In-depth: The Treatment Era: ART in Africa

DJIBOUTI: Grappling with the demand for ARVs

Photo: IRIN

Djibouti, 6 December 2004 (IRIN In-Depth) - At one stage, Roda, a 24-year-old woman living in Djibouti, had tuberculosis, a skin disorder, and was disfigured with disease. In March she began receiving antiretroviral therapy (ART) and has started leading a more normal life again.

Roda, who declined to give her second name, is among the more fortunate in Africa. According to figures released by the UN World Health Organisation (WHO) in June, just four percent of HIV-positive people on the continent have access to antiretrovirals (ARVs), the drugs that inhibit HIV.

"Despite the subsequent successes of one-after-another, small-scale pilot projects, few countries have managed to deliver HIV treatment to all, or even the majority, of those in need," the WHO report said.

In July the government of Djibouti - a small country in the Horn of Africa - announced that, with support from the Global Fund to Fight AIDS, Tuberculosis (TB) and Malaria, funding was available to provide ARVs for those in need until 2007.

The fund provided US $12 million. Omar Ali Ismael, the head of Djibouti's intersectoral technical committee on HIV/AIDS, told PlusNews the government would also improve treatment and care for those living with AIDS, target vulnerable groups through prevention and care, promote civil society involvement, and improve data gathering and surveillance.

Until now, only 200 people had been receiving free ARVs, Omar Ali said, but with the new funding the number would initially be increased to 4,000.

"Everybody in Djibouti, including refugees and legal immigrants who need ARVs, up to 2007 will be able to receive them free," he told PlusNews.

ARVs improve the quality of life for those infected with HIV and can delay death for many years. According to UNAIDS, wide-scale access to ARVs might help reduce the decimation of workforces and the destruction of families seen elsewhere on the African continent.

With an estimated HIV prevalence of three percent, Djibouti could yet become a success in the fight against the virus. Yet benefiting from ARVs is more complex than initially thought, especially when the complicated issues of training and drug supply are taken into account.

People cannot receive the medicines, for example, unless they are diagnosed with the advanced stage of HIV and can benefit from easy access to medical advice. Of an estimated 9,000 HIV-positive people in Djibouti, just 1,000 are registered with the medical services.

Many people still do not know that they can get a free test, or that they can receive free treatment, Nazer Kibangou, a Congolese expert at the Centre Yonis Toussaint for Sexually Transmitted Infections, told PlusNews.

A March 2002 survey showed that the national HIV-prevalence rate in Djibouti was 2.9 percent - a figure the country's health authorities say is low by African standards.

The research revealed that 90 percent of those infected with HIV lived in the capital and could therefore be reached easily, and women were more affected than men. Still, it also showed that less than half the population knew condom use reduced the risk of infection.

Staff at a local HIV/AIDS organisation, Oui a la Vie, in a scruffy side street off Avenue Treize, told PlusNews it took up to four months to persuade somebody to go for a test.

"They don't want to be shocked by a bad result, and they are full of shame," Ali Barkat Moumin, 34, a volunteer nurse at the centre explained.

Roda was diagnosed with HIV two years ago, but still has not told her mother. The family of Mohmed, once a petty trader and now HIV positive, face a similar dilemma, fending off questions from suspicious neighbours in his quarter.

Now that he is taking ARVs he also feels much better, though he has had to give up both qat (a leaf chewed as a stimulant) and his beloved shisha pipe, which do not mix well with the medicines.

Houmed Ali Ismael, the chief doctor at Djibouti's Paul Faure hospital for TB, thinks the stigma is linked to death and - in a conservative society - the perceived connection to what he calls "sexual vagabondage".

He added that some visitors at his hospital get angry when they are diagnosed with HIV and not tuberculosis - a curable disease.

Slowly, though, the number of tests is rising - the rate increased by 500 percent during the first nine months of this year, compared with the last nine months of 2003, Ismael said.

Kibangou said just 15 percent of HIV tests were positive at the Centre Yonis Toussaint for sexually transmitted infections and the possibility of ART offered even more encouragement. "That is a big source of hope," he noted.

"The problem is that the sick are poor, and it is difficult to treat the poor," said Hawa Hassan, a counsellor for people with HIV. "If they need medicines which are not in the centre, they have to be bought, and if you ask them: 'Do you have money for this?' then they say 'no'."

The Treatment Era
ART in Africa

December 2004
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Links & References

The WHO 3 by 5 Initiative
www.who.int
The Global Fund to Fight HIV/AIDS Tuberculosis and Malaria
www.theglobalfund.org
The President's Emergency Plan for AIDS Relief
www.usaid.gov
World Bank AIDS site
www1.worldbank.org
Pan-African Treatment Access Movement
www.patam.org
WHO Prequalification Project
http://mednet3.who.int/
Eldis Resource on ARVs
www.eldis.org

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