I. PURPOSE AND PRINCIPLES
The National Commission to Fight HIV/AIDS and Large Endemics (CNLCSGE), led by the President of the Republic of Angola, and comprised of ministers from all sectors of government, was established in 2002 to coordinate the national, multi-sectoral public response to HIV/AIDS. The national response to the HIV/AIDS epidemic in Angola is led by the National AIDS Institute (INLS), which was set up in 2005 to implement Ministry of Health (MOH) policy on HIV/AIDS. The MOH has a current HIV National Strategic Plan (NSP) for 2007-2010, which should be refined and updated through 2013 under the proposed partnership.
In 2008, the United States Congress reauthorized the President's Emergency Plan for AIDS Relief (PEPFAR) for five additional years. The goals of this phase remain increasing access to antiretroviral therapy, preventing new infections, and providing care to people affected by AIDS, including orphans and vulnerable children. In addition, this second phase of PEPFAR places greater emphasis on strengthening partnerships with host country governments, strengthening coordination with other donors, and building capacity for a more sustainable response.
This Framework illustrates the high-level Government of the Republic of Angola (GRA) commitment, national leadership and continued ownership of the national HIV response. Recognizing the importance of country ownership and sustainability, PEPFAR through this partnership intends to support the health priorities laid out in the NSP and the principles of three ones that are promoted by the INLS to fight the HIV/AIDS epidemic in Angola.
The purpose of this Partnership Framework on HIV/AIDS 2009-2013 (Framework or PF) is to provide a five-year joint strategic plan for cooperation among the GRA, the Government of the United States of America (USG), and other stakeholders to support achievement of the goals of the NSP and, in so doing, also contribute to the PEPFAR goals for prevention, care and treatment. The Angolan government's current NSP for HIV stipulates three goals, which guide Framework design, implementation and evaluation.
The Framework aims (1) to sustain an effective response through proven strategies and approaches, (2) to expand and improve preventive activities and service delivery while enhancing coverage and quality, (3) to strengthen local capacity, (4) to promote policy reform, and (5) to assist the GRA in its coordination of key stakeholders:
Framework Consultative Process:
II. FIVE-YEAR STRATEGIC OVERVIEW
The best information available to date indicates that Angola has a mixed epidemic; therefore, both Most at Risk Populations (MARPs) and general population groups should be targeted under this Framework. Angola has an estimated HIV prevalence of 2.1 percent among adults aged 15-49. Analysis from ante-natal (ANC) studies in 2004, 2005 and 2007 reveals increases in prevalence over time. Since 2004, prevalence among young pregnant women has risen from 2.7 to 3.1 percent. A country with an estimated population of 17 million, Angola is bordered by the high-prevalence countries of Namibia and Zambia, as well as the Democratic Republic of the Congo and the Republic of the Congo (Brazzaville). It is separated by only 40 kms of Namibian territory from Botswana. A review of estimated prevalence by province reveals significantly higher rates along the border, especially in Cunene on Namibia's border, where the prevalence rate is estimated at 9.6 percent.
The main mode of transmission is heterosexual sex; and the common practice of multiple concurrent partners is an important driver, though data need to be strengthened to improve understanding of the dynamics of the epidemic. Commercial sex workers and mobile workers (including truck drivers, miners, military personnel and the police) are assumed to be the most at risk populations as they are in other sub-Saharan countries. Little is known about men who have sex with men (MSM) in Angola. HIV prevalence among sex workers was reported at 23.1 percent (UNAIDS, 2008). An estimated 77 percent of young people aged 15-24 in the general population did not correctly identify ways of preventing sexual transmission of HIV, and up to 32 percent of youth initiated intercourse before the age of 15 (UNAIDS, 2008). Low knowledge of HIV prevention and early sexual debut reinforce the GRA focus on general population youth as an important risk group. Young women engaged in transactional sex also emerged as an important population for further investigation in an unpublished qualitative assessment in Cunene, the province with the highest HIV prevalence. Male circumcision (MC) is a cost-effective biomedical intervention and an essential component of a comprehensive combination prevention package. Although the prevalence of male circumcision in Angola is thought to be high (UNAIDS), no concrete data are currently available.
Angola suffered civil strife for four decades, as it fought for independence from Portugal (1961-75) and engaged in a protracted civil war until 2002. This contributed to a devastated health infrastructure. Post-war Angola is also in dire need of qualified personnel to perform almost all tasks required for appropriate health sector functioning. Angola currently has one doctor, fourteen nurses, one laboratory technician, and less than one pharmacist per 10,000 people. Only 15 percent of the health work force provides services in rural areas, where over half of the population lives. The use of the nation's resources to fight the war, along with massive population dislocation, led to sustained high levels of poverty, with 21 percent of the population now living in extreme poverty. This poverty, coupled with low access to health services, translates to poor health conditions, particularly for pregnant women. An estimated 90 percent of pregnant women living with HIV do not receive antiretroviral therapy for preventing mother-to-child transmission (UNAIDS, 2008).
Tuberculosis (TB) is the most common opportunistic infection in HIV- infected patients, resulting in significant mortality and morbidity. The MOH National TB Control Program (PNCT) estimate of HIV prevalence among TB patients was up to 15% in 2007 but less than 9%1 of TB patients are tested for HIV, according to national TB program data. The number of TB cases notified to the WHO by the PNCT has more than doubled between 1990-2007, from 21,634 to 48,777, despite significant under reporting due to the fact that DOTS (the WHO strategy for global TB control) covers only 70 percent of the country and lacks essential systems for M&E. TB prevalence is estimated to be 294/100,000 inhabitants (WHO, 2009).
Now, seven years after wars' end, increased mobility of the population, expanded commerce with high-prevalence countries, urban primacy, a large youth population, high-risk sexual behaviors, and the precarious state of the health infrastructure place Angolans at heightened risk of HIV infection, serious opportunistic infections, and AIDS.
The strategic vision for this Partnership Framework is not only to scale up HIV prevention, care, and treatment services in Angola, but also to move toward increased country ownership and a more sustainable response to the HIV epidemic in Angola. The Partnership Framework should work toward this vision for increased country ownership and sustainability by forging new types of relationships among the USG, the Government of Angola (GRA), and other implementing partners in support of the principle of the three ones, wherein the USG and GRA, in consultation with other stakeholders, intend to engage in a joint decision-making process about priorities, approaches and the allocation of resources.
The strategic focus of the USG in this Partnership Framework should be on health system strengthening, strategic information, and prevention with MARPS, youth (and other groups and/or drivers of the epidemic to be identified); on geographic border regions with higher prevalence; and on specific programmatic areas (including PMTCT and TB/HIV co-infection). Programming for male circumcision in Angola should focus on building the evidence base for decision making. The strategic focus should also address stigma and discrimination against HIV positive people, and encourage people to get tested and stay negative. This partnership should promote the inclusion of People Living with HIV/AIDS (PLWHA) at all levels of program planning and implementation.
Angola's National Strategic Plan for HIV/AIDS (2007-2010) is the nation's current plan. As a result of the devastated health infrastructure, there is little to no baseline data from which to formulate specific and measurable goals. The National Strategic Plan in its present form measures primarily outputs and some outcome indicators. The GRA has asked the USG to help build the evidence base for decision making as a primary component of its contribution to the partnership. This Framework should focus on implementing baseline studies, including three behavioral surveillance surveys (BSS) with MARPS, an AIDS Indicator, and qualitative studies on sexual behavior and male circumcision. Operations and qualitative research is also needed in order to increase the efficiency and effectiveness of prevention programming. Operations research is particularly important in the context of limited resources and in conjunction with the extraordinarily high cost of operations in Angola. In addition to scaling up prevention programming, contributing to the evidence base on what works programmatically in Angola is an essential component of the national response to the HIV epidemic over the next five years, and should be a major contribution of the USG under this Framework. These data should be used in the subsequent years of this partnership to develop data driven programmatic response and the corresponding allocation of resources.
While collecting strategic information is a crucial first step in mitigating the HIV epidemic in Angola, it will be necessary to respond programmatically to both existing and new information if the country is to achieve its goal of maintaining a population- wide HIV prevalence below 3% by the year 2013. Scaling up targeted, cost-effective and evidence-based prevention interventions should be a major contribution of the USG under this Framework. Initially the USG also plans to contribute to areas where there is already some existing data to inform programs. This should include service delivery in TB/HIV and PMTCT as well as prevention programming that targets commercial sex workers, transactional sex, military and education programs for youth.
Additionally, during the first year of this partnership, the GRA plans to begin the development of the upcoming National Strategic Plan for HIV (2010-2014). UNAIDS will provide technical assistance to the GRA in the development of this plan, and the USG should engage in this process. At the outset, this Partnership Framework intends to adopt the national targets that Angola set in the first National Strategic Plan and the subsequent modification made for the Round 8 and Round 9 GFATM grants. The Framework management team, at the moment comprised of the INLS, USG and UNAIDS (see also Section V: Technical Oversight and Monitoring) should engage in a consultative process to set specific and measurable goals to measure progress of the Partnership Framework against these targets over the next four years. The Partnership Framework goals should be adjusted to align with the second iteration of the National Strategic Plan. The USG's contributions in the area of strategic information should help the government to set more specific and measurable goals as the evidence base is established.
The strategic vision for health system strengthening is to focus on sustainable approaches to rebuild the devastated health infrastructure in Angola. To achieve the goals of this Framework, an effective investment in health system and services is necessary. The strategy for health system strengthening should build on the World Health Organization's (WHO) Framework for Action elements. Diagnosis of health system constraints and policy analysis and management should target priority areas that include laboratory and supply chain management systems. The long-term solution for sustainable HRH capacity development is to train Angolan health care workers through a partnership that improves coordination and collaboration with the GRA, the private sector and other key stakeholders such as national scientific and accreditation entities. To build human capacity to confront the country's HIV epidemic, pre-service and in-service training should be complemented with proven clinical mentoring programs and continuous HIV quality improvement interventions to facilitate task shifting and to encourage systems change for increased efficiency that ensures the provision of high-quality care and treatment; and with work with health care facilities on systems interventions to improve service delivery; monitoring and evaluation; surveillance; adherence and prevention counseling; and decentralization of health services.
This Framework should be supported and leveraged with other USG-funded activities in Angola, namely the President's Malaria Initiative, Avian Influenza Program, Tuberculosis, Maternal and Child Health, and Reproductive Health programs. The Framework should be complemented by an implementation strategy to be set forth in the Partnership Framework Implementation Plan (PFIP), which is expected to describe the role of all partners, including civil society, in conjunction with INLS. The PFIP should detail Health System Strengthening (HSS); HRH; policy reforms; respective partner commitments; a comprehensive monitoring and evaluation plan; and innovative prevention interventions, including the introduction of male circumcision, if warranted, positive living initiatives with military, and addressing male norms and behaviors. PEPFAR's comparative advantage in Angola lies in the initiative's global experience: providing evidence-based technical assistance, forming partnerships with private sector corporations, and leveraging resources from other USG-funded initiatives.
The Angolan government's National Health Policy is harmonized with the GRA Poverty Reduction Strategy Plan and the Millennium Development Goals (MDGs). With its own budgetary line item in the health sector operational plan, the INLS makes patent the Angolan government's commitment in this fight. The GRA financed 82 percent of total expenditures for HIV, including an estimated 50 percent of expenditures targeted on HIV prevention programs (UNAIDS 2009). The GRA's response to HIV was strengthened by the creation of the INLS, the increase in the availability of funds, and the partnerships with international and national organizations, including the Global Fund Round 4 grant, which has helped to finance HIV treatment, care and support. The creation of the Angolan Network of AIDS Service Organizations (ANASO), the network of people living with HIV (RNP+), and a network of faith-based organizations (Rede Esperanca) enhanced civil society's role in the HIV response. The Angolan Business Alliance against HIV/AIDS (CEC, Comite Empresarial de Combate ao VIH/SIDA in Portuguese) was established in 2006 to coordinate with national and international companies that promote prevention and mitigation of HIV in both workplace programs and the community.
In 2007, HIV expenditures including prevention, treatment and infrastructure were approximately $47.5 million USD, of which 82.1 percent was provided by the GRA. Of this amount, $23.7 million USD was spent on prevention activities and $17.1 million USD on care and treatment (UNAIDS 2009). Angola currently benefits from three Global Fund grants, totaling almost $200 million USD. One grant is for HIV, one is for malaria, and one is for tuberculosis. The HIV and TB grants will end in 2010; therefore, Round 9 applications were submitted for HIV and TB.
Sustainability rests on the GRA's commitment to achieve a high percentage of budget execution of national health accounts. GRA's overall health expenditures increased from 4.1 percent of the national budget in 2006 to 6.7 percent in 2008, in line with the government goal of 15 percent by 2015. Public investment plans for health infrastructure increased from 2.1 percent in 2006 to 7.6 percent in 2008 (R9 GFATM Proposal). Under the conceptual framework set out by the United Nations Development Program (UNDP) on capacity building, the United Nations will support the Government in designing a comprehensive capacity development package ensuring the creation of a broad coalition around the MDGs through mobilization, partnerships, alliances and networking with the private sector and civil society.
The MOH-designated priority provinces include Angola's border provinces, where ANC data show highest prevalence; Luanda, Angola's capital, which contains roughly one-third of the population; and Huambo, which has another of Angola's major cities. USG support is aligned with those provinces designated as priority areas by the MOH, i.e., Luanda, Huambo, Cunene, Cuando Cubango, Lunda Norte, Lunda Sul, Moxico, Zaire, Bengo, Huila, and Cabinda. A strategic prevention portfolio should focus its efforts on key risk groups and contexts. The collection of strategic information should continually refine target geographic areas.
Key intervention areas
Goal I: Strengthen capacity for an effective national response to combat HIV/AIDS.
During Angola's wars, a tremendous amount of health infrastructure was destroyed; seven years on, there is still limited access to health services. People migrated en masse to urban centers, thereby taxing those cities' precarious health systems. The task of re-building and strengthening Angola's health system is enormous. An updated HIV National Strategic Plan is essential to guide HIV/AIDS action for the next five years and should also strengthen the basis of this Partnership Framework. The USG intends to support this upcoming effort and also the ongoing decentralization process to provinces and municipalities through Technical Assistance (TA) support. In collaboration with the GRA, the USG intends to support an assessment of the National Health System. Existing and future GFATM grants need TA support in management and proposal writing. This partnership should strengthen Angola's health system in key ways that build on the World Health Organization's (WHO) Framework for Action elements: 1-health workforce, 2-health information, 3-service delivery, 4-medical products, vaccine and technologies, 5- health financing, and 6-leadership and governance:
Health Workforce: The long-term solution for sustainability is to train Angolan health care workers. As a first step, this partnership with USG technical assistance should conduct a human resources for health (HRH) assessment, and support the creation of a national electronic health workforce information system (HRIS) to promote the strategic planning and human resources development planning that are necessary for Angola to meet its human resources for health needs. Based on that plan, the Partnership Framework should promote policy reforms that focus on task shifting from doctors to nurses and from other specialized health workers to community health workers (lay-counseling); and address concerns relating to recruitment, retention, and administration of human resources. In collaboration with UNICEF, the USG should continue to support curriculum development and clinical mentoring in HIV prevention and care services that target community-based midwives in high HIV prevalence regions to support the MOH 2009 National Executive Plan goals to reduce Angola's maternal and infant mortality, one of the highest in the world, estimated at 1,400 per 100,000 and 114 per 1,000 live-birth, respectively (UNICEF 2009). In-service training related to PMTCT, VCT and treatment should be expanded and linked to updated job responsibilities and capacity to have an impact on the quality of the services offered. USG responded to the MOH's request to strengthen the public health epidemiology workforce by supporting a Field Epidemiology and Laboratory Training Program (FELTP) assessment. Based on the results of the assessment, the Framework, in partnership with the GRA and private sector should strengthen laboratory and public health workforce capacity to address the infectious disease control priorities through evidence-based and best-practice approaches.
Health Information: The government of Angola recognizes that monitoring and evaluation are essential program aspects to determine whether interventions are having their planned effect and at what cost. The GRA launched its national Health Management Information System (HMIS) in 2008, which will be harmonized with existing information systems for HIV/AIDS and TB. The USG provides technical assistance to the National AIDS Institute to improve its monitoring and evaluation system. Angola has taken important steps to improve its data collection and health information system, but the system needs additional improvement to ensure high quality of the production, analysis, dissemination and use of reliable and timely information on health determinants and health system performance. The partnership should help the GRA meet this challenge in collaboration with other key stakeholders and in conjunction with other USG programs in malaria, reproductive health, tuberculosis and maternal and child health. In collaboration with UNAIDS and other multilateral agencies, the USG intends to provide technical assistance targeted at HIV facility-based and community-based services, including PMTCT, TB/HIV, STI and prevention services, to strengthen data collection and monitoring systems in the provinces designated as priorities by the MOH.
Service delivery: Functional referral systems are essential for the quality of health service delivery. The USG plans to work with the GRA to improve referrals in quality and quantity to ensure that clients are linked to a comprehensive constellation of services. The GRA has identified laboratories at the national and regional levels as priority areas that warrant continued strengthening. The partnership should support a strong national laboratory and establish referral networks for decentralized facilities that require routine and specialized HIV and tuberculosis laboratory services in the provinces designated as priorities by the GRA. In collaboration with the World Health Organization (WHO), the USG intends to support improvements and monitoring of the quality of HIV and TB diagnosis and supervision in order to strengthen lab capacity as well as PMTCT, VCT, care and treatment at the national and municipal levels in targeted provinces.
Supply Chain System: A strong HIV/AIDS program requires a reliable supply of commodities, among them HIV test kits, anti-retroviral drugs and condoms (GRA, USG and UNFPA). Joining efforts with PMI, PEPFAR intends to provide technical support to conduct an assessment of the national HIV supply chain management system to bridge gaps, to achieve economies of scale in ARV procurement, and to strengthen capacity to forecast needs of drugs and laboratory commodities for HIV and TB services. Commodity security should be bolstered along the entire supply chain through GRA extra-health sector policy actions, including but not limited to the port of entry, customs, warehousing, distribution to the field, storage, use and monitoring.
Health Financing: This Partnership Framework plans to provide support for provincial level operational planning, financial monitoring and gap analysis, including follow-up support to the National Health Accounts already supported with PEPFAR funds during 2009. The USG should provide long-term comprehensive technical assistance to Global Fund grants in related areas, including developing and analyzing grant proposals and work plans, improving financial management, accountability and planning systems, and identifying ways to strengthen the Country Coordinating Mechanism's (CCM) technical oversight. The partnership should respond to related needs for technical assistance that build Angola's capacity and lead to a sustained response.
Leadership and Governance
USG technical assistance should strengthen management and leadership capacity across program areas through training efforts and policy reform related to HRH (task-shifting, provider- initiated testing and counseling, privacy and confidentiality, stigma and discrimination, and professional ethics), and to gender inequities. The USG should also support programmatic mapping among partners, completing the inventory of all stakeholder's activities in HIV/AIDS.
Civil Society Strengthening
Under this Framework, the USG should help build the capacity of civil society organizations that seek to lead the community-based response to HIV in Angola, including NGO capacity building for improved management and M&E systems. The Global Fund is currently providing support, through the GRA, to sex worker and other organizations that target MARP in the form of grants. The USG intends to add to this effort by continuing to provide technical assistance to community -based organizations in the form of technical and organizational capacity building. In addition, USG support should strengthen civil society capacity in the development and roll-out of a national toolkit to guide prevention interventions that target specific risk groups. The USG should also support faith-based organizations that have a strong desire to address the HIV epidemic, but require technical assistance related to effective behavior change communication and building management capacity. Under this Framework, the USG should continue to support community-based programs that link HIV-positive pregnant women with PMTCT services as well as civil society organizations that work with youth in the area of sexual prevention. The USG should also continue to support organizations of people living with HIV/AIDS that advocate increased access to care and treatment and the right to live free of stigma and discrimination. USG should promote through its civil society implementing partners the concept of positive living across all program areas.
Public Private Partnerships (PPP)
The CEC was created with strong USG involvement in 2006 to represent and coordinate HIV/AIDS activities in the private sector. Angola's CEC, with a membership of approximately 150 private businesses and corporations, should be reinvigorated under this Framework to carry out its charge to coordinate with national and international companies that promote prevention and mitigation of HIV in both workplace programs and the community. Especially in this time of economic crisis, poverty exacerbates the impact of HIV. Employment and income-generating activities can mitigate this contributing force to the spread of HIV in Angola. Under this Framework USG support of HRH, SI and prevention interventions should be leveraged with existing and new PPP.
Goal II: Reduce the growth of the HIV epidemic through combination prevention that is cost-effective and targeted.
This partnership recognizes that a combination of prevention methods is required to address most effectively the biological, behavioral and structural factors that influence the course of the epidemic in Angola. The choice of combinations depends on the target group or the region. For example, a basic package for CSW would include VCT and STI services, BCC, condoms distribution, and family planning, complemented by policy reform targeting discrimination and gender- based violence. Reducing the vulnerability of women and addressing gender inequality are also components of the national strategic plan for prevention, as is focusing efforts in priority provinces, especially in border areas. The USG should coordinate with UNAIDS and the GRA to conduct a gender assessment and develop a joint plan for implementation. The USG and the GFATM are currently working with MARPs, but funding should be expanded to have greater coverage of these populations. Refinement and implementation of additional interventions can be informed as the information from BSS and other studies becomes available.
Target: High risk groups (including CSW and mobile populations, including transporters, military, miners and police)
Target: General Population
Goal III: Mitigate the socio-economic impact of HIV/AIDS on the individual, family and community.
Treatment and care are supported by the Angolan government in collaboration with civil society, a shared responsibility that should continue under the Framework. The government of Angola supports the majority of HIV care and treatment programming. The target population for care is people living with HIV/AIDS and their extended families, including orphans and vulnerable children. Treatment and care objectives are to increase the access of people living with HIV/AIDS to treatment services; in collaboration with the GRA, USG support should increase the quantity and quality of VCT centers. USG support should also improve the quality of diagnosis and treatment of people co-infected with tuberculosis; in coordination with civil society and the private sector, improve and strengthen the health referral system for people infected with and affected by HIV/AIDS; and promote Provider- Initiated Testing and Counseling.
The 2009-2013 Angola National Tuberculosis Strategy seeks to promote and expand strategies for increasing diagnosis and management of TB/HIV co-infection by testing 100 percent of patients diagnosed with tuberculosis. The USG intends to provide technical assistance to support TB/HIV health system strengthening, surveillance and integration. Through a thorough assessment of the national tuberculosis program, the Framework should identify high-impact areas where synergies involving the national HIV/AIDS program, the national tuberculosis program, and the National Institute of Public Health can increase TB/HIV collaborative activities. Both TB and HIV programs should be entry points for the prompt identification and case management of co-infected patients. Under this Framework, USG support, in collaboration with WHO, should feature monitoring the HIV epidemic in TB-positive individuals, strengthening DOTS, and increasing the country's capacity by training providers in the proper management of patients infected with TB/HIV and multi-drug resistant TB (MDRTB). In coordination with WHO and Global Fund grants, the USG intends to provide technical assistance to assess the electronic data capture system that should serve as a patient management, M&E, and surveillance tool. Community-based resources should be engaged to develop functional referral systems that link HIV and tuberculosis services, thereby enabling health systems to cope with the double burden of HIV and TB and shortages of skilled health personnel.
Throughout Angola, initiatives to support orphans and vulnerable children are implemented by government and civil society organizations (Community-Based Organizations, Non-Governmental Organizations, and Faith-Based Organizations) with support from external partners. A successful priority intervention by the GRA is keeping children in communities rather than in orphanages. These programs provide psycho-social and physical help to vulnerable families.
Mobile VCT and linkages to care and treatment should be targeted at hard-to-reach military personnel and surrounding communities. The Angolan Armed Forces (FAA) are concerned that many of their HIV-positive personnel come for medical assistance too late to receive the care needed to prolong and improve life. Most of them cannot easily be tracked for follow-up purposes (e.g. strengthen drug adherence). Under this Framework, the USG should provide technical assistance for setting up a "positive living" program in the military in addition to training psychologists, lay counselors, and physicians on ARV techniques and development of policies to combat stigma and discrimination.
Preventing mother-to-child transmission (PMTCT) is a key goal of the Angolan government's HIV/AIDS plan, both to reduce contagion and attenuate the socio-economic impact on individuals, families, and communities infected and affected by the disease. Under this Framework, in partnership with the GRA and UNICEF, USG support should scale up the prevention of maternal-to-child transmission including Early Infant Diagnosis (EID) as a way to evaluate the impact of the PMTCT scale up. PMTCT support should be done in an integrated way with family planning and maternal and child health services focused in high prevalence border regions.
III. PARTNERS' ROLES AND COMMITMENTS
The central partners for this Framework are the GRA and the USG. Although signature of this Framework rests solely with the GRA and USG, the spirit of the Framework is inclusive and consultative. Achievement of the Framework's objectives is dependent on the roles and contributions of numerous key stakeholders including GFATM, civil society, UN agencies, other multilateral organizations, bilateral partners, NGO's and corporate partners.
Angolan government: the Minister of Health, representing the CNLCSGE; the Ministry of Health, especially the National AIDS Institute (INLS), the National Directorate for Public Health, and the network of Provincial Health Directorates; the Ministry of Defense/Angolan Armed Forces; Ministry of Education; Ministry of Family and Women's Promotion; Ministry of Finance; Ministry of Social Welfare and Reinsertion; Ministry of Youth and Sports; Ministry of Planning; Ministry of Public Administration, Employment and Social Security; Secretary of State for Higher Education; National Children's Institute (INAC); the Secretary of State for Rural Development; and the Ministry of Interior.
USG: Under the leadership of the U.S. Ambassador, the diplomatic mission of the USG in Angola Inter-Agency PEPFAR team, comprised of the U.S. Agency for International Development (USAID); the U.S. Department of Health and Human Services' Centers for Disease Control and Prevention (CDC); the U.S. Department of Defense (DOD); the U.S. Department of State (DOS); and, potentially as of 2012, the U.S. Peace Corps.
|Five -Year Goal 1 -|
|To strengthen the capacity of the national response to fight the HIV and AIDS epidemic|
|By 2013 Angola intends to (dependent on a successful Round 9 GFATM):|
|§ Decentralize the management of the national response to the 18 provinces|
|§ Expand and promote the response to fight HIV/AIDS by 27 ministries|
|§ Increase active participation in the network organization of commercial sector assistance (CEC) by up to 100 companies that have workplace programs in place (USG intends to provide technical assistance to 5 companies per year)|
|§ Support surveillance system in 61 municipalities (baseline: 36)|
|§ Support information systems in 18 provinces and 72 health units|
|Objectives||GOA intends to:||PEPFAR intends to:||Other Partner Roles:|
|Health System Strengthening|
|Improve human and institutional capacity of the MOH and NGOs to respond to the HIV epidemic||Provide leadership and guidance for strengthening supportive supervision and priority areas for quality improvement||Support pre-service and in-service training efforts through quality improvement interventions, task-shifting, policy reform and clinical mentoring efforts; TA support for improvement of management skills, leadership and quality of supervision|
|Develop a 5-year laboratory strategy in 2009 with support from WHO and PEPFAR to include plans for scale-up of CD4 testing and infant diagnosis||Support the development of integrated laboratory systems services, through quality-improvement strategies and relevant policy assessment and reform; improve access to TB diagnostics for HIV-positive patients; provide technical assistance to strengthen laboratory systems in the military.||WHO: Support implementation of laboratory international regulation standards.|
|PPP: Strengthen laboratory systems|
|Support efforts to build human capacity in the public health sector to address infectious disease priorities; establish and develop a field epidemiology workforce||PPP: Establish and develop a field epidemiology workforce|
|Reinforce the technical capacity of pharmacies and the management of ARV’s and test kits||Strengthen systems for supply chain management; support related policy reforms and GRA effort to achieve economies of scale in ARV procurement.||UNFPA: Support condom logistics|
|Reinforce the management of human resources||Strengthen the administration of the health workforce; elaborate a HR strategic plan and support the establishment of a Human Resource Information System – HRIS|
|Improvement of information system and surveillance|
|Conduct surveillance studies on targeted populations, and strengthen M&E and information systems to increase utilization of data on HIV/AIDS for planning, program improvement and surveillance and cost-effectiveness||Coordinate M&E and research activities||Support several studies (AIS, ANC surveillance, BSS MARP’s, sexual behavior and multiple concurrent partnerships (PLACE)).||UNICEF: Provide M&E TA to school-based prevention interventions, PMTCT, OVC|
|Provide TA by M&E specialist to support indicator harmonization, data synthesis and operational research.||UNAIDS: Help improve the national M&E system and increase the capacity of the government to evaluate the response to the epidemic based on all components of the national plan|
|Provide technical assistance to support implementation of a Demographic Health Survey (DHS) and/or training for a census|
|Increase access to support from the Global Fund||Guarantee the role of the MoH as the Principal Recipient by the functioning of the Management Unit||Provide TA for proposal writing and during execution of GFATM grants|
|Harmonize and coordinate the national response under one political and technical framework||Update the HIV/AIDS National Strategic Plan (NSP) for 2010-2014||Provide TA for the revision and extension of the National Strategic Plan (2010 – 2014); Framework management team to harmonize PF indicators with national strategic plan||UNAIDS: support development of new HIV/AIDS Strategic Plan, coordinate the UNAIDS joint team on HIV/AIDS|
|UNICEF: Support DPSs in strategic planning, TA for national strategic plan development|
|Elaborate provincial strategic and operational plans based on the National Strategic Plan||Guarantee the budget of the Operational Plans, and supervise their execution||Support the government in its decentralization process by TA in finance and planning exercises; provide assistance in the coordination of the process|
|Support financial planning and monitoring, national health accounts and gap analysis|
|Strengthen civil society governance, leadership and partnership mechanisms; (1) to monitor HIV/ AIDS policies; (2) to implement care and support activities;(3) to reduce vulnerability and gender inequality||Promote and organize prevention campaigns and educational interventions to increase HIV prevention knowledge, skills and safe practice among Angolan general population; develop a national comprehensive sexual education policy for all school curriculum and for teacher training colleges||Pursue health education and consciousness-raising with a gender focus, including gender-based violence, in schools and youth centers to promote delayed sexual debut and a reduction of multiple sexual partners, and in other community structures, the military, and the police and the workplace.|
|Scale up access to health promotion and STI/HIV prevention among most at risk populations, focusing on commercial sex workers, truck drivers and MSM, within 11 priority provinces||Support capacity building of local NGO’s to manage action in the fight against HV/AIDS, enable fundraising capacity, improve M&E and financial management|
|Improve civil society and PLWHA partnership mechanisms||Support national and community-based efforts to increase access to quality HIV/AIDS care and treatment for PLWHA as well as vulnerable and most at risk populations||UNAIDS, IOM and Civil Society Organizations: l Collaborate to support the development and establishment of protection policies for PLWHA and vulnerable populations|
|Reduce stigma and discrimination as well as women and girls’ vulnerability and gender inequalities, based on a multi-sectoral approach||Promote stigma reduction interventions for hidden populations (e.g., MSM)||UNAIDS: Monitor policies to reduce HIV/AIDS-related stigma and discrimination and gender inequalities.|
|Involvement of public and private companies|
|Expansion of the number of public and private companies that promote blood safety, PMTCT, STI treatment , and VCT in the workplace and in the community||Guarantee the functioning of the CEC and support the implementation of their activities||Provide technical assistance to the CEC and its partners in BCC and IEC||PPP: Provide leadership to the CEC|
|Five-Year Goal 2 -|
|To reduce the spread of the HIV epidemic|
|By 2013 Angola intends to (dependent on a successful Round 9 GFATM):|
|§ Organize 10 annual HIV prevention campaigns, 50 intervention projects for sex workers and educational interventions during national and provincial events (USG intends to contribute to 2 events per year)|
|§ Increase the number of condoms acquired by 2.5 times per year to satisfy the demands from the health services, civil society, ministries, and public and private companies (baseline: 30,000,000 /year; (USG intends to contribute 15 million condoms per year)|
|§ Reduce the vulnerability of youth by reaching 343,200 youth in public school, as well as out-of-school youth, and teachers. (USG expects to contribute to reach 100,000 youth per year)|
|Objective||GOA Intends to:||PEPFAR Intends to:||Other Partner Roles|
|Most at Risk Populations MARPs|
|Scale up access to health promotion and STI/HIV prevention among most at risk populations, focusing on professional sex workers, truck drivers and MSM, within 11 priority provinces||Provide interventions for MARPS -sex workers, women engaged in transactional sex, mobile workers (truck drivers, military personnel, miners) and MSM in defined hot spots, including a comprehensive package of: condom (male and female) promotion, procurement and distribution; outreach for mapping and prevention messaging; promotion and provision of HIV counseling and testing services with referral and provision of treatment and care for those persons testing positive; and diagnosis and treatment of sexually transmitted infections. Establish STI sentinel surveillance in key geographical areas for MARPs|
|Expand distribution and marketing of condoms||Manage public sector condom distribution||Purchase condoms for gratis distribution and commercialization and expand distribution||UNFPA: Integrate the strategies on HIV prevention and Reproductive Health.|
|Educate general and most at risk populations about the epidemic with aim to promote behavior change, targeted at high risk areas of the country and with special emphasis on gender considerations||Coordinate implementation of a national social and behavioral change communication strategy for HIV prevention||Support health education and behavior change for the general population and with a gender focus for vulnerable and most at-risk populations; target youth and the general population with prevention and behavior change interventions||GFATM grant: support prevention efforts targeted at youth, PLWHA, Most at risk populations, community and faith-based organizations;|
|UNICEF: Enhance HIV prevention messages through schools and community interventions in 16 target municipalities|
|UNFPA: Promote behavior change among youth|
|UNESCO: Advocate for the adoption and implementation of a prevention strategy|
|Explore the role of male circumcision in Angola’s epidemic and develop and implement policies accordingly||Develop a policy decision based on the situational analysis for male circumcision||Assist with the implementation of a situational analysis (qualitative and quantitative) of male circumcision.|
|Stigma and discrimination|
|Reduce HIV and AIDS related stigma and discrimination and gender inequalities||Develop policies to reduce women and girls vulnerability, stigma and discrimination||Reduce women and girls´ vulnerability and gender inequalities; reduce stigma and discrimination based on multi-sectoral approach|
|Five -Year Goal 3 –|
|Mitigate the socioeconomic impact of HIV/ AIDS on individuals, the family and the community|
|By 2013 Angola intends to (dependent on a successful Round 9 GFATM):|
|§ Offer VCT at new service points, Including 200 health units, 18 Military Zones and 17 NGOs (baseline: 237) (USG intends to contribute to 10 new VCT centers per year)|
|§ Will have realized a total of 5.2 million HIV tests (baseline: 500,000 tests per year); (USG intends to contribute to 50,000 tests per year)|
|§ Offer ARV’s to 100% of HIV+ pregnant women attending prenatal services (baseline: 67%)|
|§ Conduct 100% testing of registered TB patients for HIV (baseline: 10%)|
|§ Conduct 100% screening of HIV+ in care or treatment setting for TB (baseline: unavailable)|
|§ Provide services for STI management in 18 provinces|
|§ Ensure universal access to the 1st and 2nd line ARV drugs for 62,133 PLWHA|
|Objective||GOA Intends to:||PEPFAR intends to:||Other Partner Roles|
|Voluntary Counseling and Testing|
|Expand Voluntary Counseling and Testing access to contribute towards the country’s national VCT goals of 85% coverage||Provide leadership for VCT/ PMTCT expansion in all prenatal units and delivery rooms; guide the process of mapping and strengthening referrals||Support an integrated response to scale up PMTCT and VCT, and strengthen linkages with both Maternal-Child Health and Family Planning at HIV/AIDS prevention and service delivery points|
|Purchase 6.2 million rapid tests to diagnose HIV||Support establishments of VCT in key geographic regions||GFATM Provide: Round 4 – supply of test kits|
|Prevention Mother to Child Transmission|
|Scale up prevention of mother –to- child transmission, including early infant diagnosis||Develop policies for task-shifting and lay-counseling; expand PMTCT to 100% coverage of pregnant women||Expand PMTCT services in high prevalence provinces; improve M&E of PMTCT; promote task-shifting; support civil society initiatives to identify pregnant women in the community, promote their ANC and CT, increase adherence for HIV+ pregnant women to prophylaxis||UNICEF: Support provincial health directorates in the implementation of scale-up of PMTCT+ and Pediatric AIDS services in revitalization provinces, mobilize community organizations, advocacy, TA, coordination of INLS and other stakeholders|
|As an adjunct to PMTCT, scale up EID, which is at the same time an excellent tool to monitor the impact of PMTCT|
|Treatment, Care and Support|
|Ensure universal access to treatment of PLWHA and guarantee care||Ensure access to ARV’s and drugs for OI (Opportunistic Infections) to 100% of the people with identified HIV and who require treatment||Support quality of care and treatment; support CSO’s that increase adherence to treatment||GFATM Provide: Round 4 – supply of ARV drugs|
|TB co-infection and HIV/AIDS|
|Promote and expand strategies for increasing diagnosis and management of TB/HIV co-infections by testing 100%; also increase diagnosis and management of HIV with STI’s.||Develop and implement a strategy to improve linkages and coordination to increase diagnosis and management of TB/HIV co-infection||Support national and community-based programs to monitor and improve HIV testing and prevention of TB/HIV co- infection.|
|Support clinical mentoring activities to strengthen diagnosis, care and treatment of TB/HIV.|
|Establish policies for HIV testing in TB patients and vice-versa||Support a thorough assessment to identify high-impact areas where synergies can be capitalized among key MOH institutions to effectively link HIV and TB services to improve testing and prevention for patients in those programs.||WHO and GFATM: support surveillance and management of TB/HIV co-infection|
|Assess the existing electronic data capture system that serves as patient management, M&E, and surveillance tool.|
|Integrate STI services on municipal level||Improve and expand the prevention and control of STI’s including congenital syphilis||Include STI’s in the basic health package in municipalities|
|Support to vulnerable families|
|Develop and establish protection policies for 9,145 families and most vulnerable children through income generation projects||Establish cooperatives for income generation for vulnerable families in 11 provinces||GFATM grant provide support for the MOH to implement OVC services through civil society organizations.|
|UNICEF: Assist policy development to enhance OVC access to basic services: food, education, health; protection from abuse/ exploitation; strengthen the capacity of civil society to identify OVC; provide care and support|
|PPP: Support income generation projects|
IV. FINANCIAL COMMITMENTS:
The USG and GRA recognize that resources are limited and that financial commitments are subject to the availability of funds. Both further recognize that achievement of Framework goals requires resource flows beyond the ability of any one partner, and that constraints on availability of funding from either signatory or from other key partners could lead to a review and revision of goals. After the formulation of the new strategic plan and after the disclosure of the decision of the board of the GFATM in relation to the submitted proposal for Round 9, reassessment and re-prioritization of the activities of all stakeholders should be realized. Details regarding the GRA and USG financial and in-kind contributions to programs under this Framework are to be provided in the Partnership Framework Implementation Plan.
V. MANAGEMENT, MONITORING AND COMMUNICATIONS
The Framework presents an opportunity and an instrument to strengthen collaboration, coordination and accountability by ensuring a focus on key mutually defined strategies and measures of success. The governance system to manage the Framework builds on existing structures to provide oversight for the national HIV response.
Technical Oversight and Monitoring: In 2005, the National AIDS Institute (Instituto Nacional de Luta contra SIDA or INLS) was established within the Ministry of Health and designated the lead technical implementing body and coordinator of all national HIV/AIDS programs. Within the GRA, INLS is expected to have primary responsibility for monitoring Framework implementation based on mutually defined strategies and measures of success. UNAIDS in collaboration with the MOH intends to establish a multi-sectoral technical forum subdivided in Technical Working Groups (for example M&E, prevention and Health System Strengthening) that will meet regularly to monitor the full spectrum of HIV/AIDS activities in country. Technical oversight and monitoring of the PF should take place within this forum that will meet at least quarterly with USG participation. The Framework management team which currently comprises the INLS, USG and UNAIDS, should have primary responsibility to propose modifications for the Partnership Framework document especially for the modification of the Framework goals and objectives in the second and subsequent years.
Strategic Oversight: In November 2006, the National AIDS Institute, in partnership with UNAIDS, coordinated a National Strategic Plan Review Workshop. With the support of the Angolan Ministry of Health, the Global Fund, the World Bank, the USG, a host of private contractors, and a broad coalition of public, private and civil society organizations, the workshop assessed progress to date of the National Strategic Plan toward Millennium Development Goal targets. The INLS subsequently established a semi-annual coordinating workshop that provides a forum for all implementing partners of the Angolan national HIV/AIDS program to communicate, report on progress, and realign strategies. The development of the next HIV National Strategic Plan (2010-2014), supported by this Partnership Framework, should allow for course corrections and modifications to this Partnership Framework.
GRA and USG representatives intend to meet semi-annually with leaders from civil society, UN agencies, and private sector and other bilateral agencies, as appropriate, to discuss progress towards goals and objectives.
Global Fund Harmonization: UNDP is the Principal Recipient of the GFATM funds but the Ministry of Health has the lead in donor coordination and implementation. The USG, which provides 30 percent of GFATM resources, is an active member of the GFATM Country Coordination Mechanism (CCM). At the quarterly CCM meetings, members should review the integration of the Framework activities with Global Fund grants and national priorities.
High Level Oversight: The national HIV/AIDS coordinating authority is the Angolan National Commission to Fight HIV/AIDS and Large Epidemics (CNLCSGE), created in late 2002. The commission is under the direct mandate of the President of Angola and is the highest policy-making body on HIV/AIDS. Oversight should be provided through meetings between the MOH, representing the CNLCSGE, and the U.S. Ambassador to Angola.
Modifications to this Framework may be made in writing with the consent of both signatories.
1 TB Round 9 Proposal for GFATM
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