Turbocharging Eritrea’s National HIV/AIDS Strategic Plan

Results and Impact from the initial wave of 100-Day Challenges included:

• Voluntary counseling and testing (VCT): The original goal was to increase voluntary testing and counseling by 25 percent in Asmara. After the 100-Day Challenge, an increase of 80 percent was achieved, and three new testing and counseling centers were built. Typically, a VCT center would take up to 9 months to build. Commercial sex workers were also given incentives to use the centers.
• Commercial sex workers: Another goal was to get 25 out of 100 commercial sex workers to practice safe sex in one district. The result in 100 Days was that 76 percent of the commercial sex workers reported using female and male condoms.
• Sex education for students: High school students were targeted to practice safe sex and delay sexual activity. One hundred days later, new programs were implemented in six schools, targeting 1,200 students. Additionally, 120 of the 1200 students surveyed had been selected for life skills training to influence their peers. 
• Home-based care: Very little was happening in this area at the time of the project. The goal was to ensure that 25 percent of people living with HIV/AIDS and their affected family members in certain zones would be provided holistic home-based care. After the initiative, the Orthodox and Catholic churches launched new programs that reached 120 families, providing nutritional and other care. More than 40 health workers have also been trained and equipped with care kits and have started to provide coverage in targeted areas.
• Minimize exposure to HIV/AIDS in hospitals: During the workshop, the Minister of Health requested an additional initiative to eliminate all unprotected exposures among caregivers in the Halibut Hospital in Asmara caused by needle pricks, sharp object injuries, and contaminated materials. At Halibut Hospital, new supplies have been procured (e.g., needle disposal bins), and 20 training sessions will be carried out with 600 staff members in April and May.

At the end of the 100 Days, during the Sustainability Workshop, each team described what they had set out to do, what they accomplished, and what they learned. They also outlined their initial ideas for what needed to be done to scale up the initial impact by at least a factor of five.

The results and the enthusiasm expressed at the wrap-up workshop convinced the Minister of Health and his HIV/AIDS Director, Dr. Tesfazion, that the RE!NSTITUTE Approach needed to be deepened in the Central Region and broadened to other Regions.

In the Central Region, scaling up took different forms for each area of focus.

SCALING UP

After the first VCT initiative was completed, Dr. Musfin Worede, the Regional Medical Director, and his team decided to shift their VCT focus from the downtown district of Asmara to the suburbs.

There they challenged new teams to pursue different, more ambitious goals for expanding the use of VCT. Three teams were launched simultaneously; each focused on one of the Asmara suburbs in partnership with youth clubs.

The same discipline was followed: local teams were challenged to set unreasonable but believable 100 Day goals and develop their own plans to achieve them.

The third wave of VCT 100-Day Challenges shifted the focus from increasing the utilization of VCT services to reducing transmission risks.

As a result of these efforts, Dr. Worede increased the annual goal for VCT use in Asmara from 12,000 to 15,000 users, and by December, the actual number of users was just shy of 20,000!

Our 100-Day Challenge around work involving commercial sex workers offered insights into another aspect of implementation acceleration: 

• Where does the knowledge for change reside?
• And how do we tap into this knowledge? 

In the case of commercial sex workers (CSWs),  five new 100-Day Challenge teams led by CSWs themselves were launched simultaneously, each taking on a 100-Day Challenge goal that involved working with 80 of their peers to achieve anywhere from 40-70% adoption rates of female condoms and use of VCT centers. The five Commercial Sex Worker team leaders helped design the workshop, identifying key issues and challenges that they wanted to discuss at the workshop before their teams set their goals and developed their plans. The team leaders insisted that some of their clients participate in the workshop, as the issues and challenges often involved clients.

Since the workshop was co-designed by the commercial sex workers themselves, it was an opportunity for an honest dialogue between them and government officials about the difficulties CSWs encounter implementing safe sex behaviors that they hear about in the typical public health awareness-building campaigns.

A senior official from the Ministry of Health captured the essence of the shift that was taking place:

“This is new for us, and it is important for us. We’ve met with CSWs before, but it’s always been one way communications, with us teaching them. This is much better. They are teaching us and themselves. And we see that they know a lot.”

In June 2004, the Ministry was preparing to launch the third wave of 100-Day Challenges, targeting 1,000 CSWs in the Central Region. The Ministry of Health experience was documented by researchers from the Department of Infectious Disease Epidemiology at the Imperial College in the United Kingdom. Two years into the effort, at the end of 2004, UNAIDS reported that the Eritreans had managed to stabilize the HIV prevalence in the country at 2.4%.

The legacy of RE!NSTITUTE’s work was sustained in Eritrea – long after we had left the scene. Our work was featured in the National Union of Eritrean Youth & Students in 2009: Sixty-Seven Schools within A Hundred Days.

• Ministry of Health in Eritrea
• The World Bank 

• Turbocharging the National HIV/AIDS Strategic Plan in Eritrea: The Rapid Results Approach by Ronnie Hammad with contributions from Eva Jarawan, Nadim Matta, and Godwin Hlatshwayo
• Eritrea: The Rapid Results Initiative (RRI) on HIV/AIDS