in the framework of a progressive HIV/AIDS strategy
“White or black …, provided that the cat catches the mouse”, says the Chinese saying ….
In the realm of HIV screening, let’s give ourselves the means to reach our goals!
In general, the major brakes on screening are ignorance of the existence of
the medical and psychosocial coverage in the event of seropositivity, and the
fear of stigmatization, often linked to discrimination within the community
and the workplace.
In a rural setting, additionally, there is the lack of free time in very busy
days spent in the fields, a relatively high ignorance of the care structures
available in the environs and the lack of means (money and transportation) to
go to the treatment center nearest the village.
Much needs to be done to convince the people to be screened, and all new opportunities must be examined in order to limit the spread of the disease.
Despite the low HIV prevalence rate reported in 2007 by UNAIDS and WHO in Côte
d’Ivoire, this country heads the list of countries most affected by HIV
in Western Africa, with a national prevalence rate reaching 4.7% (EIS 2005).
In a rural setting, the average rate is marginally less (4.1%). With agriculture
representing 60% of the Ivorian GDP, one can well understand that HIV is not
only a medical blight, but also a social and economic one.
With the support of the American government's emergency plan to combat HIV/AIDS (PEPFAR) [President’s Emergency Plan for AIDS Relief], ANADER (National Agency for the Support of Rural Development in Côte d’Ivoire) launched in April 2006 a pilot program aimed at “The rapid expansion of access to prevention, coverage and treatment for HIV/AIDS to the poorly-served, rural populations of Côte d'Ivoire”. One of this program’s innovations is local screening performed by mobile units.
Everything began in September 2005, when ANADER received a grant of four million US dollars from PEPFAR in order to implement its Strategic Plan to combat HIV/AIDS in rural Ivorian areas. This PEPFAR-ANADER Program (PAP), of four years’ duration (2005-2009), really started in April 2006 with a period of personnel training and equipment purchase. Rolled out in the beginning to four departments, it now covers five administrative regions as planned in the specification document, that is, Moyen-Comoé, Lagunes, Bas and Haut Sassandra, and Zanzan.
Eventually, the PAP's objectives are:
| - To mobilize rural communities to get involved in the fight against HIV/AIDS,
preferably by the creation and support of a village committee to combat
HIV/AIDS (VCCA) within the community. - To promote behavioral change in rural populations. - To make available to rural communities a local voluntary counseling and testing (VCT). - To increase people’s access to psychosocial coverage and to antiretroviral treatment. - To promote coverage for orphans and at-risk children. |
In order to reach its goal in the VCT realm, ANADER supplied two 4 x 4 vehicles
converted into mobile units, to which the expertise of three NGO [non-governmental
organizations] was added:
- REPMASCI (Network of Professionals in the Media, Arts and Sports engaged
in the fight against AIDS and other Pandemics in Côte d’Ivoire) whose
motto is “Inform in order to Save”, charged with drawing up and communicating
messages in 9 local languages thanks to the lexicon that it created on HIV/AIDS;
- ACONDA, to strengthen the abilities of medical and paramedical personnel
in screening techniques, in the prevention of mother-to-child transmission,
and in the medical and psychosocial coverage available, as well as to strengthen
the abilities of community counselors in following up on therapeutic compliance,
and to organize screenings in rural and urban health centers;
- PSI, to strengthen the abilities of community counselors so as to implement
a confidential VCT for HIV, and to ensure the supply of products for community
palliative care kits.
Mobile Unit Personnel
| Each of the two mobile units used in PAP employs: - 1 or 2 district laboratory technicians, - 1 ANADER counselor, - 1 health district counselor (midwife or social aide), - 1 driver in charge of greeting volunteers for the HIV test. |
Three community counselors from the village, as volunteers, trained
at the VCT, assist mobile unit personnel in holding awareness activities before
the screening day. They offer a lot of pre- and post-test advice on the mobile
screening day and ensure the follow up of villagers living with HIV in the community,
after the mobile unit leaves. They have bicycles to get around from village
to village. As a function of their volume of activity, community counselors
receive up to 10,000 F CFA per month for cold meals and maintenance of their
equipment.
My visit to a mobile unit in the field
Friday, 11 a.m., in Ira, locality close to Dabou, situated 55 km west of Abidjan
in the Lagunes region, a prosperous zone where the salaries are very decent
with respect to the national average.
Today is market day. The main street swarms with people who sell their agricultural products (palm oil, subsistence crops), snails, dried fish or basic needs in small, corrugated, sheet-metal shacks lined up on each side of the dirt path, or even on the ground.
It is the ideal day to conduct an HIV/AIDS awareness session because, for several
hours, almost all the village is found near the school, where the mobile unit
is parked.
The fact that Ira has 5,000 souls (of which more than half come from bordering
countries) allowed it to recently obtain the official label of "village",
thus giving it certain advantages, such as the right to seek a dispensary. While
awaiting this upheaval in village life, all sick persons must still go to the
hospital, which is located 35 km from there, in order to be treated. The arrival
of the mobile unit does not go unnoticed. It gives the inhabitants of Ira a
chance to get tested without having to travel, that is to say, almost at home.
The mobile unit’s first round, in the PAP setting, began in January 2007. To date, it has gone to Dabou five times, and today is its second trip to Ira.
For two weeks, the community counselors broadcast reminders via loudspeaker throughout the camps, so than a maximum number of villagers would attend the showing of the "ciné-village" [films in the village], which opens publicly on the day of the screening and counseling.
The night before, between 9 p.m. and 11 p.m., the villagers were able to attend
the showing of one of the films loaned by ANADER that deals with HIV, its means
of transmission, its prevention, its care and treatment, and community coverage
for patients. These films often let the persons living with HIV speak in order
to show that one can live normally with this disease, and that the stigmatization
and discrimination should be banished from society.
Certain showings are punctuated by discussions with the local population; others
leave room for questions and answers at the end of the film.
Some known artists or singers are also invited to lead these evening events
dedicated to HIV. In all cases, the villagers have the opportunity to ask their
questions and are encouraged at the end of the evening to come in great numbers
the next day to have themselves tested.
Each time, the mobile unit personnel take over classrooms for their screening
and pre- and post-counseling activities.
Upon my arrival in the school courtyard, a line of 15 people is patiently waiting for the driver of the mobile unit to give them the number corresponding to their file, and to explain to them what the different test steps are. This number will guarantee them anonymity, when the test results are given back.
The villagers will pass from one class to another, preparing themselves psychologically for the big moment of the injection…
The VCT is important in that it allows the health services to:
- promote safe behavior,
- encourage people to know their serological status,
- provide an opportunity to educate the test candidates about reproductive health,
including family planning and prevention of mother-to-child transmission,
- direct them to social support organizations or educative peers,
- diagnose early and manage opportunistic infections,
- and finally to obtain timely antiretroviral treatment.
Armed with their file, the villagers meet privately a counselor with whom they fill out a questionnaire designed to measure their level of HIV knowledge, their level of risk as a function of their sexual life, and their readiness to accept the test result.
Then comes the turn of the laboratory technician who draws blood. The
reagents Genie2 and Determine allow him to look for HIV1 and HIV2 in the population.
If tuberculosis is suspected, the technician is able to push the search forward
even more.
A young mother, sitting with her baby on a wooden stool, grimaces at the moment when the needle is stuck in her arm's vein. The motives that push people to have themselves tested are almost always the same: to know their serological status, to plan their future with full knowledge of the facts, to avoid, if possible, transmitting the virus to a baby who will soon be born. Her husband, next in the waiting line, doesn't seem worried. For him, it is an occasion to reassure his wife about the nature of his trips to Abidjan, all while losing a minimum of work time to have himself tested. The main advantage that he sees in the mobile unit is the time saved for health services equivalent to those offered by stationary hospital structures.
“Forty-eight candidates since this morning”, the laboratory technician announces to me. “We will certainly have around 60 by the end of the day.” A normal number for one day for the mobile unit, if we are to believe the technical personnel. It is a little better than the first visit to Ira; but where have the two hundred people present the night before at the ciné-village gone?
“Number 52…52” calls the district counselor, who has
come out on the doorstep of the room dedicated to post-counseling. “It
happens that the people tested do not come back to get their results (around
3%), either because they are afraid that they will be told they are seropositive,
or because they have simply returned home. Once we have even faster tests, we
will have a better response from the people," she confides to me.
“When people are seronegative, we give them a follow-up appointment in
three months. When they are seropositive, we send them to the community counselors
who will help them choose the hospital where they would like to be monitored,
and will give them information about the doctor to be contacted.”
5 p.m. - the day comes to an end. While awaiting the next visit of the mobile
unit, the persons in charge of the pilot program, their government representatives
and their other partners, will try to improve the following areas before moving
to a national scale:
|
- The functionality of the system of referrals and counter-referrals
for the people who have tested positive, so as to ensure a continuum of
care and adequate follow-up, on a therapeutic and psychosocial level.
|
Nevertheless, the results of the first fifteen months of PAP are very encouraging. Here are some figures from the quarterly reports of ANADER to PEPFAR
| - more than 20,000 persons tested in 144 villages with the two mobile
units - 1355 persons living with HIV were sent to care centers - 3785 orphans and at-risk children now benefiting from coverage (medical - with inclusion in a national program for seropositive people, or through school - thanks to kits with primary education materials), including nutritional aid for the most impoverished. |
Raising awareness, information and education about HIV/AIDS have sparked a
great interest in HIV/AIDS screening and the mobile screening unit often turns
way clients, especially during the first visits. In certain regions of the program,
a victim of its own success, it often knew of situations where it lacked reagents
for the number of persons arriving spontaneously for the HIV test.
By offering a lot of local counseling and screening services, it establishes
a link between the rural areas and the private and government health services,
contributing greatly to national prevention efforts.
It is the wish of Mrs. Nathalie Konan Bogui, Executive Director of the PAP, that “the PAP contribute to rapidly improving the referral and coverage mechanisms for people living with HIV so as to reassure them, and be able to spread the success encountered by the pilot program to other regions of the country, for the good of the rural areas for which ANADER has been the favorite partner for years."
Article and photos by Sophie d'Aurelle de Paladines
