since its independence forty seven years ago, Sudan enjoyed only eleven years of peace. The civil war divided the country between the government of Sudan (GOS) in the north and the Sudan people liberation army (SPLA) in the south. In the last twenty years the war killed two million people and displaced 4.5 million1. The war had catastrophic implications for both the north and the south. However southern Sudan remains one of the most isolated, neglected and least developed regions of Africa. The entire 4.5 million displaced population are southern Sudanese out of which 3.6 million live in the eleven states of southern Sudan, 350.000 in the transitional zone (the area of southern Darfur, southern Kordofan, northern Bahr Algazal, and southern Blue Nile) and 300.000 in displaced camps outside of Khartoum.1 The infant mortality rate is 68 per 1000 live births in the north and 82 per 1000 live births in the south. The under five mortality rate in the north is 104 per 1000 live births and 132 per 1000 live births in the south, the maternal mortality rate is 509 per 100.000 in the north and 865 per 100.000 in the south.2 The war had devastating effects on the health care system, most of the health care facilities in the south have either been completely destroyed by the war or lack the most basic medical supplies .In the north, though not destroyed, these facilities suffered a lack of medical supplies in addition to limited management capacity particularly at the local level. An example of the weak health care system is the limited access to reproductive health. In the areas under government control 86% of women deliver at home with fewer than 57% attended by skilled personnel. In the areas under the Sudan People’s Liberation Army (SPLA) in the south 79% of women do not receive tetanus toxoid during pregnancy and 94% of deliveries are done without the benefit of a trained birth attendant. Additionally the absence of contraceptive protection and the high rates of unsafe abortion are considered major threats to women’s health. Famine as a direct consequence of the war resulted in significant rise in the prevalence of malnutrition rates from 18% in 1995 to 23% in 2001 in the north and the government controlled areas in the south. The situation is more serious in the (SPLA) controlled areas, where the rate is 20% of which 15% are severely malnourished.3
Inadequate access to safe water and sanitation, as well as poor hygiene practices, are the major causes of several diseases leading to the high level of infant and child mortality rates. Epidemics of water- related diseases such as diarrhea cause 40% of the under five mortality. Sudan hosts over 73% of the world’s total guinea worms cases, 99% of them in the south.3 The above mentioned consequences of the civil war represent the root causes of the spread of HIV/AIDS. The population displacement which is commonly associated with abuses and sexual violence, the hunger which increases the likelihood of infection in the malnourished, the poverty and economic collapse which increase the commercial sex practice have all contributed to the promotion of the virus transmission.
According to Sudan National AIDS Program (SNAP) survey, which is a behavioral and epidemiological survey, conducted on Nov 2002, the overall HIV/AIDS prevalence was 1.6%. The prevalence among women attending antenatal clinics was 1.0%, among refugees was 4.0%, while prevalence in other high risk groups was 4.4% among prostitutes, 1.6% among TB patients, 2.5% among tea sellers (a group of women selling tea and food items outside public buildings, government departments and private companies), who some believe to engage in commercial sex and comprise some 25% of the suspected AIDS patients.
These statistics may not reflect the actual picture of the epidemic and there is much evidence to support this argument. First, HIV/AIDS demonstrated higher prevalence in similar conflict circumstances. In Rwanda where thousands of women were raped during the 1994 genocide leaving an estimated 15.000 girls pregnant, of 2.000 women tested for HIV afterwards 80% were HIV positive.5 Also in Democratic Republic of Congo, according to Save the Children, the cycle of armed conflict which began in the early 1990s increased the prevalence of HIV/AIDS from 5% to 6.2 % with the increasing numbers of rape cases committed.5 Second, the geographic location of the country which borders countries with higher HIV/AIDS prevalence and the rapid development of trade links between the south and the north can significantly increase the disease prevalence. The HIV/AIDS prevalence is believed to be 6.6% in Ethiopia6, 6.7 in Kenya7, 6% in Uganda8, 6.2 % in DR of Congo9, and 13.8% in Central African Republic.10 Third, the Sudan national AIDS program survey was conducted in eleven states of sixteen northern states and in only three out of eleven states in the south. The weak financial resources and the civil war in the South made it difficult to cover all the states. Fourth, even when it exists, some people never seek hospital care for AIDS and some doctors may not want to record a diagnosis of AIDS because of the stigma attached to AIDS. Fifth due to the poor primary health infrastructure and lack of services, some people with HIV infection may die of other diseases before ever being diagnosed of having AIDS. Finally the overall testing capabilities for HIV/AIDS are very weak in the country. Indeed the long course of the country’s devastating civil war which reduced such capacity fuels the epidemic and dramatically worsens the situation.
In a visit to Sudan on December 2001, I met Dr. Sayd Gotob, the Director of the Sudan National AIDS Program. I sensed a great deal of dedication and courage to tackle the HIV/AIDS epidemic from Dr. Gotob and his team. Yet to me the program looks like an island isolated from the other divisions of the Ministry of Health as well as other government bodies.
The SNAP survey itself questioned the government commitment to the program structure and coordination with other health sectors and government bodies. It mentioned that the program responsibilities and authorities with regard to HIV/AIDS control are not well stated and the relationships of the SNAP with other ministries and other organizations are not identified. Also the responsibilities of the program with regard to the laboratory services and blood banks are not clear.
The SNAP survey also indicated insufficient government funding stating that the current premises where the program is housed is poorly furnished and inadequate to provide for the envisaged responsibilities and functions of the program. There are no sufficient transport facilities provided for the program, no library facilities, reference books or journals. Though the program started 16 years ago there is no documentation for the plans, strategies and activities that were carried out during the past years.
Despite the absence of sufficient and necessary political will and being forced to function within the limited financial resources, Dr. Gotob and his team were able to produce a situational analysis report. Though it did not cover the whole country, the report represented a sincere and eager effort to provide information with regard to the HIV/AIDS epidemic status in the country and serves as a good starting point for formulating a countrywide national strategic plan to control HIV/AIDS.
HIV/AIDS AND POPULATION DISPLACEMENTS (REFUGEES AND INTERNALLY DISPLACED) CRISIS
Because of the war and the limited financial resources, the SNAP survey covered eleven of the sixteen northern states and only three states in the south out of eleven states even though the Southern war zone is believed to represent the country’s most infected region. According to the survey, a total of 470 blood samples were tested from refugee and displaced persons, and out of those 20 were HIV positive, giving a prevalence of 4.3%.
The civil war forced many Sudanese to flee their homes and live as refugees in other countries. Currently there are more than 700.000 Sudanese refugees, 26.000 in Central African Republic, 325.000 in Uganda, 50.000 in Ethiopia, 118.000 in Zaire , 69.000 in Kenya , and 200.000 western Sudanese refugees from the current Darfur crisis in Chad . Refugees from other conflicts in the region also flee to Sudan, 259.057 Ethiopians, 580.173 Eritreans, 43.173 Ugandans, 4.000 Zairians and 145.835 Chadians.11 The Southern Sudanese displaced population is estimated to be 4.5 million, living both in the north and the south. The displacement population of the current Darfur crisis is estimated to be about 1.8 million living in about 130 camps and settlements.
The refugee and displacement condition is usually associated with interruption of the social fabric and human rights abuses, particularly sexual violence. Thus this population is at a higher risk of HIV infection than the overall population. The situation in the refugee/displacement camps is miserable. Most of the refugees and displaced persons face the risk of abuse, violence and sickness with little or no access to medical care, education, clean water and other essential services.
Displaced and migrant groups tend to have sexual partners often among themselves; therefore the greater risk of transmission is internal. However in other circumstances the risk of external transmission increased as in the situation of single displaced men who are employed in low status jobs and who tend to have multiple partners and commercial sex. Also displaced women have been forced to engage in commercial sex because of the poverty and economic situation. These two situations are particularly true for the displaced population in Khartoum state.
Because of the great vulnerability of the refugees/displaced population to HIV/AIDS the absence of sufficient political will to deal with the epidemic can result in particularly higher HIV/AIDS prevalence among this group.
COMMITMENT TO HIV/AIDS EDUCATION
The anti- AIDS campaigners often work in a very hostile environment and this hostility affects the efforts aimed to limit the spread of HIV/AIDS in Sudan. The stigma attached to AIDS and the pro- government religious groups are the main source of this hostility. The lack of sufficient commitment to HIV/AIDS education resulted in great stigmatization of the people living with the infection and contributed as well to the level of awareness, sexual practice and condom use. Indeed it remains a major concern in the battle against HIV/AIDS.
Stigma
There are many cultural, religious and ethnic variations between north and south Sudan. The majority of northern Sudanese are Arab Muslim while the southern Sudanese are African Christian or non-religion. In the north the Islamic values and traditional norms restrict public discussion about sex, and do not approve premarital sexual relations from a religious point of view because a sexual relation is defined to be a relation between husband and wife. The discordance between the religious rules and the publicly expressed norms on one side and the highly prevalent non-marital sexual activities on the other side create a strong barrier to the HIV/AIDS education because of the denial of the premarital sexual behavior among young people. This resulted in great stigmatization of the people infected with the virus, as they are viewed as people who bring shame and embarrassment to their families.
Additional factors contributing to stigma are ignorance, lack of awareness and traditional beliefs. According to Esther Mwanyika, HIV counselor with the International Rescue Committee at Kakuma camp for Sudanese refugees in Kenya, “the stigma is there because this is a new thing for them, they are very secretive about it, and they don’t want to declare it”. 1
In Khartoum, the country’s capital, according to The Alray Alam newspaper, O.M., a 41 year old who is living with AIDS, lost his job as a public school teacher when the Ministry of Education learned that he was infected with HIV. Also a young woman whose name was withheld told the newspaper that she was married and had been practicing commercial sex to support her family until she discovered that she is infected with HIV. "The news that I have AIDS was great shock to me, I decided to keep it secret so I would not be dismissed from my post but the psychological pressure has reached a point where I could not hide it. I was an official in the government but now I’ve lost my job because of this disease, the problem facing me is how I can feed my children."
According to the SNAP survey, "more than half of the respondents (53.2%) said they do not buy food from sellers who have AIDS. Forty four percent said they do not eat with an AIDS patient, about (30%) said they prohibit a teacher with AIDS from teaching and prohibit their student to go to school to prevent contamination."
Awareness
Many people do not know enough about the disease, its methods of transmission or devastating consequences. Many also have not heard about the disease. Some even confuse the word AIDS with aid and relief food. Dr. Osman Mohamed Alkhidier, head of the health ministry’s National AIDS Committee, said, "Our problem is we can not talk about condoms now because people have not yet heard of AIDS, secondary school students do not know what AIDS is, AIDS was included in 1996 secondary examinations but the students failed to explain it. They confuse AIDS with aid and relief food; do you think such people will dream of condoms?"
According to the SNAP survey 21% of the respondents knew about the symptoms of AIDS and less than 16.5% knew about the signs of the disease. Only 20% recognize the virus as the cause of AIDS. When asked about the mode of transmission, 53.2% mentioned sexual intercourse, 29% mentioned blood transfusion, 17.9% mentioned skin penetration and 7.6% said AIDS is transmitted from mother to child. About 62% mentioned one mode of transmission, 12.1% mentioned two modes.4 Indeed, the absence of sufficient commitment to public health education in general and to the education with regard to HIV/AIDS in particular have hampered the drive to raise the awareness.
The lack of awareness with regard to HIV/AIDS is mainly due to the insufficient government commitment towards public health education, the weak role of the media and also the latest government’s educational policies, which favor unplanned expansion in admissions over quality, and content of curriculums particularly at the secondary and the higher educational level.
Sexual practices
The government’s economic policies, the overspending on war, and the international sanctions since the early 1990s, have all contributed to create a very difficult economic situation in which incomes are very low and the unemployment rate is high. The economic situation forced some groups such as young college students and tea sellers to engage in commercial sex to meet their financial obligations or to support their limited family incomes. The SNAP survey identified tea sellers, soldiers, truck drivers and street kids as at high risk for HIV/AIDS.
In south Sudan traditions such as polygamy or widow inheritance have promoted the HIV/AIDS transmission. In an interview with Plus News Mary Biba, who is the SPLA country secretary in Yambio, said, “Behavior change is a problem. I think people here most of them are after sex. You wonder why I say that. If a man dies from AIDS another man will marry the widow immediately, so that means they are not caring for their lives."
The use of condom
As a medical general practitioner I observed the resistance to using condoms. This resistance reflects deeply rooted rejection of family planning policies particularly by religious and traditional leaders and compounded the efforts to control HIV/AIDS epidemic. Due to the lack of sufficient public health education, the use of condom has been viewed as a method of contraception more than a method to prevent sexually transmitted diseases and HIV/AIDS. The idea of preventing pregnancy to plan families and limit population growth has been strongly opposed by the religious groups because they view it as refusing and rejecting God’s will and gift.
There are some in the Sudanese society who believe that condom use is not a solution for the spread of AIDS because people continue to die in the west and some African countries, even though condoms are being used .In their view, AIDS has to be fought from a religious and moral perspective.
According to the SNAP survey channels for getting condoms are very limited as they are only available in some pharmacies (very costly), NGOs, family planning clinics, and some local shops.6 In fact even in the limited pharmacies that sell them they are kept under the counter and only dispensed to those who ask for them. In south Sudan many people do not hear of condoms and even among those who are aware of them, condoms considered a luxury many cannot afford. According to Bill Colford, an HIV/AIDS counseling trainer in Yambio, in a meeting with health NGOs working in the areas, "people can spend that money on condoms or food. They are not going to spend their food money on a piece of rubber."
Another issue of great concern is the powerlessness of women with regard to negotiating the use of condom with their partners. This powerlessness considered one factor that minimizes the use of condoms as a means of protection against HIV/AIDS and sexually transmitted diseases.
THE ROLE OF MEDIA, NGOS AND CIVIL SOCIETY ORGANIZATIONS
The campaign against HIV/AIDS receives minimal and insufficient coverage. The media is under the government control and although recently there has been some good movement towards more press freedom, still many newspapers have been subjected to confiscation and their publishers or journalists to interrogation if they approach sensitive subjects in a way that the government does not feel comfortable with. Dr. Ibrahim Mohamed Abdullah, a committee member of the Sudan National AIDS Program, admitted that the media has not yet played its expected role in the HIV/AIDS control campaign.
Another concern is the capabilities and the experiences of the health personnel, educators and people working in the media to deliver influential messages to control HIV/AIDS transmission.
The NGOs played a good role in the campaign against HIV/AIDS. Their ability to respond is to some degree better because of the absence of bureaucratic impediments; even the coordination is better among NGOs compared to other stakeholders. An example of the active role of NGOs is the HIV/AIDS pilot prevention project of the International Rescue Committee (IRC), which focuses on increasing the awareness of HIV/AIDS, improving reproductive health practices and capacity of health facilities in south Sudan.
HIV/AIDS EPIDEMIOLOGICAL SURVEY AND TESTING CAPABILITIES
According to the SNAP survey, limited epidemiological surveys have been conducted by Khartoum state and by international NGOs among the military and a few vulnerable groups such as street children and antenatal care attendants. But not a single state has surveillance activities or a blood safety program.
In the north, testing facilities are limited to big hospital and central laboratories in Khartoum, while in south Sudan there is a complete absence of HIV/AIDS testing capabilities. In her interview with Plus News, Mary Biba, the SPLA country secretary in Yambio, said, "There are a lot of people who are HIV positive, we just know by the symptoms and reactions that this is AIDS. There are signs of diarrhea, getting sick, vomiting, opportunistic diseases, so when all these appear people know that it is HIV/AIDS."
The weak testing capabilities are part of the weak health care system, which continues to suffer the consequences of the war, national disasters, insufficient funds and limited management capacity particularly at the local level. Voluntary testing of HIV is a major concern even when testing capabilities exists.
FINANCIAL RESOURCES
According to the World Bank group the GNI was 9.1 billion in 1998 and 11.5 billion in 2002. The GDP was 10.7 billion in 1998 and 13.5 billion in 200220. The overall health spending according to the World Health Organization post-conflict strategic framework in Sudan (September 2002) is at $30 per capita per year.2 The actual federal government disbursement to the Sudan National AIDS Control Program cannot be identified. However the SNAP survey mentioned that the main source of finance is the federal government. The survey also mentioned that the program office is poorly furnished, there are insufficient library facilities, no reference books or journals, no documentation and the transport facilities are insufficient. These facts indicate that the government federal fund does not completely cover the program’s responsibilities and functions.
There are many reasons for the insufficient financial resources. First the civil war which used to consume most of the country’s income. According to the WHO post-conflict strategic framework, (September 2002), 27% of the total government spending is for defense.2 The oil revenue used to fund the war by building the government’s arms industry, paying for more arm imports and spending to secure the oil exploration zone. According to Amnesty International, a direct link between the nature of the war and guarantees for security for oil exploration by companies become most obvious in intensified warfare in the beginning of 1999. Taban Deng Gai an officer in Sudan People Democratic Front (SPDF) one of the government’s southern alliances, resigned from his constitutional post of State Minister in the federal ministry of roads and communication. In his resignation letter dated December 9, 2000 Gai said, "The government of Albashir has chosen a military option, exploiting the revenue from the oil to fund its military machine rather than a peaceful resolution of the conflict." Second, Sudan is a heavily indebted country. According to the World Bank, the country struggled with a high and rising external debt burden since the late 1970s. By the end of 2003 the total debt is projected at about US$21.1 billion, most of it in arrears. Third, the government foreign policy since the early 1990s has resulted in cutting most western funding and discourages international donors from funding the country’s projects. For example, in January 1991 Britain suspended its development aid to Sudan, which had amounted to US$58 million in 1989, while continuing humanitarian aid. This policy change was caused by a number of factors including alleged terrorist activities by Sudanese agents against Sudanese expatriates in Britain.Also, the World Bank in mid -1991 announced the closing of its office in Khartoum by December 31, 1991 as a result of the deterioration in the relation between the Sudanese government and the international monetary bodies following cessation of debt repayment by Sudan to the World Bank and the IMF.
Recently the price of oil continues to climb and Sudan oil revenue has shown dramatic increase. According to Sudan Tribune, Sudan Oil revenue reaches $449m in November 2007. However, the spending priorities continue to be defense and security and the funding for the HIV/AIDS program remains insufficient.
POLITICAL COMMITMENTS AND THE ABILITY TO MAKE CHANGES
HIV/AIDS pandemic has a devastating impact in Africa, particularly in Sub-Saharan Africa, which accounts for about two thirds of the estimated number of global HIV/AIDS cases.24 In some African countries the demonstration of strong political will was the key to some reduction in the HIV/AIDS prevalence rates.
Uganda
In Uganda, a country with a population of about 23 million people according to Census Bureau’s world population profile, the HIV infection levels among pregnant women in major urban areas reached 30% in 1992. By 1998 there was about 50% decline in this level, even more for women age 15-19 years. UNAIDS reported that in two large clinics for pregnant women in Kampala, the capital, the number of HIV infected women in the age group 15-19 years dropped from 28% in 1992 to just 8% in 1997.25 According to the Ugandan government the HIV/AIDS prevalence is now 6%. Uganda is considered to be an outstanding example of strong and eager political will and commitment to combat the epidemic. President Youri Museveni’s government was the first in Africa to acknowledge that it had an epidemic, declare it, and appeal for the international community to help.
An example of the successful efforts to access external help is the $50 million contribution from the World Bank to Uganda’s sexually transmitted diseases project in 1994. The project objectives were to limit the virus and to prevent the sexual transmission of the disease through increasing awareness and prompting safe sexual behavior.
Under this kind of leadership silence was broken, all sectors of society were involved and the message was able to spread. The evidence showed that there is reduction in number of partners and increase in the use of condom, and almost every Ugandan knows about AIDS and knows about what is needed to stop its spread.
Kenya
Former Kenyan president Daniel Arap Moi talked openly several times about the HIV/AIDS epidemic. He advocated for the use of condoms for those who could not abstain or remain faithful to their partners. He showed neither weakness nor hesitation when faced by the strong criticism from church groups. Due to the government’s active interventions and the increase in the use of condoms, the HIV/AIDS prevalence has been reduced to 6.7 % from 13.6%. According to the former Director of the Medical Services, Dr. Richard Muga, the active interventions that have gone on the last 10 years have led to the HIV/AIDS prevalence reduction. Dr. Muga estimated the use of condoms to be 100 million per year up from 70 million in 1998. According to Dr. Muga also, the government was intensifying voluntary counseling and testing and increased access to condoms and teaching people on their proper use.
The Kenyan government recognized the importance of the multi-sectoral approach in tackling the HIV/AIDS epidemic. The government formed up a multi-sectoral national AIDS control council (NACC). The council is responsible for coordinating all government and non-government HIV/AIDS interventions. The representatives include key line ministers as well as persons from NGOs and private sector.
Senegal
In this West African Muslim country of 10.6 million persons, the campaign to control HIV/AIDS is considered one of the world’s HIV/AIDS success stories.
HIV/AIDS prevalence has been kept below 2% through different strategies. These include an aggressive awareness campaign, enhanced testing capabilities and the encouragement of voluntary testing, promotion of condom use, a good surveillance system and active involvement of the country’s political and religious leaders.
In fact the involvement of Senegal religious leaders in the fight against AIDS was remarkable. According to UNAIDS the government in Senegal conducted a survey of Muslim and Christian leaders to better define a role for them in AIDS mitigation. The survey found that religious leaders needed and wanted more information about HIV/AIDS, so in response educational materials were designed to meet the need of religious leaders. Training sessions about HIV were organized for Imams and teachers of Arabic and brochures were produced to help them disseminate the information. AIDS became a regular topic in Friday sermons in mosques throughout Senegal and senior religious figures addressed the issue on television and radio. In 1996 a meeting on AIDS prevention was held for Christian leaders, every bishop in Senegal attended and consensus was reached that AIDS prevention was an important national priority. The following year in late 1997 Senegal hosted the first international colloquium on AIDS and religion in Dakar. It was attended by some 250 persons from 33 countries, including Muslim, Christian and Buddhist religious leaders and the Ministers of Health of five African countries.
Senegal’s former first lady Vivane Wade encouraged voluntary testing of HIV. She thought one of the effective approaches to control the spread of AIDS in Senegal is to develop willingness among compatriots to have themselves tested voluntarily.
Indeed because of the strong political will and active involvement of all society sectors, particularly the country’s religious leaders, Senegal’s AIDS control campaign was successful in maintaining the HIV/AIDS prevalence rates between 1-2%.
WINNING THE BATTLE
The emotional and economic impacts of HIV/AIDS exceed family, friends and community to affect countries production, health care practice and the capacity of the societies to provide essential services and plan for the future. The following recommendations are aimed to help the current planning initiatives succeed in building solid and comprehensive national strategic plan for HIV/AIDS control in Sudan.
The inspiring leadership role
The lessons learned from the experiences of countries like Uganda, Kenya and Senegal can help the efforts aimed to combat HIV/AIDS in Sudan.
The active involvement of these countries leadership in the battle against HIV/AIDS and their strong commitment to fight the epidemic can serve as a model for the other countries in the region. In recognition of their commitment in the fight against AIDS in their countries President Youeri Museveri of Uganda and former President of Senegal Abdou Diouf received excellence awards at the seventh conference of the Society for Women and AIDS in Africa (SWAA) held in Dakar December 2001.28 In Sudan the overwhelming civil war consequences represent the country’s national crisis for more than 20 years. Yet HIV/AIDS is another monster and courageous movement by the country’s leadership is desperately needed. It is the right time for many reasons. First, the full implementation of the peace agreement can modify the environment and shed a considerable amount of light on Sudan, which had been subjected to isolation and sanctions for more than a decade. Second, the implementation of the peace agreement will also promote donor interest to fund the country’s projects including the HIV/AIDS control program. In an article for the LA Times former US Secretary of State Colin Powell wrote, "Once a peace accord is signed we will begin normalizing our bilateral relations with the Sudanese government, together with our international partners, we will promote reconstruction and development. Indeed we are already planning for coordinated donor assistance to get peace off to a good start."31p2 And third, the recent positive changes towards peace and democracy shall encourage leadership openness and transparency in dealing with the AIDS epidemic.
The active religious leader’s role in mitigating HIV/AIDS stigma
In Senegal the active involvement of the country’s religious leaders in the campaign against HIV/AIDS had played an important role in breaking the silence, dealing with the stigma attached to the disease and getting the message crossed. Now could the Senegal experience be considered an inspiring model for Sudan. It can be argued that although predominantly Muslim, Senegal is a secular state and an influential moderating voice among its African neighbors, Senegal had more room for transparency and openness with regard to the religious leaders approach and involvement in the campaign against HIV/AIDS. Such a role does not exist in Sudan. The truth is that such involvement can be difficult to witness quickly because of the strong pressure of the Islamic hardliner institutional lobby backing Al Basher’s government. However, the proper implementation of the peace agreement and the active involvement of the new post-conflict administration might effectively soften this pressure. It is also important to mention that the popular support for the Islamist injunctions had declined particularly in the recent years. In his article "Sudan’s Perfect War" Randolph Martin wrote, "Arab northern Sudan is not an Islamic fundamentalist culture. Traveling through the region, a westerner does not sense the kind of deep antipathy and xenophobia found in states such as Iran, the Taliban’s Afghanistan or Pakistan."32p6. Thus there is a strong base for a moderate Islamic voice in Sudan that can allow transparency and openness in discussing HIV/AIDS and the stigma attached to it within the scope of respecting human rights, promoting justice, dignity and tolerance between different groups.
The promotion of condom use
The use of condoms can be promoted through a comprehensive social marketing plan that carefully targets high risk groups. The plan can use sound strategies such as effective presentation of product, proper distribution through strong outreach community campaign and effective use of primary and secondary channels. Such a plan can seek community leader’s support and improve the quality of information to allay fears, rumors and wrong believes. One of the good approaches is the encouragement of peer group discussion with regard to the use of condom through information sharing network.
Strength commitment to public health education
Education can reduce vulnerability to HIV/AIDS by increasing literacy and general awareness level so people acquire the knowledge, attitude and skills necessary to resist negative pressure, avoid harmful behavior and make healthy choices. It is very important for the Post-conflict administration (The National Unity Government) to demonstrate great commitment to public health education in general and to the HIV/AIDS control education in particular. In order to accomplish such a goal there should be a systematic and well-planned information dissemination advocacy campaign targeting all segments of the community. The campaign should make use of all available means that would ensure maximum coverage of the information regarding HIV/AIDS transmission, prevention and control. For example, sex education programs can be included at the high school curriculum level, conferences and seminars can be organized to address the role of the community and religious leaders in the campaign against AIDS, TV and radio can repeatedly air constant warning messages. There is an urgent need for the people to understand the nature of the infection, how it is transmitted, what behavior to avoid, how to reduce the risk and what attitude needs to be adopted to limit the spread of the infection.
Building management capacity and promote coordination
The experience of countries like Uganda and Senegal showed the effectiveness of having the national AIDS program supervised and overseen by the country’s leadership. This can be an inspiring example for Sudan. It will promote the campaign against the HIV/AIDS epidemic and encourage the international donors to fund its control activities. There is an urgent need to clearly define the Sudan national AIDS program’s (SNAP) responsibilities and authorities and its relation with other ministries, laboratory services and blood banks. HIV/AIDS related interventions should be decentralized to encourage building of local capacities at the state level. Also coordination between different stakeholders such as MOH, international agencies, NGOs, and civil society organizations can be stimulated through joint meeting, workshops and seminars.
Promotion of financial resources
Internal resources can be mobilized by building financial analysis skills to improve effective use of resources and by developing alternative financing mechanisms, such as community-based health financing schemes. The external fund is better accessed by establishing well-defined and clearly articulated strategies to control HIV/AIDS. The full implementation of the peace agreement can create a good opportunity to attract donor interest and to mobilize internal resources, particularly oil revenues.
CONCLUSION
The HIV/AIDS epidemic is the next national emergency crisis in Sudan. All the optimism and the dreams of peace and development can be easily destroyed by an epidemic that is capable of wasting the country’s manpower and productivity. This epidemic is terrible, yet we are not powerless against it. The same faith and spirit that end a devastating civil war can with no doubt help to confront the HIV/AIDS epidemic and win the battle against it. There is an absolutely urgent need for strong will and commitment from the post-conflict administration in dealing with the AIDS crisis. Resources must be mobilized, external help must be sought, coalitions should be built and the current strategic planning initiatives should be developed to build a solid and comprehensive national strategic plan for HIV/AIDS control in Sudan.
The author is a Public Health Program analyst at Philadelphia Department of public Health - AIDS Activities Coordinating Office
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