CHAD: Shaky start to AIDS fight

Wracked by decades of political insecurity, HIV/AIDS simply wasn't a priority in Chad for many years. A chronic lack of health workers and uncertain funding delayed efforts further, but the government of Chad is finally starting to take action.

Chad covers around 1.3 million square kilometres and has a population of less than 10 million. In 2005, its average HIV prevalence rate was 3.3 percent, according to the authorities, with highs of 8.3 percent in N'Djamena, the capital, and 9.8 percent in Eastern Logone Region in the south, bordering the Central African Republic (CAR).

The Eastern and Western Logone regions have received most of the roughly 50,000 refugees who have fled across the border from the CAR, which has the highest HIV infection rate in central Africa.

Eastern and northern Chad, which border Sudan, have the lowest HIV prevalence rates, according to official statistics. However, they also have the least access to HIV awareness campaigns, are most exposed to insecurity, and have the highest number of refugees: more than 240,000 people from Sudan's Darfur province, as well as 180,000 internally displaced Chadians, are thought to be living there.

Officially, the fight against AIDS in Chad started at the end of the 1980s, but in reality the country has been preoccupied with the insecurity spanning the four decades since its independence. Large-scale programmes were not launched until international donors arrived: the World Bank in 2002, and the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2004.

The government has also committed funds to fighting the epidemic over the last few years: in 2007 it allocated 1.47 billion CFA francs (US$3.32 million) to purchasing antiretroviral (ARV) drugs, and plans to spend two billion (US$4.52 million) in 2008.

For a country that began exporting oil five years ago, some have argued that the government of President Idriss Déby could afford to spend more on health care and other public services, if it spent less on its military. According to the International Monetary Fund, Chad spends around 12 percent of its gross domestic product on the military, about twice what it spends on health.

Loans from the World Bank which Chad used to begin extracting oil were contingent on an agreement that Chad set aside most of its oil revenue for social services such as health and education and for "future generations". But in 2006, President Deby threatened to discontinue oil production unless the World Bank changed the terms of the agreement to allow the government much greater freedom in terms of how it spends the oil money. The government has made no secret of the fact that much of the money is now spent on weapons to defend itself from rebel attacks.

"There are many [health-related] priorities, as the majority of deaths in Chad are from preventable diseases, such as diarrhoea, respiratory infections or malaria; this also includes emerging illnesses, such as diabetes, cardiovascular problems and HIV/AIDS," Avocksouma Djona Atchénémou, Chad's Minister of Health, told IRIN/PlusNews. "But it's AIDS in particular that affects the very essence of life ... it is a disease that attacks even children."

The arrival of donor funding in Chad gradually enabled the provision of free HIV services like testing and ARV treatment, even in remote areas. However, in January 2006 the World Bank suspended its HIV/AIDS funding to Chad because of the government's lack of transparency in managing the money.

Funding was reinstated in June 2006 after agreements with the government, but it is still not known whether this funding, which ended in January 2008, will be renewed.

The Global Fund suspended its funding in August 2006 for similar reasons, but after a long process of negotiations, this funding was reinstated at the end of 2007.

HIV/AIDS prevention programmes, in particular, have suffered as a result of the funding suspensions, hindering the expansion of services to areas where large sections of the population are still ignorant or in denial about HIV/AIDS.

Across the country, but especially near the eastern border with Sudan, where the security situation is most volatile, regular explosions of violence continue to hamper the establishment of health services.

In the south, the lack of HIV/AIDS services is especially worrying in the area near a main road that runs from CAR to N'Djamena, along which traders, local people and migrants mingle.

"These areas of economic activity are high-risk [HIV/AIDS] areas; so is the oil-producing region [also in the south], but attempts to reduce risk-related behaviour have not been properly implemented," noted Claire Mulanga, UNAIDS country coordinator for Chad. "[HIV/AIDS] activities in these areas have now been increased, even though we may not yet have seen the effects."

A lack of surveillance data has made it difficult to target efforts at the most at risk groups and the most affected geographic areas. A 2003 government study of HIV prevalence in the security forces, one of the few available surveys of at-risk groups, found an average infection rate of 5.3 percent, with a high of 11.3 percent for women in uniform.

Another obstacle to scaling up HIV/AIDS efforts is a chronic shortage of health workers throughout Chad. The United Nation's Development Programme (UNDP) estimates there are just four doctors for every 100,000 people. Even in N'Djamena, where the vast majority of health professionals are based, there are not enough doctors and nurses, but in isolated areas and unstable regions health professionals are particularly scarce.

Although government and donors have made efforts in recent years to train health workers in providing treatment and care for people infected with HIV, some health facilities still have only one practitioner qualified to write prescriptions for ARVs.

Organisations for people living with HIV have also had problems in organising and making themselves heard. Rachel Koudjal, president of the Association of Positive Sisters (AS+) in N'Djamena, commented: "[Members] are not trained on the role that an organisation should have. They think that if they [join] an organisation, they will get it all right from the word go, but they don't understand that first you have to fight for the common interest."
Despite the many difficulties, people working in the AIDS sector say there has been some progress. In November 2007 the government passed legislation protecting the rights of people living with HIV and, in an attempt to improve coordination, created a National AIDS Prevention Committee (CNLS) - although this is not yet operational.

There are still very few health facilities providing ARV treatment, but they have nevertheless increased from just three in 2003 to 22 in 2006, and are supposed to exceed 50 in 2008. The number of centres providing voluntary HIV testing and prevention of mother-to-child HIV transmission is also growing.

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