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HIV programs not reaching the Central African Republic’s periphery

Sam Ouandja, Central African Republic - Along the streets here many homes sit waiting for their owners to return. Several days ago an attack on military bases caused nearly half of this city’s about 17,000 residents to flee into the countryside. But as residents as well as staff of humanitarian agencies make clear, the city, once an important center for diamond mining near the border with Darfur, has been sliding into something of a ghost town for some time.

The sharp decline in the number of diamonds extracted is one reason for the decline. The heavy presence of government soldiers and rebels from the UFDR who, residents say, regularly steal food from them, also takes a toll. But it is HIV, a hidden and locally un-remarked upon killer that some health experts say is beginning to kill residents of Sam Ouandja in accelerating numbers.

“This region is about ten years behind where a lot of places in Africa are in terms of fighting HIV,” said Dr. Guy Yogo, the head of the International Medical Corp, a UNICEF partner working in the Haute Kotto Prefecture. “Because it’s very hard to reach it’s been totally overlooked.”

Official government estimates, based on tests of 200 residents in 2007, say 10% of the population is HIV positive, significantly higher than the national average of 6.2%. But that survey had flaws. For instance, few people between the ages of 25 and 35 stepped-up for testing. Non-unofficial estimates, based on the observations of health professionals, say that perhaps 25% of residents are infected.

In other parts of the Central African Republic tens of millions of dollars get spent each year to fight the spread of HIV.  In Bangui, capital of the CAR, HIV prevention programs are so robust that billboards warning about HIV line major streets and live-saving drugs are widely available for free thanks to money from the Global Fund.

This is in marked contrast to Sam Ouandja where there are no official mortality figures and almost no support to control HIV. The city has no laboratory facilities and only nine HIV positive residents, those who have asked for it, receive medication from the IMC. The hospital has a lone public service poster hanging in its corridor and staff who acknowledge they need more training.

“We received some training three years ago but there needs to be follow-up,” said Rosalie Mandche, a nurse at the hospital in Sam Ouandja. “Every day we get many patients who have the clinical symptoms of HIV, but because we can’t test them we don’t tell them of our suspicions.”

Part of the reason for this lack of attention may be because of the city’s isolation, a recent history of insecurity and the country’s overall underdevelopment. For most people, reaching Sam Ouandja from Bangui is no easy feet. At the best of times the voyage, through jungles that gradually thin into scrubland and then into desert, a trip by car can take a week. During the wet season the same trip might take two weeks.

Another reason is that until recently much of the country was closed of to aid organizations because of insecurity. Still, as the budgets of aid groups swell anger is growing among residents that no one is visiting their community.

“The government promised to help with HIV and then they disappeared for two years. Lots of foreigners visit but we’re still waiting for them to do something also,” said Issa Mohammed, president of Sam Ouandjan’s committee for health and sanitation.

The IMC, which operates the hospital in Sam Ouandja, tries to spread the word about HIV through outdoor health classes in the community. It also gives away about 2,000 condoms per month. But doctors acknowledge that high-risk behavior is common and talking openly about sensitive sexual matters is taboo. 

Mabelle Kpawilina, a 22 year old woman who is HIV positive, illustrates the difficulty of containing the spread of the disease in a city with no social services, a socio-economic situation choked by poverty and official repression and little sustained community educational outreach.

Kpawilina returned to Sam Ouandja from Bangui after her parents died and learning she’d contracted HIV through casual sex. She is one of the lucky few in the city to receive free medication but without official support she feels reluctant to discuss her situation in this community where everyone seems to know everyone else’s business.

“I’d like to stay and educate people if I had a job and regular medicine,” said Kpawilina. “To me the situation here seems much worse than in Bangui, where there are at least efforts to educate people.”

For now Kpawilina lives in a hut beside her grandmother. She sometimes helps her grandmother on the farm and sometimes sells bags of peanuts in the city’s listless market. But most of her salary comes from turning the porch of her home into bar where she serves homemade alcohol to diamond miners. That bar is a popular community hangout and stays open all night. 

Kwapwilina says she doesn’t sleep with the diamond miners and soldier who visit her bar but acknowledges that prostitution occurs.

“Diamond miners pay a lot of money here to sleep with pretty women and this is a town without much money,” she said.

by Dorn Townsend





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