Ten years of armed conflict and perpetual insecurity have driven HIV prevalence in Côte d'Ivoire higher -- especially among women in the western zone on the Liberian border. Many of these women were infected as a result of sexual violence perpetuated by one or another of the marauding armed groups that terrorized the region for over a decade; others were infected after turning to prostitution to escape extreme poverty.
Lost to follow-up, lost from sight
In the crisis that followed the 2010 elections, more than 100,000 people fleeing fighting in the west escaped across the border into Liberia, itself only barely emerged from 14 years of civil war. More than half of them remain, according to the UN High Commissioner for Refugees, making periodic trips back into Côte d'Ivoire but too anxious to return permanently.
"So we give [anti-retrovirals] to women for a month, and then they go back to Liberia for two or three months and we lose them and they stop taking the drugs," said Dr Jonas Akafou, who runs the public clinic in Djouroutou: a tiny and isolated village that is right on the border.
Other women who contract the virus feel too much shame and stigma to seek treatment, because their secrets would be revealed: they engage in occasional transactional sex in order to pay for life's necessities and keep them from complete destitution, said Paulin Gbahi, a nurse at the health clinic in Tai, another border town.
"This population movement really makes it easy to spread HIV; young girls are in Liberia, then in Côte d'Ivoire, then back in Liberia. In the village it's not that there is a lot of prostitution per se, but it's often that, say, if a woman rents a room in her house, she will also make it known that she is available," said Gbahi.
The problem stems from a massive lack of awareness and an ignorance of testing and diagnosis. Dramane Cissé, who works at the testing center in the public hospital in Duékoué, one of the main western Ivorian cities and one of the hardest hit by the civil war, says that only about 18% of Ivorians know their status.
The rest, especially in his area, have had little exposure to messaging about the importance of safer sex, about reducing the risk of transmission and about getting tested -- especially the young former fighters, many of whom were initiated into their armed groups with forced sexual interactions with local women.
"Prevalence rates in Duékoué are already above the national levels (5.25% compared to the national rate of 3.7%) and that's only among those who were tested [before the district-level survey was conducted in 2013]," said Cissé. "And of course that was recorded only among people who were tested, so the real infection rate is much, much higher".
Stigma, fear and ignorance: a ruinous combination
Fatoumata (not her real name) is in a relationship with a former fighter. She was tested and diagnosed as HIV positive at the Duékoué hospital, where she enrolled in a treatment program.
"I am faithful to him, because I am infected and I don't want to transmit the virus," she told Aidspan. "In the beginning, I hid it from him but now he knows, and we use condoms that the hospital gave us. But I don't think he is faithful to me."
Fatoumata is one of the lucky ones, mostly because she presented herself for treatment. Others, worried about being judged, worried about cost, or distance, or any number of other concerns, or just unaware of the implications of a positive diagnosis, go without.
Interventions coming too little, too late
Since 2012, the Global Fund has supported programs that are trying to stem the tide of the epidemic, focusing their efforts on the commercial sex workers who ply their trade in the border zone. Côte d'Ivoire joins Ghana, Benin, Togo and Nigeria in the regional Organization of the Corridor Abidjan-Lagos (OCAL) grant for targeted prevention interventions for mobile populations crossing borders, but that does not specifically address the issues in the west.
Data collection on key populations is also being supported by the Global Fund, including bio-behavioral surveys on commercial sex workers and men who have sex with men.
"A study [conducted in 2011] showed that the epidemic is mostly concentrated in the country's west, where there is a lot of population movement, so that's where the Global Fund is supporting programs ," said Venance Kouakou, director of the Ivorian country office for Heartland Alliance International, a sub-recipient of a Global Fund grant administered by the International HIV/AIDS Alliance country program.
Since September 2012, some $475,000 has been spent on outreach programs about prevention and effective condom use; an additional $1.4 million will be programmed through the end of 2016.
Flavienne Ouelle, who runs the outreach programs for Heartland Alliance said that night clinics have also been opened in 13 district and 15 localities around the west. Each clinic is open twice a month, providing voluntary testing and counselling to the sex workers who operate in the area. The clinics, though staffed by doctors and nurses, do not dispense ARVs.
They do, however, a greater degree of confidentiality and discretion than the typical public dispensary, noted Dr Camille Anoma, director of the local NGO Espace Confiance (Safe Space): another Global Fund sub-recipient, which does similar work along the eastern border with Ghana.
"It's a much better strategy because it offers more accessible services, rather than waiting until beneficiaries go for treatment at the health centers," Dr Anoma said. "Before, the strategy was to refer men who have sex with men and sex workers to the public facilities, but I have always been wary that this method is not the most efficient, because how can you track whether they have been seen [by health professionals]. And it does not even begin to address the prejudice and stigma that are so strong against sex work and homosexuality, even among health professionals."
In Abidjan, the economic capital, another way to encourage people to adhere to HIV treatment is being piloted. HIV-positive women are now being provided with a condensed medical file so that they can carry it with them wherever they go, and maintain their treatment regimen irrespective of where they go to be seen. Further financial support for the program, the piloting of which was concluded in June, is being requested as part of the $112.9 million being allocated to Côte d'Ivoire for HIV under the new funding model (NFM).