The fight against AIDS in Sudan has had a slow start and only really got going in 2003, when President Omar el Bashir for the first time publicly shook hands with people living with HIV and promised them government support.
Now the Sudan National AIDS Programme (SNAP) provides testing, counselling, treatment and care in several government hospitals. In 2007 SNAP, in conjunction with the United Nations Children's Fund (UNICEF), began prevention of mother-to-child transmission and launched a public awareness campaign that includes radio spots and billboards in Arabic and English.
However, among the challenges facing Africa's largest country is the difficulty of trying to reflect and accommodate region-specific issues in its HIV programming.
High on risk, low on knowledge
In the war-torn western region of Darfur, sexual violence and highly mobile populations mean HIV is a major concern, while the busy transport route between the Red Sea coast and the capital, Khartoum, has led to an influx of truckers and the commercial sex workers that follow them.
In the south, 21 years of war virtually isolated the region, and HIV knowledge remains extremely low, while a crippled health system is not able to effectively handle HIV treatment and care.
A shortage of data across the country and poor access to certain areas due to ongoing insecurity means little is known about the actual magnitude of HIV in Sudan; testing levels are very low and in many areas voluntary counselling and treatment (VCT) centres are few and far between.
A 2002 survey indicated a national infection rate of about 1.6 percent, but was not broken down by state. A new survey to determine HIV prevalence and behaviour change, to be conducted later this year in both north and south Sudan, will provide state-by-state data, but the results are unlikely to be available before 2009.
Adding to the problems national programmes face are 'safeguards' placed on Sudan by the Global Fund to Fight AIDS, Tuberculosis and Malaria, which mean the Sudanese government has no direct access to the grants, and the United Nations Development Programme (UNDP) and other UN agencies have to channel money to implementing agencies, wasting valuable resources on administrative costs.
Sudan's mainly Islamic north has in the past resisted discussing HIV because of social taboos on discussing sexuality. Even after the public awareness campaign was launched, UNICEF and SNAP have had to limit the distribution of posters promoting condom use to health centres to avoid offending cultural sensibilities. In the largely Christian and animist south, many traditions also forbid discussions about sex, so HIV education is not easy.
Female genital mutilation - another risk factor for HIV - is common across the country, with an estimated 70 percent of Sudanese women undergoing circumcision; in the north it is almost universal. The status of women in Sudanese culture generally gives them little power to negotiate safer sex, which could also contribute to the spread of the pandemic.
Pushing the agenda
Despite these hurdles, the government and its partners are continuing prevention efforts, and providing care for people who have contracted the virus. South Sudan's AIDS commission is organising regular training sessions for groups perceived to be vulnerable, such as the army.
Prevention of mother-to-child transmission programmes are operational in seven hospitals nationally, and there are plans to increase this number in the coming months. Sudan now has 70 VCT centres, with more being set up in more remote areas of the region, and 1,500 people accessing life-prolonging antiretroviral medication at 25 centres across the country.