April 21 – May 1, 2007

HIV/AIDS Prevalence in DRC

The Democratic Republic of the Congo (DRC), with a population of approximately 60 million and an area of 2.4 million square kilometers, is the second largest and fourth most populous country in Africa. Annual per capita income is approximately US$87. In spite of recent economic growth, the country faces steep short-term and medium term socio-economic challenges. The HIV/AIDS epidemic, a major health challenge in itself, compounds the host of other dilemmas facing DRC. The epidemic poses a great public health problem and is a continuing threat to economic recovery and development. Data compiled by the national HIV/AIDS program estimates that as of 2003, about 3 million people live with HIV/AIDS, associated with a prevalence rate among the adult population of just over 5 percent , and provincial variations ranging from 4.5 percent in Kinshasa to 7.5 percent in Lubumbashi. Analysis of data available from case reporting indicates that:

• The age groups most affected in general are those aged 20 to 49 years, with women aged 20 to 29 years and men aged 30 to 39 years being most affected;
• Given the incubation period from infection to symptomatic HIV/AIDS, it appears most women are being infected between the ages of 15 and 19, while men are becoming infected between the ages of 20 and 29;
• Sexual transmission remains the most commonly observed mode of infection accounting for 87 percent of all cases with mother to child transmission accounting for 8 percent of all cases. Approximately 5 percent of cases are related to intravenous transmission resulting from contaminated blood supplies and injection equipment
• Among high risk groups, infection rates are as high as 33 percent among hospitalized tuberculosis patients and 19 percent among commercial sex workers;
• Approximately 750,000 children under the age of 15 have lost one or both parents to an AIDS-related illness.

The epidemic in the DRC is further complicated by extreme poverty and weak or nonexistent public health infrastructure. The National AIDS Control Commission (Comite national de lutte contre le SIDA, CNLS) was created in 1987 and developed a short-term plan to assess the scope of the epidemic. Political and civil unrest to date have impeded sustained implementation of prevention efforts.

National Response to HIV/AIDS and the Private Sector

There are multiple ongoing projects in the DRC to address various aspects of the HIV/AIDS epidemic including blood safety, HIV/AIDS awareness and prevention, volunteer counselling and testing and administration of anti-retroviral therapy. These projects are financed through multi-lateral and bilateral aid agencies the most significant programs are currently financed by The World Bank Multi-Country AIDS Program (MAP) and The Global Fund to Fight AIDS, Tuberculosis and Malaria.

On March 17, 2004 the President of the DRC created the Programme National Multisectoriel de Lutte contre le VIH/SIDA, PNMLS (National Multi-Sector Program against HIV/AIDS) The PNMLS is made up of the public sector represented by the Ministry of Public Health, the private and enterprise sectors and the NGO and faith communities in the DRC. The PNMLS is tasked with national coordination of all sectors involved in HIV/AIDS and STI prevention and is assisted in this effort through provincial and local representation. The mission of the PNMSL is to:

• Create and enforce a national commitment against HIV/AIDS and STIs,
• Mobilize all social sectors (public, private and civil society) and engage them in effective HIV/AIDS prevention,
• Request and access international donor assistance, and
• Implement a national strategy against HIV/AIDS in the DRC.

The goals of the national HIV/AIDS strategy are to:

• Encourage individuals and communities to adopt safer behaviours toward the prevention of transmission or acquisition of sexually transmitted infections (STIs) and HIV,
• Promote the correct and consistent use of condoms,
• Assert effective control over the spread of STIs through standardised testing and syndromic treatment, and
• Assure care of persons living with HIV.

The National Business Coalition against HIV/AIDS in the DRC, CIELS (The Comite Inter Entreprises de Lutte Contre le VIH/SIA), has recently completed a draft Five Year Plan against HIV/AIDS in the Workforce 2006-2010 (Plan Quinquennal de Lutte Contre Le VIH/SIDA sur le Lieu de Travail 2006-2010). According to the finds of this report, the principal issues regarding HIV/AIDS in the workplace and the current business/enterprise response to the epidemic can be summarized by the following six points:

• A weak response from the business/enterprise sector (this sector is compromised of private sector, as well as state owned/operated enterprises and mixed public-private ownership),
• Insufficient resources available for business/enterprise sector to engaged in HIV/AIDS prevention,
• Lack of standardized approaches and technical orientation to HIV/AIDS interventions in the workplace,
• The majority of the business/enterprise sector has not effectively integrated HIV/AIDS interventions into the work place,
• The majority of HIV/AIDS workplace interventions are implemented by external personnel,
• The business/enterprises sector lacks the capacity to monitor or evaluate the impact of HIV/AIDS on productivity, and
• Overall, the response has been weak, disregarding the impending impact of HIV/AIDS on the business/enterprise sector specifically, and on economic productivity in general.

Furthermore, while 80 percent of the members of CIELS have workplace programs, most are conducted by untrained personnel and not in adherence to national strategies for HIV/AIDS prevention; 50 percent of businesses/enterprises that have workplace programs distribute condoms, however most condoms are only distributed through the medical services/clinics; and only 56 percent of businesses/enterprises with workplace interventions have behaviour change communication components. Half of the businesses engaged in HIV/AIDS workplace interventions offer volunteer counselling and testing while almost all enterprises offer testing and treatment of sexually transmitted infections (STIs) through their medical clinics.

A study undertaken by the University of Kinshasa School of Public Health in 2005 on the perceptions of and associated cost and consequences of HIV/AIDS on the private/enterprise sector focussed on eight members of CIELS in Kinshasa, (BRALIMA, la Banque Centrale du Congo, FINA Congo, la Societe Nationale d’Electricite (SNEL), la SEP CONGO, l’Office Congolais de Controle, ECC and SHELL CONGO). The study reinforced much of what has been stated in the five year strategy as the principal problems facing HIV/AIDS prevention, care, and treatment in the DRC, and underlined the need for better management and administration of existing services, a heighten awareness within the private/enterprise sector of the consequences of HIV/AIDS, the need for trained peer educators, and a more dynamic response from the Ministry of Health vis-à-vis prevention and workers’ health and healthcare.

Mission Objectives:

The objective of this private sector HIV/AIDS mission was to continue the dialogue with the PMNLS (Programme National Multisectoriel de Lutte contre le SIDA) and private sector stakeholders, including other donors and non-governmental organizations (NGOs), on how to expand partnerships in support of the DRC National Agenda against HIV/AIDS. The discussion included development of national policies and workplace guidelines; the expansion of management capacity and service delivery within the business coalition (CIELS) to mobilize the private sector response; the implementation of other strategies to reach priority sectors (mining, transport, forestry); creation of linkages to and leveraging of other technical and financial resources (multi-lateral and bilateral); and exploration of the role of civil society in enhancing public-private partnerships and access to services for HIV/AIDS prevention, care and treatment.

The mission reviewed:

• The effects of the suspension of MAP funding in 2006 and strategies to ensure a timely release of MAP financing to the private sector for the remainder of 2007;
• Current private sector initiatives to address HIV/AIDS in DRC;
• Management capacity and activities of the business coalition, CIELS (Comité Intra-Entreprises pour la Lutte contre le SIDA), to engage the private sector on the national and provincial levels;
• Mechanisms to enhance private sector engagement, including financial and technical monitoring and evaluation (M&E) processes and tools;
• Progress in the development of a national HIV/AIDS workplace policy and national strategy for the private sector;
• Strategies for scaling up private sector involvement in the national response to HIV/AIDS including financial and technical support from donors and linkages to civil society service delivery.

In addition, we were asked to:

• Review the 2007 CIELS action plan and budget; and
• Conduct a site visit to Lubumbashi to review strategies to better engage the mining, and transport sectors in the fight against HIV/AIDS and assess the status and capacity of the provincial PNMLS and CIELS in this effort.

Results:

PNMLS – National Office

• During 2006, only two private sector projects were financed by the MAP: CIELS and FORC. In addition, many companies financed by the MAP in 2005 have yet to receive their second tranche of funding. The suspension of funding in 2006 resulted in a hardship for all sectors, a decrease in prevention activity across all sectors, and an interruption in the supply of condoms, test kits, reactive agents and ARVs. The suspension of funding has also resulted in a significant decrease in motivation among private sector actors.
• The PNMLS has suggested that remaining MAP requests for financing (either 2006 submissions or second tranche requests from 2005 projects) be reincorporated into 2007 requests for funding. While this appears to be a practical solution, it should be noted that this strategy presents an additional obstacle for the private sector to access funding (particularly considering there are only six months left in 2007), and will certainly further delay the disbursement of necessary resources for private sector activities. Therefore, there should be recognition on the part of the PNMLS that once the mechanisms and resources are in place, additional assistance should be provided to private sector applicants to expedite the submission, approval and financing processes.
• The AGF has recently introduced an electronic financial management tool to be used by MAP sub-beneficiaries to provide timely and accurate financial reports to the AGF. It is hoped that this tool will remedy the incomplete financial project evaluation reports submitted by private sector MAP sub-beneficiaries, which resulted in delays in funding in 2005. To date, only one private sector recipient – CIELS – has been trained to use the tool and has successfully employed the system to provide financial reporting. In order for this tool to be of benefit to the private sector, a training strategy must be implemented more broadly by the AGF.
• The mission noted a weak overall mobilization of the private sector. An important issue raised many times throughout the mission was the need to mobilize private sector leadership. The inability to engage senior leadership in the fight against HIV/AIDS at both the national level and within the business coalition has limited the overall private sector response and the effectiveness of CIELS and the PNMLS.
• The PNMLS has drafted an MOU with CIELS that will provide CIELS with the authority and necessary training to function as a clearinghouse for the technical aspects of private sector MAP proposals prior to submission for funding (see Annex 1 for first draft of the MOU).
• The ILO has committed $63,000 to assist the PNMLS, in coordination with the Ministry of Labor, UNDP, CIELS and other partners, to create a national workplace policy and to integrate the private sector into the National HIV/AIDS Strategy. The PNMLS has submitted a draft terms of reference to the ILO and, at the request of the ILO, is currently revising that strategy to include outreach by the private sector to communities and civil society.
• In addition to the private sector manual outlining the MAP funding process, the PNMLS is in the process of developing a draft manual to guide sub-beneficiaries in the financial and technical implementation and monitoring and evaluation of MAP projects, which will be critical to the successful execution of private sector HIV/AIDS activities and potential future funding of private sector work.
• The 2007 MAP Plan of Action was submitted to the World Bank in March 2007 for non-objection; approval by the World Bank is pending.
• A new World Bank Task Team Leader (TTL) for the DRC was appointed in March 2007 and is currently located in Nairobi, Kenya with plans to relocate to the DRC by July 2007. Given conflicting travel schedules we were unable to meet with the new TTL, Jean-Pierre Manshande. The mission plans to conduct a video-conference with members of the PNMLS, CIELS and the World Bank to discuss the findings and recommendations of the mission.

PNMLS – Katanga Office

• The PNMLS-Katanga office focal point has multiple responsibilities and is in charge of the public, private and civil society sectors. As a result, the private sector component has not received much attention and has not been fully incorporated into the strategic planning of the Katanga PNMLS. The Katanga PNMLS should define a private sector strategy, in coordination with the national PNMLS office and CIELS-Katanga. Once the capacity of CIELS-Katanga is strengthened, the organization will serve as important resource and support mechanism for the PNMLS to engage the private sector on the provincial level.
• In addition, a monitoring and evaluation plan for the province has been created, but has not been implemented. Therefore, no information is available on activities conducted at local sites outside of Lubumbashi. As the majority of the mining sector is located outside of Lubumbashi, it is critical that the PNMLS-Katanga office, with support from the national PNMLS office, starts to assess private sector activities at the local level throughout the province.
• It was clear from the mission’s meeting with the PNMLS-Katanga that there needs to be a stronger relationship between the central PNMLS in Kinshasa and its provincial counterparts, including improved communication and policy coordination, the development of standardized processes for monitoring and evaluation, and provision of guidance on project execution and financial management. The central PNMLS should also provide necessary tools and guidance on workplace policies and programs to its provincial counterparts.

CIELS - National Office

• CIELS received a small amount of funding from the MAP in 2006 ($35,000) to implement a six-month capacity building project. Although the proposal was submitted in March 2006, the funding was not received until November 2006, severely truncating the implementation timeframe for the activity. The project was officially closed in March 2007.
• One of the fundamental issues the mission identified regarding the management and technical capacity of CIELS, was the lack of well-articulated job descriptions and performance measurements for the members of the secretariat, which has left the CIELS secretariat without sufficient guidance or tools to measure, assess and enhance staff performance.
• CIELS has yet to determine a core set of services or activities to offer its membership, which has restricted the ability of the organization to attract new members, engage senior private sector leaders, and to require existing members to pay membership fees necessary for the survival of the coalition.
• The mission worked with CIELS to revise the coalition’s 2007 action plan and to focus its activities on five principle categories: 1) build management capacity within the coalition at the secretariat and the Board (the mission encouraged CIELS to accept the offer from GTZ to evaluate the work of CIELS in order to inform this and other processes for future development of the coalition) ; 2) develop strategies to engage private sector senior management in the fight against HIV/AIDS; 3) create monitoring and evaluation capacity both internally and externally for CIELS member company activities (including the identification and adaptation of tools and guides for monitoring and evaluation of workplace programs and policies (i.e., the ACCA toolkit cost benefit analysis tool, and the GTZ/GBC interactive workplace monitoring and evaluation tool); 4) build capacity of three provincial CIELS offices; 5) provide technical assistance to members to implement HIV/AIDS programs.

CIELS – Katanga Office

• CIELS-Katanga was established in 2003 with a two-year financial commitment from GTZ. In 2005, GTZ funding ended. Currently, there is no additional financial support to maintain the coalition, and consequently there is no paid staff working for the coalition. The coalition is managed by the President (FEC), Vice President (CMDT) and Secretary/Treasurer.
• A few companies in Katanga and the other regions have programs that are considered as best practices and should be leveraged as CIELS strengthens its capacity and seeks to grow its membership. One striking example is the Caisse de Solidarité created by BRASIMBA. Beginning in 2005, BRASIMBA instituted an HIV/AIDS fund to which each employee contributes $2000 per year. The money collected through the fund is used to supplement treatment costs for PLWHA. As a result of this arrangement, HIV/AIDS positive employees needing treatment are only required to pay 1/3 the cost of their treatment. As of May 2007, the PLWHA’s contribution will be reduced further.
• There was no formal monitoring and evaluation of the activities carried out under GTZ funding. Current CIELS-Katanga activities include peer education and behavior change trainings, condom marketing, and engaging senior leadership in the coalition. These activities are carried out in close coordination with PNMLS-Katanga.
• There is minimal communication and technical support between CIELS-Kinshasa and the CIELS offices in Katanga province.

Recommendations and next steps

Please contact a CCA HIV/AIDS Initiative staff member for more information