About 38 million people[1] in the world live with HIV / Aids, more than two thirds of them in sub-Saharan Africa. Although the Central African Republic (CAR) is considered a low-income country compared to many countries in Southern Africa, it is in a particularly critical situation, fueled by extreme poverty, widespread violence, a severe shortage of health facilities. and health professionals, who have long had problems with the supply chain for life-saving antiretroviral (ARV) medications, and important barriers to early detection and care of the people of CAR.
As a result, HIV remains a major cause of death in the country. Last year, about 4 800 people died of HIV / Aids from HIV, while about 5 500 new cases are confirmed annually.
A deadly cocktail of obstacles
“While CAR has the highest prevalence of HIV in the West and Central Africa region, less than half of the estimated 110,000 people living with HIV have been treated with ARV,” said Laurent Lwindi Mukota, HIV medical adviser for medical without borders / doctors without borders (MSF). “The situation is even more worrying for children: under 15-year-olds aware of their HIV status are less than a quarter in treatment.”
Counted as the country with the lowest life expectancy in the world[2] and plagued by years of conflict and uncertainty, CAR is completely dependent on insufficient external funding for its response to HIV. Few of the limited number of health care facilities in the country offer HIV testing and care, and many people living with HIV have to make long and often dangerous journeys to find a clinic where HIV services are available. Those who do manage to reach a clinic sometimes find empty shelves instead of the much-needed medicine, making it impossible to continue with their ARV treatment.
“In a country where most people live on less than US $ 2 a day, financial barriers to this situation exacerbate this situation,” said Marie Charlotte Bantah Sana, head of the Communicable Diseases Program, Ministry of Health and Population. ‘Most people have to pay to get an HIV test, and then they have to pay for several extra tests before they are allowed to start treatment. As a result, 30 percent of all patients invited for a pretreatment study do not return to begin their medication. ”
This deadly barrage of barriers, coupled with the end of free trials due to lack of funds, as well as poor information and stigma about the disease, help explain why nearly two-thirds of HIV patients in the MAG with advanced HIV the time they start ARV treatment.[3]
Support for patients with advanced HIV
In this critical environment, MSF works closely with the Ministry of Health and Population and is involved with other key players in supporting access to diagnosis, treatment and care.
In Bangui, the capital of CAR, HIV prevalence is twice the national average. Since late 2019, MSF teams have been providing free medical care and psychological support to patients in an advanced stage of the disease who are also infected with tuberculosis (TB) – the only organization in Bangui that does this. They are also implementing a referral system between the hospital and peripheral health centers, which will be further developed over the coming months.
One year after the start of MSF’s HIV / Aids project at Bangui’s Center Hospitalier Universitaire Communautaire, 1 851 patients were admitted for HIV treatment, including 558 patients newly diagnosed with HIV.
“I was in the hospital to accompany a family member when I had a fever and symptoms of malaria,” said Reine, a 34-year-old widow and mother of two. ‘During the consultation, the medical team offered to have me tested. This is how I came across my condition. I was treated immediately. I had to go back to the hospital a few days ago because I got very sick again. I am being cared for now and I feel better day by day. ”
Anita, a mother of six, also had no idea she was HIV-positive, although she had been feeling unwell for some time. ‘I felt unhealthy, but I did not know I had AIDS. I fell ill two weeks ago and was taken to the hospital for treatment. I learned about the disease when I arrived here. ”
Outside Bangui, MSF offers treatment to patients with advanced HIV in Paoua, Carnot, Kabo and Batangafo.
Increase access to treatment by community groups
To increase people’s access to treatment, MSF has set up ‘community ARV groups’ in Bambari, Batangafo, Bossangoa, Boguila, Carnot, Kabo, Paoua and Zemio. In this system, groups of patients living with HIV and in a stable condition appoint one of their members to collect the medicine refill for the whole group for the coming months, which includes the transport costs and time spent on medical consultations, reduce.
In addition to making treatment more accessible, these groups also help patients to manage and participate in their treatment themselves, and encourage their support and stick to the treatment, in a country where stigma towards people with HIV has a hard time reality is. Members of these groups are the main proponents of HIV prevention and have proven that a community approach can be extremely effective. This helps ensure that patients can continue their treatment, even in difficult or dangerous conditions, such as in CAR, where violent training can make it dangerous.
This community-led initiative appears to be even more important in the context of COVID-19, when access to health structures has been reduced, especially as a result of the prevention of infections and control measures needed to prevent the spread of this virus.
“In our group, one member goes to the hospital every year to treat the ten other members,” says Serge, part of an MSV-supported ARV group in Carnot. “This system is important because some people are ashamed to go to the hospital to get their HIV treatment.”
By the end of 2020, MSF had helped set up 276 community ARV groups in CAR, representing approximately 2,300 patients.
“In all projects where the community ARV group system has been implemented, the number of people living with HIV in these groups is constantly increasing,” says Laurent Lwindi Mukota. A similar system has been put in place in other African countries where HIV is a major issue, including Mozambique, South Africa, Zimbabwe and the Democratic Republic of the Congo.
In 2019, a total of 6,600 people living with HIV were on ARV treatment via health institutions supported by MSF in CAR. Yet there is still important work to be done to decentralize, desigmatize and ensure that HIV testing and treatment is free and accessible to all. Although some progress has been made over the past decade, the deteriorating health care system, exacerbated by years of violence, displacement and insecurity, is still struggling to remove the barriers to the HIV response in CAR. There is an urgent need to step up efforts – and to increase investment – to put free HIV testing and care within everyone’s reach.
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