Central African Republic

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.

On the border between South Sudan and the Democratic Republic of the Congo, Haut-Mbomou is the province worst hit by HIV in the Central African Republic, with HIV prevalence at 11.9% compared to a national average of 4%.

Initially spared by the conflict that engulfed the country in 2013 and 2014, since 2018 Haut-Mbomou has seen fighting between rival armed groups, continued insecurity and a large-scale displacement of people. More than 47 000 people have been displaced by insecurity and violence in the province, adding to a population of some 3500 refugees from South Sudan and the Democratic Republic of the Congo.

Alerted by accounts of persistent medicine stock-outs, substandard care for people living with HIV and barriers to access to HIV and health services owing to insecurity, a joint mission of the Central African Republic Ministry of Health, the National AIDS Council, the World Health Organization, the Office of the United Nations High Commissioner for Refugees and UNAIDS visited Haut-Mbomou from 8 to 12 April. Located 1000 km from the capital, Bangui, the province is among the most underserved by health and social services. Half of the health facilities in the province are closed owing to a lack of personnel or rundown facilities.

In the towns of Obo and Zemio, the mission met with local authorities, health-care providers, religious and community leaders, internally displaced people, refugees and people living with HIV. “This joint mission brings together the breadth of national and United Nations expertise to offer practical solutions to the challenges of HIV and health in this critical province,” said Patrick Eba, UNAIDS Country Director for the Central African Republic.

The mission noted the impact of insecurity on the population and on access to health and other services. The main routes of supply are closed and violence outside the urban centres greatly limits access to medicines, food and other essential commodities.

The Obo District Hospital, the main health-care facility in the province, lacks basic laboratory testing equipment, including for blood safety or tuberculosis screening. Access to antiretroviral medicines is greatly limited by regular stock-outs. The absence of CD4 count measurement, viral load testing and other biological tests for people on antiretroviral therapy limits the quality of care for host populations and refugees. The mission was also concerned by the absence of HIV prevention and sensitization efforts, including the unavailability of condoms.

“How can we live in dignity when we face constant stock-outs of antiretroviral therapy and the hospital staff treat us badly? Many people who are on treatment are sick with opportunistic infections, but the hospital cannot give us anything,” lamented a frail, middle-aged woman living with HIV in Obo, who also bravely spoke out against discrimination.

Access to food is increasingly a problem because insecurity limits farming, fishing and hunting and hinders the ability of humanitarian agencies to deliver nutritional support. For vulnerable people living with HIV, including refugees and displaced people, access to food and nutritional support is essential for antiretroviral medicine adherence and effectiveness.

In Zemio, the mission spoke with members of community groups established by Médecins Sans Frontières as part of an innovative programme to facilitate access to antiretroviral medicines. Group leaders collect and dispense antiretroviral medicine to members who live far from hospitals. The group members highlighted that barriers to their access to medicines included roadblocks, insecurity and extortion by armed groups. The mission held a dialogue with communities and leaders of the main armed group in Zemio to emphasize the need for unhindered access to health-care facilities.

The mission showed the complex nature of the challenges facing the HIV response in a context such as that in the Central African Republic, which is characterized by insecurity, population displacement and a collapsed health-care system. Those challenges call for urgent attention and action on the part of the government, the United Nations and others to address emerging and chronic health and HIV challenges. “Addressing these challenges is essential to show that these populations are not forgotten” said Wilfrid Sylvain Nambei, the Minister Coordinateur of the National AIDS Council. “Swift action following this mission will reinforce confidence in the government and its partners and it will advance our efforts to build peace, reconciliation and reconstruction that leaves no one behind.”

The PK5 neighbourhood of Bangui, Central African Republic, is home to much of the city’s Muslim community. Once a bustling commercial area and the centre of Bangui’s nightlife, PK5 has become a no-go zone for many.

Like much of the country, the PK5 area and its population were greatly affected by the violence that engulfed the country in 2012 and 2013. The non-Muslim inhabitants of PK5 left; rival armed groups continue to exert control. Across the country, the consequences of the violence have led to a huge displacement of people and a humanitarian crisis. At the end of 2018, it was estimated that 2.9 million people—more than half of the country’s population—were in need of humanitarian assistance and protection.

However, the people of PK5 remain resilient. Recognizing the need for a greater awareness of HIV in the community, Muslim youth leaders and the Catholic University Center, with the support of UNAIDS, organized an HIV testing and awareness-raising campaign from 23 January to 13 February at the Henri Dunant Health Centre in PK5.

The campaign was the first of its kind to take place in PK5 since the 2012–2013 violence. In the two weeks of the campaign, 1500 people accessed voluntary HIV testing and counselling services. People who tested positive for HIV were referred for treatment.

The campaign was opened by Pierre Somse, the Minister of Health, during an event attended by religious leaders, women and young people. Mr Somse took an HIV test and stressed the importance of all people knowing their HIV status. Knowledge of HIV status in the country remains low, with only 53% of people living with HIV knowing their HIV status.

“The government is committed to intensifying its efforts to deliver health and social services to all Central Africans. PK5 is not forgotten and its population will not be left behind in our efforts to increase access to HIV testing, treatment, care and support,” said Mr Somse.

Pamela Ganabrodji, Head of Information and Counselling at the Henri Dunant Health Centre, added, “We are very proud of what we have achieved through this HIV campaign, but challenges remain. We call on the government and international partners to continue supporting the HIV and sexual and reproductive health activities of the Henri Dunant Health Centre, which are critical in a community where cultural and social taboos represent a key barrier.”

On the last day of the campaign, a community dialogue was held to discuss the HIV and sexual and reproductive health challenges faced by the people of PK5. The needs are urgent and range from basic health and social services to a lack of economic opportunities. Low access to modern contraceptives, incomplete knowledge about HIV and poverty contribute to making young people and women vulnerable to HIV.

“With this campaign, we, the young people of PK5, are showing that we are not helpless and that we are part of the solution for HIV and other social issues,” said Aroufay Abdel Aziz, President of the Muslim Youth of the Central African Republic.

A second phase of the HIV testing and sensitization campaign will continue until the end of March and will include focused HIV prevention messages with sensitization by peer educators and focus group discussions on HIV and sexual and reproductive health issues.

“UNAIDS will continue to engage the government and other United Nations agencies and partners to reinforce the involvement of young people in the HIV response,” said Patrick Eba, UNAIDS Country Director for the Central African Republic.

UNAIDS' support to Central African Republic lauded by the President

GENEVA, 23 October 2018—The President of the Central African Republic visited UNAIDS to discuss ongoing efforts to rebuild his country, advance national reconciliation and deliver basic services for the populations after decades of political instability and conflict.

"The government is working with its partners to increase access to basic social services like education, health, and clean water as well as boost our HIV response,” said Faustin-Archange Touadéra, President of the Central African Republic. “Our progress remains fragile, this is why we need the support and engagement of all our partners to advance our recovery.”

UNAIDS Executive Director, Michel Sidibé, who visited CAR in early October, thanked the President for his continued commitment towards peace, saying he was encouraged to see pockets of hope. “In your reconstruction efforts, health is a powerful tool to improve social justice and stability,” said Mr Sidibé. “I commend the President for his personal engagement to ensure protection and dignity for all, including women and girls who are vulnerable to sexual violence and abuse.”

UNAIDS and the CAR Ministry of National Defence and Reconstruction of the Army and the Ministry of Health signed a memorandum of understanding (MoU) to reduce gender-based violence and HIV infections within the military and other uniformed personnel, and to increase uptake of HIV treatment, care and support services.

The Central African Republic has the second highest HIV prevalence in central Africa, estimated at 4% in 2017. However, among uniformed personnel, HIV prevalence is double, at an estimated 7.8%. Knowledge of HIV among uniformed personnel in the Central African Republic is particularly low and reports of sexual abuse and violence by military personnel are widespread. Since January 2017, the Central African Republic has seen progress in its response to HIV, with more than 10 000 people accessing life-saving treatment.

The President reiterated that after years of violence, people longed for an end to the suffering. He sincerely hopes that uniformed personnel, armed groups and the government will continue their dialogue to achieve peace with the African Union’s guidance. He repeated, “Now is the time to act to lift up our nation and we thank UNAIDS for their ongoing support.”

HIV data for the Central African Republic in 2017

• 160 000 [130 000–190 000] people were living with HIV
• 53% of people living with HIV knew their HIV status
• 32% of people living with HIV were accessing antiretroviral therapy
• 8700 [7600–11 000] people became newly infected with HIV
• 15 000 [12 000–17 000] people died from AIDS-related illnesses

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

New initiative launched to engage the military and other uniformed personnel in HIV awareness, prevention and treatment and eliminate sexual and gender-based violence by defence and security forces

BANGUI/GENEVA, 9 October 2018—UNAIDS has signed a memorandum of understanding (MoU) with the Ministry of National Defence and Reconstruction of the Army, the Ministry of Health and Population and the National AIDS Committee of the Central African Republic. The aim of the MoU is to reduce new HIV infections within the military and other uniformed personnel, reduce sexual violence and abuse by security and defence forces and increase uptake of HIV treatment, care and support services.  

The MoU comes at a critical time. The Central African Republic has the second highest HIV prevalence in central Africa, estimated at 4% in 2017. However, among uniformed personnel, HIV prevalence is double, at an estimated 7.8%. Knowledge of HIV among uniformed personnel in the Central African Republic is particularly low and reports of sexual abuse and violence by military personnel are widespread.

"We have a responsibility to protect all our people from violence and HIV, especially women and girls, who are the most vulnerable. By focusing on uniformed personnel, we aim to transform the relationship between the new army and the population, as a key to reconstruction,” said Faustin-Archange Touadéra, President of the Central African Republic.

Under the MoU the parties involved will mobilize national partners to respond to HIV and gender-based violence within the defence and security forces, reduce HIV prevalence and incidence and improve relations between the defence and security forces and the general population through integrated activities around HIV prevention and gender-based violence.

“This protocol is a first,” said Michel Sidibé, Executive Director of UNAIDS. “It translates Security Council resolution 1983 into concrete actions. It places prevention at the centre of our efforts to end gender-based violence as a cause and consequence of HIV. This is essential and complementary to all efforts to strengthen accountability for sexual violence in the Central African Republic.”

Special emphasis will be given to training and awareness-raising for defence and security forces using methods proven to be effective in reducing gender-based violence and preventing HIV. These include improving mechanisms to report sexual violence, support for survivors and ensuring access to effective HIV prevention tools. Social and psychosocial support programmes will also be made available for members of the defence and security forces and their families.

The main beneficiaries of the programmes and activities will be the defence and security forces in the Central African Republic, which include the military, the police, the gendarmerie, customs officials, water and forestry officers and the municipal police. The implementation of the MoU will also benefit the wider population through planned integrated activities between the military and civilians and through the impact of HIV prevention, treatment and care programmes and efforts to eliminate sexual and gender-based violence and abuse.

UNAIDS will provide leadership and technical support to the initiative and will mobilize its partners and Cosponsors, particularly organizations working on gender and health issues, to support the implementation of the activities outlined in the MoU. UNAIDS will also ensure effective collaboration between all project partners, including ensuring the active participation of civil society. It will also play a critical role in advocating for resources and supporting the monitoring, evaluation and documentation of the initiative.

The United Nations Multidimensional Integrated Stabilization Mission in the Central African Republic and the European Union Military Training Mission in the Central African Republic have committed to support the initiative.

The new commitments will play an important role in advancing the National Recovery and Peacebuilding Plan 2017–2021 in the Central African Republic and are part of ongoing efforts to implement United Nations Security Council resolution 1983, which underlines the importance of concerted efforts towards ending sexual and gender-based violence and responding to HIV in conflict and post-conflict settings.  
 

HIV data for the Central African Republic in 2017:

• 160 000 [130 000–190 000] people were living with HIV
• 53% of people living with HIV knew their HIV status
• 32% of people living with HIV were accessing antiretroviral therapy
• 8700 [7600–11 000] people became newly infected with HIV
• 15 000 [12 000–17 000] people died from AIDS-related illnesses

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

Some 18 months after the launch of the catch-up plan, the National AIDS Council (CNLS), the Ministry of Health and UNAIDS co-organized a workshop in Bangui, to take stock of the progress and the challenges to accelerate access to treatment for people living with HIV in the Central African Republic. The workshop also served as an opportunity to renew political commitment to the HIV response and to call for urgent action on prevention.

The Prime Minister of the Central African Republic, Simplice Mathieu Sarandji, opened the meeting with 80 stakeholders present, including members of government, civil society organisations, people living with HIV, members of key populations, as well as local governments, traditional and religious leaders.

Key areas of progress since the launch of the catch-up plan in January 2017 included the development of new policies to implement test and treat, and the increase in the number of people on HIV treatment from 25,000 in 2016 to 34,000 in June 2018. Community treatment groups have been delivering HIV treatment to people in remote and insecure regions such as the eastern town of Zemio. In addition, a community treatment observatory is helping monitor access to and quality of HIV care in Bangui.

However, there are miles to go. Less than 35% of people living with HIV in Central African Republic access treatment — this is among the lowest in sub-Saharan Africa. Challenges include an inadequate monitoring and evaluation system, a lack of effective supervision of facilities providing HIV services, limited community engagement to implement HIV testing and treatment, as well as limited financial commitments to reach treatment targets. Most agreed on the need to improve coordination.

As a result, participants identified priorities for the next six months to reach treatment targets for 2019. All stressed that communities, people living with HIV and key populations must be involved every step of the way. In addition, participants stressed the urgent need for increased domestic and donor funding.

A steering committee and technical working groups prepared the two-day workshop based on available data and on-the ground site visits. The groups included representatives from the Ministry of Health, CNLS, community organisations, people living with HIV, international NGOs such as Medécins Sans Frontières and the French Red Cross as well as UNICEF, UNFPA, WHO and UNAIDS.

Seven months after launching the catch-up plan in western and central Africa, progress on increasing the numbers of people on antiretroviral treatment continues to lag in the region. Many countries will not reach key targets by 2020 if the current systems remain unchanged.

"Overall we saw a 10% percent increase of people on treatment, which is not enough," said UNAIDS Executive Director Michel Sidibé. "Now, there is even more a sense of urgency."

Mr Sidibé, however, pointed to the success in the Democratic Republic of Congo where there was a clear increase in the number of people living with HIV accessing ARVs. The reasons for the positive trend included civil society and political leadership working closely together as well as community HIV testing and the training of 11 000 health care workers.

"More than ever there is a need to rethink health systems and alternatives for people to access health care," he said.

The call to delegate patient care to communities was a major rallying call during AFRAVIH, the international francophone HIV and hepatitis conference held in Bordeaux, France, early April. Mr Sidibé briefly shared the stage at the opening ceremony with the civil society organisation Coalition PLUS. They declared that the key to success in ending AIDS involved joining forces between doctors and community health workers and giving more leeway to communities to respond to the local needs of their own people.

Under the banner, "De-medicalize" the organisation explained that doctors will never be replaced but that there were too few of them and people living with HIV didn't require acute care.

Coalition Plus' recent report states that governments and the medical practitioners should delegate more tasks to nurses and community health workers. In addition to allowing for more targeted prevention and faster access to treatment, delegation of non-medical tasks would lighten the load on overburdened health systems. West and central Africa represent 17% of the total population living with HIV but 30% of deaths in the region are from AIDS-related illnesses. This is a region, according to UNAIDS and its partners, that can truly benefit from community models of care.

What worries Médecins Sans Frontières (MSF) is the risk of a significant drop in resources for treatment will hamper recent improvements in west and central Africa. This concern stems from the fact that Global Fund estimates a 30% drop in fund allocations to the region for 2018 – 2020 compared to signed HIV grants in the previous allocation period. In 2016, MSF was among the first to sound alarm bells regarding the region's high HIV death toll and the up to 80% of children unable to access antiretroviral therapy. MSF HIV Policy Advisor and Advocacy Officer Nathalie Cartier said that they supported the west and central Africa catch-up plan but that it needed to be fully implemented. "Political will has been promising but now it's time to make it a reality on the ground so that people living with HIV can reap the benefits," she said.

Global Fund supported the catch-up plan and works closely with countries in order to maximize the impact of the investments. They believe that leveraging additional domestic financing for health is crucial to increase country ownership and build sustainable programs.

All the more reason to decentralize healthcare systems and capitalize on innovations to keep health costs down.  HIV self-testing, new medicines and high impact strategies involving communities are critical to improving efficiencies.  "With point-of-care (POC) testing in communities and homes, delays are minimal between diagnosis and initiating treatment," said Cheick Tidiane Tall, Director of Réseau EVA, a network of pediatric doctors specialized in HIV care. “In the long run, that's a lot of people and resources saved,” he added.

Côte d'Ivoire Infectious and Tropical Diseases professor Serge Eholié couldn't agree more.  "Flexible health care systems capitalizing on various innovations makes a lot of sense," he said. Turning to the Minister of Health in the Central African Republic, Pierre Somse, he asked, 'How do you respond?'

Mr Somse, also a trained doctor, said, "We doctors will stay doctors. However, there is a need for us to lean on communities and vice versa."  He added, "at the heart of the issue are patients and they are and should always be the priority."

Only 1.8 million people of the 6.5 million people living with HIV in western and central Africa were on antiretroviral therapy at the end of 2015. This 28% treatment coverage of people living with HIV in the region contrasts with the 54% coverage in eastern and southern Africa in the same year.

In response to this HIV treatment shortfall in western and central Africa, UNAIDS, the World Health Organization (WHO) and other partners in the region have developed country emergency catch-up plans to accelerate the AIDS response. These plans call for tripling HIV treatment coverage within the next three years.

At a meeting on the sidelines of the 70th World Health Assembly to support the catch-up plan, health ministers and other representatives of countries in the region vowed to strengthen government leadership, make structural changes in their health systems and strengthen accountability.

The meeting, which was organized by the WHO Regional Office for Africa and UNAIDS, was attended by the health ministers of Benin, Burkina Faso, the Central Africa Republic, Chad, Côte d’Ivoire, Gabon, Liberia and Nigeria and representatives of Cameroon, Guinea and Sierra Leone. They all collectively agreed to put in place strong measures to accelerate HIV treatment in their countries.

All the participants agreed that health-service delivery models had to be transformed, notably by community health workers taking a bigger role in health-care delivery. WHO and UNAIDS will continue to work with the countries as they implement their plans for increasing access to HIV treatment.

UNAIDS is working with countries to achieve the commitment in the 2016 United Nations Political Declaration on Ending AIDS of ensuring that 30 million people living with HIV have access to treatment through meeting the 90–90–90 targets by 2020.

More than 540 people living with HIV in the capital of the Central African Republic, Bangui, have been able to resume taking antiretroviral therapy owing to a joint project run by UNAIDS and the government of the Republic of Korea.

The recent instability in the country forced many people away from their homes and into camps for internally displaced people, where health services are limited. In addition, many health facilities were destroyed, inaccessible or unstaffed during the crisis. Around a third of people on antiretroviral therapy across the country were unable to continue their treatment.

Social services and community volunteers have located 544 of 1500 people who left treatment programmes in Bangui, enabling them to resume access to the life-saving medication. UNAIDS and the government of the Republic of Korea aim to extend the project to other provinces and to start rebuilding some of the country’s shattered health infrastructure.

A total of 120 000 people were living with HIV in the Central African Republic in 2013, with about 16 500 on antiretroviral therapy.