Senegal's recipe for success

Early mobilization and political commitment keep HIV infections low

By Mamadou Mika Lom in Dakar

Senegal is one of the countries cited as an example in the struggle against AIDS in Africa. Since its first confirmed case in 1986, the prevalence rate of HIV infections among adults has been kept at between 1.77 and 1.74 per cent. Around 80,000 adults and children are infected, out of a total population of 9 million.

The reasons for this success against the spread of the virus lie in Senegal's early response to the disease, vigorous preventive action, care of AIDS patients and the mobilization of people at all levels, including teachers, soldiers, women, religious leaders and non-governmental organizations (NGOs). Senegal's long experience with democracy and its freedom of the press also made it possible to openly discuss the problem and easily get out information about the disease.

Profile: AIDS in Senegal
People living with HIV/AIDS (1999)	79,000
of which:
women (15-49 years old)	40,000
men (15-49)	35,700
children	3,300
Adult HIV prevalence rate (%)	1.8
Estimated AIDS deaths to 1999	7,800
Children who have lost one or both parents	42,000
Source: UNAIDS, UN Economic Commission for Africa, AIDS in Africa: Country by Country, 2000.

In 1970, well before the discovery of the first AIDS case, the government already had initiated a policy for managing blood transfusions. It was strengthened after 1986 through the systematic screening of donated blood. And to better keep the disease from spreading among prostitutes, the health authorities very early established a system for addressing their health needs, as well as a programme against sexually transmitted diseases.

Bonds of trust were forged early on between medical experts and government officials, who were convinced of the stakes involved, and allocated budgetary resources to fight the disease. They launched a national committee to combat AIDS in October 1986.

Aware that all these initiatives would have only a limited impact if they were not accompanied by other measures, health officials in 1988 launched a national campaign aimed at women and young people, particularly students. Teaching modules on the links between AIDS and other sexually transmitted diseases were made part of school curricula. These target groups in turn helped to raise the awareness of other especially vulnerable and high-risk groups of the population, such as prostitutes and migrant workers.

Senegal was also among the first countries in Africa to take advantage of the new opportunities to gain access to anti-retroviral medicines, to care for those who have become infected. The average cost of basic medicines for treating AIDS-related diseases has been reduced by 90 per cent. In addition, President Abdoulaye Wade has committed the government to doubling the amount needed for anti-retrovirals, from CFA 250 mn to CFA 500 mn (about $700,000) per year.

Peer education

In support of these programmes, the interventions were decentralized at all levels by establishing numerous awareness-raising projects among community organizations, especially cultural and sports associations and women's groups. Centres for young people were set up in different regions, to promote the use of condoms and "peer education," in which young people knowledgeable about AIDS talk primarily to other young people.

"This method has the advantage of getting around the obstacle of sexual taboos" and the reluctance of youth to talk about sex in front of adults, says Ms. Ami Seck, a high school student belonging to the sports and cultural association in Louga. "Among themselves, young people are able to say everything, looking each other in the eyes, without any qualms."

The overall formula in the schools, notes Ms. Seck, is that "the teachers speak to the students, and then they in turn talk to people their own age and to members of their neighbourhood associations." A similar system is used with women's associations.

Religious leaders in the forefront

About 95 per cent of Senegal's population is Muslim and 4 per cent Christian. Religious authorities, both Muslim and Christian, have been very actively engaged in the battle against AIDS. They have organized workshops and conferences, of which the most important was an international colloquium on "Religion and AIDS" held in Dakar in 1997, with the participation of representatives of Islamic, Christian, Buddhist and other religious communities from around the world.

From the outset, the Muslim leaders have refused to talk about condoms, preferring instead to emphasize in their sermons fidelity and abstinence as the best means for preventing the disease. They do not, however, exclude the possibility of a couple using condoms if one of them is infected. They also have done successful work in countering discrimination against infected people, some of whom previously had been rejected by their close families and communities.

Changing the behaviour of people is most important, stresses Mr. Bamar Guèye, coordinator of the Islamic NGO Jamra (Arabic for "embers"). "We have always insisted on the moral quality of the individual in our messages," he says. It was Jamra that succeeded in mobilizing the khalifs (spiritual leaders) of the main Islamic brotherhoods of Senegal to openly discuss the problem of AIDS.

Sida Service, a Christian NGO, also is heavily involved in the fight against AIDS. It is the only NGO to operate a centre that conducts free and anonymous screening for AIDS. Executive Secretary Paul Sagna acknowledges that his group does not reject the use of condoms, but most often advises "abstinence and fidelity."

Risky cultural practices

According to Ms. Bineta Bocoum, an official of the health education office in the Louga region (which has a high concentration of people who are HIV-positive), it is very difficult at the moment "to say who, among men and women, are the most infected with the disease in Senegal." Ms. Bocoum, who also is an active member of the Society for Women Against AIDS in Africa, adds that it is particularly risky to specify infection rates among prostitutes. While "official" prostitutes are well monitored and well educated about the disease, others practice the trade more clandestinely. Nevertheless, she is encouraged by the fact that information about the disease has been widely disseminated by NGOs and women's, youth and religious associations.

One problem, however, is that many of the cultural practices that are prevalent in Senegal may serve to propagate the spread of the disease. These include the levirate, in which a man is obligated to take as his wife the widow of a deceased brother, or the sororat, in which a woman marries the spouse of her late sister. Polygamy and excision (female genital mutilation) also are widely practiced. Fortunately, the involvement of religious leaders in raising awareness about AIDS has contributed to reducing such practices. As some of these authorities now emphasize, no one should be obliged to marry if it "runs the risk of losing your life."

Soldiers well-equipped

Army soldiers are regarded as the biggest consumers of condoms in Senegal. This is because special steps have been taken to raise the awareness of troops, in order to prevent the spread of AIDS. The success at this level lies with the fact that Dr. Souleymane Mboup, a colonel in the army's medical corps, has himself been deeply involved in research on the disease. He was part of the effort to isolate HIV-2, a particular strain of the malady discovered in Senegal, and he has received numerous distinctions for his research.

Generals in the Senegalese army often receive training about AIDS from military doctors, and in turn are expected to raise the awareness of their troops and the troops' families. During every peacekeeping mission involving Senegalese contingents, explained a military doctor, "the troops are well-educated about the disease and given sufficient numbers of condoms." While on mission, these troops also regularly undergo examinations and screening, the same source indicated.

Among private businesses, the emphasis is on preventive action. This is especially the case in the country's big enterprises, such as the Industries chimiques du Sénégal, a phosphate mining and processing complex in Thiès, and the Compagnie sucrière sénégalaise, a sugar plantation and milling enterprise in Saint-Louis. According to Mr. Papa Nalla Fall, a leading employers' representative, "everything is being done to safeguard workers from the disease."

"Since businesses are not isolated from society," says Mr. Fall, "it is therefore necessary to be concerned with the employee's immediate environment, and beyond that, with the entire community to which he belongs, to avoid eventual losses of time and money for the enterprise."

Mr. Fall took part in the December 2000 African Development Forum organized by the UN Economic Commission for Africa, which focused on the AIDS crisis. At the forum, he urged the reduction of developing countries' debts, so that they can devote more resources to the fight against AIDS. Upon his return to Senegal, he and other private employers initiated a series of seminars to stress the importance of disseminating information on AIDS within businesses.

A stable infection rate

In the 17 years since Senegal's first AIDS case was diagnosed, the HIV infection rate has been kept stable. Of the 80,000 or so Senegalese living with the virus, about 3,000 are children. Initially, there were about four infected men to every infected woman, but now the ratio is about equal.

According to medical experts, prostitutes, or "sex workers," are the group most exposed to the disease. Their prevalence rate is between 12 and 15 per cent. Dr. Ibra Ndoye, director of the National Programme Against AIDS and head of a major AIDS treatment and research centre at Fann Hospital in Dakar, notes that this rate compares favourably with the average for prostitutes in Africa, about 50 per cent of whom are believed to be infected. "The rate of infection of prostitutes is not alarming in Senegal," he maintains, adding that since 1988 the rate of new infections among Senegalese prostitutes has not changed. He attributes this to effective work on monitoring the population in general, and sex workers in particular.

The overall infection rate may climb somewhat over the next few years, but according to Dr. Ndoye, the goal is to not exceed 3 per cent between now and 2005.

"The greatest difficulty that we are now confronting," says Dr. Ndoye, "is the problem of access to medicines, whose prices still are too high for those who are sick." Another difficulty is the lack of information among doctors responsible for dealing with the disease. "AIDS is a new illness that requires a new approach among specialists involved in treating it," he says. Therefore better training and more medical personnel are needed to mount an even more effective response against the spread of the virus.

*****Box 1***** Health minister and AIDS specialist Dr. Awa Marie Coll Seck, a specialist in HIV/AIDS and other infectious diseases, was named Senegal's new minister of health and prevention on 12 May. She has long been active in AIDS education and prevention activities, working with Senegal's national committee against AIDS since its formation in 1986. Three years later she launched a non-governmental organization dedicated to highlighting women's particular vulnerability to AIDS, and directed the group until 1996. She subsequently joined the staff of the Joint UN Programme on AIDS (UNAIDS) in Geneva, before taking on her new duties as minister. Dr. Seck's appointment is noteworthy in several respects. Until recently, it has been rare for health professionals to actually attain ministerial office, a rank usually reserved for influential political figures. Like a number of other "civil society" ministers in the new government, which was formed in the wake of the 29 April legislative elections, she does not belong to any party. She also is one of a record number of six women in the cabinet, including Prime Minister Mame Madior Boye.

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