A tale of two countries: Senegal and Botswana
Two relatively prosperous African countries: one with an HIV infection rate of 1.4% and the other with 37%. Read on:
**DAKAR (AlertNet) **- Senegal is a poor country, yet its HIV rate is one of the lowest in sub-Saharan Africa, as a result of early, bold and open action.
Half the country’s 10 million people live in poverty, according to government figures, but Senegal has kept a stable and low HIV rate of 1.4%.
“We dared to do things even when we did not have the means,” said Dr Ramatoulaye Dioume, an HIV/AIDS specialist in Dakar with the U.S. Agency for International Development (USAID).
The economy has been in the doldrums for the last 20 years, and GDP per person is $1,480 a year, according to the Economist Intelligence Unit in 2002.
The country has not received massive injections of foreign aid for AIDS, and more than half of women and one-quarter of men are illiterate, according to the U.N. Children’s Fund, Unicef.
So why have its HIV rates remained low while they soar across sub-Saharan Africa?
When the first six AIDS cases appeared in 1986, a team of scientists and doctors convinced President Abdou Diouf to use this window of opportunity, possibly the only one, to contain AIDS.
So Senegal pulled out all the stops on prevention.
The Senegalese health authorities moved quickly to ensure a safe national blood supply, collect reliable data on infection rates, and to set up broad programmes for the control and treatment of sexually transmitted diseases.
Prostitution has been regulated since 1969. Sex workers over 21 must register at a health clinic and undergo quarterly medical check-ups.
When AIDS hit, this high-risk group could be reached at clinics with information and free condoms.
A 2001 national survey found condom use with clients was virtually universal.
However, sex workers still have higher than average HIV rates, ranging from 15 percent to 30 percent, according to the National anti-AIDS Council (CNLS for its initials in French) and the Ministry of Health.
And underage, clandestine prostitution is a growing problem, beyond the reach of health services.
Universal early male circumcision appears to keep infection down.
Studies show the removal of the foreskin appears to make the exposed skin of the glans thicker and more resistant to abrasion during sex and to STD infection.
Alcohol consumption in Senegal tends to be low, and sexual habits are conservative, with low levels of premarital and extramarital sex.
Hundreds of grassroots groups — organised around religious, political, ethnic, business, village, gender, cultural and sports affiliations — rallied around the cause of AIDS prevention as a national goal.
“Community response was wide, precocious, and brought its own resources,” said Dr Abdelkader Bacha, AIDS coordinator at Senegalese NGO Environment and Development in Africa.
The boldest element in the anti-AIDS strategy was the alliance with religious leaders.
Senegal is a deeply religious country, with 94 percent Muslim, 4 percent Catholic and 1 percent animists. Muslim networks or “confreries” are strong, and there are numerous Catholic-run schools and health clinics.
“We quickly realised we could not have an impact if religious leaders were not with us,” said Dr Ibra Ndoye, CNLS executive secretary, one of the scientists who alerted Diouf in1986.
In many countries, fear of offending religious constituencies has paralysed efforts to promote condoms or teach AIDS prevention in schools.
But in Senegal, public health, science and religion found common ground. The priority was to stop AIDS, and each sector had a role to play.
Condemning AIDS as a divine punishment would reinforce stigma, explained health officials in briefings with clerics.
AIDS experts and Muslim and Catholic leaders reached a tacit agreement: clerics would preach abstinence and fidelity but would not oppose condom campaigns.
These in turn would be modest and stress responsible sexuality.
“We developed messages that did not shatter the environment,” Dioume said.
In 2003, USAID-supported programmes sold four million condoms through 2,200 sales points.
Total condom distribution was ten million, up from 800,000 in 1987.
“AIDS afforded us an opportunity to review under Islamic teachings issues such as condom use within marriage, female excision and wife inheritance,” said Bamar Gueye, coordinator of Jamra, a conservative Islamic NGO known for its campaigns against drugs and prostitution.
“After training with CNLS, we understood the epidemic and what we could do about it,” said Gueye.
On Friday at midday, when traffic around the mosques stops and the streets fill with people kneeling in prayer, the muezzins praise Allah and remind the faithful to avoid AIDS and to help those infected.
Senegal’s early effort is all the more striking in the context of the general denial and apathy of African leaders on AIDS in the 1980s and 1990s.
“Inaction hurt Africa badly,” said Ndoye.
In contrast, Botswana — a stable, democratic and relatively rich country in southern Africa with a GDP of $9,500 per person in 2002 according to the Economist Intelligence Unit, has HIV rates of 37 percent, according to the annual UNAIDS report released in July.
Botswana only started to open up about AIDS when Festus Mogae became president in 1998.
It was timely enough to grapple with the ravages of the epidemic, but not to stem it.
Senegal knows it cannot rest on its laurels. Expanding free antiretroviral treatment from 2,000 patients in 2004 to 7,000 by 2006, or half of those who need it, requires training health personnel, improving services in the region and strengthening community participation.
Paradoxically, low prevalence makes it harder to disclose one is positive, so fighting stigma is a priority.
And prevention cannot stop. Annual population growth is 2.4 percent, so the country’s population is projected to be 16 million in 2020.
Urbanisation is even faster, with cities growing by four percent each year, according to the Economist Intelligence Unit.
Nearly half of Senegal’s population currently lives in towns. New generations will become sexually active in fluid urban settings. Keeping them HIV-free is the challenge.