Monrovia - The new Global Fund investment is advancing progress to end AIDS, Tuberculosis and Malaria in Liberia. Liberia is a low-income country, recently devastated by the Ebola Virus Disease (EVD) outbreak that killed more than 4,800 people, according to World Health Organization.
The EVD outbreak exposed major weaknesses in the health system; thus, impeding the expansion of services to meet the needs of the population in terms of effective response to the three diseases.
Since the end of the Ebola crisis, with support of the Global Fund, Liberia has made steady progress toward ending AIDS, TB and Malaria. The Global Fund to Fight AIDS, Tuberculosis and Malaria (TGF) is an international financing organization that attracts and disburses additional resources to prevent and treat HIV and AIDS, tuberculosis and malaria.
The GF works through Country Coordinating Mechanisms (CCMs) which are national bodies in each country that submit funding applications to the Global Fund on behalf of the entire country. Members of the CCM include representatives from government, the private sector, technical partners, civil society, faith-based organizations, people living with the diseases, and developmental partners.
In Liberia, the CCM called, the Liberia Coordinating Mechanism (LCM) is responsible to coordinate the development and submission of proposals to the Global Fund on behalf of the country, as well as select organizations known as Principal Recipients (PRs) to manage the funds and oversee implementation of approved grants.
The Ministry of Health (MOH) is the sole PR for the Tuberculosis grant. However, the MOH shares Co-PR relationship with Population Services International (PSI) for the Community portion of the HIV grant, PLAN International – Liberia for the community portion of the Malaria grant.
The LCM has remained optimistic of ending AIDS, TB and Malaria working with these institutions.
Liberia’s AIDS Situation
Liberia has a generalized HIV epidemic with an HIV prevalence of 2.1% and an estimated adult HIV population of over 30,000 (2013 Liberia Demographic and Health Survey - LDHS). The prevalence is higher among females (2.4%, especially those above 20 years) compared to males (1.8%, especially those above 30 years).
Significant variations in HIV prevalence also exist between and within regions and counties. Urban dwellers are more impacted (2.6%) than among rural (0.8%); while residents within the South Central Region have the highest prevalence of 2.7%, among the five regions of Liberia. Montserrado, Margibi, and Grand Bassa counties which are in that region have huge burden of 70% of the disease, among the 15 counties.
Moreover, key populations are disproportionately impacted by the epidemic because of their high-risk behaviors (sex workers-9.8%, men who have sex with men-19.8% and people who inject drugs-5% etc), according to the 2013 Integrated Bio-Behavioral Surveillance Survey.
Liberia has about 857 health facilities providing treatment, care and support services to persons infected and affected by AIDS, TB and Malaria in the country. 90% of the 857 health facilities are providing Antenatal care (ANC) services, according to the Ministry of Health statistic.
By the end of 2016, Option B+, a recommendation by the WHO to health providers in HIV-affected countries to initiate all HIV-positive pregnant and breastfeeding women on antiretroviral therapy (ART) for life, has been rolled out in 335 (53%) Ante-natal care (ANC) facilities.
About 23% of these facilities in which Option B+ has been rolled out are in the three prioritized counties, Montserrado, Margibi and Grand Bassa Counties.
Between 2012 and 2014, a total of 900 traditional midwives were trained to provide integrated Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH), Prevention of Mother-to-Child Transmission of HIV (PMTCT) and pediatric HIV care, treatment and support services.
The training has enabled them to provide adherence, counseling, and lost-to-follow-up services, while providing community-based maternal and child health services. The trained traditional midwives are linked to health facilities in their catchment areas for referral and supportive supervision by skilled health workers.
Also, Liberia has taken major steps to address key population related issues in the country. President Ellen Johnson Sirleaf, as chair of the National AIDS Commission (NAC) board has approved a National HIV Strategic Plan (NSP 2015-2020) to stop new infections and keep People Living with HIV (PLHIV) alive and healthy.
The NSP seeks to reduce new HIV infection by 50% by 2020, and to reduce morbidity and mortality among PLHIV. An operational plan to guide the implementation of the NSP is also finalized; an HIV and Sensitive Social Protection quick scan assessment tool of existing social protection programs and their interface with the AIDS response in Liberia was developed.
Moreover, Liberia has validated an Emergency Catch-Up Plan as part of the government expressed commitment to fast track approaches to achieve the 90-90-90 global targets by 2020, and eliminate mother-to-child transmission of HIV while keeping the mothers alive.
Unlike before the conduct of the 2013 Size Estimation, there are five (5) Drop-In-Centers (DICs) currently being operationalized as friendly and safe space for key populations.
The DICs provide regular Integrated Health Facility (IHF) services, including HIV Counseling and Testing (HCT) Services; STI diagnosis and treatment; referrals, psychosocial and legal support, and ART initiation.
Two doctors, a nurse, one social worker and two community mobilization officers run the affairs of the DICs in the country. Another size estimate is underway to foster progress to end AIDS in Liberia.
Presently, the government of Liberia through the National AIDS Commission (NAC) is advancing the “Know Your Status (KYS)” campaign, seeking to reach more than 286,000 persons at the end of December 2017.
The ‘Know Your Status’ HIV Counseling and Testing Campaign is reaching out to members of the general population, particularly pregnant women and youth. By 2020, the government of Liberia has set additional targets to reach and test for HIV, the total of 12,193 MSM and 16,600 SW, respectively.
Apart from counseling and testing, the campaign includes door-to-door community awareness by peer educators, intended to link communities to health facilities providing care and support services for PLHIV.
Since the start of the campaign in March to the end of June 2017, the achievements are as follows: 81,000 persons have been reached in Montserrado, 16,204 in Margibi, and 21,816 in Grand Bassa, making it a total 119,000 reached thus far during the campaign.
In terms of percentage, the actual achievements against target are as follows: Montserrado - 51 % female and 49 % male; Margibi - 54 % female and 46 % male and Grand Bassa - 48 % female and 52 % male, according to the NAC.
Liberia’s TB Situation
Though Liberia’s TB burden is not known, as there has not been a TB prevalence survey, in 2014, WHO estimated a prevalence of 494 per 100,000 population.
In 2015, the TB incidence in Liberia was estimated at 308/100,000 population equivalent to 14,000 people by WHO country profiles. The case notification of 5,849 reflects the case detection rate of 41.8% leaving out many cases.
The estimates are based on TB case notifications which are unlikely to be correct as there is evidence of under-reporting of primary defaulters and deaths, especially during the EVD crisis.
The TB case notification improved by 24% in 2015; thus, placing the overall notification at 7,119 (56%) at the end of 2016. Liberia TB treatment success rate has increased from 68% in 2015 to 76% in 2016. Similarly, the treatment success for retreatment cases was 53% in 2015 and 60% in 2016.
The Program equally identified and enrolled nine Multi Drug Resistance Tuberculosis (MDR-TB) patients in 2015. Now with the introduction of GeneXpert in the last quarter of 2015, 92 cases were diagnosed and enrolled in 2016.
Currently, the National Leprosy and TB Control Program (NLTCP) has developed detailed TB Infection Control Guidelines and costed plan for its implementation.
The plan has been rolled out in five facilities that have consistently reported a high number of TB cases in Montserrado County. There is an improved notification of DR-TB cases, effective early infant diagnosis (EID), and opportunity for integration of TB and HIV services.
With the new global fund support, the NLTCP is optimistic of turnaround in the TB epidemic in Liberia. To achieve this, the program made projections for the identification of 313 (100%) of estimated MDR-TB patients in 2018; 347 (100%) in 2019 and 377 (100%) in 2020 from 92 in 2016.
Increased treatment coverage was projected from 47 in 2016 to 162 (75%) of estimated MDR-TB patients in 2018, to 210 (75%) in 2019, and 225 (100%) in 2020.
Liberia’s Malaria Situation
Malaria remains the leading cause of morbidity and mortality in Liberia, with 38% of outpatient attendance and 42% of inpatient deaths attributable to malaria.
However, malaria prevalence in children aged less than 5 years was significantly reduced from 66% to 32% in 2005, according to the National Malaria Control Program (NMCP).
Since August 2005, Liberia has made considerable progress in malaria control and prevention, despite the EVD crisis in Liberia.
Massive disruptions in health service delivery and distrust in the health system by the population were well documented during the EVD in Liberia. However, with funds from the Global Fund and other partners, the NMCP and its partners have increased interventions in case management, prevention of malaria during pregnancy, integrated vector management, and advocacy and behavior change.
Data currently suggest that there has been a significant recovery in health system utilization. For instance, 1,256,068 cases of malaria were reported via the Health Management Information System (HMIS) in 2015, compared to 1,057,635 in 2014 and 1,483,408 in 2013.
The government of Liberia has projected that with the new Global Fund investment, the nation will experience about 50% reduction in Malaria illness and deaths caused by 2020.
The targets are to strengthen and sustain institutional and human resource capacity of NMCP for effective program management; to increase access to prompt diagnosis and effective treatment targeting 85% of the population; to ensure that 80% of the population is protected by malaria preventive measures; to increase the proportion of the population with knowledge and practice of malaria preventive measures to 95% and 75% by the end of 2020; to strengthen the national supply chain system for effective quantification and prompt distribution of commodities under a universal system; to improve routine data monitoring and program evaluation to ensure quality data management at all levels; and to increase access to safe and quality services through improved capacity of the health network to provide safe quality Essential Packages of Health Services.
The Ministry of Health, through the NMCP routinely distributes nets to pregnant mothers during their first Ante-natal Care visit, and after giving birth at a health facility.
Moreover, in a period of four years, about 5.398,635 (2.6 million in 2018 and 2.7 million in 2021) long-lasting insecticidal nets will be distributed under the GF grant through Plan International – Liberia, and selected service providers to the general populations, through mass campaigns in all 15 counties.
Solomon W. Watkins, Contributing Writer