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Although adult prevalence of HIV in Mali has dropped sharply in the past decade, more effective prevention and treatment programmes remain hindered by social stigma and underfunding.
By UNICEF Mali
Although adult prevalence of HIV in Mali has dropped sharply in the last decade, more effective prevention and treatment programmes remain hindered by social stigma and underfunding.
BAMAKO, Mali, 31 December 2013 – No sooner had Khadijda Sissoko* been admitted to hospital with excruciating abdominal pain than she faced the emotional torment of revealing to her family what was wrong. “It was four years ago. I felt I should tell them the truth – that I was HIV-positive. But that had painful consequences,” says the 38-year-old mother of four.
In Mali, HIV and AIDS are still shrouded in silence and stigma. The country reduced 15–49 age group prevalence from 1.7 per cent in 2001 to 0.91 per cent in 2012. But UNICEF Mali Chief of HIV/AIDS Dr. Ndèye Ngoné Touré warns of new challenges ahead. “Mali has just come through a period of conflict that has seen large-scale population movements, as well as rapes,” she says. “Drastic prevention measures are needed.”
Dr. Yssouf Koné, head of Mékin-Sikoro community health centre in Bamako, says his clinic cannot keep up with the rising numbers of patients, including those who are HIV-positive.
Mali's 2012–2013 conflict, which was sparked when a governance crisis allowed separatist rebels to sweep across the north of the country, combined with regional drought and food insecurity across the Sahel to push more and more people to the south, especially to the capital, Bamako.
In his four years as head of Mékin-Sikoro community health centre, Dr. Yssouf Koné has watched demographic changes in Bamako translate into swelling patient numbers. “There are few economic activities around. People sleep here and go elsewhere to work,” he says. “Sikoro is poorly lit, and there is a lot of movement of people. That makes it an area prone to HIV.”
“The numbers of patients we are seeing – not just with HIV – is mushrooming. We cannot keep up,” Dr. Koné says, while a construction worker pushes a wheelbarrow of sand through the waiting area for expectant mothers. Meanwhile, midwife Aoua Koné leads an information session on HIV, and an old man asks to see someone who can check his blood pressure.
The seeming chaos is partly deliberate. “What we do – and it is a first in Mali – is to receive all the patients in the same waiting area,” the doctor explains. “None of the patients can guess what the others are here for.”
The persistent stigma surrounding HIV in Mali means that HIV screening remains focused primarily on prevention of mother-to-child transmission (PMTCT). This process starts – courtesy of UNICEF and other partners like the Global Fund to Fight AIDS, Tuberculosis and Malaria – with pregnant mothers being offered a voluntary test. Those found to be positive become eligible for preventive treatment with antiretrovirals (ARVs), which in 2012 reached a least 44 per cent of expected seropositive mothers.
An HIV test is performed on a woman. In Mali, prevalence of HIV among people aged 15–49 has decreased, from 1.7 per cent in 2001 to 0.91 per cent in 2012. Still, HIV and AIDS remain shrouded in silence and stigma.
Ms. Sissoko comes to the health centre regularly to collect ARVs, which are available free, but also to mingle, discreetly, with other HIV-positive people, who have created a group called Espoir de Sikoro (Hope for Sikoro).
“When I revealed my status to my immediate family, they were supportive. But in the compound where I live with the extended family, it has not gone so well,” she says. “My aunts have completely rejected me. They refuse to eat any food I prepare – and that, in Mali, is a terrible thing for a woman to endure. So I spend all my time in my room watching the television.”
Ms. Sissoko would have been able to count on the support of her own children, but her husband died from a heart attack. “His family took the children – that's customary – so now I feel really alone. The company of other HIV-positive people helps.”
Another regular visitor to the health centre is Mahamoud Dicko, a 27-year-old building site carpenter. He comes to collect his treatment and see Dr. Koné, and also to mingle with fellow members of Espoir de Sikoro.
“When I discovered I was sick, I informed my boss. He had me replaced. He said I would become too weak,” Mr. Dicko says. “That was four years ago, and since then I have not been able to find work. I do not know the reason, but I think it's just that people talk.”
The founder of Espoir de Sikoro, 49-year-old Bintou Diarra, says the stigma surrounding HIV in Mali amounts to a sentence of loneliness. “Women very often face divorce and being shunned by their families. In the association, we have widows, many divorced women, a few men and several orphans. It is very tough, and there is little support,” she says.
Ms. Diarra is still married, has eight children and has known she is HIV-positive for eight years. She is in full health with ARVs. She would like the friends’ group to have its own location. “We have about 100 members, but many do not want to be seen at the health centre. We occasionally cook a meal here together, but people know who we are and why we are here. They say, ‘Look at her – she’s cooking with the HIV-positive people, so we know what's wrong with her’. If we had our own centre, we could use our talents – sewing, dying and doing carpentry – to raise money. We could support our own members, such as the widows who are struggling and the children who are not going to school.”
Since 2001 UNICEF has been engaged with other partners in the prevention of mother-to-child transmission in Mali. Its budget for the sector in 2013 was $1.3 million. More is needed for the coming years.
“UNICEF's priority is PMTCT and the treatment of infected children and mothers,” Dr. Touré says. “We really need to extend the programme so that the whole of the country is covered by screening and the availability of prophylactic medicines. In Mali we see that as the route to an AIDS-free generation.”