Accra — Ghana's Aids Commission was set up three years ago, getting legal status in 2001. The Commission reports directly to President John Agyekum Kufuor and it has 46 members, including 15 ministers of state and representatives from civil society and the private sector.
Professor Sakyi Awuku Amoa, Director General of the Ghana Aids Commission has been working in the HIV/Aids field for over a decade. In 1989, he was the World Health Organisation administrator who set up the National Aids Control Programme in Harare, Zimbabwe. He returned to Ghana a year later and was appointed to assist in the Ghana National Aids Control Programme for several months before returning to his post at the Institute of Management and Public Administration where he became deputy director-general. More recently, when the Ghana government and UNAIDS were thinking of establishing the Aids Commission, he was the consultant who designed its structure. As he was about to retire, the government appointed him to head it. Ofeibea Quist-Arcton went to meet Professor Amoa at the Commission's secretariat in the capital, Accra. Excerpts:
Setting up an Aids Commission anywhere in Africa only in 2001 seems very late, considering the impact of Aids on Africa.
It took so long because when the pandemic came on, it was seen by the government and everywhere as a disease. So it was the Ministry of Health which was acting as the lead agency. The pandemic was then being managed as a disease under the Ministry of Health.
It was later on that it was realised that the complex and multi-faceted nature of the pandemic demanded a developmental approach - as well as even human rights issues to be considered. That required the need to look at a structure that would handle it from a multi-sectoral point of view.
This is what brought the National Aids Commission into being around 2000. It was a real historic development and a realisation that the Aids pandemic cannot be handled like an ordinary disease [nor] by bio-medical methods only; and there was a need for a very strong prevention and control strategy that had to be institutionalised [on] a multi-factoral basis. And this is what led to the Aids Commission coming much later than expected.
Lets talk facts and figures. How many people in Ghana are living with HIV/Aids?
Currently, the national adult prevalence rate is 3.4 percent. This is almost a 50 percent increase in the last two years. In 2000, the recorded prevalence rate was 2.6 percent. In 2001, it was 2.9. And now were talking about 3.4. So, overall, weve seen a 50 percent increase in the prevalence rate.
The most vulnerable age group is between 15-49, as you find in other places. And in Ghana here, particularly you find that 63 percent of all the Aids cases are women. So the infection rate among women is very high. This is followed by the infection rate among young girls and the youth.
Again between the ages of 15 and 24, we also find that the prevalence rate has gone up by 50 percent. And that is something that should worry us, because it means that the most productive age group is being affected by this disease. And we have to do all that we can to make sure that we can either reduce the prevalence rate or just make sure we keep it where it is for the time being.
What are you doing to bring down the HIV prevalence rates?
This brings us to the way that were fighting it. We are focusing on five major intervention activities. The first one is the awareness creation. And we have almost achieved 90-99 percent awareness.
The second one is support and care for people living with HIV/Aids. That is very important. When infected individuals find that there is a system to support them, then they will be willing to come.
Our third major area is voluntary counselling and testing. That is a critical tool to bring about behaviour change. When somebody tests and he is found positive, the person will be counselled. He will then know how to live positively, so that he doesnt go underground and infect other people.
If the person tests negatively, it will then enable him to protect himself. He will lead a positive lifestyle just to make sure that he doesnt get the infection. So we are focusing a lot on voluntary counselling and testing now as a way to get behaviour change.
Our fourth area is treatment and care. Now this is handled by the Ministry of Health. Until recently, Ghana had not introduced the antiretroviral. We had focused majorly on prevention and control. But now, with the help of the Global Fund, we have got money to buy antiretrovrials that will cover about 2,000 patients. The preparatory work has been completed and the people living with HIV/Aids will be put on the anti-retrovirals starting from January next year and that is for two years. The drugs will be able to cater for 2,000 people for two years.
Two thousand people out of how many living with HIV/Aids?
As I said, we have already about 600,000 Aids cases. So the 2,000 is just a drop in the ocean. But Im happy to note that money now is not a problem, to get more anti-retrovirals. The Ministry of Health is capable of resourcing for more funds. We have put in a second request to the Global Fund for an amount of about 30 million dollars which will enable us to buy more anti-retrovirals and put people on them. So it means that we position ourselves now to bring in treatment.
Now treatment becomes extremely necessary for behaviour change also, because when people get to know that, at least, their life is not hopeless and they can go to the hospital for some kind of treatment, it will give them hope. It will give them confidence. And, you see, when a person has confidence, believes in himself, that in itself will contribute to his healing process. And this will probably help most of them to prolong their lives.
So you roll out the ARV treatment programme first thing next year -
Yes, January 2004 is the starting time. And it will be done in three major hospitals. Korle Bu Teaching Hospital in Accra, Komfo Anokye Teaching Hospital in Kumasi and St Martins Hospital in Manya-Krobo. These are the three hospitals that the government has decided to use as a pilot case.
They are just restricting themselves initially to these three, because of the fact that the physicians need to be trained for them to know how to manage the side-effects of the anti-retrovirals. Then, after about 6 months work in these hospitals, they will roll it out to the regions and later on, from the regions to the districts.
So there is the intention, the plan is to go all out. But the ministry is being cautious in terms of how its going to roll out the anti-retroviral treatment for these patients.
But it seems that your pilot scheme again marginalises the northern regions of Ghana which observers note are already far less privileged than the south.
If you are talking about starting the programmes from the teaching hospitals, then that is the case. But what we are looking at here is that the ministry is starting from two teaching hospitals. The two teaching hospitals happen to be in the capital, Accra, and Kumasi. The Manya-Krobo one, St Martins, is where the original pilot of this drug - particularly how pregnant people would react to it - was started.
They did that study in the rural areas for two years. And it is (from) the lessons from the Atuah Hospital and St Martins Hospital that they are now using in the teaching hospitals. So it is true that we are not moving immediately to the north, but it does not mean that they are not going to be part of the process. Only it may take a little bit of time for the drugs to get there. But the ministry has the intention of getting the drugs to all the hospitals.
And how would you assess the cooperation between the Ministry of Health and the Ghana Aids Commission in the roll-out of the ARV programme?
The collaboration has been an excellent one. You will find out that, in a number of countries, there has been some kind of conflict between the Ministry of Health and the Aids Commissions, probably because some people did not believe in the multi-sectoral approach. Particularly, some health professionals thought that this is a disease like any other disease and if it has to be handled, it has to be handled by professional health teams.
But in Ghana we are lucky that there has been a perfect understanding between the two bodies. So, here, we allow the Ministry of Health to take the lead in all technical issues. We recognise the professional skills of the Ministry of Health.
The Ghana Aids Commission is managing the national response, and treatment is just one aspect of the national response. So, once we recognise the ministry as having the expertise to carry out the job, all that we are doing is to allow them to decide on what is to be done, inform the Ghana Aids Commission, we sit together, agree on policy issues and implementation takes place.
The Ghana Aids Commission is a purely policy-formulating, coordination, supervisory body. We are not an implementing agency. But the Ministry of Health becomes an implementing agency for the Commission when it comes to treatment and care and this is what makes the collaboration much, much easier.
Where does Ghana fit into the scale of HIV/Aids prevalence in Africa?
We fall in what one may call the low prevalence rate, because if you take West Africa, the prevalence rate between the rest of West Africa and Ghana is very high. While Ghanas prevalence rate is 3.4 percent, that of Cote dIvoire is already between 7-9 percent. Togo is around the same. Nigeria is almost 9.5 percent. So you find out that we are hemmed in [geographically-speaking] between high prevalence rates. Its very low.
Compared to east and southern African countries, you will find that Ghana is way below. You are talking about Botswana with 38.5 percent. You are talking about Uganda which was almost 30 percent and has now come down to 9 percent. Kenya is around 11 percent. South Africa is around 20+ percent. So, we are still very lucky.
But I keep saying that we should not say "only 3.4%" because it can be very deceptive. From what I discussed with you, in terms of getting the accurate statistics, maybe our prevalence rate would be a little bit higher than 3.4 percent. We only have to wait for subsequent studies to be conducted for us to know where we are. But I think, for now, we can say that we are on safe ground. But that does not mean we should be complacent with it.
Professor Amoa, I travel widely around Africa and when I come here to Ghana, I really dont see many Aids awareness posters and Aids sensitisation material that everyone can see from whatever public or other transport they may take to work or to school. It almost seems as if Ghana is not quite there with Aids awareness and public education.
No, I would say that is not the case. Maybe, just as youre saying, youve just come in and you have not been able to see everything as such. But if you go through our newspapers these days, there is not a single day that a newspaper will not talk about Aids.
But there are so many people in Ghana who dont know how to read and write -
Yes, but we have a lot of activities ongoing, right in the rural areas. Currently Ghana Aids Commission is working with 2,500 beneficiary organisations, working from the national level right down to the community level. We are involving all the district assemblies and we have 110 districts. And in each district, we have district Aids committees, district monitoring and evaluation persons, district focal persons and a lot of intervention activities are taking place at the local level.
Awareness creation at the moment in Ghana is almost 90-99 percent. What we are dealing with, which is our major headache, is achieving behaviour change. But, of course, behaviour change depends on the availability of information and knowledge. Therefore, to me, its not a bad idea that now we have upscaled awareness creation and we believe, as we give more relevant information, people will begin to change their lifestyles which will bring about the needed behaviour patterns.
How are you encouraging people to change their sexual behaviour? Because I repeat that I do not see obvious educational material for Aids awareness in Ghana? It doesnt strike you once you arrive in Ghana.
I may still request you to look a little harder. There are a lot of billboards that carry Aids messages... Most of the posters we give are also, for instance, in rooms, particularly in secondary schools, in primary schools. Weve printed a lot of Aids messages that we have distributed.
We have printed about 20,000 basic readers for the primary school level which are being distributed. We also have exercise book covers with HIV information for the schools that we give. Most of our beneficiary organisations also print their own posters. So, there are a lot of posters in the system.
Yes, what I might say is that you may not see a number of them just in the streets or on the walls like that, but we still have a lot in the system and we are still pursuing that.
Now, you say theres a very high awareness of HIV/Aids among Ghanaians. Why is it proving hard to change behaviour, or lifestyle? Day to day are Ghanaians witnessing the death, through HIV/Aids, of people close to them and what is the reaction?
When you just look at the statistics, and as I mentioned, we really now have about 50 percent increase in prevalence in the past two years, then youre likely to say, "what is happening? Is there behaviour change at all?" No, the way we should look at it is this, before this year the surveillance studies which were conducted by the Ministry of Health were done on very limited samples - limited sites. So it did not give us a very comprehensive picture of what was actually happening.
Last years surveillance study was based on 25 sites and a much larger population sample. And that is what has brought us these new figures which give us the trend. So what I would say is that it is now that we are beginning to see the magnitude of the problem. Therefore if we have not been able to achieve a corresponding behaviour change, it should not worry us, because initially people did not believe that what we were saying was true, that HIV was real and that it was affecting a lot of our population.
But now that the figures are there, people are beginning to realise that they need to change their behaviour. For instance, six of our major cities have gone beyond the 5 percent experiential point, which is dangerous.
We have Obuasi, the gold-mining area, which is now at 6 percent. We have Ekwe - in the western region - which is a border town. That is also at 6 percent. Then you come to Tema, which is a port city, which is at 6.6 percent. Then you have Koforidua, in the Eastern Region, which has gone to 8.5 percent. Koforidua happens to be a catchment area around the Krobo-West Akyim.
You see, the initial infection rate was in Manya-Krobo, which was then very high. Now people seem to have moved from Manya-Krobo and gone to the Koforidua area for trading. So, the Manya-Krobo rate has come down to 7.5 percent, whereas Koforidua has shot up from 4.5 percent to 8.5 percent.
Now when you see there are six major cities with over 5 percent prevalence rate, then it tells us that we still have a problem on our hands. Remember there might be a number of people who have not tested at all, because the figures we are giving are reported cases in the hospitals. There are a lot of people who have not tested. We do not have a lot of voluntary counselling and testing centres in the rural areas. This is what the Commission is trying to do. We are trying to resource funding to assist the Ministry of Health to establish a lot of testing centres.
We are working with TASO - a training organisation against Aids in Uganda - which are helping us now to train counsellors, so that we will have enough counsellors in the system, because without the pre-counselling and post-counselling, testing becomes meaningless. So we are working on that area also.
I think once we are pushing this idea - and we are now intensifying, for instance, look at the television screens - we have come out with a new concept which is being shown called "Your Life is Precious". We have given actual cases of people who have been infected and how they got infected as a way of getting people to appreciate the need for them to really reduce the high level of denial we have in the society.
So, which areas are hardest hit by HIV/Aids - the urban or rural areas? Or is it a mix?
It is a mix, because the surveillance report indicated that one could not really make a clear distinction between the rural and urban areas. The infection rates in the rural areas are just about the same as you find in the urban areas.
And if you take a case like Accra, you find that Accra has more pocket rural areas than even rural areas outside Accra. So its not strange that the figures show that one cannot talk about big differentials. The differentials are between regions and that depends on three factors. One, it depends on the awareness of the people in the area about the disease. Two, it depends on health facilities that are available and, three, the population size.
So, if you talk in terms of population size, Ashanti is the most vulnerable region, whereas in terms of figures, the Eastern region shows higher figures than Ashanti. So that is where you see the variation, but not between rural and urban.
Would you say that HIV/Aids remains a taboo subject in Ghana - in villages, in cities, in towns? Can people talk about the pandemic?
Now we have reached a point where we have moved beyond the disease being seen as a taboo. We have reached a point where people can freely talk about it. A lot of discussions are going on in the rural areas. The only problem we have is with the methods of prevention.
We are promoting three methods of prevention: abstinence for the youth; being faithful to your partner for the elders and, for the rest of the population, the use of condoms if they cannot abstain or cannot be faithful.
Now, you see in African society you have a lot of people who tend to be moralist in their orientation and not, probably, look at the reality. You have the same problems with the churches, like the Roman Catholic Church which still kicks against talking about condoms.
So, whenever we are promoting the use of condoms, you have a situation when a number of people - maybe in the rural areas - think that the promotion of condoms is in itself the promotion of promiscuity. We have to deal with this.
We have churches who also believe that we are talking too much about the use of condoms, rather than promoting abstinence. And my answer is that, no, we are not emphasising on any one of them. As a national response we are giving emphasis to all the three, all the three.
The churches have preached morality over the years and we havent seen any dramatic change. If we had seen a dramatic change, we wouldnt see the immorality that goes on. So, we cannot pretend that people are living right. And if they are not living right, or are adopting risky lifestyles, [are they saying] we should not tell them the options for protecting themselves? So, as far as the Commission is concerned, we will promote abstinence for the youth, we will continue and we want the churches to continue.
We will promote the use of condoms for those who can no longer abstain because, whether we like it or not, they will get involved in sexual activity and we need to get them to protect themselves.
Then the third one is the partners being faithful to one another. That is also an individual choice. Now what we are trying to get people to appreciate in this country is that one can run away from this disease very easily. It is a personal choice, because lifestyle is a personal choice. If you get yourself involved in risky behaviour, you are likely to get the infection. But if you are conscious of your lifestyle, and you avoid what might force you to get infected, you are likely to stay free of infection. And this is what we are trying to get people to appreciate.
Is the message getting through?
The message is getting through, but it is a very slow process and I will admit to that. The whole idea is that habits change slowly, particularly when people are ingrained so much in their habits and lifestyles, its not that easy for them to change their lifestyle.
More so, we are dealing with a pandemic where 80 percent of infection comes from sexual activity. When it comes to the issue of sex, its not very easy for people to discipline themselves. Therefore you will realise though people know the message, they know the disease and the method of prevention, in a number of cases as a result of a lack of self discipline, they will just not do what needs to be done.
So the message is going, but we know its slow. Behaviour change is slow, but eventually we believe that we will get there.
Professor Amoa, what about the politicians, the government and the leadership? Is Aids an issue for politicians in Ghana?
In Ghana here, we are very lucky that there is a high level of political and traditional leadership that we see in our national campaign. As I said earlier on, the Commission itself is headed by His Excellency the president, Mr Kufuor.
In his absence, at all of the Commissions meetings, the vice-president himself chairs the meetings. I do fortnightly - or at times monthly - briefings to the vice-president, who in turn informs the president about whatever is going on which means that, at the highest level, they monitor whatever we are doing.
On the Commission itself, as I said, we have 15 ministers of state. And it was a decision by government to get all the key ministries represented in the Commission so that there could be mainstreaming of HIV/Aids in everything that we do. So that tells you the level of political commitment that we have.
We have also recently engaged our members of parliament for them to do advocacy and monitoring work. And we are going to support them, so that when they go to their constituencies they can monitor what is going on and give us reports. In any of their campaigns they can talk about Aids and we expect them also to take this role.
The vice-president has written to all ministers of state to make sure that, in any presentation, in any address or speech that they make any where, they must talk about AIDS and furnish the Commission with copies of their speeches. Already this is going on. We get the speeches from the ministers. That shows at least the political leadership has become very much committed to what we are doing.
From the traditional angle, our chiefs have demonstrated concern. In fact, most of our traditional chiefs have taken the HIV/Aids campaign seriously. Now traditional durbars - which are organised by these traditional chiefs - make HIV/Aids the main theme for the durbars. They flood me with a lot of requests to talk at the durbars and get support for resource persons and materials for their own people.
We have queen mothers who have also become active members in the campaign. A good example is the Manya-Krobo Queen Mothers Association. They are organising an orphanage in their area and taking care of the orphans. The Okyinhema is working closely with Osaagyefo, the Okyinhene, and they are also undertaking a number of activities.
In fact, this year the Okyinhene is organising a marathon race and a durbar to coincide with World Aids Day.
We were going to run an advocacy workshop for the National House of Chiefs in Kumasi recently. Unfortunately it had to be cancelled because of other commitments, but eventually this will be done. That shows the degree to which both the political and traditional leadership have taken up the fight.
What about Ghanas religious leaders? You have talked a bit about the churches, but what about the Imams at the mosques and others?
Our religious leaders have also come strongly on board. Until two years ago, they were not showing that much concern. They had taken an attitude of attacking people with HIV/Aids as having been immoral, or linking it with the theology of sin.
But, after a number of workshops that we had for the leadership of the churches, there has been 100 percent turnaround I would say. We are now running a programme with the Christian Council of Ghana and the Muslim Council of Ghana on compassion and care. That campaign has been on for about a year now, which brings all the church leadership together.
The Ghana Aids Commission is also currently funding about 50 different churches for their church intervention activities. So I would say that the religious leadership has also now come(s) round. The only problem that we have with the religious bodies is our promotion of the use of condoms. But we keep on talking and we have been telling them that, fine, as men of faith, they need to give hope to the hopeless. Therefore I expect that, whatever they do, they must find a way of making sure that we can protect our youth as well as the majority of the Ghanaian population. So the churches are doing very well.
Now of course, there can be as much goodwill and as much commitment as one can hope for, but what about the funding, what about the money? Where does your funding come from?
We havent got enough money, but we have enough for what were doing now. The Ghana Aids Response Fund was established with the establishment of the Ghana Aids Commission in 2001. This was with an ideal credit of US$25m from the World Bank. Later on, DFID UK also gave us 20m pounds sterling to start the Ghana Aids Response Fund.
Now we have other donors who have also been contributing in cash or in kind. We have USAID supporting us, the Netherlands Embassy supports us. We also have GTZ [Germany] and Danida [Denmark] supporting us. So we have a number of donor agencies that are giving us support.
What about the Ghana government?
The Ghana government is also making a contribution. The Ghana governments contribution is 10 percent of the USD$25m given us by the World Bank. Funds from the Ghana government have been very regular, so the Ghana government also sees its responsibility in this.
I have said this is not enough, in a sense that the US$25m was supposed to have been used for a period of four years. By the end of this year, we would have already used US$20m, which means that we need to source extra funds to continue with the project. We have every hope that we will be able to get the Bank to give us extra funds, that we will also be able to source funds from the Global Fund.
So I do not think that funding for this national campaign is the problem. What we need to do is to be able to build the capacity in the country to utilise the money that is available for resourcing.
Did Ghana look to other countries? You have talked about cooperation with Uganda - did you look to other countries on the continent or elsewhere in the world when you set up the Ghana Aids Commission?
Yes. Experiences were gathered from other countries that had done the MAP - thats the Multi Sectoral Aids Programme by the World Bank. So, apart from Uganda, we have looked at other places, like South Africa. Weve looked at Kenya. We have also worked with Asian countries, looking at what is happening in Thailand and other parts of Asia, for it to reflect on what we are doing.
One of the things we picked up from all these experiences is that, indeed, prevention and control - in other words using what I refer to as the "social vaccine" - is the most important strategy now, since we do not have a drug that will really cure HIV/Aids.
So, although we are going to have the anti-retrovirals, what we have to emphasise is that that should not replace the national campaign which is using communication and behaviour strategies. Because, it is when people change their behaviour that we can drastically reduce the current prevalence rate.
This is what has helped Uganda to come down from 30 percent to now 9 percent prevalence rate. It is all the use of behaviour change strategies. And if it has been achieved in one African country, why cant we do the same? So I think lessons from all these are helping in our national response.