Mauritania

In a suburb of Nouakchott, Mauritania, a tent has gone up for an evening of counselling and HIV testing. Staff of the nongovernmental organization SOS Pairs Educateurs field questions, and people wanting to know their HIV status queue for a rapid test.

Mohammed Bilal, above, is supervising the evening event, along with peer educators, a nurse and a social worker. Pointing behind him to a small concrete house with a corrugated roof, he said that to keep all tests anonymous, people are given a number and they enter the makeshift office one by one. “We do counselling before the HIV test and after the person gets the results,” Mr Bilal said.

More than 70 men and women have opted to get a rapid test today.

In the El Mina neighbourhood, where the outreach event is taking place, Mr Bilal says that most people scrape by making a living, many women live alone raising children and most children don’t attend school. He grew up here and knows the community well. He and his team also know the needs of the people. For Mohammed Mouloid, above right, the Programme Coordinator at REMAP+, a network of people living with HIV, community outreach fills a big gap. During the COVID-19 restrictions, for example, they teamed up with SOS Pairs Educateurs, UNAIDS and others to distribute food kits.

Adjusting his glasses, Mr Mouloid said, “Before a person takes their medicine, they have two other priorities. The person has to eat first and find transportation to pick up their treatment. If both are not combined, then the third priority falls by the wayside and the person will never take their treatment.”

“Our biggest problem in Mauritania is stigma associated with HIV,” Mr Mouloid said, explaining that people living with HIV often drop out of treatment programmes. Only 40% of the 8500 people living with HIV in the country are on life-saving treatment. Mr Mouloid has lived with HIV for nearly 20 years and was one of the first people in Mauritania to take antiretroviral medicines, in 2004. “I have been married twice and have two children who are both HIV-negative, so I am a testament to living a healthy life, but things are tough in our society,” he said.

The HIV epidemic in Mauritania is concentrated in cities and among key populations. HIV prevalence among adults is around 0.3%, but is 9% among sex workers and 23% among gay men and other men who have sex with men. Mauritania criminalizes sex work and same-sex sexual relations, so people tend to hide. 

To reach out to key populations, SOS Pairs Educateurs, with the support of the United Nations and partners, recently opened a drop-in centre, above, in front of the bus station in the capital city (they have eight other drop-in centres around town). A television blasts in the corner as peer educators mill about chatting with a truck driver. A pilot project distributing HIV self-test kits that people can use in the privacy of their own home has also been undertaken. 

Sharif (he did not want to give his last name) explains that he stops by regularly to pick up condoms and get information from the counsellor. “I came here to know more about COVID-19 and other health risks,” he said. He said he had never taken an HIV test, which are provided for free, but was thinking about it.

According to the UNAIDS Country Director for Mauritania, El Mustapha Attighie, community outreach like this is a way to support vulnerable groups.

“Stigma hinders our response to HIV and if human rights are not respected and people are left behind, this increases the risks of HIV,” he said. He added that UNAIDS’ mandate clearly states advocating for rights and treatment for all and as a trained doctor he focuses the debate on people accessing health care.

He believes that Mauritania could end AIDS by 2030. “We have the opportunity to make this objective a reality,” he said. “Channel more money and means where the epidemic is, to quash it and also stop it from reaching a broader population.”

SOS Pairs Educateurs has expanded its activities to reach different populations. It founded a school for street children and children who have dropped out of school and organized trainings for girls in sewing as well as a teen dance group. “Here for many the reality is that you have little hope so by having kids succeed in school or on the dance floor, it boosts them and impacts the entire family,” said the SOS Pairs Educateurs Director, Djibril Sy, above. He grew up in El Mina and still lives there, saying that countless people have benefitted from its work in the past 20 years. “Aside from hope, we really try to instil a sense of self-worth,” he added, explaining now that he wants to give young people trainings in entrepreneurship.

Despite progress, western and central Africa represents 8% of the world population but is home to 12% of all people living with HIV globally and experiences 22% of all AIDS-related deaths in the world.

Home to 5 million people living with HIV, western and central Africa is not on track to ending AIDS by 2030. Every day, more than 760 people become newly infected with HIV in the region and only 2.6 million of the 5 million people living with HIV are on treatment.

Insufficient political will, frail health systems and weak support for community organizations―as well as barriers such as HIV-related criminalization―are the most significant obstacles to progress. A regional acceleration plan aims to put the region on track to reaching the target of tripling the number of people on antiretroviral therapy by 2020 and achieving epidemic control. While progress has been made, that progress is not coming fast enough. Children are of particular concern―only 28% of under-15-year-olds living with HIV in the region have access to antiretroviral therapy.

“We need policies and programmes that focus on people not diseases, ensuring that communities are fully engaged from the outset in designing, shaping and delivering health strategies,” said Gunilla Carlsson, UNAIDS Executive Director, a.i., speaking at the Global Fund to Fight AIDS, Tuberculosis and Malaria Sixth Replenishment Conference, taking place in Lyon, France, on 9 and 10 October.

There are many examples of how investing in communities can make a difference. “The response is faster and more efficient if it is run by those who are most concerned,” said Jeanne Gapiya, who has been living with HIV for many years and runs the ANSS nongovernmental organization in Burundi.

Community-led HIV testing and prevention is effective, particularly for marginalized groups. “Most of the people tested by communities were never reached before and this shows how community organizations are unique and essential,” said Aliou Sylla, Director of Coalition Plus Afrique.

Reducing the number of new HIV infections among children and ensuring that women have access to the services they need remains one of the biggest challenges in the region. Networks of mothers living with HIV who support each other to stay healthy and help their child to be born HIV-free have been shown to be an effective way of improving the health of both mothers and children.

“Our community-based approach works. In the sites where we work we have reached the target of zero new HIV infections among children and all children who come to us are on treatment,” said Rejane Zio from Sidaction.

Financing remains a concern and although total resources for the AIDS response have increased, and HIV remains the single largest focus area for development assistance for health, domestic investments account for only 38% of total HIV resources available in western and central Africa, compared to 57% worldwide. Greater national investments reinforced by stronger support from international donors are needed to Fast-Track the regional response. Bintou Dembele, Executive Director of ARCAD-Sida, Mali, said, “We have community expertise, but we lack the funds to meet the need.”

Support is growing for community-based approaches in the region. Recognizing the importance of community-led work, Expertise France and the Civil Society Institute for Health and HIV in Western and Central Africa announced a new partnership on 9 October. “The institute brings together 81 organizations from 19 countries aiming to ensure better political influence at the global and country levels and to galvanize civil society expertise in programme delivery. This partnership is a recognition of our essential contribution,” said Daouda Diouf, Director of Enda Sante and head of the steering committee of the institute. “The situation in western and central Africa remains a priority. It is clear that community-based approaches are agile and appropriate for responding to pandemics,” said Jeremie Pellet from Expertise France.

Shifting to a people-centred approach has been at the core of reforms in the region. A growing regional resolve to accelerate the response and to strengthen community-led approaches that have been proved to work provides hope for the future of the HIV epidemic in western and central Africa.

How to realize Africa’s potential for the future of all its peoples and build international support for the continent’s development were key questions explored in the first session of the Africa Rising Forum held this week in New York.

Taking place at the Africa Center and organized by the Mo Ibrahim Foundation, the 22 September event brought together a number of African heads of state, United Nations partners, and leaders from African civil society and the business community.

They examined how to move beyond simply talking about the need for broad-based economic transformation and sustainable development to taking concrete steps to make them a reality, especially with regard to the post-2015 development agenda. 

A session on ensuring shared prosperity looked at ways to improve investment and resource mobilization, champion entrepreneurship and ensure social protection. Another stressed that development cannot be achieved without the existence of good governance, peace, security and respect for human rights.

It was agreed that ensuring health for all was a critical facet of Africa’s rise, and that ending the AIDS epidemic as a public health threat by 2030 now a realistic goal. There was also a consensus that the continent’s rise should not only be measured in terms of overall wealth generated but by the inclusiveness of socioeconomic progress that leaves no one behind.

The President of Mauritania and new Chair of the African Union (AU) will support African leaders in increasing action in the response to HIV.  President Mohamed Ould Abdel Aziz met with the Executive Director of UNAIDS, Michel Sidibé on 20 March in Nouakchott, Mauritania.  Mr Sidibé congratulated the President on his recent election to the rotating presidency of the AU and urged him to lead efforts to accelerate transformative reforms in the responses to AIDS, tuberculosis and malaria.

In 2012, African leaders committed to a Roadmap on Shared Responsibility and Global Solidarity for AIDS, TB and Malaria Response in Africa, charting a new course for the continent’s response to the three diseases. Mr Sidibé stressed the urgent need for African countries to take ownership of their epidemics and reduce dependency on international financing. He also reiterated the need to produce antiretroviral and other essential medicines on the continent and build capacity and knowledge on the production of medicines.

As well as playing a leading role in the African Union, Mauritania is also a member of the League of Arab States, which earlier this month endorsed a highly innovative strategy to halt the AIDS epidemic in Arab countries.  Mr Sidibé pointed out that while Africa is the region most affected by HIV in the world, the Arab region has one of the fastest growing epidemics globally. Since 2001 the number of people newly infected with HIV in Arab countries has increased by more than 47%. He called on Mauritania to leverage its unique position and act as a bridge between African and Arab institutions, spurring the transfer of key know-how and technology in the AIDS response.

Mauritania recently adopted a law which protects the rights of people living with HIV and provides free antiretroviral therapy to people eligible for HIV treatment. According to national authorities the number of people accessing life-saving treatment increased from 1 866 in 2012 to 2 400 in 2013, an increase of 27% in just one year.

During his official visit, Mr Sidibé also met with Prime Minister Moulaye Ould Mohamed Laghdaf and Minister of Health Ahmedou Ould Hademine Ould Jelvoune. He also visited an outpatient treatment centre in Nouakchott that provides integrated services including prevention, treatment and social support services for HIV and TB.