Country progress

report - Sierra Leone

Global AIDS Monitoring 2020
Contents

I. Overall - Fast-track targets

II. HIV testing and treatment cascade - Ensure that 30 million people living with HIV
have access to treatment through meeting the 90-90-90 targets by 2020
III. Prevention of mother-to-child transmission - Eliminate new HIV infections among
children by 2020 while ensuring that 1.6 million children have access to HIV treatment
by 2018
IV. HIV prevention; Key populations - Ensure access to combination prevention options,
including pre-exposure prophylaxis, voluntary medical male circumcision, harm
reduction and condoms, to at least 90% of people by 2020, especially young women
and adolescent girls in high-prevalence countries and key populations—gay men and
other men who have sex with men, transgender people, sex workers and their clients,
people who inject drugs and prisoners
V. Gender; Stigma and discrimination - Eliminate gender inequalities and end all forms
of violence and discrimination against women and girls, people living with HIV and
key populations by 2020
VI. Knowledge of HIV and access to sexual reproductive health services - Ensure that
90% of young people have the skills, knowledge and capacity to protect themselves
from HIV and have access to sexual and reproductive health services by 2020, in
order to reduce the number of new HIV infections among adolescent girls and young
women to below 100 000 per year
VII. Social protection - Ensure that 75% of people living with, at risk of and affected by
HIV benefit from HIV-sensitive social protection by 2020
VIII. Community-led service delivery - Ensure that at least 30% of all service delivery is
community-led by 2020
IX. HIV expenditure - Ensure that HIV investments increase to US$ 26 billion by 2020,
including a quarter for HIV prevention and 6% for social enablers
X. Empowerment and access to justice - Empower people living with, at risk of and
affected by HIV to know their rights and to access justice and legal services to
prevent and challenge violations of human rights
XI. AIDS out of isolation - Commit to taking AIDS out of isolation through people-centred
systems to improve universal health coverage, including treatment for tuberculosis,
cervical cancer and hepatitis B and C
Overall

Fast-track targets
Progress summary
Sierra Leone is located in Western Africa, surrounded by Guinea, Liberia, and the Atlantic
Ocean. It has five regions (Western Area, North-West, Northern, Eastern and Southern)
which are divided into 16 districts. The capital city is Freetown which is located in the Western
Area Urban. It has a population of 7,092,113 people (Census 2015).

The Country has a mixed and generalized HIV epidemic; with a prevalence of 1.7% (SLDHS,
2019). The 2019 Demographic and Health Survey (SLDHS, 2019) indicates that HIV
prevalence is higher in urban areas than in rural areas (2.3% versus 1.2%). Relating these
variations in HIV prevalence with the population density resulted in the classification of new
high burden districts, thus reprogramming for focused service delivery.

The Country has prioritized domestic resource mobilization drive as key, aimed at sustainable
program implementation. The Government of Sierra Leone Counterpart funding allocation has
improved considerably.
3.1 HIV incidence rate per 1000, Sierra Leone (2010-2019)
Number of people newly infected with HIV in the reporting period per 1000 uninfected
population

Source: Spectrum file

1.7 AIDS mortality per 100 000, Sierra Leone (2010-2019)

Total number of people who have died from AIDS-related causes per 100 000
population

Source: Spectrum file

4.1 Discriminatory attitudes towards people living with
HIV, Sierra Leone (2019)
Percentage of respondents (aged 15-49 years) who respond "No" to: Question 1 -
"Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this
person had HIV?"; Question 2 - "Do you think that children living with HIV should be
able to attend school with children who are HIV negative?"
HIV testing and treatment
cascade

Ensure that 30 million people living with HIV have access to

treatment through meeting the 90-90-90 targets by 2020
Progress summary
Sierra Leone continues to make positive strides in its HIV testing and treatment efforts. To
increase HIV testing volume, Sierra Leone is scaling-up provider initiated testing at facilities,
targeted outreach testing among vulnerable populations, family testing and key populations
targeted testing, in addition to its routine antenatal care. The number of people tested and
received results in 2019 were 689,237in both general population and among pregnant women
attending ANC and PMTCT services. The Country has adopted the WHO recommendations
on test and treat. In 2019, 32,438 People Living with HIV (PLHIV) accessed ART while 4,129
pregnant women received ARVs to reduce the risk of mother to child transmission of HIV.
Policy questions (2019)
Is there a law, regulation or policy specifying that HIV testing:

a) Is mandatory before marriage

No

b) Is mandatory to obtain a work or residence permit

No

c) Is mandatory for certain groups

Yes

Recruits at Police and Military training institutions, and Pregnant Women

What is the recommended CD4 threshold for initiating antiretroviral therapy in adults
and adolescents who are asymptomatic, as per MoH guidelines or directive, and what
is the implementation status?

No threshold; treat all regardless of CD4 count; Implemented countrywide (>95% of treatment
sites)

Does your country have a current national policy on routine viral load testing for
monitoring antiretroviral therapy and to what extent is it implemented?

a) For adults and adolescents

Yes; Implemented countrywide (>95% of treatment sites)

b) For children

Yes; Implemented countrywide (>95% of treatment sites)

HIV testing and treatment cascade, Sierra Leone (2019)

Source: Spectrum file

Progress towards 90-90-90 target, Sierra Leone (2019)

Source: Spectrum file

1.1 People living with HIV who know their HIV status, Sierra
Leone (2010-2019)
Number of people living with HIV who know their HIV status

Source: Spectrum file

1.2 People living with HIV on antiretroviral therapy, Sierra

Leone (2010-2019)
Number of people on antiretroviral therapy

Source: Spectrum file

1.3 People living with HIV on antiretroviral treatment who have
suppressed viral load, Sierra Leone (2010-2019)
Number of people living with HIV with suppressed viral loads

Source: Spectrum file

1.4 Late HIV diagnosis, Sierra Leone (2019)

Percentage of people living with HIV with the initial CD4 cell count <350 cells/mm3
during the reporting period
1.6 AIDS mortality rate per 100 000, Sierra Leone (2010-2019)
Total number of people who have died from AIDS-related causes per 100 000
population

Source: Spectrum file

1.6 AIDS mortality rate per 100 000 among adults, Sierra
Leone (2010-2019)
Total number of adults who have died from AIDS-related causes per 100 000 population

Source: Spectrum file

1.7 HIV testing volume and positivity, Sierra Leone
Percentage of HIV -positive results returned to people (positivity) in the calendar year
Prevention of mother-to-
child transmission

Eliminate new HIV infections among children by 2020 while

ensuring that 1.6 million children have access to HIV
treatment by 2018
Progress summary
There are 866 health facilities providing PMTCT services. The country practices Option B+;
treating all HIV positive women during pregnancy and providing lifelong antiretroviral
medication to mothers. The country has continued to offer dual testing for HIV and Syphilis for
pregnant using the Duo HIV/Syphilis test kits. Capacity building of national teams, District
Health Management Team (DHMT) and facility staff (across facilities in Western Area Urban
and Rural, Port Loko, Kono, Bombali districts, Kenema, Pujehun, Moyamba, Kambia,
Koinadugu and Bonthe) was conducted to optimize coverage of viro-logical testing for infants
and to enable effective delivery and monitoring of comprehensive PMTCT services. Early
Infant Diagnosis (EID) sample collection services were also strengthened through
collaboration with key units like Expanded Program on Immunization (EPI) and Under-five
Clinics, therapeutic package at the facilities. Handbook of frequently asked questions in
paediatric HIV care for pre-service and in-service health workers; job aids and Information
Education and Communication / Behaviour Change Communication (IEC/BCC) materials
were developed to improve provider and patient knowledge on Pediatric HIV. National
guidelines for Sierra Leone Hub and Sample transportation system has been validated aimed
at enhancing EID, Viral Load and routine surveillance system.
Policy questions (2019)
Does your country have a national plan for the elimination of mother-to-child
transmission of HIV?

Yes

Target(s) for the mother-to-child transmission rate and year: <5%; 2020

Elimination target(s) (such as the number of cases/population) and year: <5%; 2020

Do the national guidelines recommend treating all infants and children living with HIV
irrespective of symptoms and if so, what is the implementation status of the cut-off?

Treat all, regardless of age

Implemented countrywide (>95% of treatment sites)

2.1 Early infant diagnosis, Sierra Leone (2011-2019)
Number of infants who received an HIV test within two months of birth

2.1 Early infant diagnosis, Sierra Leone (2018-2019)

Percentage of infants born to women living with HIV receiving a virological test for HIV
within two months of birth

Source: Spectrum file

2.2 Mother-to-child transmission of HIV, Sierra Leone (2010-
2019)
Estimated percentage of children newly infected with HIV from mother-to-child
transmission among women living with HIV delivering in the past 12 months

Source: Spectrum file

2.3 Preventing mother-to-child transmission of HIV, Sierra

Leone (2010-2019)

Source: Spectrum file

2.3 Preventing mother-to-child transmission of HIV, Sierra
Leone (2018-2019)
Percentage of pregnant women living with HIV who received antiretroviral medicine to
reduce the risk of mother-to-child transmission of HIV

Source: Spectrum file

2.4 Syphilis among pregnant women, Sierra Leone (2019)

Percentage of pregnant women tested for syphilis
2.4 Syphilis among pregnant women, Sierra Leone (2019)
Percentage of pregnant women tested positive for syphilis

2.4 Syphilis among pregnant women, Sierra Leone (2019)

Percentage of pregnant women on treatment among those who tested positive
2.5 Congenital syphilis rate (live births and stillbirth), Sierra
Leone (2013-2019)
Number of reported congenital syphilis cases (live births and stillbirths)

2.6 HIV testing in pregnant women, Sierra Leone (2018-2019)

Percentage of pregnant women with known HIV status
HIV prevention; Key
populations

Ensure access to combination prevention options, including

pre-exposure prophylaxis, voluntary medical male
circumcision, harm reduction and condoms, to at least 90% of
people by 2020, especially young women and adolescent girls
in high-prevalence countries and key populations—gay men
and other men who have sex with men, transgender people,
sex workers and their clients, people who inject drugs and
prisoners
Progress summary
In 2019, more Peer Educators and Peer Navigators (PE/PN) were engaged and trained in the
provision of combination prevention services to beneficiaries (FSWs, MSM, PWID) and other
stakeholders at hot-spots located across different communities. Awareness messages on
HIV and AIDS were provided by the Peer educators to beneficiaries and their Pimps, Mammy
Queens through face-to-face encounters at hot-spots and also through designated social
media group forums. HIV testing and counselling services are also carried out on KPs with full
participation of Peer Educators, Navigators and Counsellors. Adherence to ART has
improved through the use of peer navigators who work with new case clients. The Navigators
also collect and dispatch drugs to clients who are constrained to visit the health centre on
prescribed visit dates. Activities provided include HCT services, condom and lubricant
distribution and peer support. In 2019 10,721 MSM, 85,930 FSW, and 1,548 PWID were
reached with prevention services.
Policy questions: Key populations (2019)
Criminalization and/or prosecution of key populations

Transgender people

• Criminalized

Sex workers

• Selling sexual services is criminalized

Men who have sex with men

• Yes, imprisonment (up to 14 years)

Is drug use or possession for personal use an offence in your country?

• Drug use or consumption is specified as a criminal offence

Legal protections for key populations

Transgender people

• Criminalized

Sex workers

• No

Men who have sex with men

• No

People who inject drugs

• No

Has the WHO recommendation on oral PrEP been adopted in your country's national
guidelines?

No, guidelines have not been developed

3.1 HIV incidence rate per 1000, Sierra Leone (2010-2019)
New HIV-infections in the reporting period per 1000 uninfected population (Adults,
ages 15-49)

Source: Spectrum file

3.3 HIV prevalence among key populations, Sierra

Leone (2011-2019)
Percentage of specific key populations living with HIV
3.6 Condom use among key populations, Sierra Leone (2011-
2019)
Percentage of people in a key population reporting using a condom the last time they
had sexual intercourse

3.9 Needles and syringes distributed per person who injects

drugs, Sierra Leone (2011-2019)
Number of needles and syringes distributed per person who injects drugs per year by
needle-syringe programmes
3.18 Condom use at last high-risk sex, Sierra Leone (2019)
Percent of respondents who say they used a condom the last time they had sex with a
non-marital, non-cohabiting partner, of those who have had sex with such a partner in
the last 12 months

3.19 Annual number of condoms distributed, Sierra Leone

(2019)
Number of condoms distributed during the past 12 months
3.19 Annual number of condoms distributed, Sierra Leone
(2019)
Number of condoms distributed during the past 12 months
Gender; Stigma and
discrimination

Eliminate gender inequalities and end all forms of violence

and discrimination against women and girls, people living
with HIV and key populations by 2020
Progress summary
Since stigma and discrimination remain a social challenge that limit uptake of HIV services in
many communities, NETHIPS uses its community based structures to create awareness and
demand for HIV services. Sessions on reducing stigma and discrimination in the health
facilities have been integrated into training sessions and form part of community dialogues for
many of the organizations providing services to key organizations. Furthermore, linking FSWs
to support groups have also encouraged them (i.e. FSWs) to discuss their challenges and
successes in a safe environment which is free of stigma, discrimination and judgment.

The Community Treatment Observatory (CTO) was a NETHIPS - led initiative that used
locally generated evidence to engage relevant authorities on service delivery. In Sierra Leone,
where practices of Key population is criminalized, the CTO provided opportunity for PLHIV
and key populations to engage duty bearers and/or relevant stakeholders on improving
access to quality, uninterrupted HIV treatment in Sierra Leone.
Policy questions (2018)
Does your country have a national plan or strategy to address gender-based violence
and violence against women that includes HIV

Yes

Does your country have legislation on domestic violence*?

Yes

• Physical violence

• Sexual violence

• Psychological violence

• Emotional violence

• Economic violence

• Explicit criminalization of marital rape

• Protection of unmarried intimate partners

What protections, if any, does your country have for key populations and people living
with HIV from violence?

• General criminal laws prohibiting violence

• Programmes to address intimate partner violence*

• Programmes to address workplace violence

• Interventions to address police abuse

• Interventions to address torture and ill-treatment in prisons

Does your country have policies in place requiring healthcare settings to provide
timely and quality health care regardless of gender, nationality, age, disability, ethnic
origin, sexual orientation, religion, language, socio-economic status, HIV or other
health status, or because of selling sex, using drugs, living in prison or any other
grounds?

Does your country have laws criminalizing the transmission of, non-disclosure of or
exposure to HIV transmission?

Yes
4.1 Discriminatory attitudes towards people living with
HIV, Sierra Leone (2019)
Percentage of respondents (aged 15-49 years) who respond "No" to: Question 1 -
"Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this
person had HIV?"; Question 2 - "Do you think that children living with HIV should be
able to attend school with children who are HIV negative?"

4.3 Prevalence of recent intimate partner violence, Sierra

Leone (2020)
Proportion of ever-married or partnered women aged 15-49 who experienced physical
or sexual violence from a male intimate partner in the past 12 months
Percentage of Global AIDS Monitoring indicators with data
disaggregated by gender
Knowledge of HIV and
access to sexual
reproductive health
services

Ensure that 90% of young people have the skills, knowledge

and capacity to protect themselves from HIV and have access
to sexual and reproductive health services by 2020, in order
to reduce the number of new HIV infections among adolescent
girls and young women to below 100 000 per year
Progress summary
Topics on HIV and AIDS prevention, treatment, care and support services and reproductive
health are included in curriculum for primary and secondary schools. Young people actively
participate in developing policies and strategies on their own health. There is an education
policy that guides the delivery of life skills based HIV and sexuality education in Primary,
Junior and Senior Secondary and Tertiary institutions. Topics on HIV and AIDS are part of
questions in public examinations.

Community based organizations often reach out to youths and train them as peer health
educators in and out of school to lead engagement of their peers with tailored behaviour
change communication messages. Youth friendly centres are also available across the
country to provide youth focused approaches to sexual reproductive health and peer support;
some of these centres provide HIV services as well.
Policy questions (2018)
Does your country have education policies that guide the delivery of life skills-based
HIV and sexuality education, according to international standards, in:

a) Primary school

Yes

b) Secondary school

Yes

c) Teacher training

Yes
5.2 Demand for family planning satisfied by modern
methods, Sierra Leone (2017)
Percentage of women of reproductive age (15-49 years old) who have their demand for
family planning satisfied with modern methods
Social protection

Ensure that 75% of people living with, at risk of and affected

by HIV benefit from HIV-sensitive social protection by 2020
Progress summary
Sierra Leone has a frame work on social protection for all vulnerable populations and this is
being implemented and enforced across the country. The country has supported the
establishment of the Network of HIV Positive Persons (NETHIPS), which is an umbrella care
and support organization that advocates for the rights of its constituents. The support has
been towards engendering livelihoods in the form of vocational centres, agricultural livelihood
projects and fish ponds. There are plans to launch revolving loan schemes as part of poverty
alleviation strategy for support group members. The Global Fund has supported the
establishment of one drop in centre for NETHIPs in the Western Area aimed at providing a
forum for PLHIVs to meet and articulate issues on positive living.
Policy questions (2019)
Does the country have an approved social protection strategy, policy or framework?

Yes, and it is being implemented

a) Does it refer to HIV?

Yes

b) Does it recognize people living with HIV as key beneficiaries?

Yes

c) Does it recognize key populations (sex workers, gay men and other men who have
sex with men, people who inject drugs, transgender people, prisoners) as key
beneficiaries?

No

•-

d) Does it recognize adolescent girls and young women as key beneficiaries?

Yes

e) Does it recognize children affected by HIV as key beneficiaries?

Yes

f) Does it recognize families affected by HIV as key beneficiaries?

No

g) Does it address the issue of unpaid care work in the context of HIV?

No

What barriers, if any, limit access to social protection programmes in your country?

• Lack of information available on the programmes

• Complicated procedures

• Fear of stigma and discrimination

• Laws or policies that present obstacles to access

Community-led service
delivery

Ensure that at least 30% of all service delivery is community-

led by 2020
Progress summary
The Network of HIV Positive persons (NETHIPs), the umbrella organization for Persons living
with and affected by HIV in Sierra Leone, has forty-six support groups nationwide and play a
critical role in providing care and support to PLHIVs and OVCs in Sierra Leone. Through
support group meetings, PLHIV benefit from health talks aimed at promoting positive living
practices. They are encouraged to adhere to anti-retroviral treatment, monitor their viral load,
observe personal hygiene and use condom to prevent transmission to their loved ones.
NETHIPS supports elimination of mother to child transmission of HIV agenda through its
mother-to-mother support groups. In 2019, women living with HIV as volunteer, followed up
500 pregnant and lactating HIV positive women with the aim of supporting treatment uptake
and adherence. NETHIPS has established a Drop-in-center to provide counselling and testing
support to family members of index cases. This service helps discordant couples to
understand and deal with the challenges that come with living with HIV.

NETHIPS play a critical role in reaching their peers for the purpose of improving treatment
uptake through the Community Health Worker (CHW) program led by the National AIDS
Control Program. NETHIPS supports the CHW program by providing PLHIV volunteers. Over
300 CHWs have been trained and assigned to referral hospitals in the seven high burden
districts to provide support to clinical staff through task shifting and also to follow up on
PLHIV in the community
Policy questions (2019)
Does your country have a national policy promoting community delivery of
antiretroviral therapy?

No

Are there any of the following safeguards in laws, regulations and policies that provide
for the operation of CSOs/CBOs in your country?

• Registration of HIV CSOs is possible

• Registration of CSOs/CBOs working with key populations is possible

• HIV services can be provided by CSOs/CBOs

• Services to key populations can be provided by CSOs/CBOs

• Reporting requirements for CSOs/CBOs delivering HIV services are streamlined

HIV expenditure

Ensure that HIV investments increase to US$ 26 billion by

2020, including a quarter for HIV prevention and 6% for social
enablers
Progress summary
The national response for HIV/AIDS is funded largely by international donors. The largest
donors are Global Fund (USD 9,889,000), and KfW – German Fund (€255,873.34). Domestic
resource mobilization strategy is available in country in order to generate sustainable
financing. The government has committed and allocated an HIV budget line of 14,635,627
SLL for the HIV response and continues to uphold their 5% counterpart financing to the
Global Fund grant.
8.2 The average unit prices of antiretroviral regimens (in
US$), Sierra Leone (2018-2019)

8.3 HIV expenditure by programme category, Sierra

Leone (2013-2019)
Share of effective prevention out of total, Sierra Leone (2019)
Empowerment and
access to justice

Empower people living with, at risk of and affected by HIV to

know their rights and to access justice and legal services to
prevent and challenge violations of human rights
Progress summary
A memorandum of understanding exists between the Principal Recipient and the Legal Aid
Board; a para-legal institution providing legal services for key populations across the Country.
Additional Drop-in-Centers have been established across the Country and among others,
provide a forum for interaction among Key Populations, minor health care services, and
additionally serve as a ‘Safe Havens’ to articulate issues of violation of human right for
onward referral to the legal Aid board
Policy questions (2018)
In the past two years have there been training and/or capacity building programmes for
people living with HIV and key populations to educate them and raise their awareness
concerning their rights (in the context of HIV) in your country?

Yes, at scale at the national level

Are there mechanisms in place to record and address cases of HIV-related

discrimination (based on perceived HIV status and/or belonging to any key
population)?

Yes

What accountability mechanisms in relation to discrimination and violations of human

rights in healthcare settings does your country have, if any?

• Complaints procedure

• Mechanisms of redress

• Procedures or systems to protect and respect patient privacy or confidentiality

What barriers in accessing accountability mechanisms does your country have, if any?

• Affordability constraints for people from marginalized and affected groups

• Awareness or knowledge of how to use such mechanisms is limited

AIDS out of isolation

Commit to taking AIDS out of isolation through people-

centred systems to improve universal health coverage,
including treatment for tuberculosis, cervical cancer and
hepatitis B and C
Progress summary
The National HIV programming is integrated in the health system in varying degrees. There is
TB/HIV collaboration between the National AIDS Control Program and the National Leprosy
and Tuberculosis Control Program reflected by co-location of TB/HIV facilities, joint
programing among community health workers for defaulter tracing. HIV and AIDS treatment
care and support services are also integrated into Sexual Reproductive Health services and
at Adolescent and Youth friendly centres. A pilot study has commenced for Hepatitis B among
HIV positive clients on ART in the main referral hospital in the capital city.
Policy questions (2019)
Is cervical cancer screening and treatment for women living with HIV recommended in:

a) The national strategy, policy, plan or guidelines for cancer, cervical cancer or the
broader response to non-communicable diseases (NCDs)

No

b) The national strategic plan governing the AIDS response

No

c) National HIV-treatment guidelines

No

What coinfection policies are in place in the country for adults, adolescents and
children?

• Isoniazid preventive therapy (IPT) or latent TB infection (LTBI) prophylaxis for people living
with HIV

• Intensified TB case finding among people living with HIV

• TB infection control in HIV health-care settings

• Co-trimoxazole prophylaxis
10.1 Co-managing TB and HIV treatment, Sierra Leone (2011-
2019)
Number of HIV-positive new and relapse TB patients started on TB treatment during
the reporting period who were already on antiretroviral therapy or started on
antiretroviral therapy during TB treatment within the reporting year

10.2 Proportion of people living with HIV newly enrolled in HIV

care with active TB disease, Sierra Leone (2015-2019)
Total number of people living with HIV with active TB expressed as a percentage of
those who are newly enrolled in HIV care (pre-antiretroviral therapy or antiretroviral
therapy) during the reporting period
10.3 Proportion of people living with HIV newly enrolled in HIV
care started on TB preventive therapy, Sierra Leone (2015-
2019)
Number of patients started on treatment for latent TB infection, expressed as a
percentage of the total number newly enrolled in HIV care during the reporting period

10.4/10.5 Sexually transmitted infections, Sierra Leone (2013-

2019)
Number of men reporting urethral discharge in the past 12 months; number of men
reported with laboratory-diagnosed gonorrhoea in the past 12 months