Cote d'Ivoire

It’s 10 in the morning in Abidjan, Côte d’Ivoire.

Like every morning, Arouna Bakari (not his real name), mask on his face, washes his hands before entering a “smoking room”, as people who use drugs call the open drug-taking places in Abidjan. He checks that the hand washing sink installed in front of the smoking room is working properly. He can now start his work and distribute prevention equipment against COVID-19 to the people who gather there.

Mr Bakari works for Parole Autour de la Sante (PAS), a community-led organization made up of people who use drugs and former people who use drugs, their relatives and social scientists. It operates the first “therapeutic community”, a mixed residential programme for people who use drugs, in western Africa.

Created in Côte d’Ivoire in 2016, PAS promotes the health of people who use drugs through harm reduction and services for HIV, tuberculosis, sexually transmitted infections and hepatitis. Since October 2019, thanks to funding from OSIWA (the Open Society for West Africa), PAS has strengthened its activities, with a focus on the respect of the human rights of people who use drugs—still a highly stigmatized and discriminated against community—and their access to health services. This is why Mr Bakari, in addition to his work in the smoking rooms, also trains health workers, journalists and the security forces.

There have been harm reduction programmes in Côte d’Ivoire for some years now. Community organizations have been set up and work with the national AIDS programme, the national institutions in charge of drug policy and the international nongovernmental organization Médecins du Monde.

The COVID-19 pandemic and the restrictions on movement imposed to stop it had the initial effect of freezing PAS’ work. But very quickly the commitment to continue services regained momentum at PAS.

“People who use drugs noticed that there were no associations or nongovernmental organizations out there in the field despite the fact that people who use drugs were still grouped together in places where drugs are consumed and they still shared equipment (crack pipes, joints, cigarettes, syringes, needles), with the risk of infection with HIV, hepatitis and tuberculosis. With the addition of COVID-19, people who use drugs were now also without access to reliable information and prevention equipment to fight this new health challenge,” said Jerome Evanno, a founding member of PAS.

Therefore, PAS decided to collect and distribute COVID-19 prevention materials and to continue its harm reduction work. PAS’ workers were trained in the prevention of COVID-19 and PAS produced a video clip in nouchi, the Ivorian slang that is the language of communication in the smoking rooms, on the importance of correct hand washing.

Community research was conducted on the perceptions of people who use drugs in the context of COVID-19 in order to understand the unique fears and needs in the face of the new coronavirus. The results and recommendations of the survey have been disseminated to partners in order that they can advocate and adapt their programmes in accordance with the expectations and needs of people who use drugs.

In order to reduce the risk of outbreaks of COVID-19 in prisons, PAS also has been advocating for the release of prisoners and distributing coronavirus prevention materials to inmates at the infirmary of the Abidjan prison.

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.

The Government of Côte d’Ivoire has signalled its commitment to stop people being charged for accessing HIV testing and treatment services, declaring that it will strictly apply previously announced decisions to prevent people living with or affected by HIV being asked to pay user fees.

A note circulated by the Ministry of Health has reminded all service providers that costs for HIV testing and treatment services should not be charged to people accessing those services. The directive applies for all services for pregnant and breastfeeding women, all HIV testing services, tests for viral load suppression and the prescription of antiretroviral medicines for people living with HIV.

The directive also reminds service providers that children under the age of 15 years should have free access to health services and that young women aged 15–24 years should have free access to primary health care, HIV testing and family planning services.

In several countries, the issue of user fees has been identified as a major barrier to testing people for HIV, to treating people living with HIV and to retaining people in treatment and care.  

The renewed commitment of Côte d’Ivoire to confront the issue of user fees followed discussions between the President of Côte d'Ivoire, Alassane Ouattara, and the former President of Botswana, Festus Mogae, who visited the country in March in his capacity as Chairperson of the Champions for an AIDS-Free Generation in Africa.

Following their discussions, the government also announced its intention to increase domestic funding for the AIDS response by US$ 10 million in the next budget.

During his meeting with the President, Mr Mogae congratulated Mr Ouattara and the First Lady, Dominique Ouattara, for their personal commitment to ending the AIDS epidemic as a public health threat by 2030. Ms Ouattara is UNAIDS Special Ambassador for the Elimination of Mother-to-Child Transmission and the Promotion of Paediatric Treatment of HIV.

At the conclusion of his mission, Mr Mogae underlined the importance of accelerating the response to the epidemic. “We cannot be complacent and allow the huge improvements that we have made so far to be lost. If we stop now, we will lose everything we have already invested and achieved. The entire nation must be mobilized to ensure that no one is left behind,” he said.

There were 500 000 people living with HIV in Côte d’Ivoire in 2017, with around 46% accessing HIV treatment. 

Results from population-based HIV impact surveys provide insight into where investments are needed

AMSTERDAM/GENEVA, 22 July 2018—Cameroon, Côte d’Ivoire, and South Africa have released new survey data on progress towards the 2020 targets. The Cameroon and Côte d’Ivoire population-based HIV impact assessment (PHIA) surveys and the South African survey all studied knowledge of HIV status, new HIV infections, condom use, voluntary medical male circumcision, antiretroviral therapy coverage, viral suppression and other indicators. 

In South Africa, which has the largest HIV epidemic in the world with more than 7 million people living with HIV and the largest treatment programme in the world with 4.4 million people on antiretroviral therapy, the new data combined with similar data from an earlier survey indicate that there has been a 40% reduction in the rate of new adult HIV infections between 2010 and 2017.

“These surveys are incredibly important and play a vital role in helping countries to review and refine their HIV programming to make sure that the right services are reaching people affected by HIV,” said Michel Sidibé Executive Director of UNAIDS.

The survey data confirm UNAIDS estimates which indicate that South Africa has also improved treatment coverage and is very close to reaching the 90-90-90* treatment targets. It found that 85% of people living with HIV knew their HIV status, 71% of people who knew their status were accessing antiretroviral treatment and 86% of people who were accessing treatment had supressed viral loads.

Viral load suppression among all people living with HIV in Cameroon and Côte d’Ivoire however was less than 50% reflecting low treatment coverage. The two countries are far from reaching the 90-90-90 targets at 47%, 91% and 80% and 37%, 88% and 76% respectively.

The largest difference between the southern African country and the two western and central African countries is observed in knowledge of HIV status, indicating that HIV testing services need to be significantly scaled up in west and central Africa.

The PHIA surveys provide key information for identifying characteristics of the populations that are not receiving services. In Cameroon, viral load suppression varied by province from 28% to 63%. In South Africa less than 50% of children and young men (ages 15-34 years) living with HIV had suppressed viral load (compared to 67% among the women aged 15-49). These data will provide critical information to allow programme managers to direct their responses to the populations and locations most in need of services.

The PHIA surveys, were led by Columbia University in collaboration with country governments and supported by the United States President’s Emergency Plan for AIDS Relief. The South African survey was conducted by the Human Sciences Research Council

* 90% of people living with HIV know their HIV status, 90% of people who know their status are receiving antiretroviral treatment, and 90% of people on treatment have suppressed viral loads.

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.

Côte d’Ivoire has become the first francophone country, and the first in western and central Africa, to launch an HIV situation room, a software platform designed to support informed decision-making.

This innovative tool strengthens national information systems through real-time visualization of information from multiple data sets. It will enable leaders and programme managers to make timely decisions to improve health programmes to achieve the 90–90–90 targets, whereby 90% of people living with HIV know their HIV status, 90% of people who know their HIV-positive status are accessing treatment and 90% of people on treatment have suppressed viral loads, by 2020.

The situation room is the result of a collaboration between the Côte d’Ivoire Ministry of Health and Public Hygiene, the United States President’s Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention, and UNAIDS. It was launched by Raymonde Goudou Coffie, the Minister of Health and Public Hygiene of Côte d’Ivoire, and Michel Sidibé, Executive Director of UNAIDS, on 26 March in Abidjan.

Singing “akouaba” (welcome), a group of young women crowded around Josiane Téty, the director of Bléty, a Côte d’Ivoire organization led by sex workers, as she arrived.

Located in Yopougon, a suburb of Abidjan, Ms Téty explained that in the centre one of the first things they do is give each other nicknames. Names such as Joy, Hope or Chance, because women, she said, often need a confidence boost and a sense of a new beginning.

“We take the time here to work on self-esteem, so that all the girls believe in themselves,” she said.

Most of the women at Bléty are current or former sex workers who carry out peer outreach, ranging from HIV awareness-raising and education about HIV prevention to promoting sex workers’ rights and continuing education.

“We seek to give young women opportunities and alternatives so that they are less vulnerable,” Ms Téty said. Pointing towards a young woman, she said that Happiness had started beginner accounting classes. 

Ms Téty and other sex workers founded Bléty in 2007 because they realized that they had little information regarding their health or their rights and hated feeling stigmatized.

“Getting an HIV test doesn’t mean that you are living with HIV, but that is how we were perceived when we were seen leaving a clinic,” she said.

They set out to correct that and have implanted themselves in the community. 

Marie-Louise Sery came to Abidjan to work following her parents’ death. She didn’t have much schooling and finding a job was difficult, so she started sex work. The 30-year-old, wearing braided pigtails, admitted being completely clueless about the risks she took.

“Bléty got me out of that situation,” Ms Sery said. This past year she became one of Bléty's peer educators.

Most of the time, she said, peer educators target bustling street corners to talk to sex workers, of which there are estimated to be more than 9000 in the country. Aside from handing out condoms, they also conduct rapid HIV tests and hand out cards with the contact details of Bléty’s various focal points, who can be reached day and night in the event of an emergency.

“My work involves giving a lot of support and hand-holding,” Ms Sery said.

Sex work is not illegal in Côte d’Ivoire, but the laws on it are vague. As a result, there is abuse and sex workers are vulnerable to violence. “We really stress to our friends out there that because they’re sex workers, it doesn’t mean people can take advantage of them,” Ms Téty said. If they have been abused they can call a Bléty peer educator and are accompanied to the police station or to the hospital.

Ms Téty said a recent victory had been to negotiate with doctors and health-care providers to provide a medical certificate free of charge, instead of for a US$ 35 fee. The law in the country requires a medical certificate in order to pursue a criminal case.

In its 10-year existence, Bléty has fended off pressure from the police and residents to change their attitudes towards sex work. Bléty has educated the police as well as sex workers in order to break the climate of mistrust between them.

“We have established good relationships with uniformed police, but there is a high turnover, so it can get frustrating to start all over again,” Ms Téty said.

Overall, she remains optimistic. Testing for HIV and sexually transmitted infections among sex workers is up, lawyers have stepped in to give legal advice and she sees her centre growing further.

Thrown out of the house by his parents when they found out he was gay, Ezechiel Koffi didn’t give up.

“My parents said I shamed them and that I lived the life of a sinner,” the young man from Côte d’Ivoire said. What hurt him the most were his mother's insults, saying he had no respect for their religious values. He begged them to understand that he was their son and that they should accept him as he was.

Mr Koffi, 24 years old at the time, stayed for a while at Alternative, a lesbian, gay, bisexual, transgender and intersex (LGBTI) people nongovernmental organization in Abidjan, Côte d’Ivoire, where he had started volunteering three years earlier. He kept going to classes, although admits that at times he went on an empty stomach. Psychologically he felt beaten. “It was hard, but I couldn't hide anymore,” he said.

With the help of his older sister, his parents let him move back home after six months. Although he now had a steady roof over his head and regular meals, Alternative became his second home. He has been dedicated to it ever since. Now an HIV educator and community health worker, he proudly showed his certificates on his mobile phone. 

Alternative’s project coordinator, Philippe Njaboué, describes Mr Koffi’s tireless energy. “You can call him at whatever time, day or night, he always lends a hand and he often goes out of his way to include people who have been shunned.” When asked about being a substitute family for many LGBTI people, Mr Koffi gave a hesitant smile.

The many discussion groups and support groups have helped, he said, allowing him to share his experience and help others. The once shy boy has emancipated himself. He also no longer shies away from revealing his HIV status. “It’s been 10 years now that I have been living with HIV,” he said.

Looking back, he explained, in the beginning he couldn’t always negotiate the use of a condom. He now makes a point of telling everyone that HIV is a reality. “Use condoms, there is help, you are not alone,” he exclaimed.

He described feeling fully alive among the city’s tight-knit LGBTI crowd. “I am at ease, I can express myself and it’s fulfilling,” he said. His brow furrowed, however, when he mentioned the constant discrimination he and his peers lived with. On top of the taunting and the finger pointing, Mr Koffi said social media was rampant with homophobic comments.

“We deserve the same rights as everyone else and that’s what keeps me motivated,” Mr Koffi said.

Mr Njaboué remarked that society, religion and the state all play a big part in keeping homosexuality taboo in Côte d’Ivoire. “A recent speech by Alternative’s director was tagged by a website as “The king of the homosexuals speaks”, which led to countless death threats,” he said.

Noting that this case was one of many, he believes the situation can only change if the government tackles human rights.

“Most of the population doesn’t know their rights or the law, including a lot people in charge of state security,” Mr Njaboué said. “Not only does the government need to educate people, it should also condemn unlawful behaviour,” he added.

For Mr Koffi, his visibility puts him at risk, he said, but he forges ahead. “I want to live in a world where there is no discrimination based on one’s race, one’s religion or one’s sexuality.”

Despite the scorching Abidjan heat, the Salam Plateau mosque stayed cool as imams, pastors, fathers and members of various religious groups along with women welcomed a UNAIDS delegation.

Imam Djiguiba Cissé gave an overview of his mosque and said that he and all the faith leaders gathered wanted to join UNAIDS in promoting HIV awareness.

Forty years of science and treatment have led to great progress in the AIDS response but now it's time to tackle stigma and discrimination, explained UNAIDS Deputy Executive Director Luiz Loures. Mr Loures reiterated that he needed faith leaders' help in making sure that violence against women is no longer tolerated and that men are better informed regarding HIV.

The imam said that compassion was a guiding principle of all faiths and that it should apply to faith leaders when they interact and care for people living with HIV. He also said that one of their objectives was to promote women. Women carry the greater burden of HIV globally and gender inequality is in large part responsible. Mr Cissé stressed that it was key to end violence against women and female genital mutilation.  Female genital mutilation is  prevalent in the north, north-eastern and western regions of Africa. Not only are there no known health benefits, it is painful and traumatic and can cause immediate and long-term health consequences to girls and women. The imam's final point to the congregation was to engage men to overcome some of these challenges and give young men a chance. More than 60% of Côte d'Ivoire's population is under 25 years of age, he explained, saying that more boys were resorting to migration or terrorism because they feel left out.

In January 2018, faith leaders led by Mr Cissé and with the help of UNAIDS are to attend an HIV awareness training encompassing the issues of stigma, status and empowerment. 

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.