Central African Republic

Humanity is behind in eradicating AIDS by 2030. This delay is not due to a lack of knowledge, capacity or means, but to structural inequalities such as stigma and discrimination which are obstacles to access health services.

Viruses such as HIV or COVID-19 do not differentiate between people, but societies do. They stigmatize and discriminate against people living with HIV, mostly out of ignorance, because they are afraid of the disease.

Discrimination remains one of the biggest battlefields in the Central African Republic and this is why the country was the first in the world to join the Global Partnership to fight against all forms of HIV-related discrimination and stigma.

To make this Global Partnership a reality, a Zero Discrimination Platform was established. It is composed of about thirty partners representing ministries, the National AIDS Council, UN agencies, technical and financial partners, civil society, human rights organizations and other organizations. With UNAIDS support, the Platform called on Ozaguin, the "king of Central African rumba" to use music and art to convey its messages of tolerance and compassion.

At the launch ceremony for Ozaguin's new song against discrimination, which took place on 9 December 2021 at the 20,000-seat stadium in Bangui, he was also nominated as a spokesperson for the Platform.

On behalf of the First Lady of the Central African Republic, the Minister of Health and Population invited every one, and in particular all institutions and influential personalities, not only not to discriminate, but also to fight against discrimination and stigmatization. "We must collectively report discrimination and stigma as soon as we see it and set an example. Discrimination kills. It exacerbates emergencies and fuels pandemics," said Minister Pierre Somsé.

The leadership shown by communities that are victims of discrimination and stigmatization remains a source of inspiration. Their determination, courage and vision are a star in the firmament, as demonstrated by the moving testimony of Ms. Christine Wilikon, a member of the national network of people living with HIV (RECAPEV) during the ceremony. "The first reactions to knowing my positive HIV status were dismay, and a desire to end my life. Rejection by my family members amplified my mental and social disorientation. But the support and advice provided by my parish priest gradually led to my social reintegration through income-generating activities such as petty trade, agriculture and market gardening.”, Christine shared. Her brave words were received with a standing ovation. She urged all Central Africans to put an end to feelings of guilt and shame, and to get tested to know their HIV status and if necessary, take the treatment which is free. 

World AIDS Day 2021 saw the authorities in the Central African Republic and others involved in the HIV response in the country come together to provide information on HIV, promote HIV prevention, treatment and care and show their solidarity in the face of the pandemic. This year, the President and Head of State of the Central African Republic, and President of the National AIDS Council, Faustin-Archange Touadéra, presided over the ceremony in the commune of Bégoua, near the capital, Bangui.

In line with the Dakar Call to Reinvent the Response to the HIV Pandemic, adopted at the recent High-Level Regional Summit on HIV/AIDS in Western and Central Africa, Mr Touadéra urged the Ministers of Health and Population and of Budget and Finance to ensure that 500 million central African francs is included in the government’s 2022 budget for the HIV response. He also tasked the Prime Minister to report on the actions taken in the HIV response. One of the four pillars of the Dakar Call to Action is to increase national and international resources devoted to HIV in the region by 33% by 2025.

Mr Touadéra also noted the importance of removing financial barriers to accessing health services for people living with HIV.

Bienvenu Gazalima, the President of the Network of People Living with HIV in the Central African Republic (RECAPEV), said that, “Access to antiretroviral drugs has improved, from 12% of all people living with HIV in 2013 to 58% by the end of 2020, but remains one of the lowest in the world. HIV treatment is available in only 10% of the country’s health facilities.”

On the eve of the World AIDS Day commemoration, messages from the Minister of Health and Population and UNAIDS were broadcast on major radio stations and national television. Information on preventing new HIV and COVID-19 infections was given out, especially to young people, in several provinces of the country. With the support of UNAIDS, sensitization caravans criss-crossed the streets of Bangui for several days to spread messages on HIV transmission, HIV prevention, vulnerability to HIV and HIV-related discrimination.

“We are at a crossroads. Leaders have a choice between bold actions and half measures. The transformative approach we need to end AIDS will also protect humanity from future pandemics,” said Marie Engel, UNAIDS Country Director for the Central African Republic, a.i. 

On 11 November, a project to support the empowerment of nearly 400 people living with HIV through training and involvement in agropastoral activities was launched in the seventh arrondissement of Bangui, Central African Republic.

According to Joseph Tagbale, the Mayor of the seventh arrondissement, “This project is timely and comes as a breath of fresh air, as people living with HIV have paid a heavy price during the COVID-19 pandemic, firstly because of their high risk of infection due to their weak immune systems and secondly because of the collapse of their means of subsistence due to repeated confinements.”

The Multi-Partner Trust Fund granted the UNAIDS Country Office for the Central African Republic US$ 150 000 to support activities for people living with HIV in the context of COVID-19. These activities were chosen in collaboration with the Comité National de Lutte Contre le Sida (CLNS), the Ministry of Health and the Central African Network of People Living with HIV (RECAPEV) and will be implemented by the United Nations Food and Agriculture Organization and the international nongovernmental organization Solidarité pour la Paix et le Développement Intégré.

The activities consist of agropastoral activities (small-scale livestock farming and other farming activities), the production of face masks and income-generating activities, such as sewing, catering and the sale of soap and kitchen utensils. All these activities will enable people living with HIV to sustainably meet their needs and better adhere to their antiretroviral therapy, since due to the COVID-19 pandemic many people living with HIV have stopped taking their treatment because of problems in accessing food. “COVID-19 has destroyed all our progress in adherence to treatment, and people living with HIV have a lot of difficulty feeding themselves, as many are unemployed,” said Bienvenu Gazalima, the National Coordinator of RECAPEV.

The income-generating activities will be supported in four arrondissements of Bangui and in two surrounding communes, Bimbo and Bégoua, which were selected because they have large numbers of people on antiretroviral therapy.

Throughout the project, peer educators will educate people living with HIV on treatment adherence and other health issues, such as COVID-19 prevention and vaccination. Emphasis will be placed on involving women in the activities. “I am delighted that women living with HIV are so strongly integrated in this project, because it is they who have paid the highest price during this crisis,” said Marcelline Seremandji, adviser to civil society associations at CLNS.

“In the Central African Republic we are witnessing how structural inequalities and lack of income have direct impacts on health and HIV outcomes. The lower someone’s social and economic status, the poorer their health is likely to be. Addressing food insecurity and malnutrition, keeping adults earning an income and keeping children in school helps to ensure the efficacy of HIV treatment,” said Marie Engel, the Director, a.i., of the UNAIDS Country Office for the Central African Republic.

To counter the low level of people living with HIV in Central African Republic (CAR) on treatment, the country has been testing new treatment approaches.

One is distributing up to 6 months of medicine, known as multi-month dispensing. The other is community ARV dispensation. CAR’s 2021-2025 National HIV Strategic Plan, identified these differentiated approaches at the community and hospital level and has been trying it out.

In the capital, Bangui, four pilots opened and 15 sites will progressively offer MMD (multi-month dispensing), health check-ups and community outreach thanks to funding from the Global Fund. This follows on the success of community-based treatment groups (CAGs) introduced by the Ministry of Public Health and Population and the National AIDS Control Council (CNLS) in 2015, with the support of the NGO Médecins Sans Frontières.

Certain community members deliver antiretroviral treatment to people living with HIV, especially in rural or conflict-stricken areas. Results showed that treatment intake was much more regular and people living with HIV had a rate of 75% viral suppression.

In addition, with UNAIDS support under a Luxembourg grant, the country has set up a steering committee to oversee the scale up of differentiated services, developed and validated national guidelines on the provision of differentiated services and two guides on multi month dispensing and the possibility of getting refills in a non-hospital setting.

At the end of October, clinicians, lab technicians, health care providers, community health care workers from the four pilot health centers participated in a workshop to go over the new approaches and guidelines. The CNLS and the country’s Division of Communicable Disease Control (DLMT) were confident adapting to the HIV epidemic in this way was a right step to keep patients on treatment. Currently, less than half of the people living with HIV take life-saving medicine (88,000-100,000 people live with HIV in CAR.)

Dr Marie-Charlotte Banthas from the DLMT said that "differentiated treatment models have demonstrated consistent improvement in patient engagement and retention of care, while freeing up time for the care of people with advanced disease.” She then added, ”It's a model of care for people living with HIV and staff working in the HIV field, a model of life."

These approaches came at the right time considering the lockdowns due to COVID-19, remarked UNAIDS CAR Country Director a.i. Marie Engel.

"With the long projected trajectory of the Covid pandemic, there is an even greater need to adapt the system to reduce service disruptions and not have recent gains in the HIV response stymied,” she said.

The goal of zero discrimination still eludes the Central African Republic. HIV-related stigma is pervasive in the lives of people living with HIV in the country. According to the 2018 People Living with HIV Stigma Index, discrimination affects almost all of the people living with HIV surveyed (more than 87%). And more than 45% of people living with HIV have experienced some form of stigma because of their HIV status. Stigma affects women (49%) more than men (37%).

“But the fight against HIV remains a public health priority for the government, which was the first country to join the Global Partnership for Action to Eliminate all Forms of HIV-Related Stigma and Discrimination, in December 2019,” said Marguerite Ramadan, the Minister of Gender Promotion, Women’s Protection, Family and Children, Central African Republic.

Since its engagement in the Global Partnership for Action to Eliminate all Forms of HIV-Related Stigma and Discrimination, the Central African Republic has implemented several key activities.

A memorandum of understanding was signed between the Ministry of National Defence and Reconstruction, the Ministry of Health and Population, the AIDS Control Council (CNLS) and UNAIDS to implement programmes aimed at eliminating gender-based violence and accelerating HIV prevention, treatment and care within the defence and security forces. A national charter of patients’ rights has been launched and is being disseminated progressively in health centres. A series of key human rights activities have been included in the Global Fund to Fight AIDS, Tuberculosis and Malaria’s grant for 2021–2023.

A Zero Discrimination Platform, composed of some 30 partners representing ministries, CNLS, United Nations agencies, technical and financial partners, civil society, human rights organizations and other organizations was launched in 2020 and is supporting these efforts, including through identifying synergies.

During the COVID-19 pandemic, initiatives have slowed down, so in order to relaunch the momentum of the Zero Discrimination Platform and agree on collective priorities for the end of 2021 and 2022, a validation workshop and launch of a joint workplan took place in Bangui, Central African Republic, on 28 October under the chairmanship of the Minister of Gender Promotion, Women’s Protection, Family and Children.

Priorities include the adoption of a revised law on HIV, the revision of training programmes for health professionals to include ethics and human rights, the signing of a memorandum of understanding between organizations of lawyers and networks of people living with HIV and key populations to provide free legal services and training on knowing your rights, the development of radio and television spots on discrimination issues and high-level advocacy for better integration of HIV issues in humanitarian interventions.

“The denial of health services to people living with HIV remains unfortunately common in the country, and the prevalence and effects of discrimination are often particularly severe for members of key populations, who face multiple and overlapping forms of discrimination,” said Marie Engel, Director, a.i., of the UNAIDS Country Office for the Central African Republic.

Alida Nguimale is a survivor. She has been living with HIV for 21 years in the Central African Republic. Some 10 years ago, she lost two of her children to AIDS-related illnesses. At the time, she was unaware that she was living with HIV, and life-saving antiretroviral therapy and medicine to prevent mother-to-child transmission of HIV were rare in the Central African Republic.

Speaking at the opening ceremony of a national workshop on HIV and gender, co-organized by the Ministry of Gender, the Ministry of Health, the National AIDS Council and UNAIDS, in Bangui, Central African Republic, on 30 and 31 August, Ms Nguimale explained how she was expelled from her home by her abusive partner, who accused her of bringing HIV into the household. She also recounted her helplessness in the face of denial and violence by her partner, who had refused to accept his own HIV-positive diagnosis.

Ms Nguimale’s story illustrates the vulnerability to HIV of women in the Central African Republic and the barriers that they face in accessing health services. More than 56% of all new HIV infections in the country in 2019 were among women and girls, and 60% of all people living with HIV in the country are women. According to data from the MICS-6 survey published in 2021 by the government, with the support of the United Nations, 23.6% of women and girls between the ages of 15 and 49 years were married or entered into a marital union before the age of 15 years. More than 21% of central African women had undergone female genital mutilation. In January 2021 alone, 340 cases of gender-based violence, including 72 rapes, were collected by the gender-based violence information management system in the Central African Republic.

“The vulnerability of women and girls to HIV in the Central African Republic is the consequence of protracted insecurity, violence and humanitarian crises compounded with toxic masculinities and negative social norms. There can be no end of the AIDS pandemic without renewed action and accountability to end this plague of gender-based violence and the social marginalization of women,” said Denise Brown, the Deputy Special Representative of the United Nations Secretary-General in the Central African Republic, Humanitarian Coordinator and United Nations Resident Coordinator.

For the first time, the Government of the Central African Republic, with the support of UNAIDS, conducted a thorough assessment of the gender dimensions of the HIV epidemic and response in the country. The assessment report, which was discussed and adopted during the national workshop on gender and HIV, warned that women, girls and key populations are being left behind in the recent progress made against HIV in the country. HIV prevalence is highest among sex workers, at 15%, and among gay men and other men who have sex with men, at 6.4%, compared to 3.6% among the general population. Access to prevention of mother-to-child transmission of HIV services also remains worryingly low, with less than 25% of women accessing such services in three of the country’s seven health regions.

“The gender assessment report alerts us on a blind spot in our response. We must refocus our efforts on transformative interventions that work for women, girls and key populations,” said Pierre Somse, the Minister of Health of the Central African Republic.

Building on the recommendations of the gender assessment, the participants of the meeting developed and adopted an action plan to implement key interventions in 2021–2023. The action plan includes a combination of structural, biomedical and behavioural interventions to promote gender-transformative education and sensitization, to address the legal, social and cultural barriers to access to HIV services by women, girls and key populations, to implement differentiated models of care that promote access to health, social and psychosocial services for women, including for prevention of mother-to-child transmission of HIV, and to ensure accountability for progress on gender, HIV and tuberculosis. The Minister of Gender, Marguerite Ramadan, noted that the assessment report and the action-oriented operational plan that ensued are essential to implement the vision of equality in the 2021 United Nations Political Declaration on AIDS.

Expressing satisfaction after the adoption of the operational plan, Patrick Eba, the UNAIDS Country Director for the Central African Republic, said, “UNAIDS is at its best when it brings together government, civil society, development partners and other stakeholders to critically assess the national response to HIV and articulate a collective agenda for action. There is no better way to vindicate the rights of those millions of women like Ms Nguimale who demand dignity, justice and health.”

The Central African Republic has made significant progress in its response to HIV over the past four years. New HIV infections continue to decline and the number of people on antiretroviral therapy has increased from less than 25 000 in 2016 to more than 47 000 in 2019.

Despite this progress, the Central African Republic remains far from the 90–90–90 targets. Less than half of the 100 000 people living with HIV in the country have access to treatment and the government estimates that less than 20% of people on treatment have an undetectable viral load. For those who are on treatment, the quality of care is insufficient. Recent studies reveal a very high rate of immunological and therapeutic failure among people living with HIV on treatment.

Various factors contribute to this situation, including hospital-based management, the unavailability of biological monitoring in rural areas, the lack of human and material resources in health facilities and laboratories and the absence of community-based approaches that promote treatment adherence and information. In addition to these system-related factors, since December 2020 the country has faced a resurgence of a political and security crisis, which makes access to treatment difficult.

There is a need to simplify and adapt the cascade of HIV-related services to take into account the preferences and expectations of different groups of people living with HIV while reducing unnecessary burdens on the health system. People-centred care is now the goal of the Central African Republic.

The Central African Republic aims to diversify, accelerate and generalize differentiated services. The Catalytic Initiative promoted by UNAIDS with the financial support of Luxembourg is helping the country to achieve this ambition. A first decisive step has been taken with the organization of a round-table discussion, entitled Catalytic Initiative on Differentiated HIV and Tuberculosis Services. The meeting brought together the Ministry of Health, the Comité National de Lutte contre le SIDA, civil society, people living with HIV, tuberculosis stakeholders, key populations, youth organizations, the United Nations, Médecins Sans Frontières and the French Red Cross.

The participants reviewed the existing pilot programmes of differentiated services in the country and the obstacles related to their implementation. They stressed the urgent need to expand differentiated services, particularly in the current context of the increasing insecurity and humanitarian challenges that make it difficult for people to access HIV and tuberculosis services.

“It is in the current context of the security crisis that the differentiated services approach is most valuable in the Central African Republic,” said Patrick Eba, UNAIDS Country Director for the Central African Republic.

The participants agreed on the activities to be implemented and validated the project implementation schedule to improve the quality of care and biological monitoring of people living with HIV and tuberculosis patients by stimulating the implementation of differentiated services.

“I welcome this opportunity offered by UNAIDS to remove bottlenecks to improve the overall management of HIV,” said Marie-Charlotte Banthas Bata, the Director of Communicable Disease Control at the Ministry of Health and Population, Central African Republic, pictured above, centre.

“Community organizations must be at the centre of the implementation of differentiated approaches,” said Bienvenu Gazalima, the President of the National Network of Associations of People Living with HIV in the Central African Republic 

The next key steps will be the documentation of existing differentiated approaches in the country and the development of a national guidance document for scaling them up.

On 1 March, people around the world join together to celebrate Zero Discrimination Day, which this year highlighted the urgent need to take action to end inequalities.

In recent years, the Central African Republic has made the reduction of health inequalities a national priority. In mid-2019, 10 priority areas towards universal health coverage were established. These include the objective of ensuring that every citizen in the country has access to a health centre within 5 km of his or her home.

The country was the first to join the Global Partnership for Action to Eliminate all Forms of HIV-Related Stigma and Discrimination, which through harnessing the combined power of, and using the unique skills of, governments, civil society and the United Nations aims to consign HIV-related stigma and discrimination to history.

To mark Zero Discrimination Day this year, the country organized several activities ahead of and during the day. A declaration recalling the government’s commitment to non-discrimination and equality was issued by the Minister of Health and Population on television and radio. “It is only by addressing inequalities that we can achieve the Sustainable Development Goals, including those related to well-being and health for all,” said Pierre Somse, the Minister of Health and Population.

Recent studies show that inequality and stigma are major obstacles to access to health services. For example, more than 80% of people living with HIV in the country report having experienced discrimination or stigma. “These challenges are further compounded by conflicts and attacks on populations and health personnel that deprive hundreds of thousands of our citizens of their rights, including the right to life, dignity and health,” Mr Somse added.

A civil society consultation was organized to flesh out the priorities for the elimination of stigma and discrimination in the country. A round-table meeting was also held on a national network of human rights journalists radio programme to raise awareness on the negative impact of stigma and discrimination as a major barrier to people taking up HIV prevention, treatment, care and support services. Speaking on the programme, Aminata Adoum, of the National Association of Women Lawyers, highlighted the work of her organization in supporting women living with HIV against discrimination and violence.

On Zero Discrimination Day 2020, health professionals, including professional organizations of doctors, nurses and midwives, as well as patients’ associations, signed a National Charter for Quality of Care and Patients’ Rights that sets the principles of humanism, ethics and respect for dignity to guide relations between patients and health-care providers. This year, the patients’ charter was posted in health facilities in the capital city, Bangui, and dedicated sensitization sessions on the charter took place for medical staff in two major health-care centres in the capital.

“This Zero Discrimination Day campaign is part of a comprehensive set of priority activities to address human rights barriers to HIV services that the country will be implementing over the next three years, including community-led monitoring of human rights violations, know your rights education, legal services, the development of anti-discrimination law and engagement with community leaders, legislators and opinion-makers,” said Patrick Eba, the UNAIDS Country Director for the Central African Republic.

The presidential and legislative elections in the Central African Republic on 27 December 2020 were meant to mark the consolidation of democracy and bolster economic and social recovery in a country tormented by decades of conflict and humanitarian challenges. However, the electoral process has given way to a serious political and military crisis, with the resurgence of armed conflict and a blockade of the main trade and supply routes to the landlocked country by rebel groups.

It is in this context of crisis, and in the aftermath of bloody clashes between armed groups and government forces on the outskirts of the capital, Bangui, that the UNAIDS country office in the Central African Republic hosted a workshop to produce HIV estimates for the country from 18 to 22 January. This important annual exercise is conducted by UNAIDS with national authorities in all regions of the world to provide countries and HIV stakeholders with essential data on the pandemic and the response.

Marie Charlotte Banthas, the Director of Disease Control at the Ministry of Health, oversees HIV and tuberculosis treatment programmes in the Central African Republic. Over the past three years, her services have been at the forefront of efforts to accelerate access to antiretroviral therapy from some 25 000 people on treatment in 2016 to more than 48 000 in June 2020. A former head of monitoring and evaluation at the Ministry of Health, she considers the HIV estimates workshop a priority, despite the deteriorated security situation. “There is no effective response to HIV without data. We need to hold this workshop to provide the country with reliable data to better guide our efforts and improve the care of our patients,” she said. 

Civil society also considers HIV estimates as a crucial endeavour. Bertille Zemangui is the President of the National Network of Free Girls, a sex workers’ organization representing key populations. To attend the HIV workshop, Ms Zemangui had to travel long distances each day through sensitive areas. The increased cost of public transport due to the crisis was not enough to discourage Ms Zemangui and other workshop participants. “The current situation is difficult. Everything has become expensive: transportation, food. But we have to be there to make our voice heard because it is sex workers and other key populations that are most affected by HIV in the Central African Republic,” she said. According to data from a 2019 survey, HIV prevalence among sex workers is 15% and 6.5% among gay men and other men who have sex with men, compared to 3.5% among all adults in the country. 

For security reasons, the estimates workshop was moved to the UNAIDS office and participation was reduced to national and international experts and members of civil society. “This workshop provided us with a clearer idea of the magnitude and trajectory of the epidemic for 2021. These are essential to measuring our progress towards achieving the 95–95–95 goals,” said Marcel Massanga, the Deputy National Coordinator of the National AIDS Control Council. The workshop also served to identify approaches to improve the quality and completeness of HIV data in the Central African Republic. Thus, the participants agreed on the need to integrate HIV data into the District Health Information System 2 (DHIS2) platform with a view to strengthening the health system. 

There are concerns that the volatile security situation could jeopardize the Central African Republic’s efforts to accelerate its HIV response. In 2020, the country launched an ambitious National HIV Strategic Plan 2021–2025, which aims to eliminate discrimination, halve new HIV infections and ensure that 95% of people living with HIV access antiretroviral therapy by 2025. “It will not be possible to achieve these ambitious goals without peace and stability. Already we have information that in several areas people living with HIV have fled into the bush and are without treatment. We must quickly implement contingency plans to respond to these emergencies,” said Patrick Eba, the UNAIDS Country Director for the Central African Republic.

Zemio is a city cut off from the world. In this remote area of south-eastern Central African Republic, few convoys pass and supplies are difficult to come by. Infrastructure barely exists and illegal checkpoints manned by armed men litter the roads.

Owing to conflict, more than 40 000 people are displaced in the area, and at least 30 000 people have been forced to flee to neighbouring South Sudan and the Democratic Republic of the Congo.

According to the government, the Haut-Mbomou region, where Zemio is located, has the highest HIV prevalence in the Central African Republic: at 12%, more than triple the rest of the country. 

But community antiretroviral therapy groups, or CAGs, set up in 2016 by Medecins Sans Frontières, are helping people living with HIV to support and help each other.

In Zemio, the CAGs represent hope in a forgotten conflict.