Taking It to the Streets: Bringing HIV Prevention and Treatment to the Vulnerable Communities in Côte d'Ivoire

SAN PEDRO, Côte d’Ivoire – She ran away from her home in Nigeria after her husband died in an accident. And she refused to marry his younger brother as is the custom in her region.

With no means to support her two boys and two girls, or pay for their school fees, she turned to sex work to ensure her family’s survival. She earns as little as $2 per client and sends the money to her sister in the capital Abidjan, where her children live.

“I’m here, because I have four children,” explains the 48-year-old sex worker, who asked that her name not be used. “I lost my husband. I got into debt, and I couldn’t afford to feed my children.”

Today she is being tested for HIV at a mobile clinic, run by the volunteers of APROSAM, the Association for the Promotion of Mother, Child and Family Health. Services include HIV testing and the prevention of mother-to-child transmission of the virus. The sex worker says she gets tested every six months and, if positive, would seek treatment through the association.

Jeanne, a 37-year-old sex worker, is also being tested at the clinic, which is serviced by one doctor, one counsellor and a technician. “When they told me about this sickness, I decided to come here for the test,” Jeanne says.

Bringing services to the people

The generator pumping electricity into the clinic rumbles nearby, drowning out the noise of the surrounding shantytown. Inside, a pristine reception area leads to the examination room with an examining table and gleaming medical equipment. The clinic is clean, bright and very professional.

“The mobile clinic plays a very important role in the fight against HIV,” said Philippe Delanne, the Côte d’Ivoire Representative for UNFPA, the United Nations Population Fund. “With its trained personnel and volunteers, it can reach multiple towns and villages targeting sex workers, internally displaced persons and those made vulnerable by the crisis in Côte d'Ivoire who might otherwise not have access to health services.”

Dr. Pascal Attobrat is a volunteer doctor working for the mobile clinic. Instead of trying to get impoverished patients to a doctor’s office, the clinic delivers services directly to their doors.

“We see how AIDS has invaded this population. It is very important to teach the population about how to prevent and treat this disease,” he explains. “Everybody is involved with this disease.”

When someone was infected, they used to chase them out of the house. We need to help them – their partners leave them, and their families throw them out.

—Eloise Tohsede

Staying healthy and positive

Mobile clinic volunteer Theodore Magui is also HIV-positive. He says he bears witness to the fact that you can be infected with HIV and still live in good health. When clients see an apparently healthy person with the infection that they, too, carry, they feel more comfortable confiding in him.

Knowing your HIV status can be empowering, Theodore insists. The knowledge often gives clients the impetus to obtain the necessary treatment they need to stay healthy.

“When you live in ignorance and fall sick, it’s not good,” he says. “It’s better to have the test, know your status and get the medicine you need.

Midwife Odette Koffi-Brou helped create APROSAM to serve the health needs of the impoverished residents of Bardot, one of the largest shantytowns in West Africa. Bardot is home to 80 per cent of San Pedro’s 160,000 residents. Each of its 24 districts are served by two APROSAM volunteers, who are readily accepted as members of the community they serve.

The majority of HIV infections are sexually transmitted or associated with pregnancy, childbirth and breastfeeding. HIV vulnerability, like poor sexual and reproductive health more generally, is exacerbated by poverty, gender inequality and social marginalization.

For Koffi-Brou, sex workers should not be stigmatized, but should be treated like any other client in need of health services.

“It’s not our role to talk them out of prostitution,” Koffi-Brou says. “Our role is to sensitize them and protect them against HIV.”

Stemming the spread of the disease

UNFPA recognizes that a community-based approach, like that of APROSAM, is essential when responding to the AIDS epidemic and stemming its spread. UNFPA is funding the completion of a new maternity clinic in neighbouring Zimbabwe, mirroring the successful Bardot model. The equipped centre, which will offer HIV testing and treatment as well as other maternal and reproductive health services, will cost about $80,000 to complete.

UNFPA is also training association members in sewing, so that they have skills to help them earn additional money to survive.

APROSAM volunteers visit the homes of those infected by the virus to offer support, prevent mother-to-child transmission and provide counselling about treatment. On a recent visit, HIV-positive volunteer Eloise Tohsede threads her way through the maze of shanty shacks under the myriad makeshift power lines that weave overhead like a massive spider web. Weak lights shine a feeble glow onto the slum below.

“When someone was infected, they used to chase them out of the house,” says Eloise, who was herself diagnosed with HIV in 2004. “We need to help them – their partners leave them, and their families throw them out.”

Tonight Eloise is visiting 32-year-old Cecile Adakou, whose baby girl was born just five days earlier. Cecile’s partner left her when she tested positive for HIV. Her young son also tested positive for the virus, but she doesn’t know yet if her infant has contracted the disease. Eloise urges Cecile to seek treatment using her status certificate, which will enable her to get low-cost medication.

“I’m telling my sisters, ‘You are not alone. Your life can continue. You can take medicine and have hope,’” says Eloise, her smile lighting up the dim room wallpapered with photos torn from magazines. “If you take your medicine and continue to see a doctor, you can live a long time.”

– Angela Walker