Cote d'Ivoire

By Brigitte Quenum, UNAIDS Country Director for Côte d’Ivoire

It is with great sadness that I learned on 15 July 2021 of the death of Cyriaque Yapo Ako, one of the pioneers in the response to HIV in Côte d’Ivoire and in Africa as a whole.

A founding member of Ruban Rouge CI in 1994, he never stopped promoting the role of communities in the response to HIV. The Executive Director of RIP+ in the 2000s, he then contributed his expertise to several organizations, including the International Treatment Preparedness Coalition, African Men for Sexual Health and Rights and I CHANGE CI, and collaborated with several partners, including UNAIDS, Population Services International, the United States President’s Emergency Plan for AIDS Relief and the United Nations Development Programme, as a resource person for technical assistance.

As a founding member of Arc-en-Ciel in 2003, the first nongovernmental organization for gay men and other men who have sex with men in the AIDS response in Côte d’Ivoire, he advocated for the need to create a safe space for sexual minorities in Africa, in particular in Côte d’Ivoire, where gay men and other men who have sex with men were commonly subject to stigma, discrimination and violence.

His dynamism and activist spirit enabled him to speak out on behalf of the most marginalized and neglected people in the AIDS response.

From 2004 to 2009, he was the representative of people living with HIV and sexual minorities on the Country Coordinating Mechanism Côte d’Ivoire, where he made a significant contribution to defending people-centred HIV responses in the development of HIV applications to the Global Fund to Fight AIDS, Tuberculosis and Malaria.

His participation in several international conferences contributed to the advocacy of the rights of people living with HIV and more broadly the rights of key populations. He defended his positions, notably through his participation in events such as the International Conference on AIDS and STIs in Africa (ICASA) in 2008 in Dakar, Senegal, ICASA 2011 in Addis Ababa, Ethiopia, ICASA 2013 in Cape Town, South Africa, and the 2016 International AIDS Society Conference in Durban, South Africa, with his contribution in the form of oral presentations and statements.

His passing is a great loss to all those involved in the AIDS response, especially those committed to defending the most vulnerable.

He was a friend, brother and colleague to many of us.

May his soul rest in peace.

Like the rest of the world, COVID-19 has hit Côte d’Ivoire hard. As soon as the first cases of COVID-19 were confirmed in March 2020, a national response plan was developed by the government. Unfortunately, the restrictive measures to protect the population had an impact on the use of health services, including those related to HIV, threatening the fragile retention in care of people living with HIV. Pregnant and lactating women living with HIV and their children, one of the most vulnerable groups, have been particularly affected, and maintaining their access to services and care was essential to avoid undoing years of effort.

The United Nations Development Programme (UNDP) and UNAIDS joined forces to help retain 333 pregnant and lactating women living with HIV in antenatal, maternity and paediatric services in Abidjan. The project will provide, over nine months, 1000 food kits and 1000 hygiene kits to help beneficiaries with food assistance and help them protect themselves against COVID-19.  A food kit contains 20 kg of rice, six litres of oil, 10 pieces of soap and four boxes of children’s flour, and a hygiene kit contains two bottles of hydroalcoholic gel, two bottles of liquid soap and 50 surgical masks. The project also aimed to ensure that the women have access to the comprehensive package of services developed under Côte d’Ivoire’s prevention of mother-to-child transmission of HIV (vertical transmission) programme, to ensure that all exposed children of the project’s beneficiaries are screened early and have access to appropriate care and to document and share good practices.

One of the beneficiaries, Ouattara Maimouna, who has been living with HIV for five years and is a breastfeeding mother of three children, said, “Doctor, this gift was incredibly important to us. It has helped us a lot! This stock of food helps me feed my family. I cannot thank you enough, because I ran out of ways to sustain the small business that used to support my family.”

“About 700 hygiene kits and 700 food kits have been distributed since the project started in December 2020. The United States President’s Emergency Plan for AIDS Relief’s (PEPFAR) implementing partners unanimously indicate that the kits have contributed to the loyalty of pregnant and breastfeeding women to prevention of vertical transmission of HIV and paediatric care services, as well as to self-support groups,” said Brigitte Quenum, the UNAIDS Country Director for Côte d’Ivoire.

At this stage of implementation, some lessons learned are already emerging. The project has been very well received by the beneficiaries because of their vulnerability, which has been aggravated by the COVID-19 crisis. The support has helped to increase their compliance with appointments at the various prenatal consultations, to improve the continuity of treatment and viral load testing for pregnant and breastfeeding women and to strengthen the link between women living with HIV and the staff providing both clinical and community care. The project also emphasizes the importance of taking into account the social component in the care of women in prevention of vertical transmission of HIV services.

The distribution of food and hygiene kits will continue until the end of 2021. Pregnant and breastfeeding women living with HIV have become more vulnerable in the midst of the response to COVID-19 and assistance strategies that respond to their specific sensitivities must be designed. “The mobilization of UNDP, UNAIDS, PEPFAR implementing partners and their nongovernmental organization partners has ensured a coalition of support for advocacy and the scaling up of outreach efforts to vulnerable populations,” added Ms Quenum. “While this one-time initiative is useful, efforts should be made to integrate other activities, such as nutrition promotion and the integration of a social component in the care of women living with HIV in vertical transmission services and other care sites.”

An HIV-sensitive and inclusive social protection assessment will start in the coming months in collaboration with the key ministries involved. Mobilization of funds for social aspects related to women living with HIV and advocacy for sustainable support measures will be required.

Despite the great progress made since the early days of the HIV epidemic, the HIV response for children is still lagging behind the response for adults.

Children living with HIV are particularly susceptible to tuberculosis (TB), one of the leading causes of AIDS-related deaths. In 2020, according to government statistics, 9400 people died of AIDS-related illnesses in Côte d’Ivoire, including 800 children under the age of 14 years. There were 21 000 people under the age of 15 years living with HIV in the country—only 49% had access to antiretroviral therapy. How to correct such an inequality was the question at the heart of a national consultation on paediatric HIV and TB that was held from 8 to 10 June in Abidjan, Côte d'Ivoire.

The consultation, Acting Together for a Generation without AIDS and Tuberculosis, was aimed at improving the prevention and management of HIV and TB among children and adolescents in Côte d’Ivoire.

In her opening speech, Dominique Ouattara, the First Lady of Côte d’Ivoire, called for “The development of an ambitious road map that will enable Côte d'Ivoire to achieve its commitments.” She invited all the participants to engage in a dialogue on the challenges and priority actions needed, and to discuss the roles, responsibilities and contributions of each partner.

The consultation is part of the Confessional Initiative, a UNAIDS and United States President’s Emergency Plan for AIDS Relief initiative that is organizing national consultations and training in Cameroon, Côte d’Ivoire, Kenya, Nigeria and the United Republic of Tanzania.

“The consultation presented the national situation regarding diagnosis, treatment and prevention of HIV and tuberculosis among children, identified the key challenges, outlined the solutions, priority actions and resources needed to improve the national roll-out of optimal paediatric HIV and tuberculosis treatment and diagnosis and identified good practices for replication through civil society and faith-based organizations,” said Patrick Brenny, the Director for the UNAIDS Regional Support Team for Western and Central Africa.

The targets in the 2016 United Nations Political Declaration on Ending AIDS and in Start Free, Stay Free, AIDS Free for paediatric AIDS have not been met. Globally, during 2020 an estimated 160 000 children acquired HIV, far from the global 2020 target of 20 000. Modelling has also shown that the COVID-19 pandemic could have a major impact on new HIV infections among children in sub-Saharan Africa.

Ms Ouattara appealed to the 350 participants to work towards reducing inequalities and asked all stakeholders to join forces to achieve certification of the elimination of mother-to-child transmission of HIV. “Today, in 2021, no child should die of AIDS or tuberculosis in our country," she added.

The Gboklè/Nawa/San Pedro region is the second largest economic hub in Côte d’Ivoire and one of the regions most affected by the HIV epidemic. The region attracts many workers because of its important economic and industrial activities, mainly related to the port and agriculture, as well as sex workers and other members of key populations.

A joint United Nations Development Programme (UNDP)/UNAIDS mission to the region from 16 to 20 April learned about the realities of the HIV response in the region in the context of COVID-19 and assessed how the response takes into account the needs of the most vulnerable.

The mission first paid a courtesy call on the region’s administrative and health authorities, and then quickly focused on the sites where services are offered to people living with HIV and key populations. In the health-care facilities visited, whether at the Regional Hospital of San Pedro, above, or at the health centre of APROSAM (Association pour la Promotion de la Santé de la Femme, de la Mère et de l’Enfant) nongovernmental organization, the mission team saw the commitment and determination of the health-care teams and the administrations of the facilities. “We have set up a quality assurance team within the hospital to guarantee services centred on the needs of each patient,” said Alexandre Kissiedou, the Director of the Regional Hospital of San Pedro.

The visit to APROSAM was one of the most captivating moments of the mission. During the visit, the mission team had in-depth discussions with representatives of a dozen associations, who had come to APROSAM’s headquarters to meet the mission delegation. Useful discussions took place with representatives of associations of people living with HIV and associations representing key populations, as well as with representatives of nongovernmental organizations working with young people.

“It is the first time that civil society is honoured with the visit of the country representatives of two United Nations agencies,” said Odette Koffi, the Executive Director of APROSAM, an association involved in the response to HIV, tuberculosis and malaria in the region. She also noted that civil society is truly committed to the HIV response but lacks the means to meet the needs of all.

“Income-generating activities are no longer working as they used to. Today we can’t even feed ourselves properly and we can’t take antiretroviral medicines on an empty stomach,” said Maya Rose Nean, the head of the local CERBAS association for women living with HIV, when describing how COVID-19 had impacted women living with HIV in the country.

Brigitte Quenum, the UNAIDS Country Director for Côte d’Ivoire, speaking on behalf of the delegation, underlined the vital work of nongovernmental organizations in the HIV response and praised the commitment of civil society organizations, people living with HIV and key populations. She said that a dialogue between UNDP and UNAIDS will address some of the pressing needs discussed with civil society. A donation of 400 food and hygiene kits was made by UNDP and UNAIDS to vulnerable people living with HIV and key populations.

The last day of the mission focused on human rights, with a visit to the Elan d’Amour reception centre, above, which offers temporary accommodation to people living with HIV and people who are victims of stigma, discrimination and gender-based violence, including people who come from remote areas for care and/or to collect their antiretroviral therapy. The delegation then visited a legal clinic supported by UNDP. These visits allowed the delegation to get a good understanding of the realities of human rights in the region, but also to understand their implications for specific HIV-related vulnerabilities. As a result of these two visits, the two agencies agreed to consider a joint project to better address HIV and human rights issues in the region.

For both teams, this mission was a success. The various needs identified will be the subject of concerted action either between UNDP and UNAIDS or by working with other Cosponsors that can provide relevant solutions.

Brigitte Quenum, the UNAIDS Country Director for Côte d’Ivoire, above left, met with the Prefect of the San Pedro department. 

Faith-based organizations play a key role in all areas of the HIV response and provide a significant part of HIV-related health care through their networks of hospitals, clinics and community systems, particularly in high-burden countries. For this reason, UNAIDS and the United States President’s Emergency Plan for AIDS Relief (PEPFAR) launched a joint initiative to capitalize on the global and national leadership of faith-based organizations and to harness the power that a network of faith-based organizations could offer in some countries, including Côte d’Ivoire.

The UNAIDS–PEPFAR faith-based initiative was launched in Côte d’Ivoire on 14 October 2020 under the leadership of the Ministry of Health and Public Hygiene through the national AIDS control programme.

Following the national launch, several activities were initiated in the country as part of the initiative. These include the ongoing development of the Faith-Based Action Plan, under the leadership of the national AIDS control programme, which aims to ensure effective coordination and close monitoring of programmes, as well as synergy and complementarity in their implementation.

Caritas Côte d’Ivoire, which is a member of Caritas Internationalis, the organization in charge of implementing the social doctrine of the Catholic Church at the global and country levels, launched the GRAIL (Galvanizing Religious Actors for Better Identification and Linkage to Paediatric HIV) project on 9 February. This project will strengthen the involvement of faith-based organizations in accelerating the early diagnosis and treatment of children living with HIV in Côte d’Ivoire.

During the launch of the GRAIL project, a representative of the Ministry of Health and Public Hygiene welcomed the commitment of the Catholic Church in the national response to HIV and recalled the place of paediatric AIDS in national priorities.

“The COVID-19 pandemic that we are facing is a very worrying health and social emergency that requires a strong response. Many of the people affected are children living with HIV,” said Bruno Yedoh Essoh, the President of Caritas Côte d’Ivoire.

“Gaps in the diagnosis and care of children living with HIV are notable and an effective national partnership with faith-based organizations in Côte d’Ivoire can help fill these gaps,” said Jean-François Somé, a UNAIDS PEPFAR/Global Fund to Fight AIDS, Tuberculosis and Malaria Implementation Adviser who represented UNAIDS at the launch.

The GRAIL project will focus on training religious leaders and faith-based health service providers on paediatric HIV and on actions to reduce stigma and discrimination against people living with HIV, including children. The first session of a training workshop for religious leaders and faith-based health service providers on paediatric AIDS started immediately after the launch of the GRAIL project. Other training sessions are planned around the country.

Côte d’Ivoire has launched its Harnessing the Power of Partnerships faith-based initiative.

As one of several focus countries for an initiative of the United States President’s Emergency Plan For AIDS Relief (PEPFAR) and UNAIDS, which was launched in June 2020 to leverage global and country leadership by faith-based organizations in the HIV response, Côte d’Ivoire will work with faith-based organizations in the country to align their activities to faith action plans in support of the national HIV response. Experience shows that such an alignment results in a better coordinated and sustained participation of the faith sector in national responses to HIV.

Faith-based organizations have always played an important role in the response to HIV through their strong links with communities and their broad network of hospitals, clinics and other health facilities. However, to unleash the full potential of those organizations, there is still a need to reinforce their capacities to adopt new policies and innovations, to improve their collaboration and coordination with partners in the HIV response and to further address HIV-related stigma and discrimination within faith communities.

“This initiative will build on the global and national leadership of faith-based organizations in the response to HIV, with a particular focus on areas where faith-based organizations have a real and sustainable impact,” said Samba Mamadou, Director-General of the Côte d’Ivoire Ministry of Health and Public Hygiene.

Through the partnership, PEPFAR’s implementing partners in the country will work with faith-based organizations to develop messages of hope to reduce HIV-related stigma and discrimination and increase demand for HIV services. Key issues to be addressed will include treatment cessation through “faith healing” and the need for strengthened HIV literacy.

The next steps of the initiative include convening a meeting with all the relevant stakeholders to develop a faith action plan in support of the national HIV strategic plan for 2021–2025.

“The initiative is designed as a consortium of longstanding faith-based organizations and partners working together to build and combine their strengths, promote evidence-informed policy and practice and strengthen advocacy efforts,” said Brigitte Quenum, UNAIDS Country Director for Côte d’Ivoire.

The initiative, which is under the leadership of the Ministry of Health and Public Hygiene and the National AIDS Control Program, and is supported by UNAIDS, was launched in mid-October at an event attended by more than 50 partners that was hosted by UNAIDS and streamed online. 

"The faith-baith institutions welcome this interfaith initiative to strengthen the contribution of our institutions and leaders in a more synergistic way,” said Pastor Yapi, Deputy Vice-President of the Alliance des Religieux pour la Santé Intégrale et la Promotion de la Personne Humaine.

The restrictions on movement and lockdowns currently being enforced to curb the spread of the new coronavirus in both Côte d’Ivoire and Nigeria are having an impact on many people living with HIV. To help mitigate those effects, the International Community of Women Living with HIV (ICW) West Africa is partnering with health-care facilities to facilitate the home delivery of HIV and other treatments.

Key to being able to provide this service is the recruitment of community pharmacists, who collect and deliver antiretroviral therapy and other medicines to people, especially adolescent girls and young women, who can’t access their treatment themselves. An initiative of ICW and its partner, Positive Action for Treatment Access (PATA), 59 women living with HIV are now serving as community pharmacists, visiting hard to reach semi-urban and rural areas and helping to ensure that no one is left behind because of the COVID-19 crisis.

Under the arrangement, the medicines are provided by the Institute of Human Virology Nigeria, while PATA provides the logistics with support from the Open Society Initiative for West Africa (OSIWA) and ICW West Africa is responsible to the final home delivery.

“I willingly accepted to do this work because as a woman living with HIV, I know what it really means staying without antiretroviral therapy and the likeliness that people may develop drug-resistant strains, whose long-term effects could be worse than COVID-19,” said Queen Kennedy, a community pharmacist in Nigeria.

In Nigeria, community pharmacists are providing services in three COVID-19 high-burden states, Lagos, Federal Capital Territory and Oyo, covering 26 health-care facilities, while in Côte d’Ivoire community pharmacists are working in three provinces covering nine health-care facilities. In addition to their work delivering medicines, the community pharmacists are also sensitizing adolescent girls and women living with HIV on COVID-19 prevention measures, such as physical distancing, wearing face masks and regular hand washing.

“Ensuring access to quality health-care services for adolescent girls and young women and key populations living with HIV is one of our mandates. The only difference here is that we are providing these services in an emergency situation, putting at risk also our own health,” said Reginald Assumpta Ngozika, the Regional Director for ICW West Africa.

Through this partnership, ICW West Africa is also facilitating access to antiretroviral medicines for two foreign women living with HIV who are stranded in Nigeria because of border closures. Since the two women ran out of their medicines, they are being assisted by ICW community pharmacists, who collect and deliver their treatment in Lagos and Rivers State.

“Thank you ICW West Africa for keeping me on my medicines during this COVID-19 lockdown in Nigeria,” said one of the beneficiaries.

Thousands of households have been helped in Abidjan, Côte d’Ivoire, through a joint initiative to reach vulnerable households with money for nutrition and food security and basic health kits during the COVID-19 pandemic. 

Restrictions on movement imposed to stop the spread of the new coronavirus in Côte d’Ivoire have had a significant impact on the ability of people to earn a living, resulting in an increasing danger of hunger. For people living with HIV, malnutrition and food insecurity reduce HIV treatment adherence, impacting their health and increasing HIV transmission, since stopping treatment can increase a person’s viral load, which increases the chance of passing the virus on. Food insecurity can also increase HIV risk behaviours, potentially putting people at increased risk of acquiring HIV.

The partnership between the World Food Programme, UNAIDS and the Magic System Foundation—a nongovernmental organization that works in the fields of education, health, the environment and culture—allows for a cash transfer of 51 000 central African CFA francs (around US$ 89) per household to cover food needs for two months, distributes hygiene kits and protective equipment to limit the transmission of COVID-19 and gives advice on nutrition.

“The cash transfer allowed me to buy my medicine for three months and to stock up on rice for my family. It gave me the strength to live and smile again,” said one of the recipients.

The priority focus of the campaign are female-headed households and households with pregnant and breastfeeding women, young children, the elderly, people with disabilities and people living with HIV.

“UNAIDS and the Ivorian Network of People Living with HIV are working with various partners—mayors, nongovernmental organizations, the Red Cross, mosques, churches, community leaders, neighbourhood leaders and traditional chiefs—to facilitate access to especially vulnerable people living with HIV,” said Brigitte Quenum, the UNAIDS Country Director for Côte d’Ivoire.

“The health crisis has forced some households to adopt irreversible food strategies, such as selling assets or borrowing money to meet their food needs. Cash-based food aid helps build the resilience of vulnerable households and preserve their livelihoods. The cash transfer provides the opportunity to have a diversified and balanced diet for good health, while leaving recipients with a choice,” said Adeyinka Badejo, the World Food Programme Representative in Côte d’Ivoire.

A further round of assistance for vulnerable households, especially households containing members of key populations or people living with HIV, will take place soon. The second round will draw on a rapid assessment of the needs of people living with HIV during the COVID-19 pandemic, which was carried out by the network of people living with HIV with the support of UNAIDS, and on the lessons learned from the first round of assistance.