Gabon

Foreword

HIV/AIDS is the most far-reaching and damaging epidemic the world has ever seen. Within a single generation, it has grown into an individual and social tragedy with huge implications for human security, for social and political stability and for economic development and spiritual challenge that sub-Saharan Africa region including Gabon is now facing. Taking into aCCount the many people in their prime ages especially women that have suCCumbed to HIV/AIDS and leaving behind them generation of orphans that should be cared for by grannies, HIV/AIDS is worsening than any other attack that has ever befallen on mankind since the slave trade and the continent conflicts combined altogether. Therefore, HIV/AIDS should be a priority in Gabon since it is the greatest challenge facing the development community today as devastates entire communities and roll back decades of development progress gained in Gabon and elsewhere.

As mentioned earlier, the number of people that are dying because of the dreadful virus is not just statistics but they are people namely our parents, children, brothers, sisters, cousins, nephews etc. Additionally, they are neighbours, workmates, church members and church goers and above all members of the body of Jesus Christ.

The unfortunate reality of HIV/AIDS in Gabon is that it carries out stigma, denial and discrimination rarely associated with diseases in modern times we are living in. Those people infected and affected by HIV/AIDS can be fired from their respective jobs, their properties, denied insurance, medical and spiritual care and they are even ostracised just because of their illness. In my opinion, the issue of stigma really call all of us to deeper level of prayer and concrete actions and deeds to turn hearts from fear to love.

In Africa, many meetings have been held over the HIV/AIDS issues. However, I am afraid to mention that sometimes little information gets down to the grass root levels where they are badly needed. That is why I call on the churches and church related organisations that are very close to those affected and infected in Gabon to help end all forms of discrimination and stigmatisation against HIV/AIDS. On the contrary, the church must remain the bastion of love, compassion, tolerance and forgiveness that are part of the Christian's heritage and background. This will be feasible with concerted effort of people of good will to build the capacity of Gabonese churches in developing sustainable, effective, comprehensive approaches to stop the spread of HIV, and provide services to their communities.

In Gabon, HIV/AIDS was originally viewed as just another disease although it has long since moved beyond the boundaries of the health system. It is now generally acknowledged that addressing the pandemic requires concerted efforts across all sectors involving a wide array of actors. Therefore, churches should know that they are the primary partner of the government and other people of good will to combat HIV/AIDS. They need to be equipped, empower and engage themselves to expand and sustain their responses to HIV/AIDS. Hence, HIV/AIDS must be both passion and priority for the churches to reduce its impact through partnering with government, key agencies, organisations, faith and the local communities for increased HIV prevention, AIDS care and advocacy. In addition, as Christian organisations, they have a unique opportunity to share God's hope with those suffering and in pain in this particular context of HIV/AIDS in Africa.

1.   General and HIV/AIDS Epidemiological data in the Republic of Gabon

1.1.  General data

1.1.1.     Country profile

Located in Central Africa region, Gabon has 267, 000 square kilometres. Gabon is bounded to the East by Congo/Brazzaville, to the South by Atlantic Ocean, to the North by Cameroon and Equatorial Guinea. The Republic of Gabon is divided into 9 provinces of which Libreville is the Capital City. Gabon is ranking among the intermediate income countries and benefits from political stability and social cohesion. It is rich in natural resources such as oil, uranium, manganese and forestry. Mineral resources attract many internal and external migrants and sex workers to mine fields. Gabon acquired her independence in 1960 from the French. After the independence, the government began to set up post-colonial structures to comply with the state of independence and to adjust to the socio-cultural realities of the nation in many sectors. This led to progressive reforms in most sectors which was the public service. In the early 1980s, public service reforms in turn produced impact on sectors such as health, education, social affairs and public work.

1.1.2.     Population

ACCording to the census carried out in 2003, the Gabonese population is estimated at 1,321,560 of whom 42.3% would be less than 15 years old, 53.5% would be 15-64 years and 4.2% 65 years and over. It is estimated that 73% of Gabonese live in urban cities. The population growth is estimated at 2.54%. Although life expectancy at birth is 55 years for male while 58 years for female, estimates for this country explicitly take into aCCount the effects of excess mortality due to AIDS. Consequently, this can result in low life expectancy, higher infant mortality and death rates, lower population and growth rate, and changes in the distribution of population by age and sex than would otherwise be expected.

In Gabon, Bantu tribes comprise four tribal groupings such as Fang, Bapounou, Nzebi and Obamba. Other Africans and Europeans count for 154,000 inhabitants including 10,700 French and 11,000 persons of dual nationalities. In Gabon, Christianity and Animist respectively 55% and 75% are the main religions whereas Muslim is less than 1%. French is the official language whereas Fang, Myene, Nzebi, Bapounou and Bandjabi are the vernacular languages. The table below shows basic demographic indicators

1.1.3.     Economy

When it comes to comparing the Gabonese economy, it has to be mentioned that Gabon enjoys a per capita income four times higher than that of most sub-Sahara nations. Gabon mainly depended on timber and manganese until early 1970s when oil was discovered offshore. The oil sector currently aCCounts for 50% of GDP. Due economic international rules, principles and constraints Gabon is facing fluctuating prices for its oil, timber and manganese exports. In addition, devaluation of its Francophone currency by 50% in 1994 sparked a one inflationary surge, to 35%; the rate hopefully dropped to 6% in 1996. These shortcomings coupled with poor fiscal management are weakening the economy.

In 1994-1995, the IMF provided a one-year standby arrangement at near commercial rates followed by another standby credit worth of USD 119 million in 2000. Those agreements made some progress in privatisation and fiscal discipline. France provided additional support in 1997 after Gabon had met IMF targets for mid-1996. In 1997, an IMF mission to Gabon criticised the government for overspending on off-budget items, over borrowing from the Central Bank, and slipping on its schedule for privatisation and administrative reform.

Short-term progresses are nevertheless depending on an upbeat world economy and other fiscal and adjustments in line with IMF policies. Although Gabon has recently established a fund to fight HIV/AIDS, criticisms fault President El Hadj Omar Bongo for failing to respond quickly to rising prevalent rates.

Table 2 shows updated and relevant economic indicators in Gabon

1.1.4.     Education

At the 1999 Biennale Meeting in Johannesburg, South Africa, President MBEKI made a strong plea for the Development of education in Africa (ADEA) to tackle the educational and social challenges presented by HIV/AIDS epidemic in Africa. In response to this call, ADEA launched an initiative called “Identifying Effective response to HIV/AIDS” whereby ministries of education and training institutions in sub-Saharan Africa were invited to take the stock and analyse effective preventive practices and policies in the education sector in the fight against HIV/AIDS.

In response to these requests for a sub-regional meeting on HIV/AIDS and education in Central Africa region, ADEA and the Inter-Agency Task Team are working with the affected countries to combine a technical seminar and ministerial meeting in Libreville, Gabon, May 24 th to 29 th 2000.

In Gabon, some schools have an HIV/AIDS programme in place. It focuses on using appropriate protocols to limit the risk of infection as well as education about HIV/AIDS, but only some staff has participated in the programme. However, child counselling has not been firmly integrated into the academic mainstream in primary teachers' colleges. Consequently, children (such as orphans) frequently faced with psychosocial problems are in dire need of counselling services.

Table 3 illustrates the education indicators in Gabon

1.1.5.     Health

Like other developing countries, Gabon is facing major health problems that include diseases of poverty such as tuberculosis, malaria, poliomyelitis etc. ACCording to health experts, the outbreak of infectious diseases in Gabon is due to unequal medical care and poor public health services. The high cost of medical care and increasing poverty, mostly among the country most disadvantages people have given way to an outbreak of the mentioned diseases suCCessfully controlled in other Central Africa countries.

ACCording to Mr Benoit Makana, head of epidemiological services at the health ministry, the effectiveness of the health service is mainly the result of political choices and strategies. He went on saying that sometimes in one area there will be two programmes for the same issue, while in other region certain issues will be unaddressed.

This was recently seen when the national UNDP representative handed over XAF: 642,000,000 the Ministry of poverty in order to help combat both poverty and HIV/AIDS. This money was given to the so-called civil society perhaps including faith-based organisations. However, nothing or little was written on how faith-based organisations could aCCess those resources. Additionally, the follow-up mechanism that was described to manage these resources was similar to those in place in the Ministry of Health. This could lead to duplication of efforts and time consuming.

ACCording to Minister of Health, the fight against malaria, which remains Africa's most deadly disease, is a priority. He stressed that the roll back of malaria goal in Gabon is to halve malaria-related deaths by the year 2010 and to roll the toll by another 30% by 2015 and 20% by 2020. Of course, worldwide malaria kills between two or three million people every year. “Of 487,688 people examined in 2000, 79,401 (16.28%) had malaria. This is an indication showing that an infection rate such as this with Gabon's most deadly disease among all other groups remained an issue of great concern.

It is well known that AIDS is ravaging several African countries, and Gabon is no exception. The most recent estimates are that 9 % of the sexual active population is HIV+, a jump from 1.6% in 1986. ACCording to government, in Libreville alone, the numbers are 7.8%. Although, the government has recently established a fund to fight HIV/AIDS, privately national officials and donors complain that not all allocated money to control public health conditions is used as intended since waste and corruption remain serious problems in the government sphere.

1.1.6.     Poverty and Vulnerability

ACCording to the Red French Cross, the HIV prevalence rate increased from 2.2% in 1989 when oil production and the government revenues were still rising comfortably, to 9% in 2003 when oil production was in free-fall as offshore reserved dried out and government spending has been cut aCCordingly. Consequently, road infrastructures have been deteriorated and spending on health and education sectors have fallen.

A recent survey of 15 to 26 year-old carried out for the UNICEF showed that unemployment was the main concern in life, with catching HIV in second place and final poverty. In Gabon, where government spending is falling and unemployment growing as the oil starts to run out, young people are more worried getting jobs than catching HIV/AIDS.

In response to help slow down the spread of HIV/AIDS, the government set up USD: 20 million last year. This money was also expected to help people living with HIV/AIDS to meet their needs. But both the PNLS and the Solidarity Fund failed to effectively use the money at their disposal.

Mrs Edith Bongo, First Lady of Gabon to the participants in one workshop that she organised in interior of Gabon that despite progress in mobilising many sectors of society against HIV/AIDS, there still a lot to do. She went on stressing that ignorance is one of the worst enemies, and knowledge is the ultimate tool in tackling the epidemic effectively.

Additionally, she urged the youth not to become discouraged by the enormous challenges, pointing to progress on the national and international levels in providing aCCess among the youth, linking efforts to overcome poverty and HIV/AIDS and providing care and support for mothers infected with the virus.

In fact, the reality is that most Gabonese teenagers have their sexual encounter between the ages of 12 and 14 and teenage pregnancies are common. This could be increased by the current unemployment rate of 21% (estimates of 1997) of the population that lives under the poverty line. Meanwhile the state is faced with the challenge of looking after estimated 9, 000 orphans of people who have died from AIDS. The projection is that the number of AIDS orphans in Gabon would increase to 14,000 by 2010 unless people changed their behaviour. The government policy is to encourage extended families to take these children under their wing.

It is well known that poverty goes hand in hand with HIV and AIDS. This also concerns Gabon which the already fragile economy should be further weakened with much of the trained labour force lost to HIV/AIDS. Poverty facilitates the transmission of HIV, makes adequate treatment unaffordable, aCCelerates death from HIV-related illness and multiplies the social impact of the epidemic.

1.1.7      Politics

Gabon is a republic. Its head of State is an elected president. The president nominates a Prime-Minister. Ministers are appointed by the prime-minister in consultation with the president. Also elected in general elections, the legislative branch consists of lower (Parliament or National Assembly) and upper (Senates) chambers. It is responsible for creating and controlling laws. The opposition parties were legalised in 1990s. The constitution was adopted in 1991 and the legal system is based on French civil law system and customary law.

President Omar Bongo, Africa's longest serving head of state has declared the fight against HIV/AIDS to be a “national priority”. However, though it should be encouraged, the government programme to combat AIDS has been marred in recent years by the corruption of certain administrators who have used funds for their own need sand this is well known, said Hubert G., a leading member and AIDS activist Group Solidarity for Young Christians.

However, the first outpatient treatment centre for people living with HIV/AIDS was only established in Libreville in 2001. Antiretroviral are difficult to obtain despite the willingness to deliver them free of charge to those (poor people) that need them most. When talking to the general population, there is a widespread belief that government efforts to combat the pandemic are hampered by rampant corruption.

Despite the political will to make antiretroviral free of charge for ingenious people, another problem is that many people living with HIV/AIDS cannot afford treatment at local hospitals; some of them were complaining that AIDS patients were not even welcome by health professionals.

2.   HIV/AIDS Epidemiological data in Gabon

2.1.  HIV/AIDS epidemic in Gabon

The first cases of HIV/AIDS were diagnosed in 1986. The fight against HIV/AIDS started in 1987 through the establishment of the National Committee to fight HIV/AIDS and other Sexually Transmitted Infections. Shortly afterwards, it was decided the National AIDS Control Programme would be the executive body. With regard to the national data on HIV/AIDS, no data were found. However, a study was jointly carried out by Institut de Recherche et de Développement and the University of Montpellier 1 in order to find out the seroprevalence in urban areas. This study showed that the seroprevalence in Libreville7.7%. The HIV/AIDS epidemic increased from 1.8% in the late 1986 to 7.7% in 2000.

ACCording to the National AIDS Control Programme, nearly 60% of people living with HIV/AIDS are diagnosed at the stage of full blown AIDS. In 1991, 2.3% of hospitalised patients at the Centre Hospitalier de Libreville people were living with AIDS compared to 23% in 1999. This means that the disease was 10 times higher than initially. At Jeanne Ebori Fondation, 3 patients out of 10 admitted to the service de réanimation would have developed full blown at an advanced stage. ACCording to the Rapport sur l'épidémie mondiale de VIH/SIDA published in 2000, AIDS claimed the death of 2000 people aged between 15-49 against 400 deaths from the youth people.

STI are an important public health concern although existing data in Gabon are not reliable since they come from a few health service reports. The consequences of untreated STIs can be devastating to health of men, women and their children. These conditions are responsible of infertility, chronic ill health, and sexual dysfunction and disseminated disease in Gabon. ACCording to National AIDS Control Programme, STIs are leading to chronic pelvic pain and pregnancy complications such as ectopic pregnancy.

Fig 1: shows the new cases of HIV annually declared at WHO from 1987 to 2002

Comments

Although these figures are alarming, the Ministry of Health's surveillance system is weak and provides unreliable data due partly to underreporting. However, it should be noted that some movement took place following the UN General Assembly on HIV/AIDS in June 2001, when the Ministry of Health adopted official guidelines for HIV/AIDS work and declared the epidemic a priority.

In Gabon, many people, particularly women, who have HIV or other Sexually Transmitted Infections, do not receive proper care and treatment for the following reasons:

· Stigma, denial and discrimination against people living with HIV/AIDS is rampant in the communities;

· Individuals may have symptoms of STIs, but they do not identify them as infection;

· Since sexual education is no longer given in families and in the communities, many young girls lack information about normal vaginal discharge;

· Some women have had an infection for so long that they may think the symptoms are normal;

· Many people suspect they have HIV and STIs, but they do not seek care because:

§ They are too embarrassed to attend a clinic;

§ HIV/AIDA and STIs carry social stigma;

§ They do not recognise the seriousness of HIV/AIDS and STIs;

§ They have no aCCess to treatment;

§ They cannot afford treatment.

2.2.  Sentinel surveillance

HIV/AIDS prevalence information among antenatal clinic attendees has been available since the mid-1980s. In Libreville, the Capital city, HIV prevalence among antenatal women tested increased from 1% in 1988 to 4% in 1995. Outside, Libreville, HIV prevalence information is available from Franceville in 1996, 1987, and 1989-90; from South-Eastern Gabon in 1987-88 and from Estuaire in 199. There is no information available on HIV prevalence among sex workers. In the late 1980s, 2%-4% of STI clinic patients tested in Libreville were positive. In 1996-1997, 17% of STI patients in Libreville, Franceville, Moanda and Port-Gentil tested HIV-postive. In 1997, 6% of military personnel in Port-Gentil tested HIV-positive. The following figure and table illustrate the HIV prevalence in Gabon.

Comments

This table provides hints and insights that HIV/AIDS is obvious in main towns since the epidemic has increased. Churches can play a unique role in delivering prevention and care interventions and can use its structures as entry points for reaching out to people in need.

Figure 2: shows the distribution of HIV prevalence from 1986 to 2003

Source: Epidémilogie du VIH/SIDA au Gabon

Comments

The figure indicates that since the outbreak of HIV/AIDS, the disease is still on the increase. This requires a community response that put in place effective leadership and committed participation from involved stakeholders including churches.

The church in Gabon has an opportunity and responsibility to lead a rights-based approach to orphan and child care, to continue to advocate for policies and public programmes that address the underlying causes of HIV/AIDS crisis, to coordinate community level efforts in partnership with the National AIDS Control Programme, etc.

In order to achieve these goals, national churches in Gabon must build their capacity to play an effective and leading role in order to help curb the epidemic.

2.3.        Contributing factors

· Lack of political will: it took longer than expected to develop a proactive leadership to combat HIV/AIDS. One of a high-ranking leader said on the national television “ Gabonese are immunised against HIV/AIDS. Therefore, they cannot get HIV ” (personal communication)

· Potential barriers which include: ignorance, interpersonal and system-wide

1. Knowledge barriers are indicated since many people have only rudimentary knowledge of HIV/STI transmission and symptoms; Example of the knowledge barriers mentioned above are evident in these statements gleaned from verbal data: “ I cannot get STIs from clean girls ”, and “ condom do not work ” . In addition, misinformation on AIDS is widespread. Many people are still arguing whether mosquito bites can transmit HIV.

2. Other barriers related to knowledge include a disbelief that HIV exists in Gabon, a disbelief in the ineffectiveness of condoms, and misinformation related to HIV and STI transmission and symptoms; interpersonal barriers reflected in statements such as “ I do not like condoms. Sex feels best “carne a carne”; and, “ drinking gives me courage to meet girls and have sex ”

3. The systematic barriers included a lack of available condoms when troops deployed on missions, non-disclosure policy when a patient tested positive for HIV and limited aCCess to voluntary testing and counselling. System-wide barriers appeared in: “I cannot find condoms when I am in mission, but I can find girls”, “ I do not know where to get tested for HIV”; and “Even if you do have HIV, the medical doctors will not tell you ”.

· Poverty: Gabon has the highest GNP per capita (4,120 USD) in Central Africa region. Yet, poverty is crucial since a huge proportion of the Gabonese wealth is benefiting by only a few proportion of the population. Additionally, unemployment is very high.

· Heavy external debt: ACCording to the estimates made in 2002, Gabon is heavily indebted with USD: 3.8 billion. This could partially explain why unemployment is still an issue of concern particularly for the youth.

· Sexual behaviour and sex education: the reality is that most Gabonese teenagers have their sexual debut and encounter between the ages of 12 and 14 and teenage pregnancies are common. I met one university student who said that her parents are reluctant to discuss sexual issues with her and other children. She said:” It is difficult to talk about sex education at home. It is a taboo subject. I am 25 years old; my sexual education has been carried out in streets, at school and in the homes of other friends and families ”.

· Resource misallocation: Both the National AIDS Control Programme and the Solidarity Fund have been widely criticised for falling to use effectively the money at their disposal.

· Broadly speaking we know that poverty; income inequality, labour migration, gender inequality, low education status, and a range of context-specific socio-cultural variables and poor health facilitate the spread of HIV/AIDS and are associated with higher prevalence rates.

2.4.  Impact of HIV/AIDS in Gabon

Virtually there is no study carried out in Gabon in order to measure the impact of AIDS on individuals, families, communities and the country as such. This section discusses the impact of AIDS from data gathered through limited surveys that took place on the ground during the AIDS situational analysis in Gabon

2.4.1.     Impact on individuals

HIV/AIDS affects the physical, mental and social well-being of people living with HIV/AIDS particularly when it comes to the development of opportunist infections. In 1998, the Foundation Jeanne Ebori Internal Medicine department in Libreville diagnosed the following opportunistic infections.

Additionally many people affected and infected by HIV/AIDS are not treated with respect, love and dignity. Instead, they are ostracised, rejected, stigmatised and discriminated. Another problem is that many people with HIV/AIDS cannot afford treatment at local hospital, some of which complain that they are not welcome.

2.4.2.     Impact on the community

HIV/AIDS has impact on the communities since they lose the most economically active-groups who are breadwinners. The death of a parent can have disruptive impact on orphans. The impact of the disease on individual children depends on a variety of factors such as their age, the socio-economic status of the families, the number and age of their siblings. Very often, the care of these children falls on extended families over stretched because of their limited and declining resources. In Gabon, there is an estimated of 8,600 orphans due to HIV/AIDS. Many children are more likely to be out-of-school, malnourished, less likely to receive assistance and are extremely poor. Many end up on streets where they may be abused, exploited, vulnerable to contracting HIV/AIDS.

2.4.3.     Impact on different development sectors

Impact on health

In Gabon, health care system-one the front-line with the AIDS crisis-are overburdened and the services that health professionals can provide are woefully inadequate. In addition, not only are beds filling up with AIDS patients but also health professionals themselves are vulnerable to HIV/AIDS. A study carried out by the National AIDS Control Programme between 1996 and 1999 showed that out of 482 health personals whom undergone HIV testing, 33 tested HIV positive. This lead to personal shortage since their skills will be difficult to replace.

Impact on other developmental sectors

ACCording to the National AIDS Control Programme, HIV/AIDS severely affects other societal sectors such as mining, oil, agriculture and housing, etc. In the public sector, the HIV prevalence would be 10% between 1996 and 1999. Similarly, the education sector is devastated since 439 personals tested, 65 tested HIV+ in 1999. Because of early sexual debut and sexual promiscuity, students and schoolchildren are vulnerable. This is equally true for lorry drivers and militaries.

3.   The National HIV/AIDS Control Programme

3.1.  Background of the National AIDS Control Programme

In order to contribute to halting the spread of HIV/AIDS in Gabon, an inter-ministry commission convened by the Prime Minister in collaboration with 11 ministries was set up in 2000. This was an indication that HIV/AIDS deserved attention from the highest level of the government. The role of the inter-ministry commission is:

· To propose a multi-sectoral approach to fight against HIV/AIDS;

· To coordinate the fight inter-sectoral against HIV/AIDS;

· To help implement the national plan adopted in respective ministry;

· To analyse progress reports of those institutions that are fighting HIV/AIDS on the ground;

· To define modalities of actions taking into aCCount the context and constraints of HIV/AIDS in Gabon.

The Comité National contre le VIH/SIDA et les Infections Sexuellement Transmissibles which is responsible for defining the HIV policy and guidelines was established in 1993. The Ministry of Health is the head of the so-called committee. The National Committee comprises an ethical and a follow-up committee, the National AIDS Control Programme, the Coordination Office, nine provincial committee and departmental committees.

The National AIDS Control Programme is the executive body of the National Committee to combat HIV/AIDS. The main roles of the NACD are as follow:

· To improve the knowledge related to HIV/AIDS and reinforce the epidemic surveillance;

· To prevent HIV transmission through sexual encounter and through blood transfusion;

· To improve an enabling environment in health institutions and to help administrate adequate care to PLWHA;

· To set up management boards in health institutions which are fighting against HIV/AIDS.

Comment

The National AIDS Control Programme is acting as an executive body rather than a coordination mechanism. Therefore, the NACD finds it difficult to play its role of infusion and facilitation. The many sub-committees put in place are ineffective. For instance, the ethical committee is paralysed since there is no legal protection draft towards the rights and obligations of people living with HIV/AIDS. There is little implication from ministries other than Health to fight against HIV/AIDS aCCordingly. The multisectoral approach to combat HIV/AIDS did not take off because of the inexistence of the National Committee. There are quite no networks between associations and Non Governmental Organisations dealing with HIV/AIDS issues. Provincial and departmental committees hardly work since they exist on papers and there were no mechanisms for follow-up. Moreover, financial and material resources are limited for decentralised structures. Training of health personnel, epidemiological, social and clinical research planned within the second medium-term did not take place. The above comment is self-explanatory about the poor quality of the national response.

3.2.  The Gabonese National Response

Since the first HIV/AIDS case was reported in 1986, the disease spread rapidly in the country. Thus, a National HIV/AIDS and Sexually Transmitted Infections Control Programme was established in 1987 in order to coordinate with the Ministry of Health, a sound control of the epidemic as well as a monitoring of the programme. However, the second medium-term did not take place because of the change in the leadership. The new team that took over carried out Information, Education and Communication as well as epidemiological surveillance. The table no 6 provides important dates and significant events.

Table no 6 indicates Dates and main events of the national response

The National Strategic Plan 2001-2005 was mooted, reviewed and amended during a national workshop which brought altogether 4 provincial representatives of whom the governor, representatives from ministries, representatives from the Prime Minister Office, delegates from the national presidency, delegates from the National Assembly, delegates from faith-based organisations, People living with HIV/AIDS and delegates from private sector.

The general objectives of the National Strategic Plan for 2001-2005 are as follow:

· To reduce the HIV/AIDS prevalence within the general population by implementing preventive strategies;

· To guarantee the well-being of people living with HIV/AIDS through psychological and medical aCCompaniment, social, legal and economic measures;

· To mitigate, evaluate HIV/AIDS impact in the country.

3.3.  Donors and Partners in the fight against HIV/AIDS

Although it took sometimes for people to realise that HIV/AIDS is not merely a medical problem, and the fight against HIV/AIDS does not involve the only National AIDS and STI Control programme. Several other partners, donors and partners are involved in this fight; they can be grouped into several categories such as:

Donors

· The bilateral and multilateral partners are many and provide a technical and financial support. They include Coopération Francaise, Fonds monétaire International, Banque du Développement des Etats de l'Afrique Centrale, CEEAC, CEMAC, etc.

· The United Nations agencies such as UNESCO, WHO, UNAIDS, UNICEF, FNUAP, PNUD, World Bank, etc are providing financial support.

Partners

· The Non-Governmental Organisations which are numerous and mainly intervene trough awareness-raising, information-education-communication activities;

· Association of people living with HIV/AIDS;

· Some churches are involved through awareness-raising, education for the moral and spiritual integrity of citizens.

4.   Partnership between government and religious communities to fight AIDS

The early Gabonese national response did not include religious communities to fight HIV/AIDS since religious communities were not considered as key players in the fight against HIV/AIDS. This could be probably because the early church response was indifference, silence, condemnation, and inadequacy for faith leaders to speak or to act as disciples of to Jesus, the compassionate. Additionally, the National AIDS Control Programme staff felt at that time, churches leaders would oppose the condom use since many of them used to associate the epidemic with God's punishment of immorality.

The Ecumenical HIV/AIDS Initiative in Africa has been recognised by many church leaders to be the first organisation that helped churches in Gabon to work hand in hand to fight against HIV/AIDS. In fact, many Gabonese delegates attended the theological reflection held in Yaoundé in 2002 and the theology of compassion in 2003. These regional workshops gave opportunities to network between workshop participants themselves with the spirit of ecumenism when they went back home. Since then, many things have changed in a positive way. For instance, the National AIDS Control Programme is working closely with two religious communities namely the Catholic and the Revival churches. In addition, a revival pastor is working as full time staff in the National AIDS Control Programme. He is also member of the Country Coordination Mechanism for the Global Funds.

During the mapping study, the NACP asked the Catholic Priest and the Revival Church Pastor to submit a paper related to the spiritual aCCompaniment of PLWHA. I attended the meeting where this paper was discussed. Once this paper is amended by other pastors involved in the fight against HIV/AIDS from the rest of the religious communities, the spiritual aCCompaniment paper will be adopted as national strategy to help churches address the spiritual needs for those who are affected. This good practice is relevant and can be replicated elsewhere since they show how the government and the churches could make plans to defeat the common enemy, which is HIV/AIDS.

5.   Faith-based organisations response and involvement in addressing HIV/AIDS

5.1.  Faith-based organisations in Gabon

With regard to the mapping study, I met religious and other interested people of the following religious communities: Eglise Evangélique du Gabon, Eglise Catholique, Centre d'Evangélisation de Béthanie, Eglise Protestante Réformée and Eglise Alliance Chrétienne et Missionnaire du Gabon .

5.2.  Perceptions of HIV/AIDS

5.2.1.     Eglise Evangélique du Gabon

Religious leaders are well aware of AIDS although the disease still affects people before preventive measures are launched. This could be the results from confusion about which values serve people best. The culture of silence related to most aspects of sexual behaviour may have served the people in the past, but this is no longer applicable in the context of HIV/AIDS, which affects many people in Gabon. Finally, internal problems related to the leadership did not help the Eglise Evangélique du Gabon to get involved in the fight against HIV/AIDS since the onset of HIV/AIDS.

“HIV/AIDS is every body's concern. However, because of the many internal leadership conflicts that the church faced, the Eglise Evangélique du Gabon did not have the opportunity to put in place appropriate mechanism to fight against AIDS”.

5.2.2.     Eglise Catholique

In spite of the debate over condom promotion, there is a responsibility within the Catholic Church to the community to do what can be done within theological boundaries to both prevent HIV/AIDS and support the individuals who have the disease and their families. Other comparative advantages within the Archdiocese of Libreville include a long historical commitment to address the issue of HIV/AIDS and its openness at “individual” instead of “institutional” level to collaborate with other churches in order to put HIV/AIDS in Gabon under control.

“Recognising that HIV/AIDS affects and is affected by all aspects of life, the Episcopal Conference response entails a broad of strategies aimed at creating a supportive environment in which individuals can make informed choices, free of stigma and prejudice, in a context where basic rights as citizens and humans are recognised and upheld”.

Father Jean Kazadi, ACERAC, Coordinator.

5.2.3.     Eglise Evangélique Réformée du Gabon

The Eglise Evangélique Réformée du Gabon recognises that sexual promiscuity, poverty, gender inequality and rapid urbanisation foster the spread of HIV/AIDS that would be a scourge because of God's punishment for immorality.

“There is nowadays such a huge sexual promiscuity in Gabon that it goes down to incest. HIV/AIDS could be a sign of divine malediction from God aCCording to Deuteronomy 28:58-61. That is why I should preach the word of God without compromising the truth that is revealed in it”.

5.2.4.     Eglise Alliance Chrétienne et Missionnaire du Gabon

For the past years, Eglise Alliance Chrétienne et Missionnaire du Gabon has been very concerned with the increase of HIV infection within the Gabonese population. Eglise Alliance Chrétienne et Missionnaire du Gabon had participated in a number of workshops in order to identify the role and the place of the church in the fight against HIV/AIDS.

“The stigma of AIDS is still so high in Gabon that people have a high threshold to cross in order to speak with someone about the illness and their fears about it. Additionally, counselling is a new concept in this culture, so it is not easy for someone to understand how sitting down and speaking with a stranger may help him or her. This is at the core of what makes HIV/AIDS so deadly in this society: the nature of transmission of the virus, coupled with a reluctance to talk about it openly works together to greatly exacerbate the problem.”

5.2.5.     Centre d'Evangélisation de Béthanie

As part of its mandate, Centre d'Evangelisation de Bethanie has, for over a decade, supported the efforts of people in poor, marginalised communities including church members to understand the roots of the problem, to find ways of preventing the virus from spreading further and mitigating its impact. Centre d'Evangélisation de Bethanie recognises that it has much to learn from the men, women and children who live the day-to-day reality of HIV/AIDS and seeks to contribute to the global response to the HIV crisis by ensuring that their voices are heard by decisions making at all levels.

“In churches, HIV/AIDS issues are still confined with the fact that many people would like to know whether HIV/AIDS is a natural disease, or a curse or a judgement from God. I think that HIV/AIDS is not a curse is because HIV/AIDS does not discriminate as it embraces every body. HIV/AIDS is a preventable disease whilst a curse is imposed. In my opinion, HIV/AIDS is a disease like cancer, diabetes and Hypertension, etc. The God of my understanding is love and merciful and he cannot punish his children through a dreadful virus like HIV.”

Pastor Gaspard Obiang, Centre d'Evangélisation de Béthanie.

Comments on HIV/AIDS perceptions by churches in Gabon

Although church leaders' perceptions brought out mixed findings, their statements give some indications on the limited their knowledge to fight against HIV/AIDS aCCordingly. Of course, some churches are doing their best to respond to the HIV/AIDS crisis but there is still a lot to do.

There are many barriers to an effective response within church settings in Gabon. These include:

· The attitude of churches towards the HIV/AIDS epidemic, including fear, ignorance and denial are real barriers towards mobilising them to work in HIV/AIDS.

· Some churches are afraid that if they start providing HIV/AIDS interventions, they will harm their institutional image and they will thus lose the people they now serve.

· In many churches, people living with HIV/AIDS are unwilling to disclosure their status because of the associated stigma and discrimination. Consequently, PLWHAs have difficulties organising themselves into organisations led by churches.

· Many churches believe that HIV/AIDS is not a problem for the church members and churchgoers they work with and that there is no need to get involved.

· Others believe that those people who are infected by HIV are responsible for their infection, so they are only concerned with prevention.

· Additionally, there is a misleading tendency in some churches to believe that only sex workers and their clients are at high risk of contracting HIV.

· A few churches believe that investing in care and support for PLWHAs is a waste, because they will die anyway.

In my opinion, these barriers have to be addressed if churches are to engage communities to respond to the epidemic in a positive and caring ways.

5.3.  nvolvement of FBOs in addressing HIV/AIDS

The responses of churches confronted with the HIV/AIDS issues in Gabon are simply limited to simple prevention messages particularly on World AIDS Day. Therefore, I did not come across a single church that is providing holistic comprehensive care apart from public hospital. The involvement of Faith-Based Organisations is outlined as follow:

5.3.1.     Eglise Catholique

ACERAC stands for ( Association des Conférences Episcopales de la région d'Afrique Centrale ) is the catholic structure in the fight against HIV/AIDS in the Archdiocese of Libreville/Gabon. It is affiliated with many other groups and movements such as CARITAS, GSM, Foyers chrétiens, Equipe notre dame, Légion de Marie, Renouveau Charismatique, Chevaliers de l'immaculée, SOJECS, MES, Disciples d'Emmaus, JEC, JOC, Chorale, Serviteurs du Christ, les amis de Jésus crucifié, Visitation, Triomphe de Marie, Toutes les chorales, les Commissions liturgiques Catholiques, et toutes les communautés eCClésiales de base.

Objectives

The ACERAC's objectives from 2002 to 2003 were:

· To reinforce sensitisation in school, in parishes, in organised groups and universities using medias (TV, printed leaflets and banners, newspaper publication)

· To broadcast advertisements or spots on Television channels about voluntary counselling and testing before marriage;

· To actively involve clergy, pastoral agents and catholic school headmasters in the sensitisation in the fight against HIV/AIDS

· To disseminate aCCurate information about sensitive issues related to HIV/AIDS

· To reinforce the partnership with business world (public and private enterprises, trader unions) in Libreville and elsewhere.

Main Activities

· Day care prevention activities run at Sainte Marie, Saint Michel de Nkembo, Saint André and Rois Mages d'AKEBE

· Skills training for schoolchildren and students (College de Quaben, Immaculée Conception, College Bessieux, CEMEF, CEFOR, ESAM, ALFRED SAKER)

· Community talks with parents and their children during Christmas at Saint Jean Seminary in 2002

· Television spots and sensitisation

· Participation during the World AIDS Day

· Organisation of a regional consultation with Bishops and partners in the field of HIV/AIDS in order to assess best practises and to help churches address reasons for failure.

Results

· 4/6 Dioceses are fully engaged in the fight against HIV/AIDS

· A core group of trained Christians meet once a week in order to acquire the capacity to reflect on their concerns about HIV/AIDS, make decisions and changes in the area of prevention, name indicators of these changes, document their response, and transfer experience and skills to others.

· In collaboration with Centre d'Evangélisation de Béthanie : Elaboration of “ten commandments” against HIV/AIDS in Gabon

· Cloche d'Or: an HIV/AIDS newsletter used to be a resource learning material

· Twelve Bishops from Gabon, Congo/Brazzaville, DRC, Chad, Cameroon, and Central Africa Republic committed themselves to mainstream the issues of HIV/AIDS in their respective Dioceses.

5.3.2.     Centre d'Evangélisation de Béthanie

The Centre d'Evangélisation de Béthanie received the complete endorsement and support of its partnership (Fédération des Eglises de Réveil du Gabon). There is one activist pastor who responded by working to build the capacity of partner churches. At the time the partnership was established there was limited HIV/AIDS programming due to lack of resources, education, material and services.

In conjunction with the National AIDS Control Programme, the Centre d'Evangélisation is also working to build capacity of churches from different denominations, enterprises and lastly the members of Parliament. The aim is to provide a comprehensive HIV/AIDS programme to equip church leaders, senior staff of enterprises and Member of Parliament in addressing the challenges of the HIV/AIDS pandemic within congregations and communities.

During the official launch of “ten commandments to fight AIDS in Gabon”, the Archbishop of Libreville thanked the Centre d'Evangélisation de Béthanie for its commitment to working with faith communities in Gabon. The process of writing the Ten Commandments to fight against HIV/AIDS in Gabon has forged new linkages between the Catholic Church and the Centre d'Evangélisation de Béthanie. They have not only joint meetings but also they have developed a joint HIV/AIDS Spiritual ACCompaniment requested by the National AIDS Control Programme.

The Pastor of Centre d'Evangélisation de Béthanie is finally seen as a vehicle with the National AIDS Control Programme using a common voice on policy issues. The weaknesses of Centre d'Evangélisation de Béthanie is that when its pastor is invited to carry out a workshop at any denominational church, the local pastors are not encouraged to take the lead to fight against HIV/AIDS within their congregations. Consequently, the activist pastor of the Centre d'Evangélisation de Béthanie felt overloaded and overworked with many responsibilities. Additionally, the relationship between the Catholic Church is more interpersonal rather than interfaith one.

6.   Youth, sex education, HIV/AIDS and migrants

6.1.  The youth people

Rates of HIV/AIDS and other Sexually Transmitted Infections are increasing in sub-Saharan Africa including Gabon where AIDS is the leading cause of death. The interaction between HIV/AIDS and STIs are well known since STIs are very often precursors to HIV/AIDS. Whilst STIs can be treated suCCessfully with antibiotics, no cure is not yet available for HIV/AIDS. This leaves prevention as the primary method for controlling the epidemic. In Gabon, youth are particularly vulnerable to STIs and HIV infection due to their high level of sexual activity, temporary sexual relationships, and insufficient of condom use, “sugar daddy phenomenon” and poverty.

“To overcome this situation, the ACERAC's Coordinator organised a 4 day-workshop in Libreville in order to discuss preventive measures and what could be done to curb the AIDS epidemic among the youth. The Coordinator invited a well-known Tanzanian priest as the main resource facilitator for the seminar. In the end of the workshop, the priest requested youth people who would like to remain abstinent to sign a written commitment. Most participants who were girls refused to sign it because sugar daddy provided them with financial and material support.”

Comments

This statement is in contrast with the influential Roman Catholic Church, while active in the fight against AIDS, and steadfastly preaches abstinence before marriage. “ The Church favours dialogue above all else ”, said Father José Maria who works with street children. “ We tell young people about the dangers they face if they have sex in an uncontrolled manner” , he added.

AIDS is ravaging several countries African countries, and Gabon is no exception. The most recent estimates, issued in 2003, are that 6% of the sexually active population is HIV positive, a jump from 2.2 in 1989. In Libreville alone, the numbers are even higher: 7.8 % aCCording to the government.

Although many youth realise that STIs and HIV constitute a threat for young people in their communities, some of them find it difficult to personalise risks and make required decisions to reduce the risk. Studies indicate that youth often use partner attributes such as appearance or reputation to determine whether they are safe (Hillier et al, 1998). Likewise, many youth presume that trusted partnership contain high level of emotional commitment, intimacy, and fidelity.

There are some opportunities in terms of youth networks such as Union des jeunes Chrétiens Catholiques, Union des jeunes Chrétiens Protestants, and Union des jeunes Musulmans. However, these networks are not fighting HIV/AIDS. In my opinion, there is a significant contrast in terms of AIDS prevention that is recognised as national priority in Gabon and in some churches since officials said that they have implemented intensive AIDS prevention programme and the unwillingness for the youth to undertake appropriate measures to address the HIV/AIDS crisis. This could be a matter of priorities setting. For instance a recent survey of 15-26 years-old carried out by UNICEF in Gabon, showed that unemployment was the main concern in life, with catching HIV in second place and poverty in third.

6.2.  Sex education in Gabon

Mobilising churches to tackle sex education is not easy since sexuality is a taboo subject in Gabon particularly when HIV/AIDS is perceived as a theoretical threat. The traditional source of sex education in sub-Saharan Africa is the paternal or maternal uncle/aunt. In general, sex matters are not discussed at interpersonal level. This cultural tradition is no longer a viable strategy because of the increasing rural-to-urban rapid urban migration in Gabon and the subsequent social change.

Following this line of thinking, sex education is not considered necessary and is even unwanted, because “theory may lead to practice”. Many church leaders have negative attitudes towards sexual education as they feel that sexual education is conducive to sexual promiscuity.

A priest from the Solidarity of Young Christians put it even more strongly when he says: “ In my view, contraceptives should not be distributed because they just encourage young people who have not yet had a sexual experience to try it. In addition, most of available contraceptives are often of poor quality in Gabon”.

Despite the many efforts, that churches and other interested organisations in the field of HIV/AIDS are deploying, in my opinion, HIV/AIDS is still perceived as a medical issue and church leaders are ill equipped to deal with. However, Catholics are to the fore of all the religious communities since during the mapping study, I attended a one day-workshop organised and facilitated by ACERAC in collaboration Mrs Lucette LALABACHE, Professor of Psychology at Sorbonne University. The workshop theme was “ Understanding Human Sexuality: a challenge for a truly behaviour change in the context of HIV/AIDS in Africa ”.

This was the first time that such a sensitive topic was discussed in a participatory manner in the Catholic setting especially within a nun's convent. 50 participants of whom 30 were young people attended this workshop. This shows the hunger of aCCurate information on sexuality that the youth needs more.

Another issue that emerged during the mapping is the unwillingness and the reluctance that many parents are expressing to discuss sexual issues and HIV/AIDS with their children. The perception is similar to that of church leaders stressing that sex education will violate religious teachings as well as cultural norms and principles. Instead, abstinence must remain the name of the game. This constitutes an enabling environment for the youth to be exposed to double standard messages coming from various sources namely: the media, advertisements, culture and religion.

Peer support organisations face even greater challenges. The lack of role models and the fear of negative consequences for themselves or their family, have contributed to the fact that very few people living with HIV/AIDS are willing to identify themselves in any forum, let alone in public. SIDA-ZERO/GROUPE DES PAROLES, the national peer support network for people infected with, or affected by AIDS, is in contact with only about 100 PLWHAs nation-wide. Those who meet share their experiences about HIV although they come from different social, education and professional backgrounds.

Ms Emilie (PLWHA) said: “ In my family, nobody knows my new serological status. Very often, my parents kept saying that I should pay attention to HIV/AIDS whilst I am already living with the virus. I am very pleased to be part of SIDA ZERO/GROUPE DES PAROLES. In the end of its meetings, I feel relaxed and edified as I share my concerns with people who are HIV+ as I am.”

Many others like her are crying for open discussions with parents on sex issues including HIV/AIDS. Thus, a culture of silence, denial, stigma and discrimination is no longer the answer. People have a right to know their HIV status, and testing and counselling should be widely aCCessible through innovative, ethical and practical models of delivery even in the home environment. Whatever the route of HIV transmission could be HIV, testing and counselling are entry points to HIV-related care and prevention services.

6.3.  HIV/AIDS and migrants

Gabon is one of the few stable countries in Central region. Therefore, it attracts many people who request asylum as refugees. There are now 20,000 refugees in Gabon. Most of them live in provinces such as Ogooué Ivindo, le Haut Ogooué, la Nyanga and la Ngounié. Refugees are very often moving to major urban areas by creating “spaces for urban poverty” where fornication, sex for many, homosexuality and paedophilia, and behaviour risks related to HIV and other STIs take place. Of course HIV/AIDS is a serious problem for refugees especially women and young girls who are vulnerable to HIV because of family breakdown, poverty, powerlessness, social instability, exploitation and sexual abuse. “ HIV/AIDS is a disease related to foreigners particularly refugees that come to Gabon to seek asylum ”, a Gabonese woman said.

Not only local people, but also politicians, media people, people working at immigration services hold such resentments. This could one reason among other explaining immigration is so complicated to enter Gabon. In a world of increasing hostility towards asylum seekers, there are too many misperceptions about refugees and HIV/AIDS. Studies across the world documented that HIV/AIDS rates are lower in refugee camps than in surrounding populations. In addition, a new study found that the perception related to spread of HIV by refugees into the country of asylum following the transmission of HIV to host population false and discriminatory (RUUD, 2003).

What is outstanding in the Gabonese Strategy Plan 2001-2005 is that the National HIV/AIDS strategies to combat HIV/AIDS among the refugees are included. Therefore, refugees should neither be blamed nor they should be ignored. Instead, they must be actors rather than spectators in the fight against HIV/AIDS if sustainable response to HIV/AIDS is to be reached in Central Africa region, which is beset with armed conflicts and civil wars.

The international community has the responsibility of adopting innovative and creative approaches to fighting HIV/AIDS epidemic across national and international boundaries. Recent armed conflicts and civil wars in Rwanda, Burundi, DR Congo, Congo/Brazzaville, Chad and Central Africa Republic are self-explanatory about refugees moving across borders in Central Africa region.

7.   Gender issues and HIV/AIDS

In the context of HIV/AIDS, many factors count for why vulnerability and risk differ for men and for women, and for men and women at different ages. There are three critical factors-all interconnected-that place gender issues at the core of HIV/AIDS in Gabon. Some are physiological, where women's risk of infection is higher than in men. Others are socio-cultural, reflecting different roles, norms, and expectations and duties. Finally, economic reasons that influenced over assets such as productive resources, employment and education entailed different in power relationship. The power relationship between men and women grounded in economic inequality and vulnerability are the major factors contributing to the spread of HIV/AIDS. The July 2000 Durban conference on AIDS identified power relations between men and women as fundamental to both sexuality and gender.

The unequal power balance in gender relation that favours men, translates into an unequal power balance in heterosexual interactions, in which…men have greater control than women over when, where, and how sex takes place. An understanding of individual sexual behaviour, male and female, thus necessitates an understanding of gender and sexuality as constructed by a complex interplay of social, cultural and economic forces that determined the distribution of power. Source: Geeta Rao Gupta

A major problem is the lack of information and insufficient analysis of the responses that failed to address social, economic, and power relations between women and men. In fact, strategies to prevent the spread of HIV have focused on the promotion of condom use, reduction of sexual partners, and treatment of STIs. Additionally, most HIV surveillance studies have been done among pregnant women and female sex workers, leading to a tendency to “feminise” the epidemic on women, although it could be that the epidemic is concentrated among men. The dynamics of HIV transmission in the context of men's vulnerability have received little attention. Consequently, prevention strategies have concentrated on women and school children, while prevention efforts among particularly vulnerable groups have not been taken to scale.

Unfortunately, I did not come across many women's organisations dealing gender issues and HIV/AIDS. Pont de la Vie , a new Non Governmental Organisation is addressing discrimination, inequalities, low education status, economic dependence on men in a timid way. In churches themselves, women are very often excluded from decision-making process. Since the Gabonese society is a male dominating society condoning the subordination of women, one could understand why desperate measures such as “prestigious prostitution”, sexual promiscuity and begging are still the strategies implemented particularly by women and young girls who have kids to feed.

Another issue that is worth to be mentioning here is the wide misconception that sex with virgin (girl child) will cleanse an infected man of HIV/AIDS. Some traditional healers and witchcrafts promote this strategy whose recommendations clash with those of scientific medicine. This misconception has to be addressed in a meaningful way since this could lead to increased incidence of rape among young girls. As far as HIV/AIDS is concerned in Gabon, one of the lessons to learn is the need to address openly the underlying cultural and behaviour factors that contribute to the spread of HIV particularly among women.

8.   Poverty, HIV/AIDS and Human rights

In Gabon, 75% of the general population live in urban areas where financial hardship, sexual promiscuity and poverty are conducive to the spread of HIV. As mentioned earlier, Gabon still relies on wood and oil, which lost its values because of international market uncertainty. The subsistence agriculture sector is underdeveloped and Gabon is provided with food by neighbouring countries namely Cameroon, etc. ACCording to a recent study carried out by the World Bank, 20% of Gabonese living in Libreville and Port-Gentil are falling below the line of poverty. Rural exodus increased since most of unproductive people reach main urban areas where unemployment is high.

Gabon is ranking among the intermediate income countries although it is heavily indebted. Due to its so-called “high income”, Gabon cannot benefit from assistance provided to other African poor countries. In response to this, the Gabonese government reacted to the spread of HIV/AIDS by setting up a billion XAF (USD 20 million) solidarity fund to help people living with HIV/AIDS and prevent the disease from spreading. However, this study did not look at the efficiency of this huge amount of money.

Another problem that I came across is that many people living with HIV/AIDS cannot afford treatment at local hospitals, some of which quite plain that AIDS patients are not welcome because of stigma and discrimination attached to HIV/AIDS.

“Dr Chantal Zamba is well known in this country as the medical doctor that deals with HIV/AIDS epidemic. Last week, she sent me to the laboratory for ordinary medical check up. The lab technician was not pleased to take my blood for examination because of Dr Chantal's signature. I wasted 3 hours without being tested since the lab technician knew that I was HIV positive”, a PLWHA said.

By contrast, the medical signature might have a positive effect in certain settings. Another PLWHA commented:

“I went to my insurance company with a letter written by Dr Chantal Zamba in which she asked my insurance company to provide me with financial resources for medical reasons. Since the cashier knew Dr Chantal's good job in the field of HIV/AIDS, he gave me the money without delay”.

Despite the existence of mixing results, time is come to mention that stigma and discrimination are still rampant from the political level down to the community in Gabon. Few people know their serostatus and the motivation is constrained both by the lack of subsequent availability of treatment and denial. In addition, the widespread ignorance of HIV status is the result of poor aCCess to HIV testing, or serious problems with its delivery and uptake.

In Gabon, the lost of opportunities for providing care and for strengthening prevention efforts are enormous because of legal aspects of HIV/AIDS that are not respected once somebody is found to be HIV+. The table below illustrates the motive of doing HIV testing.

Comments

1. Unless stigma and discrimination are progressively replaced by aCCeptance, care and support for people affected and infected by HIV/AIDS, the changing face of the HIV/AIDS epidemic that has resulted in many opportunities, as well as imperatives might not increase aCCess to HIV testing and counselling and to knowledge of HIV status.

2. Time has now come to implement HIV testing and counselling more widely using existing health-care settings, moving beyond the model of provision that relies entirely upon concerned individuals seeking out help for them to permit broader aCCess for all in respect to human rights.

3. Increased aCCess to care and treatment, and decreased stigma and discrimination in Gabon present new opportunities associated with taking an HIV test.

4. The right one has to know his/her own serostatus helps communities reduce the denial, stigma and discrimination surrounding HIV/AIDS as well as mobilise support for appropriate responses.

5. The information presented here relies on service statistics and on expert assessment and is therefore much less precise than estimated based on population-based surveys.

6. These results should be interpreted with caution but they are useful indicating the starting point in effort to achieve future goals.

9.   Resource Facilities

9.1.  Réseau National Pour la Santé de la Réproduction des Adolescents et des Jeunes (RENAPS A.J.)

is an institution dedicated to strengthening the capacities of organisations and youth working in the field of reproductive health, population and development in order to contribute to improving the quality of life of families in Gabon. To achieve its mission RENAPS A.J conducts workshops, seminars and refreshing courses for youth in order to help them acquire life skills because of the widespread of early sexual debut and subsequent sexual promiscuity. Highly qualified professionals, who form a multidisciplinary team within the fields of reproductive health and population and development, provide its service in three provinces in Gabon. RENAPS A.J is looking forward to scaling-up its programme to the remaining six provinces since RENAPS is opened to working with youth from different religious backgrounds.

9.2.  SIDA ZERO/GROUPE DES PAROLES

is forum where HIV infected and affected Gabonese and their care givers meet together to share experiences, ideas and updates on the responses to the HIV/AIDS epidemic. During the mapping study, I noticed how quickly trust levels developed in the group when a PLWHA who submitted to be member of the group came to justify why she could not attend the meetings so far. She said that she lacked money for transport in order to be part of the group every day. Additionally, she went on saying that she was worried because of her son who is HIV+ did not get medicine for opportunistic infections. The group care for the women by identifying somebody else who was living with her in the same area to look after her when this is needed. A quick fund raising between the members gathered some money that was given to her for satisfying her needs. Furthermore, the members raised concern about income generating activities. They bought a ground where crops and vegetables could be sown. While some members participated with financial contributions, others promised to offer the work force in terms of weeding the field.

9.3.  REGOSIDA

Following the theological reflection on HIV/AIDS and the theology of compassion and healing that were organised by the Ecumenical HIV/AIDS in Africa respectively in Yaoundé and Brazzaville. Upon their return at home, the workshop participants established the platform whose mission is to work ecumenically through church structures at grass root level by training pastors and volunteers to not only raise HIV/AIDS awareness, but also to provide care, training, and support, and follow-up.

9.4.  RESEAU GABONAIS DES PERSONNES VIVANT AVEC LE VIH/SIDA (REGAP).

Began in 2003, REGAP is meant to be the response to the widespread misperception that AIDS is contracted because of sin that has caused intense stigma and discrimination towards people living with HIV/AIDS and their families. REGAP has a large network of volunteers and peer educators who work in communities, clinics, youth centres, office and projects. REGAP is committed to the fact that it is only by confronting stigma and discrimination that the war against HIV/AIDS will be won. “ Responding to AIDS with blame, or abuse towards people living with AIDS, simply forces the epidemic underground, creating the ideal conditions for HIV to spread. The only way of making progress against the epidemic is to replace shame with solidarity, and fear with hope …” Peter Piot.

9.5.  Centre de Traitement Ambulatoire (C.T.A)

CTA is among the few organisations that provide aCCess to voluntary counselling and testing in Gabon by offering free confidential testing services through local health facilities. Additionally, CTA is providing treatment for opportunistic infections, including tuberculosis, antiretroviral therapy and palliative care and psychosocial support. The professional counselling offered at CTA so far helps one make informed choice on whether or not to take an HIV test. CTA helps and encourages one to know his/her HIV status and live positively with whatever the result.

Care and understand by ensuring proper and prompt medical attention in sickness proved to be of great value. I met a PLWHA in C.T.A who told me that if she had a job she would not care about the HIV/AIDS infection. What is harmful for her is unemployment and not the HIV/AIDS since her child who is also HIV+ is not provided with proper medical care.

Conclusion

My first conclusion is that churches like society as whole are being devastated by HIV/AIDS and the church responses is a brave effort to raise the congregation awareness in order to involve them in the control of HIV/AIDS. However, in Gabon, the Christian response is currently inadequately arranged for effective church responses towards HIV/AIDS since most of them are weak and scattered. Christians end up with inaCCurate data and only half of the message because of misconceptions and theological barriers that need to be overcome by Christians in the struggle against HIV/AIDS. Since HIV/AIDS is a major problem not only for churches but also has damaged economic aspects for Gabon, it is important that the necessary, updated and aCCurate information is given.

Next, apart from the Catholic and the Revival Churches, silence is the motto in many Gabonese church settings. Many church leaders remain detached, silent and inactive not only to combat HIV/AIDS but also in advocacy and policy development. In my opinion, I think that church leaders should play a crucial role in the HIV/AIDS control if in-service training programme about the disease is provided and if they fully understand that addressing the HIV/AIDS issues is a key part of their Pastoral ministry.

Moreover, some churches have the willingness to fight against HIV/AIDS aCCordingly, but they have limited resources. Since Gabon is ranking among the intermediate income countries, major donors have not found ways of reaching small, community level groups with funding to scale up the church efforts to combat HIV/AIDS. Consequently, most funds are driven to the government's institutions with no or little implication of church structures. There is no doubt that churches are well positioned to mobilise people and implement programmes, especially at the local level. Therefore, coverage for services related to prevention, care, treatment and support would need to increase significantly through churches in the next few years if the goals of the Declaration of Commitment on HIV/AIDS and the millennium development goals are to be met.

The data available from this mapping clearly indicate that, although progress has been made in some areas, such as blood screening, much work remains to bring essential services to a significant portion of the population in need. The perception that AIDS is contracted because of sin has caused intense stigma and discrimination towards people living with HIV/AIDS and their families. Stigma and discrimination has enabled HIV to spread unchecked over the last twenty years in Gabon. Time is come to stress the theology of compassion in church settings because stigma and discrimination associated to HIV/AIDS is one of the greatest barriers to preventing further infections and to aCCessing the care, support and treatment that allow people living with HIV/AIDS to lead productive lives. Christians are called by God to show compassion, love, and mercy and to serve others without judgement. Therefore, there is an unprecedented urgency for compassionate care of those infected and affected by HIV/AIDS including any other dangerous infectious disease.

In Gabon, talking about sexuality is a taboo. Since HIV/AIDS is inextricably intertwined with human sexuality, the church is often reluctant to talk forthrightly about sexual behaviour activities that encourage alternative prevention measures such as abstinence and fidelity, which have received scant attention in most HIV/AIDS strategies. The church should be the forum where every one enjoys sexual and reproductive health rights and aCCess to services in a society free of sexual violence and HIV/AIDS. During the mapping, REGOSIDA organised a workshop entitled: “understanding the human sexuality”. This workshop proved to be of great value taking into aCCount the lively and constructive discussion that followed. This is an indication to me that sexuality could be discussed in church settings and the church could provide a welcoming community to those who are willing to break the silence surrounding sexual issues. Churches must become involved in affective and sexual education for life in order to help young people and couples discover the wonder of their sexuality and their reproductive capacities. Out of such wonder and respect flow a responsible sexuality and method of managing fertility in mutual respect between men and women.

The result of this mapping study suggests that most people in Gabon do not have aCCess to several key prevention and care services. In addition, aCCess is very low for voluntary counselling and testing, the prevention of mother-to-child, antiretroviral therapy and prophylaxis for opportunistic infections. The services are available are usually located in capital cities and other urban areas and not in rural areas. Churches that I met in Gabon had national coverage since they reached from the educated elite to the urban slums to the village. It is well known that Churches often provide high quality services than government or secular institutions, with political constraints and more highly motivated personnel. This set of compared advantages of churches necessitates churches to play a crucial role in combating HIV/AIDS if the results have to be sustainable in Gabon and elsewhere.

SuCCessful HIV/AIDS programmes in sub-Saharan Africa have involved local communities in the design, preparation and implementation of activities. However, most communities particularly churches lack the resources to mount programme of adequate scope and the Central Government in Gabon lacks the means to deliver resources quickly and sustainably to the community. Towards this end, African leaders and the International Community at large have recognised the need for quick, forceful and sustain action against the epidemic. Guided by these principles, Global Funds and the Multi-Country HIV/AIDS Programme (MAP) are established to channel funds directly to the communities. The Revival Church Pastor who is the vice-president of Global Fund could be influential to help churches benefit from those funds.

Finally, one has to realise that poverty goes hand in hand with HIV and AIDS since the fragile economies should be further weakened with much of the trained labour force lost to HIV/AIDS. Poverty facilitates the transmission of HIV/AIDS, makes adequate treatment unaffordable, aCCelerates death from HIV-related illness and multiplies the social impact of the epidemic. In the light of these issues, Christians are called to “let all the parts of the one body feel the same concern for one another”. The battle against AIDS ought to be everyone's battle. Therefore, I urgently ask church leaders and other interested people of good will in the field of HIV/AIDS moved by love and respect due to every human being, to make use of every means and opportunities at their disposal in order to bring gradual improvement by slowing down the epidemic for God's glory. “Never give in then, brothers and sisters, never admit defeat, keep on working at the Lord's work always, knowing that, in the Lord, you cannot be labouring in vain” (1 Corinthians 15: 58)

Recommendations

Based on the findings the following issues have implications in the design of appropriate church response on HIV/AIDS:-

Policy

· The HIV/AIDS issues must be raised as a high priority on the church agenda, ensuring that it is streamlined, coordinated and included in all church endeavours;

· Churches should focus on breaking barriers to effective HIV/AIDS prevention, care and support. It is only by confronting stigma and discrimination that the war against HIV/AIDS will be won;

· Churches have to rise above theological differences to collaborate in addressing the suffering caused by HIV/AIDS;

· Churches should make use of being represented at the Country Coordination Mechanism to advocate boldly in national settings for policies favouring the poor and marginalised and for increased resources for the struggle against AIDS;

· Churches should pay for God's blessing on those infected and affected by HIV/AIDS and show compassion, love, and mercy to serve others without judgement.

Congregations

· Church leaders should help their congregations break the silence and eliminate the stigma and discrimination surrounding HIV/AIDS and provide a welcoming community to those infected and affected;

· Church leaders could undertake special programmes that can mitigate the impact of HIV/AIDS by addressing some of the most severe problems such as reduced school fees can help children from poor families and AIDS orphans to stay longer at school;

· Church leaders should empower men, women and youth to rise above the predominant, often destructive, sexual practices including female genital mutilation;

· Congregations should support and care for people and families who are living with HIV/AIDS and doing this as an integral part of “the competent AIDS church” at the congregational level

· Church leaders should also help design refugees and migrant populations as a target group for HIV/AIDS interventions

Communities

· Communities are well positioned to mobilise people and implement HIV/AIDS programme, especially at the grass root level with an unprecedented urgency for compassionate care of those infected and affected by HIV/AIDS;

· Church leaders must teach communities to consider women and youth, two vulnerable groups, that are often not aCCepted as equal members of the faith community to play a leading in the fight against HIV/AIDS;

· Communities need precise information, up-to-date and complete factual information as part of the church preventive work, both as regards the causes of the epidemic and its dimensions and consequences, and as regard on how HIV/AIDS is linked to other issues;

· Church leaders should teach communities on unpleasant and unfounded beliefs and myths such as some men believe sex with a virgin and young girls can cleanse them of HIV/AIDS;

Counselling

· AIDS is not a sin; pastors cannot stop discordant couples from being married. Instead, church leaders should establish voluntary counselling and testing facilities where couple should make informed decision on their marriage;

· Church leaders should encourage members of their congregations and communities, especially those intending to marry, to get to know their HIV status through voluntary counselling and testing and develop positive attitude;

· Church leaders should ensure that all church members involved in the HIV/AIDS work observe both in public and private life the following values: confidentiality, respect, integrity, stewardship, faithfulness and diligence, etc.;

· Churches should promote primary and secondary sexual, abstinence, and faithfulness in marriage and avoid condemning the use of condoms;

Advocacy

· Church leaders should advocate for open, constructive and frank discussion on sexuality and HIV/AIDS;

· Church leaders advocate for gender considerations regarding aCCess to resources, education, health care, other essential services, decision-making in communities and sexual practices;

· Church leaders should advocate for aCCessible and affordable antiretroviral and opportunistic infection drugs;

· Church leaders should advocate for the support of marginalised and disadvantaged people such as orphan and vulnerable children, etc.

· Church leaders should advocate for dignity and human rights for people living with HIV/AIDS and their families;

Networking

· Churches should collaborate with National AIDS Council, National AIDS Control Programme, other government departments, parastatals, other churches, NGOs, Community Based Organisations, AIDS service organisations, religious institutions and groups, national and international partners.

· REGOSIDA should be revitalised since it constitutes an appropriate channel and forum for advocacy and lobby.

· Church leaders could reduce to some extent the impact of AIDS on household level by submitting to the government project proposals that could address the most severe problems. Such programmes could include home-based care for people with HIV/AIDS, support for the basic needs of households copying with AIDS, foster care for orphans, food programmes for children and support for educational expenses etc.