The Ivory Coast

1.  General and Epidemiological Data

1.1.    General Data

Bounded to the North by Burkina-Faso and Mali, to the North West by Guinea, to the South West by Ghana and to the South by the Atlantic Ocean, the Ivory Coast covers a total area of 322,460 km² of which 167.000 km² are for agricultural purposes. Its economic capital is Abidjan. The total population was estimated at 14,526,000 in 1999 of which 53% are rural dwellers. The population expansion rate is very high on aCCount of the immigration of the population along the borders with a rate of 3.01% between 1988 an 1999.

The country's resources come mainly from coffee and cocoa production. For long years and up to the death of its first President Mr. Felix Houphouet Boigny in 1993, the Ivory Coast experienced some political, economic and social stability. However, since the devaluation of the CFA franc and the imposition of the Structural Adjustment Programme, things changed. More than once, foreigners were harassed and the traditional values of hospitality, solidarity and mutual assistance were sometimes put under severe strain.

The Ivorian population is made up of over 60 ethnic groups which are composed of many beliefs, traditions and customs. In addition to this ethnic plurality, there are religious choices: originally animist, the Ivory Coast today has a very a high proportion of Muslims and Christians.

Even though the Ivory Coast's socio-sanitary situation is relatively better than that of other neighbouring countries, the indicators are far from good. Thus, the literacy rate which was 75% in 1975 fell to 57% in 1994. The education rate was 72% in 1992 for boys and 60% for girls. Life expectancy was 56 years in 1996, infant mortality rate was 1150/00 in 1996, currently it is 960/00. The number of doctors per inhabitant is one for 9,000.

1.2.    Epidemiological Data

The Ivory Coast had 31,963 AIDS cases declared in December 1995 as against 26,646 in May 1994, 466 cases in 1987 as against only 2 in 1985. From 1989 to 1993, there had never been less than 3,000 new cases per annum. The epidemiological data gathered showed that HIV seroprevalence among pregnant women increased from 3.6% in 1989 to 8% in 1993 in the rural areas, from 10% in 1989 to 12% in 1992 and 14% in 1995 in the urban areas. In 1993, there was an estimated number of 640,000 HIV positives, 34,000 adult AIDS cases, 7,000 paediatric AIDS cases and 78,000 orphans.

As from 1990 AIDS has become the economic capital in Abidjan, the leading cause of death among people, followed by malaria and any other disease. Among the women, it was the second cause of death after pregnancy and child-birth related complications.

The national study conducted in February 1989 quoted by SORO showed that on the average, 7.4% of the adult population were infected in the urban area as against 5% in the rural area. In 1994-1995, an average of 13% pregnant women consulted in the various regions of the country were HIV carriers peaking at 18% in the East of the country.

This shows the urgency for the strengthening of the AIDS control strategies in order to try to check the alarming spread of the epidemics. The following table shows the data of UNAIDS estimates in June 2000:

The most vulnerable population groups

Four social categories emerge as being the most affected and most vulnerable: these include youth, women, prostitutes and migrants.

Youth aged between 10 to 25 years are the most sexually active. These include school children, students of both sexes, young school drop outs and AIDS orphans. It is this important segment of the national population which pays the highest price for HIV/AIDS. In terms of morbidity and mortality, 85% of AIDS victims are between 20 and 49 years.

Women are more dependent because they are less educated and removed from the communication, decision-making centres and lucrative sectors of activity, the women are subjected to the laws of men and society. The overall prevalence of the HIV infection among pregnant women of Abidjan varies between 14,98% and 16 to 17% (1996 – 1997).

Until recently prostitutes were the most outstanding risk category. This characteristic has certainly not disappeared however, a significant drop has been noted in HIV/AIDS prevalence, where prostitutes operate as a result of effective initiatives.

Since the Ivory Coast is a land which plays host to people of various nationalities for geographical, historic and economic reasons, migrant groups represent a large risk category. These include seasonal workers, long distance truck drivers and refugees.

2.  National HIV/AIDS Infection Control Policy

Just as in the other countries, the government established a national programme to deal with the situation; the Ivory Coast has the peculiarity of combining the struggle against HIV/AIDS/STI with the fight against tuberculosis. Only the HIV/AIDS/STI component was covered by this study.

2.1.    Strategy Thrusts of the HIV/AIDS Infection Control Policy

• Preventing the sexual transmission of HIV and the STI by diagnosing and treating effectively all the STIs including STI infection among women; by reaching all the organs through the appropriate channels, by undertaking the promotion of the use of condom
• Preventing HIV/STI infection through blood transfusion practices should make it possible to reduce the cost of safe blood and ensure its availability at all the levels where it is necessary
• Preventing the perinatal transmission of HIV/AIDS and STIs; development of specific directives, care of STIs among women, psychological supervision of HIV positive women and their partners should ensure the reduction in paediatric AIDS cases
• Ensuring the clinical, therapeutic and psychological care of the PLWAs. It should be pointed out that therapeutic guides (adults and children) already exist for the Ivory Coast. What remains to be done is to train the users, provide them with the tools and drugs while strengthening the existing structures to guarantee the mitigation of the impact on the patients

Political aspects for the fight against HIV/AIDS

The viability of the strategies and the interventions for the prevention of the transmission of HIV, STIs and for the mitigation of their impact requires a clearly defined political and legal framework as stipulated in the final recommendations of the September 1993 national consensus workshop.

A number of cultural and ethical aspects relating to the HIV infection and the rights of the man, woman and child must be subject to political commitments legal provisions and related directives. These include, inter alia:

· The content of the mulitisectoral approach

· The promotion and distribution of condoms

· Ethical problems concerning research on HIV

· Promotion of voluntary screening and information of the sexual partners (discordant couples, prenuptial tests, prevention of prenatal transmission);

· Legal protection of HIV positives and AIDS patients, orphans, women, prostitutes and minors;

· Health insurance and coverage for the treatment of opportunistic infections and STIs (procurement of essential drugs)

· Regulation of prostitution;

· Organisation of assistance to the orphans and separated or single HIV positive mothers;

· Different modalities for the care of the HIV positive woman.

2.2. Stakeholders Involved in AIDS Control

Several stakeholders were involved in the combat against HIV/AIDS infection in collaboration with the NACP/STI.

The NGOs and associations

Since the beginning of the programme, the partnership with the NGOs, grassroots communities and associations was expressly sought in the implementation of some components of the programme, such as social care and awareness-raising. They are numerous and their sectors and locations are very diversified.

The Family Planning Department

In view of the very limited resources for the prevention and the coherence of interventions, it appeared pertinent to integrate actions of STI and HIV/AIDS control with those of the family planning department. The National Family Planning Department has therefore embarked on the performance of this task.

Public or denominational health facilities

They intervene through awareness-raising among the populations for a positive change in attitude by supporting the PLWAs through visits to homes, food aid and oCCasional assistance. They collaborate with a number of NGOs or associations with a view to the orientation of the sick orphans or the provisions of benevolent manpower and also for the mobilisation of funds for the needy.

Cooperation agencies

These agencies are many and intervene in the various disease control programmes through financial support, technical expertise, donation of drugs and the promotion of condoms. The agencies concerned include the French Co-operation, UNDP, UNAIDS, UNESCO, UNICEF, WHO, ECS - Ensembles contre le Sida (Together Against AIDS) Christians and AIDS, MAP (Medical Assistance Program) PSI, the Red Cross, USAID and UNFPA...

Finally, it is necessary to highlight the intervention of traditional healers, the civil society and the private sector.

3.  Position and Involvement of Churches

In the view of the churches visited, the AIDS epidemics, is a major problem, a social and pastoral challenge of extreme gravity for the country which has a relatively high prevalence rate as compared to those of neighbouring countries. The country is a crossroad which attracts migrants for economic reasons but also a place sought for international meetings particularly on AIDS.

3.1.    Perception of the Churches

The Protestant Methodist Church (EPMCI - Eglise Protestante Méthodiste)

For the EPMCI, the Bible shows that some catastrophe situations are the consequence of the sin of humanity. Sin and AIDS seems to be one of these catastrophes. One should avoid making the patients feel guilty and easily and necessarily linking AIDS to sin. “We should acknowledge that we have risk attitudes either in the field of sexuality or that of blood transfusion or still that of drug use”.

The Catholic Church

In the view of the co-ordinator of the National AIDS Control Committee of the Catholic Church Mr Louis Auguste BOA II, AIDS is a social disease related to multiple factors such as poverty, sexual deviancy, cultural practices (levirate), prostitution, migration etc...

The Protestant Baptist Church

ACCording to the viewpoint of Reverend pastor Dion on the aetiology of AIDS, each person can be infected by a virus which can kill him at any time. Furthermore, no person is without sin before God, we are all guilty. AIDS is only the consequence of bad attitude from an erroneous utilisation of sexuality against the plan of God. Likewise, a person's guilt is always at the root of contamination either by non respect of the rules of hygiene, or through professional negligence...

Union of Evangelical Churches Services and Works - the Ivory Coast (UEESO-CI - Union des Eglises Evangéliques Services et Oeuvres - Côte d'Ivoire)

From the theological viewpoint, AIDS appears to the UEESO-CI as a disobedience by man of the divine laws, the utilisation of sexuality against the norms fixed by God. In order to check the rising propagation of AIDS in the country, Church leaders must mobilise against false rumours on the causes, cultural practices such as levirate in some ethnic groups, and prostitution.

The Evangelical Presbyterian Church of the Ivory Coast

Recently located in the Ivory Coast, this Church has few faithful. Even though it did not start any action in the field of the struggle against AIDS, Church leaders aCCepted to speak of their perception of the epidemics.

From their viewpoint, if AIDS is a disease caused by a virus and whose dramatic propagation is due to reckless sexuality, which is itself encouraged by difficult situations, massive displacement of the populations during armed conflicts, refugees and enticement of young people by adults to indulge in sex will take place. Thus, in the fight against AIDS, the Church should not only guide the faithful but also rise up against these situations.

3.2.    Prevention Adopted by the Churches

The Protestant Methodist Church

In the field of prevention, the Church has a large responsibility in the promotion of new attitudes through information, teaching, an effort of spiritual renewal of the faithful and a profound analysis of religious barriers which impede prevention. The formalists and intransigent persons stick to fidelity and abstinence as means of prevention. However the “religious officials”and “doctors of law”of our time should rethink their approach and their understanding of the HIV/AIDS infection. Jesus asked us to obey the law of love of our neighbour to the detriment of religious legalism. The Church tolerates the use of condoms in the case of a spouse or infected couple.

The Catholic Church of the Ivory Coast

In 1997, a three-year development plan (1998-2000) was designed with the financial support of the Catholic Relief Services of France. Currently eight projects have been presented by the dioceses and grassroots communities with a view to the prevention of HIV/AIDS infection and the care of PLWAs. The strategy of the Church is based on:

· Awareness-raising which targets the diocesan leaders (bishops, priests, religious officials) leaders of associations, diocesan directors of education

· The training concerned all the diocesan leaders by the motivators' and supporters' training sessions and in the whole diocese of the Ivory Coast

The AIDS prevention message is based on abstinence and chastity, mutual faithfulness by the couples and hygiene (avoid objects soiled by contaminated blood).

The use of the condom is authorised only in the event of the contamination of a spouse on condition that it is of good quality, well preserved and that the user knows how to use it.

The Baptist Church

The focus is on abstinence and fidelity as means of prevention. The HIV serology test demanded for the pastoral corps is optional for all the faithful. Neither is the use of the condom an official position of the Baptist Church of the Ivory Coast.

Union of Evangelical Services and Works of the Ivory Coast (UEESO)

With regard to the struggle against AIDS, the UEESO established a committee in 1985. Initially, the purpose of the committee was to pray with PLWAs in the hospitals. Currently, the committee undertakes awareness-raising activities among the faithful through lectures to lift the veil of ignorance and misinformation on the causes, sign of the disease as well as prevention measures. Education in family life must insist on abstinence before marriage and fidelity. The use of the condom is recommended only for the spacing of births by the couple. The Church also solicits the financial contribution from the couples in order to meet the needs of the PLWAs whose identity is kept secret.

3.3.    Position of the Churches in the Light of Serology Test

No Church – outside the Protestant Baptist which subjects the members of the pastoral corps to it – demands this test. It is estimated that this would generate panic among the faithful. The initiative is left to the discretion of each.

3.4.    Care for the AIDS Infected and Orphans

If prevention is the focus of the actions of all the Churches, care of the patients and orphans is still at its beginnings. It is mentioned in the three-year or five-year plans by a number of churches, however no concrete action has as yet been taken for lack of expertise or lack of resources in the light of the scope of the problem. The Protestant Methodist Church, has made two recommendations in favour of the sick and orphans in an excellent document as follows:

• “That the Church should embark on the procedure for the retrocession of the Dabou day nursery with a view to making it a home for abandoned children and mainly AIDS orphans.
• That the welfare and counselling centre (CAC - Centre d'ACCueil et de Conseils) at the Dabou Protestant hospital (HPP - l'Hôpital Protestant de Dabou) should be enlarged and equipped to receive AIDS patients”.

With regard to the Protestant Baptist Churches, the basic unity of the Church is the “unit”whose members are known and each of whom is paid a systematic weekly visit regardless of his health status. It is during these visits that the needs of each faithful are identified and evaluated. The reports of these visits, checked and signed by pastors responsible for the unit are submitted to the President of the Church...

4.  Poverty and Human Rights

The situations of poverty and non respect for human rights, which are already a cause for concern, are alarming with regard to HIV/AIDS infection. The Churches last resort for these problems have neither the power nor the adequate resources to rise to this challenge. As with the care of patients and orphans, we noted a lot of good intentions but few concrete achievements. The rare actions taken by the Churches are carried out in collaboration with the associations, NGOs or State Social Welfare Services.

Otherwise, the Churches try to maintain or strengthen their traditional service delivery in education, health, agriculture... establishing vaguely a direct link between AIDS and poverty. On the other hand, no link has been established between AIDS and human rights.

5.  Involvement of the Muslim Community

The Muslim community has not remained in the margin of the struggle against AIDS of the religious denominations of the Ivory Coast. This is what has emerged from the training project which was submitted to us by the Imam of Plateau in Abidjan. “the Imams animate the spiritual life of Muslims, they therefore have the time to speak extensively during baptism, funeral, marriage and social conflict resolution ceremonies but also especially on Fridays during prayers. From these different communications, they are capable of informing and enlightening their audience on the AIDS phenomenon and its socio-economic complications. This information activity cannot be carried without training. This training will target 420 imams, preachers and leaders of Muslim associations to be chosen in the ten provinces of the country.

Indeed, many religious leaders still chronically lack clear information on the AIDS epidemics. Thus, the goal pursued by this training project is to improve the knowledge of the Imams on the seriousness of the epidemics, its symptoms and to prepare them for community care and prevention initiatives.

6.  Involvement of Ecumenical Movements and Denominational Health Facilities

6.1.    AIDS Project with the Churches in Partnership with MAP ( Medical Assistance Programme)

Medical Assistance Programme (MAP) International is a Christian NGO established with the “Christian Medical Society”now known as “Christian Medical and Dental Society”. MAP International aims mainly at the promotion of health within the Churches and specifically the prevention and eradication of the disease through mobilisation and community awareness-raising actions.

The fight against the HIV/AIDS infection in the churches in Africa has become one of the priorities of the programmes of the Abidjan office of MAP which covers the entire West Africa sub-region.

The purpose of this project “AIDS with the Churches”is to mobilise and equip the Churches with a view to their effective involvement in HIV/AIDS prevention and the care of PLWAs. This programme is based on the observation that Church leaders are not sufficiently informed on the seriousness of the disease, its mode of contamination, moral and spiritual consequences. They are poorly prepared for the care of the infected and affected persons.

The organisation proposes to the Churches in the event of HIV/AIDS infection, several areas of co-ordination such as:

• the regional co-ordination of HIV/AIDS control plans of the Churches
• Support to the various programmes
• Exchange of expertise, sharing of experiences between the Churches
• Promotion of knowledge and ecumenical care of the problem of HIV/AIDS infection
• The setting up of ecumenical regional reference groups on HIV/AIDS infection
• The dissemination of information through the edition of the French review 'Contact'

At the local level, the activities of the programme concern the establishment of awareness-raising committees and the organisation of conferences in the churches, discussions within the organised groups of churches (youth, choristers, brass bands...). During these meetings, the discussions concern the mode of transmission of the HIV infection, the propagation factors, the family and AIDS, cultural practices and AIDS and the means of prevention.

Furthermore, seminars for Church leaders of French-speaking churches were also organised by MAP international which ranks among the best resource centres in the sub-region in the field of HIV. By the production of teaching aids, the training of leaders and the promotion of network operations, MAP encourages Churches and Christians to take an active part in controlling the epidemics. For MAP international, the churches are grassroots communities which can induce a true transformation in attitudes.

6.2.    Hope Worldwide

Hope World-wide, established in 1991, is an international organisation based on faith in Christ. Its aim is to combat the HIV/AIDS infection in the Ivory Coast. Its headquarters has a clinic for day hospitalisation, a pharmacy, a counselling hall, a meeting and documentation room. Hope World-wide which has specialised in traditional AIDS prevention service delivery has now reached the stage of community mobilisation and care of PLWAs and research. It uses a permanent staff of 12 persons of various expertise such as doctor, psychologist, nurse and social welfare assistant. All Church denominations taken together are special partners. They enable it to mobilise funds and also have aCCess to the benevolent actions of the faithful.

This agency currently manages 3,000 PLWAs and 150 orphans. It receives an average of 20 to 30 persons a month whose average age is between 20-35 years and who are sent by churches, hospitals, screening centres, with which Hope World-wide collaborates and also by families or associations such as Club des Amis, MAP International and GAPS - Groupe d'Auto-assistance des personnes vivant avec le VIH et la Promotion Sociale (self-assistance group of persons living with the HIV and social welfare promotion).

6.3.    Dabou Protestant Church

The Dabou Protestant Church is a private non-profit making denominational health facility involved in a public service. The welfare and counselling centres intervene in the field of AIDS particularly the psychosocial and medical care of patients, the organisation of the patients' day and awareness-raising among the population.

Statistical data of the activities of the welfare and AIDS counselling centre of the DABOU Protestant Hospital are as follows.

Within the framework of the struggle against AIDS and STI, the hospital which is currently facing difficulties wishes to strengthen the welfare centre and counselling units and the mobile agency by providing them with adequate technical resources in order to put its extensive experience in preventive health at the disposal of the populations. It intends therefore to serve as reference centre for the other health facilities in the region for a more effective fight against AIDS and an effective care of patients.

6.4.    Resource Structures

Lumière Action (Action Light)

Lumière Action is a PLWA organisation established in 1994

Its objectives are as follows :

• improving the living conditions of members ;
• providing psycho-social support to infected and affected persons;
• providing information on HIV/AIDS and its prevention;
• defending the rights of infected persons;
• promoting aCCess to health care and the treatment of members.

The number of persons managed reached 174 including 161 infected persons, 108 women and 66 men. These are persons of 18 to 60 years, the majority is between 25 and 45 years.

With regard to activities, Lumière Action has today diversified its activities. Among the activities, we noted mainly:

· Psycho-social care: this is a psychosocial and counselling support prepared by UNAIDS in 8 aCCredited centres located in a number of hospitals in the city of Abidjan.

· The AIDS orphans project: it was initiated by Lumière Action to provide educational, medical and nutritional support to orphans who had either lost a father or mother and aged between 5 to 18 years. This project is financed by UNAIDS and UNICEF. It affects a total of 411 children: Abidjan 164, Bouake 125 and Korhogo 122.

· The pharmacy community with the financial support of UNAIDS

· The student project: awareness-raising in the university campus financed by AIDS2 of the Canadian co-operation

· The Saint Valentine project: awareness-raising in public places on Saint Valentine's day (14 February of each year) financed by PSI

· The Flotilla project: awareness-raising in the schools and colleges, financed by UNESCO.

· Thematic workshops. It should enable the PLWAs to live positively with the HIV infection and any other person to have the necessary information on AIDS.

7.  Networks and their Involvement in HIV/AIDS Control

In addition to their co-operation with MAP International and Hope World-wide, the Churches in the Ivory Coast operate individually and they lack the structures which will enable them to operate as a network. Conditions should therefore be created to attain this objective.

Meanwhile, Abidjan hosts the West African Office of the African PLWA Network (PAN) which is also present in the four regions. PAN pursues the following objectives:

· assisting in the establishment of PLWA self-assistance Groups

· strengthening the existing associations and co-ordinating their activities

· promoting an effective medical, legal care of PLWAs.

8.  Conclusion

The Ivory Coast is currently the most affected country in the West African sub-region and no initiative is too big to curb the menace. All efforts should be made so that the Churches and religious communities which have the extensive bare and the highest credibility harness their forces with a view to strengthening their commitment and improving their service delivery in the field of AIDS control.