Yopougon is a working-class neighbourhood of Abidjan, Côte d’Ivoire’s economic capital. When I was there in May, Médecins du Monde (MDM) had pitched two huge plastic tents on the market, between a stall selling medicinal plants and one selling alcoholic beverages in small bottles from a padlocked wire cage. Over the tents was a banana wearing a condom, with the slogan, in Nouchi, ‘Avant de djô, toujours porter le prézère’ (When you have sex, always use a condom). The nouchi is the guy with the moustache in gangster films that everyone’s afraid of, but who is afraid of no one; Nouchi is also the Ivorian slang/dialect spoken by drug users living in precarious social conditions who are the targets of this campaign.
AIDS kills 24,000 Ivorians every year and, according to UNAIDS, around 500,000 or 2.8% of those aged 15-49, are infected with the human immunodeficiency virus (HIV) (1). A 2014 study by MDM found that the percentage was as high as 9.8% among drug users (2), and among homosexual drug users it has now reached 39%. The government wants to eradicate AIDS by 2030 as part of its drive to achieve the UN’s sustainable development goals. But the authorities and local NGOs are finding it hard to reach the people concerned, even though the aim is not to lock them up for using drugs but to treat them.
Promiscuity, lack of hygiene and dirty drug paraphernalia all contribute to the TB epidemic. Users are reluctant to get tested, which leads to delays in screening and treatment
Socially precarious addicts usually indulge their habit in ‘smoking rooms’, sheds with a tarpaulin or corrugated iron roof; there are about a hundred in Abidjan, catering to between 6,000 and 10,000 users. There are vendors selling every type of drug and sometimes there is food too; there are carpets and wooden benches to sleep on, and there is rubbish everywhere. Each smoking room has a babatché (boss) who looks after security and warns users against stealing in the immediate neighbourhood. Police officers paid to look the other way come to collect their bribes at regular intervals. Dozens of lookouts watch for intruders.
MDM had pitched its tents near one of these smoking rooms in Yopougon. The doctors were offering free medical care and screening for HIV and tuberculosis, West Africa’s other great health scourge (see Women’s health means autonomy, in this Supplement). A young woman called Sandrine went to tell users in the smoking room that the doctors had arrived. She took crack cocaine and heroin up until 2015; now she has put on weight and her MDM vest is a bit tight. MDM recruited Sandrine four months after she was raped by a police officer during an arrest for drug use; she is now one of 40 ‘peer educators’ in Abidjan, all current or former users who keep an eye on the health of people they consider their protégés.
Major trafficking hub
The port city of Abidjan (population 5 million) is a major drug trafficking hub (3). Heroin produced in Asia passes through on its way to the US. In Côte d’Ivoire it is divided into small doses and cut with other substances (sometimes just as toxic) that reduce its price on the local market. It is smoked in cigarettes made of tobacco or cannabis. Cocaine from Latin America, headed for the European market, is turned into crack (so called after the noise the crystals make when heated). It’s smoked in pipes, which users often share. At its prevention sessions, MDM hands out disposable mouthpieces originally designed for shisha pipes, to limit the risk of transmission of infections, especially TB, the world’s most deadly infectious disease, which is out of control among drug users. According to the World Health Organisation, 36,000 new cases were detected in Côte d’Ivoire in 2016, bringing the disease’s prevalence to 0.2%; among drug users, it’s 9.8%.
Promiscuity, lack of hygiene and dirty drug paraphernalia all contribute to the TB epidemic. Users are reluctant to get tested (they say they are stigmatised, or even turned away from clinics), which leads to delays in screening and treatment. When they need a fix, users can be aggressive and tend not to follow their treatment correctly. After diagnosis, peer educators make sure that patients attend medical appointments and take their medication.
Sandrine is responsible for female patients in particular. When she was using, she would ‘catch a bloke’ and live with him so that she ‘wouldn’t have to sleep with everyone’. With heroin at 1,000 CFA francs ($1.70), crack at 2,000 CFA francs per dose, and the minimum monthly wage at 60,000 CFA francs ($100), users without a regular job often resort to theft or prostitution, with all the health risks that involves. Sandrine lost a baby in late pregnancy, and her third child has respiratory problems.
MDM recently tried out night patrols to fit with the lifestyles of their target population. The last eight identified 10 cases of HIV infection, all among prostitutes. Four of the 15 samples collected also revealed TB infection. The previous week, the patrol had identified five cases of TB. But Renaud Boulet, coordinator of MDM’s risk reduction programme, said, ‘We’re giving up night patrols for the moment, because we want to be able to support the people we find, and our peer educators are already snowed under.’ MDM used to refer people to the anti-tuberculosis centre at the Yopougon-Attié general hospital, but ‘fewer than half actually went, fewer than half of those bothered to get their results, and fewer than half of those took their medication correctly.’ Now a member of staff from the anti-tuberculosis centre takes part in the screening, and peer educators support patients through their treatment.
Prostitutes of the Phare district
The seaside resort of Grand-Bassam, on the outskirts of Abidjan, is known for its beach and luxury hotels, and also for the prostitutes of the Phare district. There is nothing to identify the makeshift rooms they work in: soliciting in any form is illegal. The young women sit on plastic chairs outside their doors, waiting silently for customers. Some have tight dresses, wigs and false eyelashes; others just wear tracksuits. On the day I visited, an unmarked white HGV belonging to the NGO Espace Confiance (Trust Space) was parked in one of the streets where the English-speaking prostitutes work. Princess was waiting behind the lorry for a free medical consultation and an HIV test. Back home in Nigeria, Princess was a nurse. An aunt talked her into going to Côte d’Ivoire, promising her a job. But instead, the aunt stole her passport and sold her for 1m CFA francs ($1,700) to one of the pimps sitting in a group the next street. The ‘bosses’ keep an eye on their ‘girls’ while they chat.
Princess’s parents are unaware of all this. She now sells sex for 2,000 CFA francs ($3.35) a time. Her home (and place of work) is a room measuring 9 sq m, harshly lit by a blue lamp. There’s no bed, just a mattress on the floor with a TV set at its foot. The only decorations are a few beer posters pinned to the wall. She shares toilets and showers with the other tenants. The rent is 2,500 CFA francs a day, well above market rate, and doesn’t include electricity. She confided that she hoped to ‘meet someone’ among her clients who would help her go home to Nigeria and open a pharmacy. Princess only agreed to climb into the lorry because Gladys, another sex worker who is also a peer educator, reassured her about Espace Confiance’s motives. Last year, traffickers pretending to be screening for HIV actually collected blood and never came back. It’s rumoured that they sold the blood.
Without Gladys, the pimps would not have allowed the lorry to pass: its presence could have affected business. A few metres further on, a passer-by jostled two prostitutes violently, but the pimps did not react. The night before, someone had broken down several doors and a mobile phone had been stolen. The women have clubbed together to pay for a guard to protect them against violence and vandalism, but he won’t come out when it’s raining. Gladys, too, was sold into prostitution by a relative. She paid back the debt the traffickers claimed she owed them, but had to stay on the job to pay for her return trip to Nigeria. In the end, she accepted her fate and her new homeland. She now lives with distant relatives who know nothing of her work. She wears a ring to make people think she’s married and ‘because it looks nice’.
‘More HIV among Ivorians’
Inside the Espace Confiance lorry, a doctor, Serge Ahoule, was mainly treating pelvic pain and genital discharge. ‘We find more cases of HIV among Ivorians,’ he said. ‘English-speakers here use condoms, mainly to avoid becoming pregnant and not being able to work.’ According to Ahoule, prostitution is more often a side job for Ivoirian women. That makes it more difficult for peer educators to get the prevention and risk-reduction message across, and as a result, fewer use condoms. The young women of the Phare district work around the clock, seven days a week. Espace Confiance found no cases of HIV among the 33 people they screened the evening I visited.
Men who have sex with men had also heard about the mobile clinic. ‘My partner doesn’t know I’m gay too,’ said Stéphane (working name ‘Fanny’), a young waiter. The legal status of homosexuality is ambiguous in Côte d’Ivoire. It can fall under the purview of a law that prohibits ‘unnatural and indecent acts’. In 2016 a court in Sassandra, in the southwest, sentenced two men to 18 months in prison for having sexual relations.
Fewer than half actually went to the anti-tuberculosis centre, fewer than half of those bothered to get their results, and fewer than half of those took their medication correctly Renaud Boulet
Stéphane would like to have a family but not live with his partner (who thought he was out with friends for the evening). Five other men who have sex with men were talking on their mobiles as they waited. Peer educators, also homosexuals, approach them on the beach and in certain bars. One explained, ‘We tell them our stories, so they know we’re like them. They have STDs, but are reluctant to visit a hospital for treatment. We show them pictures of people infected with HIV. It scares them, and they come to the lorry to be tested. When they realise they can trust us, they tell their friends to come too.’
Eboi Ehui is a doctor and the coordinator of Côte d’Ivoire’s national programme for the fight against AIDS (PNLS). He makes sure that representatives of drug users, prostitutes and homosexuals are invited to all awareness-raising meetings, including those held at the health ministry. ‘If we put our heads in the sand, the risk is that infection will continue to spread through the general population,’ he said. The programme also tries to persuade patients to take antiretroviral treatments (ARVs), which halt the progression of HIV. These have been free of charge since 2008, but ‘people with chronic illnesses are shunned in Côte d’Ivoire: if you don’t get better, you must be under a curse,’ he explained.
Some evangelical Christians prefer to attend prayer camps, where patients stop taking their medication and pray together for a miraculous cure. There are supposedly around 100 in Abidjan. ‘Now we’ve identified the problem,’ Ehui said, ‘we can try to educate pastors and get them to encourage patients to take their pills no matter what, as we did with practitioners of traditional medicine. ’He admitted that the weakest link in Côte d’Ivoire’s struggle against HIV is prevention. HIV is no longer fatal, so it’s less scary than it used to be. Most new cases are among those aged 15-25. The PNLS programme is planning to shift the emphasis of its PR message away from the risk of death towards the benefits of being diagnosed and treated: you can live longer and in better health. Taking all these factors into account, the new campaign being pursued on social networks and on television features HIV-positive clergymen. They show their faces, state their names and ages, and tell viewers, ‘If you believe in life, take your ARVs.’
The stigma is such that most of those who test positive for HIV keep quiet about it. I met Foufana (4) after a talk she gave for people with HIV in Toumodi, a town with a population of 60,000, 200km northwest of Abidjan. After her husband died while abroad, Foufana (4) went through his papers and found that he had tested positive for HIV. He had never told her. But she didn’t blame him: ‘He was scared.’ Foufana is taking ARVs but says she feels more and more tired. No one in her village knows she is ill. Her son, who was with her that day, often prepares meals for her, and gives her her pills when she’s sleeping. He believes his father was killed in an accident.
A vicious circle
At a support group organised by the NGO Hope for Children, Foufana and 30 other women shared their problems. The main issue was food: they are weakened by their illness and can’t work as hard as they used to. It’s a vicious circle since undernourishment also reduces their ability to benefit from treatment. It was the rainy season, and as farmers they were anxious: they should have been planting yams, but there wasn’t enough rain. The weather had affected their crops last year, and their diet too.
Most of these women found out they were HIV-positive when they got pregnant: screening then is virtually automatic, to prevent the virus from being passed on to the baby during childbirth or through breastfeeding. ARV treatment reduces the risk to less than 5%. Traoré (5), aged 20 though he looks no older than 14, was diagnosed at 13. His mother had died some years earlier, and he was living with his aunt. At the time, his joints were so painful he couldn’t walk; now, with treatment, he is better、 though still in pain. He is often ill with influenza or malaria. Traoré’s friends don’t know why he can’t work in the fields. He dreams of getting an office job.
Buses only leave the bus station at Toumodi when they are full, so Hope for Children were using the waiting time for prevention and screening. The people in the refreshments area (women on one side, men on the other) listened attentively. Once the ice was broken they had many questions and comments: ‘Can the virus be in your sperm?’ (yes) or ‘Sometimes, you get a defective condom’. The educator then demonstrated how to open the sachet and put on the condom correctly, using a wooden model of a penis. When he mentioned use-by dates, an old man said, ‘But I can’t read. How can I tell?’ (there should still be air in the sachet). Afterwards, 29 people got themselves tested; none were positive. Hope for Children also visits businesses twice a month, and places open to the general public (hair salons, shops) eight times a year.
Early diagnosis enables cure
The public hospital in Toumodi, 7km from the bus station, automatically tests all its patients for tuberculosis. Nurse Simon Kouassi told me that around 10% also have HIV. In the eight years that he has been in charge of TB patients, he has seen an improvement: if the disease is diagnosed in time, it can be cured. The 11 ‘community agents’, auxiliary healthcare workers who go from house to house, identify many cases. After referring patients to the hospital, they offer a range of help, including free medicines. A patient named Julien said, ‘My parents abandoned me, but not Sylvain [one of the community agents].’ Julien’s mother was sure he would die of this illness that made him cough up blood, and begged him to come home to their village so that he could be buried there. He is a lumberjack by trade, and never thought he would be able to hold a chainsaw again, but he’s been cured for three months and has gone back to work, though he is still weak. Friends have lent him a chainsaw, because he had to sell his own for food when he was bedridden. The 100-130 TB patients the hospital in Toumodi treats every year also get free treatment for any other illnesses they may have, as do their families.
Last August, MDM opened an Addiction Treatment and Counselling Centre (CASA) for drug users in Abidjan, which tries to do more. The centre tries not to attract attention from local residents or the authorities. There is no sign at the entrance, and to reach it you have to go down a long alley next to a carwash. People in the neighbourhood have been told it’s a hostel for the homeless and seem satisfied with this explanation (though the police have already followed one drug user into the centre, and handcuffed him in the courtyard before taking him away to jail). Users can consult a psychologist or get advice from a social worker, including help reconnecting with their families. The décor is colourful, and there are showers and a laundrette. CASA also helps people ‘get their heads out of the smoking room’, explained Marie-Julie Toha, a social worker known as ‘Mother CASA’. Here they can play table football or board games, or just sleep in peace: in the street, they have to be constantly on their guard. Around 30 addicts visit each day.
CASA may eventually provide overnight shelter. At present, it works with a religious institution that has beds. The founders plan to offer adult literacy classes, to help users ‘take the first step towards getting back into work’. Methadone, a substitution treatment that helps to reduce withdrawal symptoms, should also soon be available in Côte d’Ivoire.
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