West and Central Africa

When non-essential shops and markets were closed in Senegal in response to the COVID-19 outbreak in the country, and movement between regions in the country was stopped, many people working in the informal sector, including people living with HIV, lost their income. Hunger was dangerously near for many.

Within days, the National Network of Associations of People Living with HIV in Senegal (RNP+) mobilized, setting out to its members the food aid options available from the government for 1 million eligible households and offering advice on how people should prevent themselves from becoming infected by the coronavirus.

“When people are asked to isolate themselves, we also need to make sure they have food and medicine. Communities of people living with HIV help each other to take care of themselves, isolate themselves, access medication when needed and take care of each other’s families,” said Soukèye Ndiaye, the Chairperson of RNP+.

Community leaders and nongovernmental organizations are playing an active role in Senegal in giving out clear and accurate information in order to avoid panic and in combating stigma and discrimination, against both HIV and COVID-19. RNP+ is monitoring the response to COVID-19 as it unfolds, mapping how COVID-19 is affecting the most vulnerable and bringing urgent issues to the attention of the government and service providers.

Advocacy with the National Alliance of Communities for Health and ENDA Santé enabled RNP+ to distributed more than 200 food and hygiene packs to the poorest families of people living with HIV. The UNAIDS country office in the country has stepped in by providing a grant to ensure that the One Family–One Kit programme continues to distribute aid to the people most in need.

RNP+ is also advocating for funding for people living with HIV to help them to travel to health centres, since transport costs have increased, and for financial support for the scaling up of the work of community health workers, who are active in the delivery of antiretroviral therapy.

During the COVID-19 pandemic, ensuring continuity of HIV treatment by distributing multimonth supplies of antiretroviral therapy is vital. Although RNP+ has called on the government for all people living with HIV to get multimonth refills, weaknesses in the supply chain, including inadequate assessments of the needs at some clinics for supplies of antiretroviral therapy and irregular supplies centrally, has meant that not all people who need such supplies are getting them. UNAIDS is supporting the government in tracking orders of antiretroviral medicines and in strengthening the supply chain.

The role of communities, especially communities of the most vulnerable, is critical in the time of COVID-19. “The history of the HIV epidemic has made it clear that the response to an epidemic is only effective if affected communities are fully involved in the response, from its planning through to its implementation and monitoring. Only then can a response be based on the realities and needs of all,” said Demba Kona, the UNAIDS Country Director for Senegal.

Q&A with UNAIDS Country Director Savina Ammassari 

Savina Ammassari has been the UNAIDS Country Director for Cameroon since 2018. Before that, she worked for UNAIDS in India, Myanmar and Cambodia as a Strategic Information Adviser. She has supported initiatives promoting sustainable development, equity and human rights in more than 20 countries. 

Because she has lived and worked in so many countries and speaks many languages, she considers herself quick to adapt, but COVID-19 has definitely tested her. 

Savina, did you feel like COVID-19 was a tsunami coming your way? 

Yes, indeed, I saw the tsunami coming. I’d followed the COVID-19 outbreak in China, the rapidly unfolding epidemic in Italy, my home country, which already has claimed more than 24 000 lives. I was acutely aware that many countries in sub-Saharan Africa, including Cameroon, would be ill-prepared to address the devastating health and economic impacts of COVID-19, where fragile health systems and chronic poverty represent significant challenges for government, community and United Nations system responses to the pandemic. 

The realities of the crisis enveloping the world were starkly brought home to me when my brother-in-law, working as a surgeon in Brescia, the epicentre of the Italian epidemic, developed severe COVID-19 symptoms, leading to bilateral pneumonia. Fortunately, he was ventilated and received experimental treatments. His life has been saved. But I know this will not be the case for everyone, especially in countries with weaker health-care systems. 

Cameroon is now the COVID-19 epicentre in western and central Africa. The first cases were detected at the airport of the capital, Yaoundé. Additional cases were soon recorded in Douala, the largest city of the country. Despite early measures taken by the Government to isolate initial cases, testing and contact tracing, community transmission has taken hold. Limited access to testing services makes it difficult to know the extent of transmission.   

The Cameroon response has faced significant constraints, not least the capacity to scale up testing and expand contact tracing and the provision of intensive care unit/ventilation support for the seriously ill, as well as adequate personal protective equipment for medical staff. The rapid implementation of community education programmes, emphasizing hand hygiene and social distancing, is an ongoing challenge, especially in poor, often overcrowded, urban areas.  

How did Cameroon prepare? In Cameroon, there initially was a sense of optimism that, somehow, Africa, unlike other regions, would manage to avoid the catastrophic consequences of the pandemic. There was little awareness that Cameroon was most likely just a matter of a few weeks behind. 

Today, Cameroon is the most affected country in the region and second in sub-Saharan Africa, with a quickly rising rate of infections. The scarcity of test kits obviously hides the real number of infections. Counting individual infections, recoveries and fatalities does not provide the real picture. UNAIDS advocated for a modelling of the epidemic in order to enable quantification of health-care needs and procurement. 

As the first COVID-19 cases were detected in Yaoundé, a small number of health-sector officials gathered with the Minister of Health to discuss and plan epidemic containment and impact mitigation measures. I was one of the United Nations officials requested to be part of the group, given UNAIDS’ experience in epidemic management. I underscored the need to build on existing systems and make use of the community-driven efforts of the national AIDS response. I advocated for frontloading investments in communication and community mobilization to prevent COVID-19 infections, using a multisectoral approach. 

The multisectoral response fell into place through the direct involvement of the United Nations Resident Coordinator (UNRC) with my support. I facilitated the UNRC’s efforts to connect the Minister of Health with development partners in weekly teleconference calls. Partners were ready to assist but lacked information on the most immediate needs.  

UNAIDS has supported the Ministry of Health to model the COVID-19 epidemic to better understand and quantify needs. This has been done through teleconferencing, with the participation of various technical and financial partners. It has helped with the prioritization of needs and the quantification and costing of urgently required supplies and equipment. Partners were ready to support this effort, but required not only a modelled, costed national COVID-19 response plan but also a well-articulated procurement schedule based on the plan. UNAIDS has also successfully advocated for the establishment of a strategic information working group to analyse more in-depth data from surveillance, model the epidemic, and monitor and evaluate the COVID-19 response.  

Communicating is indeed key. But how do you deal with things as basic as the lack of running water in many sub-Saharan African countries, making handwashing difficult. How are people coping with this and other measures, such as physical distancing? 

This is indeed a major challenge in Cameroon as there is a lack of consistent water supply in many urban and rural communities. The use of hand sanitizers is not an affordable option for most people and locally produced product is not necessarily quality assured and safe for use. 

Similarly, physical distancing and self-isolation are remote, often unrealistic options for communities where large numbers of people, as a rule, share common spaces in their home and community environments. The government has put in place a series of strict measures to contain the spread of COVID-19 (closing schools and educational or training institutions, banning gatherings of all kinds, imposing the use of face masks on public transport), although a comprehensive lockdown has not been promulgated to date. There are legitimate concerns on how a full lockdown could affect the majority of people, as more than 80% of the population work in the informal sector and live hand-to-mouth. Yet, from a public health perspective, lockdowns are a must. Balancing concerns is a major challenge. 

Savina, you have never shied away from challenges. Would you say this is the biggest challenge you have faced, and why? 

Yes, this crisis is unprecedented, unpredictable. I’m concerned at how the COVID-19 pandemic will affect not only our staff and their dependents but also people living with HIV, who need to continue accessing antiretroviral therapy and services, and people who are already stigmatized, vulnerable and socially and economically marginalized. 

We have already witnessed a worrisome rise in stigma and discrimination against members of key populations in Cameroon and are making sure that the UNCT and partners keep human rights issues high on the agenda.  

Our work is already challenging in normal times as Cameroon is facing enormous development and humanitarian hurdles. Already, Cameroon’s humanitarian crises on three fronts are not getting enough international attention. It’s the least funded humanitarian crisis worldwide. The COVID-19 epidemic multiplies these challenges several times over. 

UNAIDS is mobilizing communities and networks in COVID-19 prevention work and making sure that civil society is adequately consulted and involved in the national response to the new virus. 

How do you unwind in the evening? How do you recharge your batteries? 

I’m afraid I don’t give enough time to relaxing, as I work around the clock, which isn’t good. Perhaps one of the challenges of COVID-19 is to take up new interests outside of work, that can be sustained and enjoyable well into the future. 

What are the lessons learned? Will you do things differently from now on?  

I’ve learned once again that unity makes force. In unpreceded emergencies like the current one, where no one has the answer or a magic bullet, everyone’s competence and experience is needed. Connecting people, bringing in resources, getting a transparent exchange—all this is paying off. It requires strong leadership and a cohesive team effort. 

“Le baobab est tombé.” “The baobab has fallen,” was Francine Nganhale’s post against a black backdrop on her Facebook page on 30 April 2020.

Her husband, Charles Domingo Noubissi, had died.

Many couldn’t believe it, because Mr Noubissi had such a fighting spirit. He had health problems, but rarely missed a meeting to advocate for the response to HIV.

As President of the Board of Directors of the Cameroonian Network of Associations of People Living with HIV, he became a pillar of the AIDS response in his country and across the region.   

We will miss him dearly and thank him for his years of leadership and commitment and for being a champion of the community-led response.

UNAIDS had the pleasure of interviewing Charles Noubissi and his wife in 2019, showcasing proud people living with HIV. Here is that story:

The right to disclose your own status

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.

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.

Western and central Africa continues to lag behind the rest of Africa in preventing and treating HIV, leaving millions of people vulnerable to HIV infection and 2.4 million people living with HIV without treatment. Following calls to action made at the 2016 United Nations High-Level Meeting on Ending AIDS and the July 2016 African Union summit, UNAIDS and partners launched a plan to accelerate efforts to stop new HIV infections and ensure that everyone in the region has access to life-saving treatment.

Although resources available in western and central Africa to respond to HIV increased by 65% between 2006 and 2016, reaching an estimated US$ 2.1 billion, most countries remain highly dependent on donors. However, international funding is declining and current investment levels are far lower than what is actually needed to make a sustainable change.

Luxembourg is one country that remains committed to investing in western and central Africa. Marc Angel, Chair of the Foreign Affairs and Development Committee in the Luxembourg Parliament and UNAIDS Champion for the 90–90–90 Targets, joined UNAIDS on a recent visit to Senegal to see how Luxembourg’s contribution to UNAIDS for the acceleration of the AIDS response in western and central Africa was helping to make a difference.

Supported by funding from Luxembourg, UNAIDS and partners have established the innovative Civil Society Institute for HIV and Health in West and Central Africa. The institute acts as a coordinating mechanism for around 80 nongovernmental organizations working in the interests of people affected by HIV in 20 countries across western and central Africa.

One such group is CEPIAD, the first centre for harm reduction for people who inject drugs in western Africa. The medical staff and social assistants are pioneers in the region, treating people who use drugs with a public health approach rather than judgement. In Mbour, at the treatment centre for key populations, Mr Angel heard from people who had injected drugs in the past, who shared their personal stories of how the centre had helped them to reintegrate with their families and society.

“Only by including key populations can the 90–90–90 targets be reached,” said Mr Angel. “Senegal’s public and civil society actors have to continue working hand in hand towards this objective. For Luxembourg’s development cooperation, the human rights dimension in the fight against AIDS and in global health is key. Together with UNAIDS we need to ensure that voices from communities are being heard, working all over the country, in particular with vulnerable populations, including children.”

Mr Angel also visited the paediatric treatment ward of the Albert Royer Hospital, where he met young people living with HIV. They shared their experiences of treatment for HIV, which is allowing them to live normal lives. He noted the progress made in stopping new HIV infections among children in Senegal and the important work done around sexual and reproductive health and HIV to prevent new HIV infections among adolescents.

During meetings with the Minister of Health and Social Action of Senegal, Abdoulaye Diouf Sarr, and the Secretary-General of Senegal’s National AIDS Committee, Safiatou Thiam, Mr Angel praised Senegal for decreasing the national HIV prevalence.

However, he also highlighted areas of concern, including the high HIV prevalence among key populations, emphasizing that access to treatment for key populations was instrumental to ending AIDS by 2030. He also advocated for an increase in national resources to respond effectively and sustainably to HIV in Senegal.

Young people in Ghana have committed to help promote a sustainable environment by reducing the amount of waste they generate, both at home and in school.

“Reduce, reuse, recycle,” was the theme when the advocates met the UNAIDS Ghana Country Director, Angela Trenton-Mbonde, in Accra, Ghana. The advocates took turns to make personal pledges to adopt better waste management practices in order to promote environmental sustainability.

“I commit to acquiring a personal reusable water bottle and to avoiding single-use plastic bottles. This, I believe, will safeguard the planet for everyone,” Pricilla Addo said. 

Another advocate, Samuel Nyarko, said, “I pledge to personally ensure that waste generated in my household is well separated so that plastics can easily be collected and recycled. I will educate my schoolmates and community to do the same.”

Ms Trenton-Mbonde encouraged the young people to ensure that their commitments to the planet are fulfilled. “For a sustainable environment, each of us must take personal responsibility and make one commitment, no matter how small and insignificant it may seem in the beginning, because in the end we are all connected: people and planet,” she said.

The youth advocates comprised young people from Hope for Future Generations, a Ghanaian not-for-profit nongovernmental organization focused on empowering women, children and youth.

At 17, preparing for her baccalaureate, Francine Nganhale was carefree. She followed her classmates out of curiosity to the local hospital in Yaoundé, Cameroon, since they had heard about an HIV awareness campaign with free testing.

“This was my first time getting an HIV test and I had no expectations,” she said.

When the results came back, her test was inconclusive. She retook the test and at the fourth try, her result was positive. “The explanations given to me throughout the process piqued my interest and I became much more motivated to find out more,” she said.

Ms Nganhale felt scared and she admits being clueless about what to do next. A doctor walked her through the process and gave her a lot of information about HIV. It suddenly dawned on her that her three-year old son, who was often sick, had never been tested for HIV. He tested positive and both started treatment.

The hard part for her was telling her mother. She postponed telling her, but she felt more and more isolated. And she recalls hearing negative comments from her extended family about people living with HIV. “I had decided to challenge myself and live a long and healthy life and no one would deter me,” she said. When her mother finally found out, she told others about her daughter’s HIV status. Regardless, Ms Nganhale forged ahead. She holds no grudges, saying that her mother cared for her and her son financially for years.

As a social worker, Ms Nganhale works mainly with people living with HIV, raising awareness and distributing HIV treatment.

Her husband is also a social worker overseeing 106 Cameroonian HIV associations. He can relate to his wife’s experience. Charles Noussi used to be a professional football player in the Maldives. During a routine team medical check-up, all his teammates underwent a battery of tests. The next day, when he showed up for practice, he bumped into the manager, who forbade him to train with the others.

“I had no clue what was going on,” he said. “Meanwhile I slowly realized that most people were hiding something from me.” He wanted to get to the bottom of it and asked to see the medical team responsible for the check-up. That’s when finally someone told him his HIV-positive status.

“I suddenly realized that I was the last to know,” Mr Noussi said. The news only got worse. He had 48 hours to pack up and leave the country. “Do you know how hard it is to abandon a career I loved and lose my good salary all because of my HIV status?” he asked. “It broke my heart and more.”

A sponsor helped him flee to Thailand, where he accessed health services. “So many people were supporting me and reassuring me,” Mr Noussi said. Quickly, he joined an HIV advocacy group. “After a year, I told myself that perhaps I should use my knowledge and return to my home country,” he said. Again, mentalities differed in Cameroon. He faced discrimination and despite being healthy and open about his HIV status, many of his acquaintances and friends abandoned him.

“Thank goodness my mother helped me a lot, not only on a nutritional level, but also socially and psychologically,” he said.

Two decades later, he believes HIV-related stigma has decreased in Cameroon. HIV treatment is free, unlike many years ago, when he paid for everything himself. No doubt about it, he said, knowing your status is crucial.

His wife agrees. “No need to tell someone not to worry—it's normal to worry,” she said. “What's key is reassuring someone that they are in control of their life.”

Related story: A tribute to Charles Domingo Noubissi

This story was first published by WHO

Getting life-saving harm reduction services to people who use drugs in Burundi was the aim of a recent learning trip to Kenya supported by the World Health Organization (WHO). This saw a team of Burundian physicians and health advocates travel to Mombasa County, Kenya, to learn about good practice from one of the pioneers of harm reduction on the African continent.

Led by Burundian non-profit, Jeunesse au Clair Medical (JCM), the team will push for a comprehensive package of harm reduction interventions in Burundi. Like many other countries in Africa, injecting drug use is not often acknowledged, and a public health response therefore not implemented.

Drug use is widely criminalised and stigmatised and its complexities misunderstood. WHO defines harm reduction as an evidence-based public health response that includes the provision of needle and syringe programmes (NSP), opioid substitution therapy (OST) and access to testing and treatment of HIV, tuberculosis (TB) and viral hepatitis B and C.

Keen to gain insight into the Kenyan experience and inform the development of a programme in Burundi, the Burundian team of doctors, a counsellor and a national coordinator of a network of people who used drugs, visited the Reach Out Center Trust in Mombasa. They observed the delivery of OST programmes and learnt about advocacy with local influencers – in an excellent example of south-to-south learning.

Kenya’s response to minimising the adverse effects of drug use, although not without its own challenges, has succeeded largely through grassroots advocacy and on-boarding key influencers – making it easier for harm reduction to be accepted. This multi-level approach includes collaboration between government and civil society, involving both law enforcement and networks of people who use drugs.

At a visit to the Mombasa Inspectorate in charge of drug-related offences, the team learnt first-hand from the Chief Inspector the importance of police engagement, highlighting the negative impact drug use can have on young lives and the need for strategies that work. Today, some 100 police officers in Mombasa are trained on harm reduction with their work focusing on supporting, not punishing.

In addition to police buy-in, identifying other key influencers such as spiritual and village leaders, other government officials, and people who use drugs themselves, can ensure that harm reduction programmes are effective and sustainable.

Advocacy wasn’t the only thing on the agenda, the team from Burundi also saw in practice how the Kenyan clinics functioned, how methadone is dispensed, they spoke with peer educators and outreach officers, and were trained on data collection for programme monitoring. An important learning if they want to show evidence to get government and donors on their side.

While Kenya is several years ahead in its harm reduction journey, with local input, their learnings can be adapted to other contexts.

“The burden caused by drugs requires interventions at grassroots and education must be provided by trained people to avoid misinformation,” said Dr Egide Haragirimana, clinical officer at JCM.

JCM are putting into action their learnings and will next be involving networks of people who use drugs to better understand what their needs are, to inform future harm reduction initiatives.