Teams conducting External Quality Assurance for HIV testing to verify quality of laboratory testing in Gedo

1 December 2021 - World AIDS Day is commemorated on 1 December every year to shed light on the plight of people living with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), and the challenges they face. This year’s global World AIDS Day is being held under the theme “End inequalities. End AIDS”. In the Eastern Mediterranean Region of the World Health Organization (WHO), the campaign has “Getting back on track – Focus on testing” as a regional theme in response to the disruption of HIV testing services during the COVID-19 pandemic, with a special focus on reaching the people left behind.

Given that HIV remains a major public health issue and is still a pandemic around the world, WHO is calling on global leaders and communities to rally to address the inequalities that drive AIDS and to try to reach those who do not have access to essential HIV services. The growing inequality, if not addressed, can only fuel and aggravate the divide between those having access to HIV testing and services and those who do not have access to testing, treatment and care.

HIV prevalence in Somalia

Periodic surveys conducted on the prevalence of HIV in Somalia have shown that the rate of infection has been dropping over the last 14 years. The findings of a 2014 survey showed that the HIV prevalence in Somalia had reduced to a level that could be classified as a low-level epidemic in all the states. The most recent survey, conducted during 2018, showed that average antenatal HIV prevalence across the country stood at 0.1% for all states. By geographical area, it was at 0.15% in Somaliland, 0.17% in Puntland and 0.04% in other federal member states. Despite the overall decline, the more dramatic drop in Somaliland, from just over 1.0% between 2004 and 2010, to 0.15% in 2018, meant that for the first time in 14 years of surveys, HIV prevalence in Puntland stood above that for Somaliland.

“The low HIV prevalence in Somalia can be attributed to Somali culture and society, and few risk factors as a result of behaviour,” said Dr Sadia Abdisamad Abdullahi, National HIV/AIDS Programme Manager.

Despite the general decline in HIV prevalence across Somalia, there are locations such as Garowe and Bosasso in Puntland where the infection rates have merely levelled off, with the risk of increasing yet again. The next survey among pregnant women is scheduled for 2023.

Salim Musa* – diagnosed with HIV in March 2014 and an advocate for supporting HIV and AIDS patients in Somalia – thinks the HIV rates may be higher in some groups and locations that were not covered in recent surveys. It is fairly easy for Somalis living in urban areas to access HIV tests and antiretroviral therapy (ART) free of cost in 17 health facilities in various states. For those in rural areas, it can be difficult for people to get tested, explains Salim. Most people do not even know about the symptoms of HIV and where to access services. It is usually at a late stage that many people living with HIV contact doctors for support.

Despite the challenges, by September 2021, 3784 patients were receiving ART at the 17 health facilities spread across different states, 72.5% of whom were already on the newer, more effective dolutegravir-based regimens.

Families, workplaces, health care workers and policies are key to bringing about change

Salim feels he was lucky – he credits his father, a doctor, and his well-educated siblings for encouraging him to seek early treatment after his diagnosis, and for giving him the confidence to deal with his struggles in life.

Persons living with HIV still face a lot of stigma, including in health facilities, in Somalia

There is still a lot of stigma and shame associated with HIV in Somalia though, Salim adds. Years ago, at his workplace, people treated him very badly, and requested him to work from home so that no one could be in touch with him. This experience isolated him and forced him to leave to look for a more empathetic team. Now, Salim wears many hats – he works with nongovernmental organizations, vulnerable populations, the government, AIDS commissions, and technical advisors to advocate for the rights of people living with HIV. People he speaks to have been fired from their jobs or denied employment over their HIV positive status.

When Salim first visited a health facility to confirm his HIV status, he was surprised to see that the director of the facility, who tested him, was judgemental and overbearing, and did not respect him and other patients.

Salim shares some of the stories of patients he has worked with. One day, he spoke to a lady who was living with HIV and had fractured her leg. She was in excruciating pain. Even though she had enough money, Salim describes, not one doctor from nine hospitals she visited was ready to help her because of her HIV status.

In another case, a lady who was living with HIV contracted COVID-19. She rushed to the hospital when she needed oxygen but, sadly, no one helped her and she died. Another woman was forced to deliver her baby herself right at the doors of a hospital when medical personnel refused to let her in, as she was known to be HIV positive.

“I feel really sad when I hear these stories,” said Salim. “I feel that policy-makers should help enforce systems and oversight mechanisms to ensure that health personnel do not discriminate against any patients at all, including those living with HIV. No one should have to miss out on receiving medical care, and no health personnel should deny anyone services. They are in a profession where they must help others.”

“We must all work together to put an end to inequalities that leave Somalis out of the health service system. Decision-makers, health facilities, families and individuals all need to provide support to people living with HIV and prevent the spread of this disease,” said Dr Mamunur Rahman Malik, WHO Representative to Somalia. “Early testing and treatment can help people with HIV to battle this disease in good time.”

*Name changed to protect identity.

Related link

World AIDS Day 2021 campaign site

Photo credits: WHO/Andrew Kent

22 November 2021 – Injuries are one of the major public health concerns in Somalia, owing to road traffic accidents and ongoing conflicts. From blast injuries alone, approximately 80 lives are lost every month, and for every death related to an injury, there are 20–50 non-fatal injuries that result in some form of disability, impacting quality of life, productivity and financial security.

There are 2 primary providers for first aid in Mogadishu ─ Aamin Ambulance and the Somali Red Crescent Society ─ but between them they have only 21 functioning ambulances to serve a large population. Approximately, one third of these deaths related to injuries could be avoided if community trauma care, paramedical services and transportation were made available. However, there is currently no effective pre-hospital care system beyond Mogadishu and after emergencies, patients are rushed to hospitals through their own means, often in a private vehicle or carried by relatives.

The lack of an organized pre-hospital transportation system, along with no organized community first aid means that the delay between the point of injury and first contact with the hospital will lead to increased likelihood of death or disability.  The situation is further compounded by the lack of a formal organized transport system to move patients from one hospital to another, when they require more complex interventions. 

Receiving the right care to avoid injuries and death  

Dr Musa Haji, who serves as a first responder to emergencies at the Keysaney Hospital in north Mogadishu, knows the importance of providing early trauma care close to the point of injury. 

The driver of the rented car and Ali’s family were not conversant with how to deal with the injuries sustained. If his family had called the local pre-hospital provider, they could have prevented the secondary, serious spinal injury, as Ali would have received professional advice and support. 

Investing correctly to reduce high burden and cost of injuries  

In low-income countries such as Somalia, families face high burdens and costs of injuries. Yet, this burden can be reduced significantly. Paradoxically, even though Somalia faces recurrent emergencies and natural disasters, it does not have the capacity to offer this crucial support equitably to all of its communities. 

“By investing in injury care, we can help communities and countries at large to avoid the exorbitant costs of early death, complications, prolonged recovery, and prevention of disability. The true costs of all these to a family in a fragile, low-income country such as Somalia can be really high,” said Dr Mamunur Malik, WHO Representative to Somalia. 

Pre-hospital care key to survival in emergencies 

WHO has teamed up with the federal and state ministries of health to build Somalia’s capacity to offer timely and crucial, life-saving prehospital care. This is an integral component of both the emergency care pathway, a journey that begins at the point of injury through to the hospital, and a patient’s referral pathway, which facilitates the transfer of patients with medical conditions from the point of injury or one health care facility to a health facility that can offer the right attention.

“The training and support that WHO and the Government are offering to first responders will serve as scaffolding for emergency health services in Somalia, as we are empowering both health professionals and eventually lay people at the front lines, from the point of an incident or injury to facilities that can care for victims, right back to victims’ reintegration in the society,” added Dr Malik. 

As part of this initiative, a team of experts from the WHO Regional Office for the Eastern Mediterranean and WHO country office conducted a workshop on 2 November 2021 to engage with 15 participants from various ambulance services, mostly based in Mogadishu. 

“Our findings have revealed that between 60 and 80% of all trauma deaths in humanitarian emergencies across the Eastern Mediterranean Region, occur before reaching the hospital, frequently referred to as dead on arrival (DOA). Community volunteers and frontline providers lack training and supplies for basic life-saving interventions, such as haemorrhage control and airway management. It follows then, that by focusing on immediate and early trauma management as the first phase of this initiative, a significant number of deaths can be demonstrably avoided,” said Dr Sara Halimah, WHO Regional Trauma Specialist. 

During their discussions at the workshop, participants also discussed the current situation and low-cost, high-impact solutions to establishing pre-hospital care. 

“People don’t make way for us” 

Participants also highlighted some of the challenges they face, including no roads and insecurity, which hinders access to people in need. 

“At times, when emergencies occur, families of victims don’t call or use us. They prefer to use private vehicles, as they don’t understand what we do, and why we would help them,” said Dr Abdirahman Ali Dahir, Anaesthetist and Consultant from the Aamin Ambulance services. “In many cases, in traffic, people don’t make way for us, as they do in developed countries. The lack of community awareness is a big challenge for us which slows down our response during emergencies.”

In addition to this challenge, most states do not have ambulances. On the limited occasions when ambulances have qualified staff, they do not have adequate life-saving equipment, such as torniquets that can help reduce severe bleeding, and staff cannot access standard accredited courses or training to help them refresh their knowledge, skills, and reaction time during emergencies. 

Given the need for frontline emergency responders to continuously develop their skills, workshops like this will help to develop manuals and a roadmap for future training programme. This in turn will have a positive impact on enhancing emergency and trauma care services in the country.   

Credits: WHO

17 November 2021 – World Antimicrobial Awareness Week, commemorated from 18 to 24 November every year, aims to draw attention to the crucial issue of the proper use of antimicrobials, such as antibiotics, antivirals, antifungals and antiparasitics. 

This year, the theme for the campaign is to ‘Spread Awareness, Stop Resistance’. The theme calls on 'One Health' stakeholders, policy-makers, health care providers, and the general public to be antimicrobial resistance (AMR) awareness champions. 

Improper use of antimicrobials a root cause of resistance 

The lack of a functioning national medicine regulatory authority, coupled with unregulated private pharmaceutical suppliers, personnel and quality of medication, has resulted in the circulation of substandard imported medicines and AMR in Somalia. In addition, the misuse and overuse of antimicrobials are the main drivers in the development of drug-resistant pathogens.

Anecdotal evidence states that health care professionals tend to oversubscribe antibiotics, offering them over the counter, without prescriptions, and often without the right advice. Together, these challenges have encouraged the spread of AMR, whereby microbes, such as bacteria, parasites, viruses and fungi, become resistant to antimicrobials. As a result of the high incidence and prevalence of AMR, it is likely that prescription medicines are becoming less effective at fighting infections, which in turn is increasing the risk of disease spread, severe illness and death. 

Joining forces to “spread awareness, stop resistance” 

“While antimicrobial resistance is a global issue, in Somalia, we can reduce resistance to antimicrobials only if all stakeholders – policy-makers, health care providers and community members, pharmaceutical suppliers – play their role in spreading awareness about the right use of medication, prevention of resistance, and galvanizing consistent action around this topic,” said Her Excellency Dr Fawziya Abikar Nur, the Federal Minister of Health and Human Services in Somalia.

She added that policy-makers can help to design and implement policies to regulate the importation, sales and quality of medications. Communities can be more responsible with the use of medication, noting when to use antimicrobials, and to complete courses once started, for instance. Health professionals can be careful not to overprescribe medications and to dispense only high-quality medication. Agencies such as the media can support to spread the right messages.

Actions being taken to address antimicrobial resistance 

In 2020, Somalia developed a national action plan to combat AMR, with support from the World Health Organization (WHO). The plan, which is yet to be endorsed formally by the Federal Government, outlines 4 pillars that would help control AMR — raising awareness, increasing surveillance of cases of drug resistance to infectious diseases, infection prevention and control (IPC), and the proper use of antimicrobials. 

Recognizing the interconnectivity between humans, animals and plants outlined in the ‘One Health’ approach, the national action plan also advocates for the prevention of AMR at the human-animal interface and in food chains, by raising awareness as well as by implementing concrete health actions.     

Highlighting ways in which Somalia and its partners can address this situation, Dr Mamunur Rahman Malik, WHO Representative to Somalia said, “Education is a key component in driving action. Even though we have seen many other urgent health issues such as COVID-19 take over the limelight, we must have conversations about the impact of antimicrobial resistance on the health of both humans and animals, and to incorporate this topic at all levels of health education.” 

AMR remains a global health and development threat. It requires urgent multisectoral action in order to achieve the Sustainable Development Goals (SDGs). WHO has declared that AMR is one of the top 10 global public health threats facing humanity. The cost of AMR to the economy is significant. In addition to death and disability, prolonged illness results in longer hospital stays, the need for more expensive medicines and financial challenges for those impacted. Without effective antimicrobials, the success of modern medicine in treating infections, including during major surgery and cancer chemotherapy, would be at increased risk.

Somalia will celebrate the week through awareness raising sessions among health care providers and policy-makers in the country, as well as through committing to implement the national action plan for AMR, costing the national action plan, taking concrete actions for understanding the burden of AMR in the country through point prevalence studies, and introducing a sentinel-based surveillance system for regularly monitoring the threat and trend of AMR in the country. Building country capacity for detection and responding to the emerging threat of AMR in the country will be at the heart of these activities.   

For additional information, please contact: 

Khadar Hussein Mohamud
Head of Coordination and Communication
Federal Ministry of Health and Human Services, Somalia
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
+252 615 602 637

Fouzia Bano
WHO Chief of Staff ai, Communications Officer
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+252 619 235 880 

11 November 2021 – In the last 3 decades, Somalia has faced protracted conflict and emergencies — as a result of which the high burden of injuries has been ubiquitous and often poorly addressed from the public health lens. 

The public health burden of injuries and trauma 

In December 2020 and January 2021, the Federal Ministry of Health, with technical support from World Health Organization (WHO), conducted a rapid assessment of critical care services in 136 hospitals across 18 regions and focus group discussions with frontline health care workers in Somalia. This was supported by the World Bank under its Pandemic Emergency Financing Facility to improve access to health services in Somalia. 

The assessment revealed that trauma imposes a heavy burden on the Somali health system and the community at large. The hospitals had recorded more than 37 000 civilian trauma cases over 12 months. Yet, the survey referred to cases of conflict alone. If it had included road traffic accidents, domestic injuries and burns, or covered small peripheral hospitals and primary health care centres, the number of civilian trauma cases recorded would have been even higher. The Global Burden of Disease Study published in 2019 by the Institute for Health Metrics and Evaluation, Seattle, shows that the share of the disability burden of injuries increased from 6.23% in 2000 (age-standardized rate: 5617.28 disability-adjusted life years (DALYs) lost per 100 000 population) to 8.60% (age-standardized rate: 5739.72 DALYs lost per 100 000 population) in 2019. These figures are projected to increase to 6300.88 age-standardized DALYs per 100 000 population and 6.49% of DALYs lost in Somalia in 2030. The substantial increase in conflict and terror as well as the increased burden of road injuries observed between 2000 and 2019 were the main factors driving the upward trend in injury-related deaths and disability in Somalia. The study also showed that deaths caused by injuries were estimated to be 119.10 per 100 000 population in Somalia in 2019, and injuries were responsible for an estimated 7.35% of all deaths reported in the country. 

Injuries and trauma pose a double threat to affected communities. In addition to the physical burden caused by injuries, trauma is also known to have a negative effect on the socioeconomic environment in a country. By this measure, it increases poverty levels, as families of the injured need to spend substantive time, money and efforts caring for their loved ones. 

The capacity of the existing system  

In Somalia, there is a scarcity of health personnel. For example, there are no paediatric trauma specialists and no recognized medical anaesthetists working in the public sector. Half of the hospitals surveyed functioned with only one or 2 general surgeons and only 5 hospitals claimed to have surgeons with a background in orthopaedic surgery. 

There is currently no effective pre-hospital system beyond central Mogadishu; and communities in rural and remote areas have little or no access to trauma care.  In the wider picture, this includes maternity services and women die needlessly for want of basic prehospital care. 

“It is an undeniable paradox that in recent times those most in need of trauma care services are the least able to access those services. As one of the few UN agencies working in this field, WHO has stepped up to provide technical assistance and coordinate the trauma care response in the country,” said Dr Mamunur Rahman Malik, WHO Representative to Somalia. “This support is largely being steered by the Government of Somalia, and we are working closely with hospitals and personnel to make advances in this field.”  

Establishing a WHO trauma programme for Somalia 

The WHO country office for Somalia, with support from the WHO Regional Office for the Eastern Mediterranean, is setting up a trauma care programme that is built on the vision of a holistic approach to trauma, from the point of injury, when one is injured, through surgery to the physical rehabilitation of the patient, back into the community.  

As part of this initiative, the WHO delivered the first Surgical Team Approach to Trauma (STAT) course, using high technology surgical simulation facilities and virtual reality. Overall, 31 health workers were trained, bringing together surgeons and anaesthetists to embed a team-based approach to trauma management. The training took place from 3 to 7 October in Mogadishu and 11 to 15 October 2021 in Berbera. Trainees were exposed to high fidelity scenarios in an operating theatre, all while observing strict COVID-19 protocols and minimizing the spread of infection. They also learnt how to use ultrasound at the point of care and in emergency departments.  

As an anaesthetist working at the Baidoa Medical Hospital, Dr Abdirahman Mohamed Hassan shared his reflections: 

Trainees were able to watch live how a trauma teams works in other contexts, including the UK“After the training, I realized the value of working together as a team in my hospital. Now, we have started to share all the knowledge we have and experiences we go through, both in person and on group chats, and it feels really good for all of us, as we are learning best practices together every day. I can already see that this has better outcomes for our patients. Before this, there was no groupwork or teamwork – we all worked on our own,” Dr Hassan said. 

Two other crucial lessons Dr Hassan learnt is that anaesthesia can be administered on patients even if they aren’t fasting, as previously, he believed he had to wait until the patient had been on an empty stomach for a while, which caused unnecessary delays in fragile situations. Dr Hassan also learnt that anaesthetists play a key and active role in responding to trauma patients, and that their role is not limited to addressing patients before and during the surgeries.

“Last week, a 35-year-old man who was involved in a car crash outside Baidoa was rushed to the hospital. He was bleeding profusely around his pelvic area. I took over the situation as a team lead. I assessed the case, compressed the wound, checked the patient’s airway, offered intubation, and rehydrated him. I worked swiftly with the teams in the emergency ward and operating theatre, and, of course, also checked on the patient before, during and after the surgery,” said Dr Hassan. “I was so confident in my response to him, thanks to this training by WHO.”

Using creative and effective ways to create an impact  

Both the Ministry of Health and WHO also arranged for trainees to work in simulated situations in high-quality operating theatres. By way of this initiative, they learnt how to maintain hygiene and wear their protective equipment to reduce the spread of infections. 

The trainers also lent the participants modern, virtual headsets for them to use to test their knowledge, by experiencing different virtual reality scenarios. Trainers used these creative and highly effective methods of imparting knowledge in addition to presentations and theory.    

Dr Sara Halimah, WHO Regional Trauma Specialist, explained that the trauma programme attempts to provide a stepwise, practical, and realistic approach to the management of victims of trauma. 

“Although the acute humanitarian needs of Somalia are at the heart of this initiative, it recognises that a long-term problem necessitates a long-term solution, and that humanitarian and development efforts must be aligned to build a trauma care system that not only responds to today’s humanitarian needs but also developing a system that will serve the future needs of Somalia to reduce the high burden of injuries as a public health problem in the country,” Dr Halimah added.

Through the training, health professionals worked with animal carcasses to learn how to address bullet wounds

Building on what has been achieved with support from the World Bank‘s funding from Pandemic Emergency Financing Facility in January-March 2021 and capitalizing on this new initiative on “Surgical Team Approach to Trauma (STAT),” the WHO country office will work with the federal and state ministries of health to set up a trauma care system as part of emergency, critical and operative care services in the country, as part of Somalia’s overarching goal of achieving universal health coverage, leaving no one behind.