Burkina Faso

Ms Martine Somda Dakuyo was 34 years old when she was diagnosed with HIV. The news, which she describes as traumatic, suddenly shattered all the hopes and plans of this mother of four. "I suffered a lot from the fear of dying prematurely and in deplorable conditions," she says. Despite a deep sense of anger and injustice, she finally came to terms with her status and even went public in the media to encourage people living with HIV to accept themselves and get help.

Today, with her treatments controlling her viral load and keeping her healthy, Martine can look forward to a happy and productive life. She is one of the pioneers in the fight against AIDS in Burkina Faso, having fought for nearly 29 years with the NGO Responsabilité Espoir Vie Solidarité (REVS+). This association, of which she is the initiator and President of the Board of Directors, works for the prevention of HIV, the care of people exposed to the virus and the promotion of their human rights.

"The fight against AIDS in West and Central Africa remains a health emergency," says Ms Somda. Although the HIV prevalence rate is 0.7% in Burkina Faso, Ms Somda asks us about the situation of key populations, who are more exposed to the dangers of HIV, and the reasons that lead to this sad reality. In particular, she mentions the political and security context in the region, proposed laws that discriminate against key populations and the low involvement of people affected by HIV in the fight against AIDS as obstacles to effective care.

In order to protect key populations from the dangers of HIV, Martine’s ambition is to provide universal access to prevention methods, which are a crucial aspect of the fight against AIDS.

"Focusing on effective access to health and rights for people in situations of social rejection and criminalisation is the challenge for the fight against AIDS," she says.

In order to achieve universal access to prevention, care and follow-up services, Ms Somda advocates, among other things, greater involvement of people affected by HIV in the development of national AIDS strategies, better recognition of actions carried out on the ground and the elimination of social and economic inequalities that fuel the epidemic.

In addition, Martine expressed concern about conservatism and cultural, religious and traditional pressures that lead to stigma and discrimination against people living with HIV.  This discrimination manifests itself in various forms; through verbal or physical attacks, threats, harassment, arbitrary arrests, she observes. Such behaviour is dangerous and represents a major obstacle to the fight against AIDS, as it discourages people living with HIV from seeking appropriate services. There is an urgent need to stop such violence in order to create a climate where the rights of people living with HIV are respected and protected. Establishing a more inclusive discourse, free of discriminatory and erroneous prejudices, will allow for a more effective response guided by values of respect, integrity and equality.

With this in mind, in 2015 REVS+ set up workshops and training for decision-makers, religious and customary leaders, health professionals, police and the media. The aim of these activities is above all to denounce stereotypes about people living with HIV and to put an end to discrimination.

"The contribution of community services to the response to HIV is well known and proven, as they complement the services offered by the public health system," explains Ms Somda. Ensuring the continuity of their activities and allowing the greatest number of people to benefit from them, is a necessity for effectively combating AIDS in the region. The resilience of networks such as REVS+, which ensured that prevention activities and care services for people affected by HIV were maintained, was one of the reasons why the impact of the COVID-19 pandemic on people living with HIV was minimised.

Finally, to ensure the effectiveness of the fight against AIDS in the region, and more specifically in Burkina Faso, Ms Somda hopes to see more funding that is "more field-oriented, aligned with policies, strategies and in line with the needs of marginalised groups".

Through this exchange with Martine Somda, we see once again that there is still a long way to go to end AIDS in the region. However, this goal is within reach if all actors in the HIV response work together to develop multi-sectoral strategies. Implementing measures to achieve universal access to prevention services, eliminating HIV-related inequalities and stereotypes, and better managing investments are key priorities for ending AIDS by 2030.

Home to 5 million people living with HIV, western and central Africa is not on track to ending AIDS by 2030. Every day, more than 760 people become newly infected with HIV in the region and only 2.6 million of the 5 million people living with HIV are on treatment.

Insufficient political will, frail health systems and weak support for community organizations―as well as barriers such as HIV-related criminalization―are the most significant obstacles to progress. A regional acceleration plan aims to put the region on track to reaching the target of tripling the number of people on antiretroviral therapy by 2020 and achieving epidemic control. While progress has been made, that progress is not coming fast enough. Children are of particular concern―only 28% of under-15-year-olds living with HIV in the region have access to antiretroviral therapy.

“We need policies and programmes that focus on people not diseases, ensuring that communities are fully engaged from the outset in designing, shaping and delivering health strategies,” said Gunilla Carlsson, UNAIDS Executive Director, a.i., speaking at the Global Fund to Fight AIDS, Tuberculosis and Malaria Sixth Replenishment Conference, taking place in Lyon, France, on 9 and 10 October.

There are many examples of how investing in communities can make a difference. “The response is faster and more efficient if it is run by those who are most concerned,” said Jeanne Gapiya, who has been living with HIV for many years and runs the ANSS nongovernmental organization in Burundi.

Community-led HIV testing and prevention is effective, particularly for marginalized groups. “Most of the people tested by communities were never reached before and this shows how community organizations are unique and essential,” said Aliou Sylla, Director of Coalition Plus Afrique.

Reducing the number of new HIV infections among children and ensuring that women have access to the services they need remains one of the biggest challenges in the region. Networks of mothers living with HIV who support each other to stay healthy and help their child to be born HIV-free have been shown to be an effective way of improving the health of both mothers and children.

“Our community-based approach works. In the sites where we work we have reached the target of zero new HIV infections among children and all children who come to us are on treatment,” said Rejane Zio from Sidaction.

Financing remains a concern and although total resources for the AIDS response have increased, and HIV remains the single largest focus area for development assistance for health, domestic investments account for only 38% of total HIV resources available in western and central Africa, compared to 57% worldwide. Greater national investments reinforced by stronger support from international donors are needed to Fast-Track the regional response. Bintou Dembele, Executive Director of ARCAD-Sida, Mali, said, “We have community expertise, but we lack the funds to meet the need.”

Support is growing for community-based approaches in the region. Recognizing the importance of community-led work, Expertise France and the Civil Society Institute for Health and HIV in Western and Central Africa announced a new partnership on 9 October. “The institute brings together 81 organizations from 19 countries aiming to ensure better political influence at the global and country levels and to galvanize civil society expertise in programme delivery. This partnership is a recognition of our essential contribution,” said Daouda Diouf, Director of Enda Sante and head of the steering committee of the institute. “The situation in western and central Africa remains a priority. It is clear that community-based approaches are agile and appropriate for responding to pandemics,” said Jeremie Pellet from Expertise France.

Shifting to a people-centred approach has been at the core of reforms in the region. A growing regional resolve to accelerate the response and to strengthen community-led approaches that have been proved to work provides hope for the future of the HIV epidemic in western and central Africa.

Towering over a throng of young people, Christine Kafando peppers the crowd with questions.

“Do you feel pressure from other boys and girls?” “Do you feel abandoned because of poverty?” “Do you have all the information you need regarding your health and HIV? If not, ask me, ask your partners, ask! Okay!”

The 40 boys and girls nod and shrug. They have come for a workshop run by the Association Espoir pour Demain (AED) in Bobo-Dioulasso, Burkina Faso, which aims to create a space for young people to learn about sexual health and to train some to become peer educators.

“After having seen a number of young students come to us pregnant, we felt a need to start these workshops,” Ms Kafando, the founder of AED, said.

Issa Diarra said the workshop enabled a dialogue. “In our society, we really don’t talk that much about sex and, I would add, health issues, but here we really had the chance to discuss all that,” he said. Another attendee of the workshop, Roland Sanou, agreed, “Sex today remains taboo for young people, but I don’t want it to stay that way.”

Many of them say times have changed and that the way they think is different from the way their parents thought. “Currently, we young people are aware and we know what we want and we know that being sick can keep us from realizing our dreams, so that’s why we are rallying,” said Baba Coulibaly.

At the beginning, AED helped women living with HIV to access treatment. It then grew to help mothers and their babies born with HIV. Fifteen years later, many of those children are now teenagers and still drop by. Reflecting on her two decades as an HIV advocate, Ms Kafando said, “For so many years, women have been the face of HIV, but it’s key to include men and boys to raise their awareness.”

Jacinta Kienou, a nurse who has been at the association since it was founded, said that there were two big challenges: a number of young people living with HIV no longer take their treatment regularly and many young people are unsure about how to deal with relationships.

“Because they live with HIV, and they are young, lots of problems bubble up concerning affection and acceptance by others with regard to their HIV status,” she said. “Often relationships end because of someone’s HIV status. We council them and their parents at that time,” she added.

In Burkina Faso, young people make up more than 60% of the population and data show that many of them do not know their HIV status. UNAIDS Strategic Information Officer André Kaboré describes two gaps concerning young people. “Despite high-quality treatment being readily available, there are children out there who don’t know they’re living with HIV. Worse, many of those who do know that they are living with HIV aren’t accessing treatment,” he said.

In the country, 94 000 people are living with HIV, 9400 of whom are children under the age of 15 years. While 65% of adults living with HIV are on life-saving antiretroviral therapy, only 28% of children living with HIV whose status is known, about 3500, are on treatment. Ms Kafando calls them the forgotten generation. “They fell through the cracks because until now they had never been sick or needed attention and thus were never tested for HIV,” she said.

The head of the National AIDS Council for Bobo-Dioulasso and the surrounding region, Suzanne Sidibé, said, “We lost sight of children born with HIV. Our aim, with the help of the Association Espoir pour Demain, is to fan out to families through health mediators.”

Hoho Kambiré, who is living with HIV, has four children, two of whom are living with HIV. As an AED health mediator, she speaks about the benefits of knowing one’s status to all who will listen. She visits families, accompanies women to clinics and provides support.

“It is necessary to test all the children to know who is sick and who is not sick and follow up to keep them healthy,” she said. AED has now more than 50 health mediators, mostly women like Ms Kambiré, who originally came to the association seeking health services herself. 

The United Nations Children’s Fund (UNICEF) and UNAIDS both support AED financially. Mireille Cissé, a UNICEF HIV specialist, said that the United Nations in Burkina Faso had identified the top priorities for the AIDS response in the country, including working with civil society.

“We agreed that a community link needed to be established, because they are our entry into families,” she said. UNICEF formalized the health mediators’ contribution by providing a stipend for their work and works hand in hand with the regional office of the Ministry of Health.

“A real victory for us was to have the health mediators integrated into the health teams of the districts,” Ms Cissé said. “That buy-in really facilitated the role of the health mediators and has raised their profile.”

UNAIDS has reinforced the capacity of the health mediators to widen their scope of work, which ranges from psychosocial counselling to training on treatment adherence. “To maintain our progress in the HIV response and end AIDS depends a lot on civil society like the Association Espoir pour Demain,” Job Sagbohan, UNAIDS Country Director, said. “We really hope for maximum impact.”

For the past four months, Benjamin Sana has been regularly attending the Oasis Clinic in Ouagadougou, Burkina Faso, where he sees a doctor who gives him a full check-up.

The doctor and peer educators also check whether Mr Sana has any questions regarding his pre-exposure prophylaxis (PrEP) regimen. PrEP is taken by people who are HIV-negative but at higher risk of infection, and has proved to be very effective at keeping people free from HIV.

“Two plus one plus one,” answers Mr Sana, referring to when he needs to take the pills—two pills two hours before sex, then one the day after and one again the following day or one a day until his last sexual encounter. After his check-up, the 34-year-old gay man said, “PrEP protects me and I feel reassured.” He still uses condoms and lubricant, but when he doesn’t he said he feels safer.

Mr Sana is one of 100 men taking part in the PrEP pilot project at the Oasis Clinic, run by the Association African Solidarité (AAS). Health clinics in Côte d’Ivoire, Mali and Togo are also taking part in the pilot project, which has been running since 2017.

Camille Rajaonarivelo, a doctor at AAS, said that PrEP is part of a combination prevention approach that also involves trained peers from his community. The project will gauge adherence to treatment and whether participants take PrEP correctly, she explained.

“The final aim of this pilot project is to scale up and roll out PrEP nationally once the authorities give the green light,” she said. 

The study aims to evaluate whether the preventive option gains traction and how feasible it would be to roll it out nationally and regionally. Financed by the French National Agency for Research on AIDS and Expertise France in partnership with Coalition PLUS and three European health institutes, the pilot project will provide data and ascertain if the treatment lowers the number of new HIV infections among gay men and other men who have sex with men.

Burkina Faso does not penalize homosexuality, but stigma against it is high. As a result, gay men and other men who have sex with men often hide their sexuality and tend to avoid health services. HIV prevalence in Burkina Faso among gay men and other men who have sex with men stands at 1.9%, more than double the rate among the general population.

The first definitive results of the PrEP pilot project in Ouagadougou should be available in 2020. Mr Sana said that many of his friends had shown interest in taking PrEP. “Because the pilot project has limited participants, a lot of people have been turned away,” he said.

He believes that PrEP will save lives, especially those of young men. “Nowadays, young men take a lot more risks and they don’t protect themselves,” Mr Sana said. Ms Rajaonarivelo agreed and added that this applies to young men and young women. “I am stunned to see new cases of HIV every week,” she said. “We have to beef up HIV prevention and awareness again.”

Leaving the meeting of the REVS PLUS nongovernmental organization, the women bid each other farewell, saying, “A demain soir (See you tomorrow night).” They had gathered at a health drop-in centre that also acts as a network hub for various HIV networks in Bobo-Dioulasso, Burkina Faso, to discuss the following evening’s plan: HIV testing among their peers at selected sites.

“We share our experiences and act as confidantes,” said Camille Traoré (not her real name), a sex worker and peer educator. Her colleague, Julienne Diabré (not her real name), wearing a long flowing dress, chimed in, “In our line of work, it’s hard to confide in someone, so confidentiality is key.”

REVS PLUS/Coalition PLUS advocacy manager, Charles Somé, described the group of women as an essential link in the chain to reach out to sex workers.

“Because of stigma and discrimination, many sex workers hide and move around so they miss out on health services and are much more likely to be infected with HIV,” he said. HIV prevalence among sex workers is 5.4% in Burkina Faso, while it’s 0.8% among all adults in the country.

By recruiting peer educators who know the realities of the job and can relate to other women, Mr Somé said that HIV awareness has increased in the community.

“We also innovated and started HIV testing in the evenings in places where sex workers gather,” he said. Prostitution in Burkina Faso is not illegal, but the penal code forbids soliciting. 

The following evening, along a darkened street, REVS PLUS set up foldable tables with two stools at each table. A solar lamp allowed the peer educators to see in the pitch dark and jot down information. Donning plastic gloves, the trained peer educators sat with women, who had their finger pricked and within five minutes were given their HIV test result. No doctors, no nurses were needed. The testing was done by peers because sex workers are afraid to be identified as sex workers. 

Mr Somé explained that over the years REVS PLUS outreach has gained the trust of sex workers.

Peer educators, he said, regularly called him to complain about police violence. “It went from arbitrary arrests, to stealing their money, to rape,” Mr Somé said.

Ms Diabré described her dealings with the police. “During the day they point a finger at you and discriminate, while at night they become all nice to get favours and if we don’t deliver then it gets ugly,” she said.

After documenting police abuse for a year with the help of bar owners and feedback from sex workers, REVS PLUS met with government officials and then the police.

“Our approach got their attention and we started awareness training with police officers based on law basics and sex work,” Mr Somé said.

Slowly, REVS PLUS identified allies in each police station, facilitating dialogue whenever an issue occurred. In addition, all sex workers now need to carry a health card showing that they have had regular health check-ups.

A Nigerian woman wearing purple lipstick, Charlotte Francis (not her real name), said, “We still have issues and stay out of their way, but it’s gotten better.” She waved her blue health card, which she says bar owners regularly demand.

Showing off his bar and a series of individual rooms around an outdoor courtyard, Lamine Diallo said that the police no longer raid his establishment. “Before, police would haul away all the women and even my customers,” he said.

UNAIDS, with funds from Luxembourg, is currently partnering with REVS PLUS to scale up the police awareness training across the country. Trainings have taken place in the capital city, Ouagadougou, and in Bobo-Dioulasso.

UNAIDS Burkina Faso Community Mobilization Officer Aboubakar Barbari sees the programme as two-fold. “We supported the awareness sessions for police and security forces because it not only reduces stigma, it also puts a spotlight on basic human rights.” 

“I am lucky,” Charles Somé said. The hyperactive human rights advocacy worker from Burkina Faso recalls going to a training event and chiding some of the men there about their sexual orientation. “I had pre-conceived ideas and asked them “Don’t you want to get married?”, “Don’t you want to have kids?”” he said. One young man opened up to him and, after days of honest conversations, Mr Somé had a sea change in his views.

“It dawned on me that if I am not judged, why should I judge others,” Mr Somé said. From then on, when lobbying on behalf of gay men and other men who have sex with men, he has used the word “we”.

“I defend them and respect them,” Mr Somé, who works for the REVS PLUS/Coalition PLUS nongovernmental organization, said. 

Homosexuality is not illegal in Burkina Faso, but stigma and discrimination remains high. Many men marry and hide their double life. Support groups for lesbian, gay, bisexual and transgender people have popped up, but discretion is key.

“I am forced to hide because I am not accepted,” Rachid Hilaire (not his real name) said. He joined an informal conversation group in his home town, Bobo-Dioulasso, where young men talked about relationships, sex, HIV and other issues. “I had many doubts about myself, but once I had more confidence in myself, I felt I could help others,” he explained. Standing outside the REVS PLUS meeting room, he joked with Mr Somé about keeping an eye on him. Mr Hilaire is one of 50 REVS PLUS peer educators who facilitate informal talks like the one he had attended tailored to gay men and other men who have sex with men. After being trained, he and another peer educator led frank talks with men.

Mr Hilaire’s biggest challenge, he said, remains educating the general public, along with political and religious leaders. “I blame the older generation for their lack of awareness,” he said. “Everyone deserves to be free and I long to feel that freedom,” he said. 

Yacuba Kientega (not his real name) fled his home in Bobo-Dioulasso and moved to Ouagadougou when his family found out he had relationships with men. “I eventually came back to pursue my studies in Bobo-Dioulasso, but am living in a different neighborhood,” he said. For him, he felt things had become better for gay men, but he would not give up the fight.

As a lobbyist for an HIV umbrella network, Mr Somé’s battle for people’s rights never ends.

“I really try to have underrepresented communities heard by the government and parliamentarians,” he said. He believes support groups and peer education have helped to reach key populations, such as people who inject drugs, gay men and other men who have sex with men and sex workers. “We have seen an uptick in health-care services by focusing on certain communities and I hope it will stay that way,” Mr Somé said. “Ending AIDS will necessitate really tackling stigma and putting the onus on prevention,” he added.

The UNAIDS Country Director for Burkina Faso, Job Sagbohan, couldn’t agree more. “The HIV response must follow the evolution of the epidemic,” he said. At one time, we had to save lives and we succeeded by concentrating on treatment for all, he explained. “To end the HIV as a public health threat, we need to zero in on prevention and awareness,” he added. “It’s the only way to maintain our progress and end AIDS.”