Senegal

Daouda Diouf comes daily to the Fann Hospital compound daily. He is one of 250 people enrolled in CEPIAD*’s opioid substitution therapy programme (OST). OST is a globally recognized intervention to reduce injecting behaviours that put people who inject drugs at risk of contracting HIV and other blood-borne diseases, such as viral hepatitis.

“I am here to take my treatment and I am also a tailor, so I teach a few other users of drugs how to sew,” Mr Diouf said, cutting fabric in his makeshift outdoor workshop. Keeping occupied and selling his wares has helped him stay healthy for the last seven years.

Another enrollee agrees. He has found a passion for gardening and now oversees other patients at the centre’s green area.

For El Hadj Diallo, planting seeds, pruning trees is like a type of therapy. “When we are here, we forget our problems, I am happy doing it and it’s therapeutic for me,” he said.

Their other therapy consists of a daily dose of methadone. Mangane Boutha, the centre’s pharmacist carefully measures and distributes each dose in his office.

“Methadone is a medicine that acts as a heroin substitute, in our case it’s a syrup that is dosed in 10mg/ml portions with doses varying from patient to patient,” he explained.

Founded in 2014, CEPIAD has cared for more than one thousand people and is one of the first harm reduction centres in West Africa. Aside from opioid substitution, clean needle exchange and psychosocial support, they also offer health care.

“CEPIAD has become a testing and diagnostics center for HIV, and also tuberculosis as well as hepatitis and we distribute condoms,” said Dr Idrissa Ba, who coordinates the centre.

In Senegal, HIV prevalence among people who inject drugs is 9%, well above the 0.5% among the general population. Globally, due to stigma and criminalization, people who inject drugs face a 35 times higher risk of acquiring HIV than people who do not inject drugs.

Three-quarters of patients here are men but CEPIAD has been working hard to reach more women. Among people who use drugs, women are more likely to live with HIV, according to Dr Ba.  

Mariama Ba Thiam, who formerly used drugs, lived for years on the streets. She is now a peer educator in Dakar.  “I go out into the community and visit colleagues to raise awareness about getting off drugs and also how to reduce health risks so I refer them to CEPIAD and they can do like me, stop drugs,” she said.

Her plea: Get more funds to get more women and young people to come to the centre.

In Senegal, whilst drug use is a criminal offense, CEPIAD’s work has the support of the government, the United Nations as well as other partners.

On international Harm Reduction day, UNAIDS firmly believes that if we are to end AIDS by 2030, we can’t leave anyone behind. And that includes people who use drugs.

*The Centre de Prise en Charge Intégrée des Addictions de Dakar (CEPIAD)

Two years into the COVID-19 pandemic and there is still much misinformation around the disease. This is fuelling vaccine hesitancy and undermining efforts to respond effectively and protect the most vulnerable.

To respond to misinformation around COVID-19 and HIV, UNAIDS and the Africa Centers for Disease Control and Prevention (Africa CDC), with support from the German Ministry of Health, are organizing a series of training sessions to strengthen the capacities of African Ministries of Health and National Public Health Institutes. The sessions cover key areas of risk communication and community engagement on COVID-19 and HIV such as strategic communication planning, media engagement, familiariziation with continental and regional guidelines, social media and rumour management.

“These trainings aim at harmonizing and coordinating our risk communication and community engagement interventions on COVID-19 and HIV, and better engage our communities in the response to pandemics” said Benjamin Djoudalbaye, Head of Public Health Diplomacy at Africa Centers for Disease Control.

According to the World Health Organization, in the first three months of 2020, nearly 6 000 people around the globe were hospitalized because of coronavirus misinformation. Rumors on COVID-19, HIV, and most recently Monkeypox are reinforcing stigma and discrimination affecting populations which are already marginalized due to their race, economic status and/or gender identity.

To track and address rumors and fake information surrounding COVID-19 and HIV, UNAIDS and Africa CDC are running a rumor management system—a software that uses machine learning combined with human expertise to collect and analyze rumour data from open source traditional media (web-based, broadcast) as well as social media (Facebook, Twitter, Whatsapp). The system enables the identification of false and misleading narratives and sentiments related to COVID-19 and HIV. Weekly reports are then consolidated and used by Africa CDC as an alert system across the continent.

The first training session was held on 28 June in Dakar, Senegal for eleven countries of the West Africa Region. Two other training sessions will be held in the central and north African regions in July 2022.

As part of the Education Plus initiative, young women advocates in Senegal have met with key female figures in the region to discuss the education of girls in sub-Saharan Africa and the challenges they face.

A social work student in her second year of professional training said young women like her who are living with HIV still face stigma and economic marginalization in most spheres of life “Sometimes, the medicines are not in stock, and young women living with HIV often have to share their medication with each other while waiting for a new supply.” According to her, education guarantees a better future for young people, as it did for her in helping her to overcome the challenges she faces because of her HIV status and her difficult upbringing.

Another participant, Maah Koudia Keita (known as Lady Maah Keita), a Senegalese woman with albinism, and a musician, said that women with albinism are victims of harassment and the majority of them have experienced rape and sexual violence.

She is one of three professional female bass players in Africa and the only one in Senegal. She said, “People like me who were lucky to get an education now have to do the work of dispelling myths around women with albinism that drive the violence.” According to Ms Keita, the more educated and aware the community is, the better women and people with albinism can defend themselves.

Adama Pouye, a feminist activist and member of the Senegalese feminist collective that led the Buul Ma Risu (Don’t Mess with Me) movement, spoke at length during the meeting about raising awareness on sexual assault on public transport.

“Every day, you hear violent words and women come to believe that’s what they deserve,” she said. “You are told how far you can go by standards put in place by a patriarchal society, by men, and by religious standards, but our religious interpretations cannot be about oppressing women,” Ms Pouye said.

Young women are key advocates who the Education Plus initiative is working with to rally political leadership, development partners and communities in order to fulfil every adolescent girl’s right to education and health by enabling all girls to complete a quality secondary education in a violence-free environment.

As UNAIDS Executive Director Winnie Byanyima stressed at the meeting, “In this region of western and central Africa, the vulnerability of girls is high.”

She also said that four out of 10 young women are married before the age of 18 years, saying that children becoming brides is a gross violation and a failure to harness the full potential of girls.

“Keeping girls in a classroom, if she stays and completes secondary school, has a protective effect for girls from HIV. What we fought and won for primary school is what is needed for secondary education,” Ms Byanyima said.

Fatou Nar Mbaye Diouf, the Deputy Executive Secretary of the National AIDS Council, Senegal, could not agree more. “We know that allowing girls to complete secondary education protects them from HIV and improves many other health and development factors,” she said.

Sharing key data from Senegal, Ms Nar said the level of comprehensive knowledge about HIV increases with the level of education. “Among young women, it is 10% among those with no education and 41% among those with secondary education or higher, while among young men knowledge of HIV varies from 9% among those with no education to 51% with education,” she said. “Education is key.”

The Regional Director for West and Central Africa for UN Women, Oulimata Sarr, concluded the intergenerational dialogue by saying that girls’ education is not a threat, nor should it be seen as that. “We want to move the needle and move it together with young women,” she said.

Ms Sarr wants the next generation to be supported as they seek more space in decision-making. “We need to pass the baton to young people, who organize differently from us, create an intergenerational legacy with young people holding us to account.”

Participants from four countries—Côte d’Ivoire, Guinea, Guinea-Bissau and Senegal—recently met in Saly, Senegal, to capitalize on the know-how developed during the implementation of the Capacity Building and Capitalization of Experiences for Improved HIV Care among Key Populations in West Africa (ReCCAP) project, implemented by ENDA Santé and funded by L’Initiative through Expertise France.

The project aims to strengthen local people so that they are able to map sites and estimate the size of key populations on a continuous basis at the local level, conduct detailed analyses of HIV services and needs, and use the results to adapt the services offered and increase their effectiveness.

“The lack of data on key populations hinders the development of interventions that address their specific needs. Programmatic mapping and size estimates are usually conducted by international consultants and are not always adapted to the needs of field actors, and data may exist but are often quickly outdated because targets are dynamic and mobile,” said Sidy Mokhtar Ndiaye, Research Manager at ENDA Santé.

Guinea-Bissau, for example, was able to share its experience in estimating the size and/or needs of four key population groups, including a needs analysis of prisoners in three prisons in the country. “This is the first time that a study on HIV has been done in prisons in the country. The data will be used for the development of the new national HIV strategic plan,” said Miriam Pereira, Monitoring and Evaluation Officer at ENDA Santé Guinea-Bissau. The country has completed the deployment of two national trainings, including on community-based surveillance, which has been useful for monitoring the COVID-19 pandemic, and on the implementation of key population mapping in four regions—Bissau, Bafatà, Bubaque and Mansôa—in sites including bars, restaurants, hotels and public spaces.

The meeting, which welcomed members of partner entities and people who had benefited from two regional trainings in 2019 and 2021, was an opportunity to share South–South operational experiences and to develop recommendations for scaling up lessons learned and extending the project, particularly in terms of geographic coverage, with the support of UNAIDS.

“Key populations and their sexual partners account for 69% of new HIV infections in western and central Africa.  And yet in the region the funding received for programmes for key populations represents only 2.4% of funding between 2016 and 2018. Projects like ReCCAP are essential for advocating for greater investment in key populations and evidence-informed programming,” said Marie Engel, UNAIDS Regional Adviser.

Since key populations and their sexual partners account for 69% of new HIV infections in western and central Africa, reaching 95–95–95 among key populations will result in a significant impact on the overall HIV epidemic in the region. However, programmes focusing on key populations are insufficient. In western and central Africa, funding for programmes for key populations represented only 2.4% of the region’s overall HIV funding between 2016 and 2018, according to Frontline AIDS.

Having strategic information—quality data and analysis—is vital for an HIV response, for ensuring accountability and since it allows ambitious and measurable time-bound targets for monitoring progress to be set. 

“The old adage “What gets measured gets done” may be a cliché, but it is still very true for the HIV response. Over the years, data collection, analysis and dissemination have led to a better understanding of the HIV epidemic and helped programmes to reach the right people in the right place at the right time,” said Marie Engel, Adviser at the UNAIDS Regional Support Team for Western and Central Africa.

In order to strengthen their skills in building and analysing data on the location and size estimates of key populations, approximately 30 people from four countries—Senegal, Côte d’Ivoire, Guinea and Guinea Bissau—and who were mainly from organizations for key population recently attended a training session in Saly, Senegal. During the training, which was part of a subregional project called RECCAP, funded by Expertise France, the Enda Santé nongovernmental organization, in collaboration with Johns Hopkins University, trained the participants on basic statistical analysis methods, population size estimation, health mapping tools and the analysis and presentation of collected data. UNAIDS and the World Health Organization sponsored the participation of several participants.

“The development of local capacities will allow for programmes that are best adapted to contextual changes by locating the dynamics of HIV vulnerability and analysing how sociospatial combinations influence epidemiological data. The diversity of the selected participants’ profiles and the plurality of the training team’s experiences guarantee a transfer of know-how and true sharing,” said Daouda Diouf, Enda Santé’s General Manager.

It is hoped that the training will empower key populations to exercise leadership—an essential mainstay of HIV responses to ensure that they are inclusive, equitable, effective, efficient and sustainable.

The Network of People Living with HIV in Senegal (RNP+) marked Zero Discrimination Day 2021 by hosting a dialogue on the extent and impacts of the stigma and discrimination faced by women and girls living with HIV in Senegal—a country in which the 2017 People Living with HIV Stigma Index showed one in two people living with HIV experienced stigma and/or discrimination from others.

“Discrimination continues to affect women and girls and this is the reason why they are often excluded from the labour market, are isolated in their communities or experience stigma in health centres. Key populations are also historically the target of discrimination in Senegal,” said Soukèye Ndiaye, the President of RNP+.

Various assessments undertaken in the country have revealed that women living with HIV face obstacles in accessing reproductive health services, that sex workers face high levels of stigma in health-care settings and that the economic and social vulnerability of women living with HIV is not sufficiently taken into account in HIV programmes.

This dialogue served as the spearhead for the advocacy strategy that RNP+ will develop this year on human rights and gender issues in order to better respond to the expectations of its members and communities affected by HIV. This strategy will be accompanied by communication tools such as videos in several local languages and dialogue and sensitization sessions with key actors in the regions most affected by HIV.

During the dialogue, the participants were invited to support the RNP+ in this process. In particular, they were asked to become “champions” committed to making a better use of journalists, community radio and social networks to sensitize the general public to the challenges of discrimination.

Abdoulaye Ka, in charge of human rights issues at the National AIDS Control Council (CNLS), recalled the importance of continued collaboration between the state and non-state sectors. “Community organizations and networks have long been essential in the fight against AIDS because of their central role in raising awareness, informing, dispelling myths and misinformation and providing services to marginalized, vulnerable and discriminated against populations.”

The dialogue, which was supported by UNAIDS, brought together about 30 participants, including people living with HIV, representatives of women’s movements and key populations, human rights advocates, policymakers and health service providers in a meeting held both virtually and physically.

“In Senegal, we know that discrimination against people living with HIV is still a major stumbling block in all aspects of the HIV response. The United Nations Joint Team on AIDS has always placed human rights and gender considerations at the centre of its work and support,” said Demba Kone, the UNAIDS Country Director for Senegal.

Forty years of responding to the HIV epidemic has provided considerable experience on the importance of a human rights-based approach to all epidemics. UNAIDS spoke to Abdoulaye Ka, who is responsible for human rights issues at the Senegal National AIDS Control Council (known as the CNLS in the country), about the lessons that the CNLS has learned from the response against HIV that can be applied to the fight against COVID-19.

How is Senegal addressing stigma and discrimination during the COVID-19 pandemic?

The experience of the fight against stigma and discrimination related to HIV services has enabled the CNLS to draw the attention of the national COVID-19 management committee and public opinion to the importance of developing communication materials adapted to specific communities. The involvement of affected communities in the definition, implementation and follow-up of COVID-19 programmes has helped to reduce stigma around the disease.

The CNLS Executive Secretary has made several broadcasts to explain the importance of simplifying messages for communities, including to help them develop their own community responses.

The psychosocial care unit in Dakar is also being supported by the CNLS to draw lessons from the experience of HIV and stigma and discrimination in its work against COVID-19.

What measures are being taken to deal with the socioeconomic consequences of COVID-19 in Senegal?

To respond to the socioeconomic impact of COVID-19 on individuals and households, Senegal has deployed an economic and social resilience programme and has earmarked a budget of 1 trillion West African francs (about US$ 1.7 billion) to support the economic sectors most affected by the crisis and to provide food aid to the most vulnerable. A total of 59 billion west African francs (about US$ 100 million) has been earmarked to buy food for one million eligible households.

In particular, the CNLS is partnering with UN Women to increase the resilience of women living with HIV through the provision of food and hygiene kits.

How is the response to COVID-19 in Senegal responding to the specific needs of people living with HIV?

To respond to the needs identified by the national network of people living with HIV, the country is moving to multimonth dispensing of antiretroviral medicines, in accordance with the guidance of the World Health Organization. We are collaborating with service providers and communities in assessing needs in order to avoid stock-outs.  

The CNLS has also set up a free telephone hotline for people living with HIV at the Antiretroviral Therapy Treatment Centre of Dakar. It has also set up a WhatsApp network for all antiretroviral therapy care site managers and gives them recommendations on how to adapt the provision of care for people living with HIV, including proceeding with the delivery of at least three months of HIV treatment.

What is the role of community-based organizations today?

Community-based organizations and networks have long been critical to the AIDS response because of their central role in raising awareness, informing, dispelling myths and misinformation and providing services to marginalized and vulnerable populations.

Now more than ever, community actors need to be supported to innovate and be recognized as providers of essential services for HIV and COVID-19.

Community service providers have innovated quickly in the context of COVID-19 in Senegal using appointment systems to prevent too many people being accommodated at the same time in an institution and holding educational sessions virtually.

The CNLS is currently providing logistical support to people living with HIV for the community-based distribution of antiretroviral medicines.

The right to information is a constitutional right in Senegal. What is the role of information in preventing and protecting against epidemics?

The CNLS very quickly developed messages, press releases and banners on social media to draw attention to the preventive steps to be taken against COVID-19, especially for people living with HIV. We also informed people living with HIV in real time regarding the evolving knowledge about HIV and COVID-19.

Information was developed to be expressed in simple terms and to prevent false/fake news that can undermine the use of health services, including vaccination services, that are useful to preserve the health of people, in particular children living with HIV.

When non-essential shops and markets were closed in Senegal in response to the COVID-19 outbreak in the country, and movement between regions in the country was stopped, many people working in the informal sector, including people living with HIV, lost their income. Hunger was dangerously near for many.

Within days, the National Network of Associations of People Living with HIV in Senegal (RNP+) mobilized, setting out to its members the food aid options available from the government for 1 million eligible households and offering advice on how people should prevent themselves from becoming infected by the coronavirus.

“When people are asked to isolate themselves, we also need to make sure they have food and medicine. Communities of people living with HIV help each other to take care of themselves, isolate themselves, access medication when needed and take care of each other’s families,” said Soukèye Ndiaye, the Chairperson of RNP+.

Community leaders and nongovernmental organizations are playing an active role in Senegal in giving out clear and accurate information in order to avoid panic and in combating stigma and discrimination, against both HIV and COVID-19. RNP+ is monitoring the response to COVID-19 as it unfolds, mapping how COVID-19 is affecting the most vulnerable and bringing urgent issues to the attention of the government and service providers.

Advocacy with the National Alliance of Communities for Health and ENDA Santé enabled RNP+ to distributed more than 200 food and hygiene packs to the poorest families of people living with HIV. The UNAIDS country office in the country has stepped in by providing a grant to ensure that the One Family–One Kit programme continues to distribute aid to the people most in need.

RNP+ is also advocating for funding for people living with HIV to help them to travel to health centres, since transport costs have increased, and for financial support for the scaling up of the work of community health workers, who are active in the delivery of antiretroviral therapy.

During the COVID-19 pandemic, ensuring continuity of HIV treatment by distributing multimonth supplies of antiretroviral therapy is vital. Although RNP+ has called on the government for all people living with HIV to get multimonth refills, weaknesses in the supply chain, including inadequate assessments of the needs at some clinics for supplies of antiretroviral therapy and irregular supplies centrally, has meant that not all people who need such supplies are getting them. UNAIDS is supporting the government in tracking orders of antiretroviral medicines and in strengthening the supply chain.

The role of communities, especially communities of the most vulnerable, is critical in the time of COVID-19. “The history of the HIV epidemic has made it clear that the response to an epidemic is only effective if affected communities are fully involved in the response, from its planning through to its implementation and monitoring. Only then can a response be based on the realities and needs of all,” said Demba Kona, the UNAIDS Country Director for Senegal.

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.