SENEGAL

Monitoting and Evaluation of HIV/AIDS programs

Idrissa Diop and Alpha Wade

Background

Senegal has a population of about 9 million and a GNP per capita of $600. The first AIDS case was reported in 1986. Until recently, the HIV/AIDS epidemic in Senegal is characterized by relatively low and fairly stable seroprevalence of HIV-1 and HIV-2 compared to many other African nations. According to the new classification of HIV epidemics Senegal is on the verge of moving from a concentrated to a generalized epidemic, when HIV prevalence in some low risk groups exceeds 1%.

National response

The national AIDS control programme was established in 1987. In collaboration with WHO and other donors, the programme has developed a donor blood screening programme, a surveillance system, the beginnings of a public information programme and two medi um-term plans. Numerous donors have become involved in the effort to slow down HIV transmission in Senegal. Their collective experience and the results of research and programmes in other parts of Africa have contributed to the development of a comprehens ive strategic approach to HIV/AIDS control in Senegal. Since 1970 Senegal had a national STD control programme and also a health and social programme for prostitutes with notification of syphilis and gonorrhoea. With regard to STD, treatment guidelines were formulated in 1987 and algorithms for treatment came into use in 1991. From 1995 the syndromic approach was used, two years later additional emphasis was put on IEC on STDs.

Monitoring and evaluation

There is a three-tiered system of monitoring and evaluation: central level, regional level (10) and district level. The districts send monthly reports about AIDS cases and other information to the regions, which in turn send quarterly reports to the na tional AIDS programme.

HIV sentinel surveillance has been carried out in three antenatal clinics since 1989, which was increased to five sites in 1993. HIV prevalence is also monitored among other population groups in the same and other sites: TB and STD patients, hospital admissions, and commercial sex workers.

There is no STD surveillance system in place, and the only data available are derived from several research studies in Dakar, the capital. Several strategic changes were made during the past decade pertaining to STD treatment; most of these were preced ed by evaluations of the existing approaches. In 1997 a national health facility survey was done to assess the implementation of the syndromic approach for STD treatment. It showed that 97% of the health workers in six of the ten regions had been trained.

The 1992 national DHS included questions on knowledge about HIV and STD. A 1997 study in Dakar was carried out to estimate prevention indicators on sexual behaviour and self-reported STD. Six KABP surveys were done in rural areas and in 1997 the nation al DHS included some questions on STD and AIDS. A behavioural surveillance system (BSS) was initiated and in 1997 included several target groups: male and female secondary school students, male and female university students, male workers and registered p rostitutes. In the second round in 1998, four groups were added for behavioural surveillance. Several qualitative studies have also been carried out.

Input, output and context

Levels of knowledge as measured by citing at least two appropriate means of protection against HIV (PI 1) was above 90% in all BSS target groups in 1997. Data from the 1992 DHS and 1997 BSS indicate a rapid increase of condom availability, from 26% to 85-99% of women said they could easily procure a condom.

A detailed assessment of prevention indicators 6 and 7 was done in 6 regions in 1997. Before and after observation of STD treatment practices revealed only a modest improvement on PI 6 (treatment practices), although its components, effective treatment and examination, improved significantly. The health workers' score on appropriate condom advice and partner notification (PI 7) improved significantly from 3% to 22% after training.

Proximate determinants

Trends in prevention indicators 4 (prevalence of non-regular sex) and 5 (condom use) can be monitored in the target groups of the BSS. Comparison of DHS and BSS data shows a rapid increase of condom use. Commercial sex workers reported very high levels of condom use. A study in one area in rural Senegal showed improvements in AIDS knowledge, perceptions and risk behaviours over a two-year period.

HIV and STD

Data from the monitoring sites indicate that HIV (1+2) prevalence ranges from 0.1-1.5% among women attending antenatal clinics. Among commercial sex workers high rates have been registered HIV (1+2) prevalence has been monitored since 1989 and ranges f rom 5 to 15%. Among STD patients HIV prevalence ranges from 2 to 8% (1996). In most cases HIV-2 prevalence is about the same as HIV-1 prevalence. Clinical STD incidence data are only available from small-scale studies.

AIDS impact mitigation

By the end of 1997, 60,000 AIDS cases are estimated to have occurred in Senegal, but the degree of underreporting is not fully known. There is very limited monitoring and evaluation of care and support for people living with HIV/AIDS.

Conclusion

HIV-1 and HIV-2 monitoring data from several population groups and a limited number of surveillance sites during 1989-1996 suggest that the AIDS epidemic has rested on the border between concentrated and generalized for a much longer time than in other countries in Africa. This has been partly attributed to the national response.

Consequently, the national programme and donors put much more emphasis on monitoring sexual behaviour. These data show a reduction in non-regular partnerships and an increase in condom use, even in recent years.