In-depth: Beyond ABC: The challenge of Prevention
COTE D'IVOIRE: Ingenuity and cooperation keys to fighting AIDS in a conflict zone
Photo: Sarah Simpson/IRIN
The country's instability has considerably hampered the fight against HIV/AIDS
ABIDJAN, 14 November 2005 (IRIN In-Depth) - A little shrewdness and savoir-faire go a long way when waging a prevention campaign during a military conflict, according to those involved in the fight against HIV/AIDS in Cote d'Ivoire.
"In order to flood the war zone with condoms, we have to work together," explained Moussa Keita who works for the NGO Health Renaissance Bouake (RSB). "In Bouake, for example, condoms came easily from Abidjan before the crisis. But now, we need the help of other agencies and social marketing organisations."
Bouake is the main headquarters of the New Forces, the rebel group that tried to overthrow President Laurent Gbagbo in September 2002 and has held the country's northern half ever since. The government still controls the south, including the economic capital, Abidjan.
Some 10,000 UN and French soldiers keep the peace, which includes maintaining the confidence zone that keeps the two sides apart.
The proliferation of armed men and the resulting instability have considerably hampered the fight against HIV/AIDS in a country that has one of the highest infection rates in West Africa, according to Ivorian officials.
"We've been hit so hard by the war, and so disorganised that our response hasn't been appropriate to the scale of the epidemic," said Ivorian Health Minister Albert Mabri Toikeuse.
According to a study conducted by Cote d'Ivoire's Ministry for the Fight Against AIDS, the rate of new infections has climbed by one percent annually over the last three years, with youths making up 70 percent of the cases.
The official infection rate of seven percent is based on old data, and humanitarian groups say the true figure is much higher, possibly up to 10 or 20 percent in rebel-held areas.
The ministry's Doctor Ambroise Able Ekissi blames the New Forces for the failures of the national prevention programme.
"We don't know anything about efforts in the rebel-held areas - the area is unreachable for awareness campaigns and personnel are often threatened. In Bouake earlier this year, a group of researchers was falsely accused of spying and held in detention for 15 days."
LITTLE OR NO COORDINATION
However, most of those involved in the fight against AIDS blame poor organisation and a lack of coordination in prevention efforts, such as the distribution of condoms, and educating people about how the virus is spread, and being tested.
"There is a lot of inefficiency in how NGOs work due to a lack of coordination. The better they are organised, the more partners they will have in order to become more efficient," said Louis-Auguste Boa II, the director of COS-CI, an association of NGOs created in Abidjan a decade ago to coordinate the fight against AIDS in Cote d'Ivoire.
Of the approximately 600 NGOs involved nationwide in this struggle, about 200 are members of COS-CI, according to Boa.
In order to attract the attention of donors and carry out their prevention efforts on a significant scale, the NGOs have had to set up partnerships and get involved in a number of humanitarian activities, such as assisting refugees and internally displaced people, as well as broader health and nutrition programmes.
For example, Aweco, an NGO based in the western town of Guiglo, has forged links with the UN refugee agency (UNHCR) and the International for Migration (IOM), which provide condoms.
The condoms are then redistributed to vulnerable populations - in the west of the country, economic hardship, separation of family members and an increasing number of soldiers have contributed to a jump in sexually transmitted infections (STIs) including HIV, according to an April report by Medecins Sans Frontieres (MSF).
The western area is split in two, forcing MSF to work out of rebel-held Danane and government controlled Bin Houye.
"Since the country's division and the 2003 ceasefire, there is a greater military presence throughout the country. These soldiers are clearly concerned by health issues and STIs in particular," MSF commented.
To meet the needs of the 500,000 people in the west, MSF has been active in the region since 2003, stepping in to fill the void left by the collapse of the health infrastructure and the exodus of medical personnel after the civil war began.
TRUST IS ESSENTIAL
The presence of MSF has been vital in establishing prevention efforts and providing care for people living with HIV/AIDS.
"We started by treating patients at the regional hospital in Man before setting up a national care programme. At the same time, we're raising awareness of HIV," said MSF's Jean-Paul Jemmy.
"A lot of factors combine to shut people off," he added. "To begin with, trust is a major issue, and their immediate food and security concerns tend to get in the way of their listening to educational messages - an approach based on trust is necessary."
MSF started an HIV/AIDS programme for people in the region a few months ago, offering free treatment and anonymous voluntary testing in two of the west's hospitals as well as in Bouake, a commercial hub at the country's centre.
These facilities, which are always in need of condoms and testing equipment, also provide food aid through the World Food Programme, one of the UN agencies working with local NGOs and international relief agencies.
"During military conflicts we are able to get condoms from international organisations like CARE, the Red Cross and others," said Yao Bla, who works at Bouake's Social Action Solidarity (SAS) centre, the main private care facility in the region.
"We also get deliveries from friends because public transportation still exists in our zones," he said.
The number of condoms is far from adequate to meet the needs of the local population, according to John Bull of Aweco, which receives shipments from UNHCR. "We always need more for refugees, displaced people and host communities," he commented.
According to UNHCR's Doctor Anastase Butusure, each refugee or displaced person receives 12 condoms per month, "based on the principle that the average adult male has sex three times a week".
But the biggest problem, in Bla's opinion, is getting these condoms to the people. "We hand them out during mass education campaigns and people visit our centre - we give them condoms whenever we can but the results are not tangible," he said.
According to Bull, access to populations in Guiglo is especially difficult because of bad roads and the limited resources of NGOs. "We don't have the logistical means of educating refugees, displaced people and host communities," he said.
Most of those involved in the fight against AIDS in conflict zones have to rely on partnerships and taking advantage of the relative strengths and networks of others to reach vulnerable populations more effectively.
CARE International, which started up an emergency HIV/AIDS prevention project in April 2004, works with the region's community groups. "People relate better to these organisations," said project director Yssouf Ouattara.
"To promote prevention in a crisis situation it's necessary to be involved in humanitarian activities," he said. "Because we provide food aid to people, they are willing to listen."
As a result, CARE has distributed more than four million condoms, increased the capacity of local organisations, and set up committees to coordinate community prevention efforts, according to Ouattara.
The UN Office for the Coordination of Humanitarian Affairs (OCHA) has organised coordination sessions to allow information sharing and get better results.
"Every two weeks we have meetings with OCHA and other NGOs. The WFP provides food and UNICEF [UN Children's Fund] finances our projects that target orphans and vulnerable children," said Bla of the SAS centre in Bouake.
Whenever possible, this integrated centre - the first in the region - helps the families of orphans to buy drugs that increase life expectancy, pay school fees and find work in the devastated city.
"There haven't been any prevention or education campaigns here since the start of the conflict while, at the same time, there is total sexual freedom," said the SAS centre's Penda Toure. "People aren't worried about HIV/AIDS - the only topic of conversation is the conflict, and the only concern is survival."