The persistent and increasing outbreaks of violence against members of the gay community in Africa are jeopardising efforts undertaken to combat HIV, both within this group and across the population as a whole, AIDS activists warned at a recent meeting in Limbé, Cameroon.

The extreme vulnerability of members of the gay community to HIV on the continent was highlighted during the meeting, initiated by the French non-governmental organisation, AIDES, and its partners, which took place at the beginning of July in the south west of Cameroon and brought together many AIDS activists from Francophone African countries.

On average it is estimated that HIV infection rates amongst MSM (men who have sex with men) are four to five times higher than the population overall, with highs in certain areas.

In Bamako, the capital of Mali, screening tests carried out on a few hundred MSMs revealed that the infection rate was around 37 per cent, according to ARCAD-SIDA, an organisation in Mali that supports people living with HIV/AIDS. Official statistics set the national infection rate of the population at 1.3 per cent.

In Senegal, a survey carried out in 2005 showed that 21.5 per cent of MSMs in the capital, Dakar, were infected with HIV, compared to a national prevalence rate estimated by the authorities at 0.7 per cent.

The 2007 “Off the map” report, which was produced by the International Gay and Lesbian Human Rights Commission (IGLHRC), an American organisation that defends the rights of homosexuals, highlighted that “the vulnerability of same-sex practicing men and women is not due to any biological predisposition, but is the result of an interlocking set of human rights violations and social inequalities that heighten HIV risk”.
Criminalisation of homosexuality

According to IGLHRC, 38 of the 53 countries in Africa still consider homosexuality as an offence punishable by sentences ranging in severity up to imprisonment.

This is the case in Cameroon, where 11 people were put in prison in 2007 for homosexual activity, according to the 2008 report of the human rights organisation Amnesty international. Due to lack of care, one of the men imprisoned died of an HIV/AIDS related infection a few days after his release.

Dr Steave Nemande, a doctor and the president of the human rights organisation Alternatives Cameroun, believes that by criminalising homosexuality “social homophobia is legitimised and it increases fear amongst MSM, who take further risks to live their sexual life in secret”.
In Senegal, homosexuality remains illegal, although in 2005 MSM were integrated into AIDS programmes. Here, the ‘manhunt’ and arrests that have taken place over the last few months, following photos of a gay festival being published in the local news, forced certain members of the MSM community to go into exile, and others, including those infected with HIV, to hide – therefore, giving up their treatment.

Even in countries with no legislation on homosexuality, such as the Côte d’Ivoire, MSM are far from able to claim their rights, noted Hervé Beuté, a member of Arc-en-Ciel+, an HIV/AIDS prevention association for MSM. “We are still fighting for [MSMs to have] access to health centres”.

Members of the community died from HIV/AIDS without receiving healthcare, after they were turned away by certain health facilities, he stated. He added that he had himself been “a victim of violence a few times” during prevention campaigns for MSMs.

Ill-informed communities

“On the continent, more and more MSMs are organising prevention campaigns, however, they will never be effective whilst they are being hunted down and/or imprisoned, or even excluded from official strategies to combat the pandemic”, said David Monvoisin, a member of Africa Gay – a group fighting against AIDS within homosexual communities – also working with the French NGO, AIDES.

Philippe (last name withheld) is being monitored by a centre providing free information and care for MSM, which was opened very recently by Alternatives Cameroun in Douala, the large city port.

He decided to risk revealing his sexual orientation and his HIV positive status to give others something to hold on to, “in the hope that this will serve as an example for others so that there is more discussion about the illness between [MSMs] and health professionals”.

Such initiatives are indispensable, because many MSM “are not educated and ignore all or nearly all prevention methods”, said Aboubakar Dabo, a member of ARCAD-SIDA, in Mali. According to a survey carried out in 2006 by this organisation, 77 per cent of the MSMs questioned had had unprotected intimate relations.

“Many MSM told us they were sure that there was no risk of infection with anal penetration”, said Yves Jong, coordinator of Alternatives Cameroun’s sexual health and prevention unit.

Dangerous clandestine existence

Even when MSM are aware, their exclusion from the majority of health policies on the continent means that it is difficult for them to obtain what they need to protect themselves from infection. The most frequent problem is access to lubricating gel, explained Monvoisin. “Many [MSM] use butter or oil, but unfortunately this damages condoms.”

The clandestine existence that gay communities are forced to hide away in exposes them not just to the risk of HIV, but the rest of the population too: because they are unable to live openly as gay men, many MSMs also have sexual relations with women, or are even married, activists have highlighted.

In Mali, “the majority of homosexuals – 88 per cent according to a study – are bisexual, which increases the spread of the disease”, said Dabo.

African governments must, therefore, act as quickly as possible and protect these vulnerable groups in the interest of the population as a whole, urged participants at the meeting in Cameroon.

“As long as [MSMs] are ignored, all efforts undertaken in the world to combat AIDS will be destined to fail”, concluded Joël Nana, from IGLHRC’s African office.

IRIN

In response to the inflow of Chadian refugees into Cameroon’s northeastern town of Kousséri earlier this month, 5,523 persons have already been relocated to a newly equipped camp in the village of Maltam, while an estimated 10,000 more are expected to join them in the coming weeks.

“At one point, we had at least 30,000 refugees in the country, but many have returned to Chad,” said Sophie de Caen, United Nations Resident Coordinator for Cameroon. “At present, along with the Cameroonian authorities, we plan to continue providing assistance and protection to an estimated 15,000 refugees, until they feel comfortable enough to return home,” she stated.

The refugees, who started to arrive on 2 February when fighting erupted in the Chadian capital N’Djamena, were initially hosted in two temporary sites in Kousséri, as well as in local schools, churches, and private homes. “We have immediately started equipping a camp in Maltam, 32 km away,” explained Jacques Franquin, Representative of the Office of the United Nations High Commissioner for Refugees (UNHCR) in the country. “The camp will enable us to provide assistance and protection in the best possible way,” he added.

The first refugees arrived in Maltam on 16 February, and more are being offered transport from Kousséri to the camp every day. The camp has already been equipped with 1,060 family tents, two boreholes, and 226 latrines – the latter funded and constructed by the International Federation of Red Cross and Red Crescent Societies (IFRC). All refugees relocated to Maltam have already received essential non-food items (NFIs) from UNHCR, such as plastic sheeting, sleeping mats, blankets, mosquito nets, jerry cans, cooking stoves, soap, and sanitary items.

The transport operation and the equipment of the Maltam camp, as well as the aid and protection provided there, are largely possible thanks to a grant of $4.7 million from the United Nations Central Emergency Response Fund (CERF) to six United Nations entities involved in the operation.

“So far, we have completed five general food distributions, targeting all refugees newly arrived in Maltam,” said Abdoulaye Baldé, acting Representative of the World Food Programme (WFP) in the country. He added that a total of 28 metric tonnes (MT) of food was distributed, due to last until the next distribution planned for 03 March. The WFP is also providing logistic support for the operation, especially in terms of transport and storage of aid supplies.

As the refugees reached Maltam, nutritional screening started under the leadership of the United Nations Children Fund (UNICEF), the Red Cross Movement, and Médecins Sans Frontières (MSF) from several countries. “About 25 cases of moderate malnutrition and nine of severe malnutrition were identified, and we are working to address these,” said Christyne Bahringer, a UNICEF spokesperson in Cameroon. “Following successful completion of vaccinations against measles and poliomyelitis on 17 February in Kousséri, a campaign against meningitis is also due to start this Thursday, in the Maltam camp and its surroundings,” she added.

The UNICEF has also concluded a cooperation agreement with the non-governmental organization (NGO) Action Aid, in order to provide recreational and educational opportunities for children in the Maltam camp.
While the Chadian refugee emergency in Cameroon is now under control, the United Nations remains gravely concerned about the continued humanitarian crisis in eastern Chad. “There are over 250,000 Sudanese refugees and over 180,000 internally displaced persons [IDPs] in eastern Chad, the vast majority of whom are heavily reliant on humanitarian aid for their survival,” said Eliane Duthoit, head of the Office for the Coordination of Humanitarian Affairs (OCHA) in Chad. “Our life-saving operations in eastern Chad have continued despite the recent deterioration in the security situation. We must ensure that they are never interrupted, as the current crisis could otherwise turn into a humanitarian disaster,” she added.

The United Nations has announced today the allocation of $4,720,260 from the donor-supported Central Emergency Response Fund (CERF) to meet the humanitarian needs of Chadian refugees who fled to Cameroon’s north-eastern town of Kousséri earlier this month.

“Thanks to these funds, the United Nations will be able to assist and protect thousands of refugees over the coming weeks,” said John Holmes, United Nations Emergency Relief Coordinator (ERC) and Under-Secretary-General for Humanitarian Affairs.

The allocation includes grants of $1,687,843 to the Office of the United Nations High Commissioner for Refugees (UNHCR), which leads the operation, $1,654,482 for the World Food Programme (WFP), $843,053 for the United Nations Children Fund (UNICEF) for six different projects, $330,630 for the World Health Organization (WHO), and $82,040 for the United Nations Population Fund (UNFPA). In addition, $122,212 has been allocated for the United Nations Department of Safety and Security (UNDSS) to ensure the operation’s safety.

“These grants are vital for funding our humanitarian response,” said Sophie de Caen, United Nations Resident Coordinator in the country. “In many instances, we had diverted funds and stocks from other activities. We will now be able to respond to the emergency in a systematic manner,” she added.

“With the funds granted to UNHCR, we intend to cover assistance for up to 20,000 refugees in Kousséri, and to relocate and register an estimated 15,000 of these refugees to a camp in the village of Maltam,” stated Jacques Franquin, Representative of UNHCR in Cameroon. “The camp, located 32 kilometres from Kousséri, is currently being equipped, and it started receiving the first refugees on 16 February,” he explained.

The UNHCR’s activities covered by the grant include the provision of emergency assistance to all refugees, the transport of refugees to Maltam and their registration, and the establishment of the camp in Maltam, including shelter facilities as well as two boreholes. The funds also enable UNHCR to procure basic non-food items (NFIs) such as plastic sheeting, sleeping mats, blankets, mosquito nets, jerry cans, cooking stoves, soap, and sanitary items.

The WFP will use its grant to procure and deliver food aid to the refugees and to provide essential logistic support such as transport and storage of supplies. The UNICEF’s six projects include immunisations, maternal and neo-natal care, child nutrition, water and sanitation, and child protection, as well as recreational activities to ensure the well-being of refugee children. The WHO will be able to provide health care to the refugees, while UNFPA will carry out activities for reproductive health and against gender-based violence (GBV).

The Chadian refugees, most of them from the capital N’Djamena, started to cross the border into Cameroon on 2 February, when armed fighting erupted in Chad. At least 70 percent of them are women and children. Together with the Government of Cameroon, UNHCR and other United Nations agencies have already responded to the most urgent life-saving needs of all refugees. The International Federation of Red Cross and Red Crescent Societies (IFRC) and non-governmental organizations (NGOs), particularly Médecins Sans Frontières – Switzerland (MSF-CH), have played an important role in the response so far.

Approved by the United Nations General Assembly in December 2005 as a successor to the Central Emergency Revolving Fund, the CERF aims to save lives by providing a more predictable and timely response to humanitarian emergencies. For 2008, 67 United Nations member states, as well as foundations and corporate and individual donors, have already committed nearly $420 million to the CERF. All United Nations agencies as well as the International Organization for Migration (IOM) can access CERF funds within 72 hours of a crisis. This enables them to save lives, especially during the earliest stages of a disaster, by immediately focusing on quick life-saving assistance.

Traffic jams and urban bustle have returned to main towns and cities in the west and centre of Cameroon, belying the violence that just weeks earlier left many people there dead and a general population so scared most did not leave their homes for several days.

Yet human rights groups remain concerned that the government is employing heavy-handed tactics in clamping down on the media and arresting and imprisoning hundreds, possibly thousands, of youth who they say are not receiving due process.

“The arrests [of those accused of taking part in the violence] continues,” human rights advocate Madeleine Afité, of House of Human Rights, told IRIN

The number of arrests is in dispute. A government spokesmen said the total is around 1,500 but Afité said the number is much higher. “Around 2000 people were arrested in Douala alone,” she said.

A lawyer in Yaoundé, Me Francis Djonko, told IRIN that those arrested are not receiving due process. "The accused should have at least three days to prepare their defence but that is not being respected in the cases I have had to defend,” he said, adding some of the accused have already receiving prison sentences of up to three years.

A source close to Cameroon’s President Paul Biya said that some members of the government are suspected of fermenting the violence and may soon by taken into custody. President Biya went on state media on 27 February during the rioting to say that “certain politicians” were seeking to overthrow his government in a coup d’état.

Figures on the number of dead also remain unclear. The government spokesperson Jean-Pierre Biyiti Bi Essam told the French Agency Press (AFP) on Wednesday that only 24 people had been killed but human rights groups say the number is far higher.

“We are still trying to cross-check information but we can already say that a hundred or so people must have died,” Afité said.

International media monitoring groups have accused government of censoring the media and beating and intimidating journalists as well as confiscating their equipment.

The government has also closed down at least three media houses but denies that it is part of a general effort to censor the press. “[The media houses] either carried out certain broadcasts which are insensitive, provocative, or controversial and obviously certain administrative decisions have been taken in order to ensure that these broadcasts do not endanger the stability or social order,” government minister Elvis Ngolle Ngolle told Voice of America.

The riots started in the economic centre Douala in the west of Cameroon on 25 February, and quickly spread to the political capital Yaoundé and other cities as youths protested against rising fuel and food prices and efforts by President Biya to change the constitution so that he could run again in the 2011 elections.

As refugees began moving from the northern Cameroonian town of Kousseri to a more permanent site in Maltam some 32 kilometres away this week, services and facilities were being rapidly prepared to accept them but conditions remain extremely basic.

Refugees, most of whom fled Chad at the beginning of February when anti-government rebels launched an attack on the capital N’djamena, started being trucked to Maltam on 16 February.

“It is very cold at night,” said Esther Deborah, who arrived with her three children, echoing concerns expressed by many refugees about conditions in the windy camp which is on a flat piece of land buffeted by dust storms during Cameroon’s dry season.

Tents for an initial 800 people were already in place, and there are plans to expand the camp, the UN refugee agency (UNHCR) said. Ely Salem, a World Food Programme official, told IRIN that 4,500 families had expressed interest in moving to Maltam. So far around 2,400 refugees have been registered at the camp.

Conditions remain difficult

Because the camp is far from town, some were also concerned by the lack of food stuffs available to buy and sell—particularly fresh fish and vegetables. “They gave us rice, grain, oil, and biscuit,” Bambaye Ramaud, age 43, told IRIN. “But without the sauce [which adds flavor], how can I convince my children to eat it?”

Others who had made a basic living with petty commerce in the bustling border town Kousseri in the preceding week are discouraged that they have not found the same opportunities in Maltam.

Each family registered at Maltam has received a 14 day supply from aid agencies that includes rice, grains, mosquito nets, kitchen sets, lamps, water containers, blankets, and floor mats.
Still staying

Many refugees still said they would remain in Cameroon, for fear that security had not yet returned to Chad’s capital.

UNHCR representative Jacques Franquin said in a statement on 12 February that the agency expects around 20,000 Chadians to stay in Cameroon “for the medium term”.

Youths in particular, who were reportedly being forcibly recruited into the Chadian army and by rebels, seemed especially concerned about their futures back in N’djamena.

“Everything looks good to me here because I feel better,” 25-year-old Aldombaye Ngara, a student in his third year of university back in Chad told IRIN. “I fled because of the war, and because of the security… I will go back when the political situation changes.”

Stability is returning to N’djamena, and returns are continuing. However, should another disturbance push more refugees over the border, many UN and non-governmental organisations have set up offices in Kousseri.

“We are even better prepared now than previously,” Sophie de Caen, the UN Coordinator for Cameroon, told IRIN. “Now if refugees came, they would be moved immediately to the permanent site in Maltam.”

Most of the 45,000 Central African Republic (CAR) refugees living in eastern Cameroon are diseased, malnourished and generally in bad health, non-governmental organisation (NGO) and UN workers say.

Since 2005 the Mbororo pastoralists of western CAR have been fleeing child kidnappings and violent attacks - including throat-slitting - by masked bandits whose identities remain unknown.

The refugees arrive “very weakened, after long days of walking and a lot of stress and they live in very difficult conditions”, Eric Grimaldi of Médecins Sans Frontières (MSF) told IRIN.

Once settled in some 60 villages in eastern Cameroon, their health does not improve significantly. For every 10,000 people, there are between three and seven deaths per day among the refugees. According to MSF, the situation is particularly bad in the village of Ngaoui in Adamaoua Province, home to 5,000 refugees and receiving 100 new refugees a month.

“[The refugees] suffer from malnutrition, typhoid and amoebic diseases,” said a nurse in a missionary hospital in the small eastern town of Letta. “The health of the refugees is really very bad… And they always arrive in a critical state to begin with.”

Rare paralytic disease

According to the UN Children’s Fund (UNICEF), 17.2 percent of refugee children under five are malnourished.

MSF has registered several cases of tuberculosis and about 50 cases of a rare paralytic disease called `konzo’. Known as “the disease of the poor”, it results from exclusive consumption of the bitter manioc plant, which, though inexpensive, is poor in vitamins and nutrients. Manioc also contains salt cyanide, which can be toxic if improperly cooked. The result can be irreversible paralysis of the lower limbs, as well as hearing and sight problems.

“We have met families where several children are now paralysed,” MSF’s Grimaldi said, adding that the Cameroonian authorities do not have the material or human resources to prevent the disease and very few doctors know how to treat it.

Difficult to access nutritional centres

The nutritional situation was “so alarming” according to MSF, that in July the UN Refugee Agency (UNHCR), the World Food Programme (WFP), MSF and another aid agency, CARE, in collaboration with the Cameroonian Public Health Ministry, began monthly food distributions.

Five nutritional centres have also been created, but refugees have settled over such a wide area that “[they] have trouble getting to the centres,” the head of UNHCR in Cameroon, Jacques Franquin, told IRIN. “Plus, it’s hard for a mother to stay at a nutritional centre for a month with one of her children while leaving the others at home.”

The refugees have limited access to healthcare, largely because of the bad roads and ill-equipped health centres.

Refugees lack water

Many refugees are equally confronted by a lack of water.

“It takes us six or seven hours to find water,” said Aladji Abdoulaye Gidjo Gargain, father of a refugee family in Borongo, about 450km northeast of Yaoundé. “When we were in CAR, we didn’t have this problem.”

“The arrival of the refugees created imbalances,” explained UNHCR’s Franquin. “They don’t always have access to the wells of the Cameroonians.” Either they cannot afford to pay or there is not enough to share, he said.

The UNHCR has built 15 new wells, but 10 times more are needed.

“Many water points in the region have already run dry, and the dry season hasn’t even started yet,” MSF’s Grimaldi said.

Traumatised

He added that many refugees were still affected by the attacks and kidnappings that they experienced. “We realised that many children refused to eat because they were traumatised by what they had seen and lived [through].”

Unfortunately, Grimaldi said, no one has taken the time - or has the time for the moment - to treat these psychological problems.

Cameroon’s ministry of health has declared that antiretroviral drugs have been made free to anyone eligible as part of a national distribution programme.

The decision, made public by health minister Urbain Olanguena Awono in the capital Yaoundé during a press conference, is part of the 2006-2010 national strategic plan to combat AIDS. The minister stated that the aim is to make ARV’s accessible to 75 percent of adults and 100 percent of children requiring this treatment by 2010.

First-line and second-line ARV’s, which are distributed to all public and private hospitals across the country, will be free, as will treatments for opportunistic infections related to HIV/AIDS. Olanguena Awono stated that, in due course, 43,000 adults and 4,000 children will have access to the ARV’s.

According to official statistics, more than 30,000 people currently take these drugs in Cameroon, at a price of 3,000 and 7,000 CFA francs (US$6 and 14) for first-line and second-line treatments respectively. According to the United Nations, 5.4 percent of Cameroon’s 16 million people are living with the virus, one of the highest prevalence in West and Central Africa.

The minister stated that it had been made possible to distribute drugs for free thanks to subsidies from the Cameroonian government and financial backing from partners including the Global Fund to Fight HIV/AIDS, TB, and Malaria, the Clinton Foundation and Unitaid, the international initiative to finance medicines in poor countries, which Cameroon signed up to at the beginning of 2007.

According to the Cameroonian health ministry, the cost of providing free ARV’s has been estimated at 5.5 billion CFA francs (US$11.5 million) for 2007 alone.

The decision, made by the Cameroonian government, follows an announcement in January that HIV screening tests will be free for vulnerable people, including pregnant women, children under 15, school children and students, patients suffering from tuberculosis (the main opportunistic infection linked to HIV), and people in prison.

Although organisations supporting people living with HIV in Cameroon welcome the move to make ARV’s free, they are cautious about the impact of this measure.

“We are not turning our nose up at the decision, this is very good news for people living with HIV,” Nathalie Machoussi, the Executive Secretary of the Cameroonian network of organisations for people living with HIV (Recap+), was quoted as saying in Mutations, a daily newspaper. She added that organisations fighting to combat AIDS have been pushing for this measure for a long time.

However, Machoussi emphasised the need to “geographically decentralise medicines which are not available everywhere.” Although the treatments have been made available for free, “ill people would have to continue to pay often exorbitant transport costs [to get to the treatment centres],” she said.

Machoussi also raised concerns about the possibility of ARV stocks running out. “When the ARV’s were sold, the problem of stocks running out existed. Now that they are free, everyone will come to claim them and this will be difficult if no measures have been put in place”.

Once patients have started taking the ARV treatment, they must take if for life. If there are any interruptions to the therapeutic protocol, the patient is exposed to the risk of developing resistance to the medicine and will have to resort to more recent and expensive ARV’s.

In response to these concerns, Olanguena Awono confirmed that an inventory of ARV stocks for treating opportunistic infections will be carried out before the 30 of April.