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| How a Simple Map Turned into a 23+ Million Dollar Project |
| Fighting Against HIV/AIDS in Rural Communities in Côte d'Ivoire |
SIDA, the French word for AIDS, is known as a dance in some regions of Côte d'Ivoire, a West African nation bordering Liberia and Ghana that is slightly larger than New Mexico.
How would you react if you found out rock 'n roll was fatal?
It was not until a planned visit from the National Agency for Rural Development and Support in Côte d'Ivoire (ANADER) [1] in March 2002 that people in the rural village of Bodo even knew AIDS existed as a disease. Bodo is one hundred and nine kilometers north of the country's economic hub Abidjan.
Villagers were familiar with ANADER since the rural development agency's agricultural advisers and technicians work with cocoa, cassava, banana and corn planters here to train and advise them how to better optimize and commercialize their crops. Côte d'Ivoire is the world's top cocoa producer.
ANADER's employees have been running HIV/AIDS awareness and prevention campaigns in rural areas throughout the country since 2000.
Our work is communication with people," says ANADER's CEO Behinan Guede. " if we can convince them to accept a certain variety of plant, we can do the same for HIV", he asserts.
| ANADER's Risk Map: How It Works |
After getting permission from the village chief in Bodo, ANADER's HIV/AIDS committee responsible for running prevention campaigns in Tiassale, Bodo's nearest city, met with inhabitants of this village of approximately six thousand people.
The committee divided the one hundred and nineteen villagers present into different age groups and sexes (old men, young men, old women, young women), and asked each group to come up with its own map highlighting different places in the village at risk for HIV infection, obstacles to behavior change and proposed solutions with action plans. After each group showed its map, the village created one common map representing all the places it thought was at risk for HIV.
Two water pumps, two schools, a cemetery, a local bar, an empty store, a church, a barber shop and a mosque. Who would have thought these places had anything in common?
ANADER's risk map lies at the center of the rural development agency's HIV prevention and awareness program. It is valuable in two ways. First, it provides a forum through which different sectors of the village including elders, adults, young adults and children can unite to talk openly about sex, traditionally a taboo topic.
Second, it provides a simple, visual means through which the ANADER and Bodo HIV/AIDS committees can launch into important HIV prevention messages. For example, the map serves as a platform from which they can discuss the importance of using condoms to prevent sexually transmitted infections (STIs) and HIV transmission, and sterilizing sharp objects when performing customs such as scarification and circumcision.
| Keeping communities accountable: the village AIDS committee |
After creating the risk map for the entire village, villagers in Bodo participating in the awareness campaign elected a village HIV/AIDS committee made up of different ages and sexes. The committee provides a liaison with ANADER's HIV/AIDS committee and ensures the continuation of prevention campaigns in Bodo and its twelve neighbouring camps where planters work and live.
Members of Bodo's HIV/AIDS committee include religious leaders, teachers, students and elders. Seventeen women are on the committee. The presence of women is important since they are the care-givers in the family and the ones responsible for children's education.
| Progress Report |
Two and a half years later, in October 2004, ANADER asked Bodo's HIV/AIDS committee to gather the villagers together to track the progress the village had made in terms of HIV awareness.
This photo is used for illustrative purposes only. It does not imply that those featured within are HIV positive.
ANADER had invited me, a freelance journalist, and a representative from the Paris-based HIV/AIDS division of pharmaceutical company Merck Sharp & Dohme to meet villagers and members of Bodo's HIV/AIDS committee. We were there to understand how ANADER's HIV prevention campaigns work in rural villages throughout Côte d'Ivoire.
We were late. The villagers were waiting for us. From the window of the 4x4, I could not help but notice signs reading 'Stop SIDA' and 'Let's Talk about AIDS' hanging on tree trunks near the area where the meeting was to take place. Was this a show to impress a delegation of outside visitors? I kept an open mind.
After an exchange of greetings ("Akwaba" means welcome in Agni, one of the local dialects) including our acceptance of a water bottle from the village chief, a symbol signifying the village's desire to meet us and receive our news, the meeting began.
Benjamin, ANADER's agricultural adviser based in Bodo, ensured the translation from French into the Abbey dialect. The Abbey are the main ethnic group in the village although other ethnic groups such as the Baoule, Agni, Senoufo, Gouro and Abidji along with migrants from Burkina Faso, Mali and Benin also live here.
| Challenges associated with HIV/prevention campaign |
The village HIV/AIDS committee explained how since the first prevention campaign in March 2002, they had replaced run-down doors and windows on the two school buildings so people cannot enter the classrooms as easily as before. They said it had also put lights in the schools to deter people from visiting at late hours.
After a tour of the village, it became clear that the committee faces a variety of challenges:
- Policing at-risk places does not guarantee people are going to necessarily stop frequenting them.
Where else can villagers go for privacy away from their families when they live in such close proximity with each other? The state of the dilapidated, empty local boutique or shop originally identified as an at-risk location hadn't changed much and looked like it could still be an enticing location for a private moment.
- Of the people who buy and receive condoms from the AIDS committee or the local pharmacies, how many people actually use them?
Bodo's HIV/AIDS village committee claims to have sold 800 condoms and distributed 2,500 condoms for free over thirteen prevention campaigns since March 2002.
- Planters are often forgotten in the camps.
It is difficult for Bodo's HIV/AIDS committee to reach coffee, cocoa and other kinds of planters living in the twelve camps surrounding the village. Planters often cannot participate in village meetings because they are working in the fields. One villager estimated that only about twenty percent of the village was present at the progress meeting in October 2004.
To reach the planters in the camps surrounding Bodo, the village AIDS committee needs transport. Without it, it is limited to taking on 2 to 3 campaigns a month, and by foot. The closest camp is 5 kilometers away, the furthest 7 kilometers.
- Information is lacking from bottom to top.
The visit to Bodo also confirmed there is a lack of access to important information on HIV/AIDS in rural areas. National HIV/AIDS programs have largely neglected them even though, according to a 1998 study by the country's National Institute of Statistics, approximately 59 percent of Côte d'Ivoire's over 16 million people live in rural areas.
For example, villagers in Bodo are unaware of the Ivorian Government's decision in June 2004 to drop the prices of anti-retroviral (ARV) drugs from 100,000 F CFA ($200) to 5,000 F CFA ($10) for three months of treatment.
And women here do not know about the program sponsored by the Ministry of Health (Prevention of Mother'“to-Child Transmission or PMTCT) that allows pregnant women to receive free treatment for themselves and their babies. The treatment prevents the baby from getting the virus. The program also allows infected children to receive free treatment until they are 15 years old.
Some people in Bodo think they have to travel as far as Abidjan for the voluntary HIV test but there is a hospital where they can get tested in Tiassale, an 18 kilometer taxi ride away. They also do not know the government is now offering the test for free.
But it's not just villagers who are lacking information. Before we arrived in Bodo, we visited Tiassale's sub-prefecture or district government council, as local protocol requires, informing them about our visit. The woman who has been responsible for Tiassale's sub-prefecture for the past three years was not aware of ANADER's HIV activities in Bodo. She also didn't know about the recent decision to drop ARV prices. Apparently, the Ministry of Health has not yet formally set up a departmental committee for HIV in Tiassale, which will eventually be the liaison with ANADER's and Bodo's HIV/AIDS committees.
| New role for ANADER: Facilitator of Access to HIV care. |
Up until this point, ANADER has been involved primarily in HIV/AIDS prevention through HIV awareness campaigns and condom distribution. While it will continue to strengthen its existing prevention campaigns, its new aim is to facilitate access to the free voluntary HIV test offered by the Government, which allows people to find out whether they are HIV positive or negative. Through facilitating the provision and organization of 4x4 vehicles equipped with trained medical staff capable of administering the test, the rural development agency hopes to take the HIV test directly to villagers.
After people in rural villages take their test and are aware of their HIV status, ANADER then plans to help them access HIV care through referring them to health clinics already set up by the Côte d'Ivoire's Ministry of Health. The Ministry of Health is in the process of rolling out a national initiative to make HIV care accessible outside of the country's economic hub, Abidjan .
ANADER has previous experience assisting the Ministry of Health with vaccinations in rural areas but it is not an expert HIV care. ANADER's Chief Executive Officer, Behinan Guede is the first one to admit HIV care is not the agency's realm of expertise. 'We don't want to replace anyone," he says. 'œThis is why we are partnering with HIV experts."
Because of its vast network, the rural development agency is in an ideal position to achieve its new goal. Currently, it is present in thirty-two out of fifty-five departments inCôte d'Ivoire , excluding areas in the north where the war has halted activities. Eighteen hundred out of ANADER's two thousand five hundred employees are based in villages throughout the country. The agency claims to be reaching around four million people in eight thousand villages. There are approximately eleven thousand villages Côte d'Ivoire.
| Potential Partners for the project |
Its mammoth network among rural communities in the country has attracted partners such the HIV/AIDS division of pharmaceutical company Merck, Sharp and Dohme. HIV experts within the pharmaceutical company, the country's Ministry of Agriculture and Ministry of Health, have helped ANADER develop its new role as a facilitator of access to HIV care.
The initiative offers an ideal opportunity for those participating in HIV/AIDS initiatives throughout Cote d'Ivoire to make their own programs more accessible to rural communities.
| Challenges ahead |
Being the facilitator and coordinator of such a large project will not come without its fair share of challenges. The total cost of the initiative, to be rolled out between 2005 and 2007, is estimated at about 11.9 billion CFA (approximately $23.3 million).
First, the project will require an enormous amount of human resources. ANADER's employees are not nurses, doctors and laboratory technicians trained in comprehensive HIV care. They are the vectors to get the right information to the people in the rural villages.
And it may not be as easy as it looks on paper to persuade villagers to jump into a vehicle and take the voluntary HIV test, especially if people are able to see them as they enter the vehicle. People are scared to be associated with the disease.
The project also lacks health infrastructure, which is not a given in rural villages. Bodo has a local hospital, but it consists of walls and a tiny amount of medical equipment. Even supplies such as bandages and plastic gloves are difficult to procure.
Will the Ministry of Health be able to provide the human resources and infrastructure necessary to ensure top HIV care for those living in rural villages?
In Abengourou, the fourth largest city in the country, in the southeast near the border of Ghana, and the first city where Cote d'Ivoire's Ministry of Health has begun to roll out its national HIV program, there are only eight doctors trained in HIV care to treat a population of one hundred and twenty thousand. One doctor who works in one of the city's four medical clinics has trouble keeping up with his one hundred and seventy-six HIV positive patients.
ANADER will also face the challenge of helping the Ministry of Health's HIV initiatives take into account people in rural areas who cannot afford to pay the subsidized cost of ARV treatment or transport costs from their villages to big cities.
Finally, it will not be easy to advance an initiative in a war-torn country with a tense political climate. The rural development agency's employees based in the north were forced to leave because of the breakout of war in September 2002. ANADER is negotiating with the Government and the UN Forces to ensure the safety of its agents when redeployed.
[1] Agence Nationale d'Appui Au Développement Rural in French
Interview conducted by freelance journalist Ms. Karie Atkinson.
Photographs by Ms. Karie Atkinson and Mrs. Sophie d'Aurelle de Paladines
