Decentralised HIV/AIDS services are slowly being rolled out with the backing of donors and the government, but in many remote areas of this huge country (nearly 1.3 million square kilometres, with a population of less than 10 million), these have yet to become a reality.

In Danamadji, an area in the southeast of Sahr, the third largest city in Chad, near the border with the Central African Republic (CAR), the poorest people cannot afford an HIV test that should be free, said Randjita Beoudoum, 42, coordinator of the United Association for Sustainability and Action for Positive Life (UPAV+), a network of HIV-positive people.

"There is no electricity, so when someone wants a test we ask them to pay 150 CFA francs [US$0.33] because we need fuel to start up the generator set," said Beoudoum, who has been living with the virus for about 20 years. "We've appealed on radio until we're blue in the face to at least get a mobile testing centre, but nobody comes to help."

UPAV+ has around 400 members in the region and assists people with HIV/AIDS, most of whom live in villages in the bush. "We do home visits in each village, using our cow-drawn cart, and ... if [a patient] cannot stand up, we pick them up ... When we have two or three people we set off for the hospital in Sahr," he told IRIN/PlusNews.

It takes a day and a half to cover the 125km between Danamadji and Sahr, the only town in the area where antiretroviral (ARV) drugs are available. "We [can] lose people along the way because they are too [weak]," Beoudoum said. His organisation lost five people in 2007.

The journey can also be dangerous. "There are lots of elephants in the region and they can attack you. To escape from them we have a sound system on the cart and we put music on really loud to scare them off into the forests," he said. "Once, when we didn't put the music on, the elephants attacked us. We abandoned the cows and ran. People from the villages came to our rescue."

The "axis of death" in the south

With HIV infection rates as high as 9.8 percent (compared to 3.3 percent nationally), the south is one of the areas worst affected by the epidemic. A road that many Chadians call the "axis of death" runs for hundreds of kilometres from the CAR to N'Djamena, capital of Chad, through the oil-producing regions of the south.

The strong economic activity attracts traders and people from other countries, but also brings an increased risk of spreading HIV/AIDS in an area where treatment services are scarce, according to AIDS workers.

Denial and ignorance in other regions

The situation is not any easier for patients in Oum-Hadjer, administrative centre of the central Batha-est region. Those needing ARVs or CD4 tests (to assess the immune system's resistance) have to travel to Abéché, around 150km to the east. Most of these patients live in extreme poverty.

"ARVs are free now [since 2007] but this is theoretical for us because it costs 5,000 CFA francs [$1.00] to do the return journey to Abéché. On top of this you have to pay for accommodation, food, and treatments for opportunistic infections. Few make the journey," said Giscard Sirrobe Ignabaï, president of ANNIDAL, which means "combat" in Arabic, a youth association for people living with HIV, established in March 2007.

"When we come across someone who is sick and weak, and we still have some money left in the organisation's fund, we help them with their medical treatments," he said. In spite of their efforts, he felt that the huge obstacles to obtaining treatment were causing the health of HIV-positive people to decline and their life expectancy was falling.

In the largely Muslim eastern and northern areas of Chad, AIDS organisations have noted that it is much more difficult to raise awareness of issues linked to sexuality and AIDS.

"It seems that people ignore the fact that bad things happen," said Sirrobe Ignabaï. "For many people here, it is blasphemous to speak of sexuality and AIDS. We are trying to raise alarm bells, but people refuse to listen to us."

Of the 16,415 people screened across the country in 2006, only 3 percent took the test in the east and north, compared to 66 percent in the south and 31 percent in the capital, according to official statistics.

Difficulties recognised

The government has also found it difficult to decentralise healthcare. Besides problems with the management of HIV/AIDS funding from the World Bank and the Global Fund to Fight AIDS, Tuberculosis and Malaria, which led them to suspend funding for many months during 2006 and 2007, and delayed the expansion of HIV/AIDS services in the provinces, Chad is also struggling with a lack of health workers.

"There are no more than 300 doctors in the whole country and less than 200 of them have received ARV prescription training," said Dr Djouater Barou, coordinator of the National Programme to Fight AIDS (PNLS). "And they are not everywhere: at the general hospital in N'Djamena there are thirty-odd, but in certain areas [of the provinces] they only have one."

To alleviate staff shortages and inadequate training in the provinces, PNLS and its partners have started training nurses to write repeat ARV prescriptions, while those managing ARV stocks will be trained this year.

PNLS is also attempting to combat myths about the illness and develop infection prevention programmes in high-risk areas of the south, and in the isolated areas of the east and north, which are most exposed to insecurity due to tensions with neighbouring Sudan.

Decentralised HIV/AIDS services are slowly being rolled out with the backing of donors and the government, but in many remote areas of this huge country (nearly 1.3 million square kilometres, with a population of less than 10 million), these have yet to become a reality.

In Danamadji, an area in the southeast of Sahr, the third largest city in Chad, near the border with the Central African Republic (CAR), the poorest people cannot afford an HIV test that should be free, said Randjita Beoudoum, 42, coordinator of the United Association for Sustainability and Action for Positive Life (UPAV+), a network of HIV-positive people.

"There is no electricity, so when someone wants a test we ask them to pay 150 CFA francs [US$0.33] because we need fuel to start up the generator set," said Beoudoum, who has been living with the virus for about 20 years. "We've appealed on radio until we're blue in the face to at least get a mobile testing centre, but nobody comes to help."

UPAV+ has around 400 members in the region and assists people with HIV/AIDS, most of whom live in villages in the bush. "We do home visits in each village, using our cow-drawn cart, and ... if [a patient] cannot stand up, we pick them up ... When we have two or three people we set off for the hospital in Sahr," he told IRIN/PlusNews.

It takes a day and a half to cover the 125km between Danamadji and Sahr, the only town in the area where antiretroviral (ARV) drugs are available. "We [can] lose people along the way because they are too [weak]," Beoudoum said. His organisation lost five people in 2007.

The journey can also be dangerous. "There are lots of elephants in the region and they can attack you. To escape from them we have a sound system on the cart and we put music on really loud to scare them off into the forests," he said. "Once, when we didn't put the music on, the elephants attacked us. We abandoned the cows and ran. People from the villages came to our rescue."

The "axis of death" in the south

With HIV infection rates as high as 9.8 percent (compared to 3.3 percent nationally), the south is one of the areas worst affected by the epidemic. A road that many Chadians call the "axis of death" runs for hundreds of kilometres from the CAR to N'Djamena, capital of Chad, through the oil-producing regions of the south.

The strong economic activity attracts traders and people from other countries, but also brings an increased risk of spreading HIV/AIDS in an area where treatment services are scarce, according to AIDS workers.

Denial and ignorance in other regions

The situation is not any easier for patients in Oum-Hadjer, administrative centre of the central Batha-est region. Those needing ARVs or CD4 tests (to assess the immune system's resistance) have to travel to Abéché, around 150km to the east. Most of these patients live in extreme poverty.

"ARVs are free now [since 2007] but this is theoretical for us because it costs 5,000 CFA francs [$1.00] to do the return journey to Abéché. On top of this you have to pay for accommodation, food, and treatments for opportunistic infections. Few make the journey," said Giscard Sirrobe Ignabaï, president of ANNIDAL, which means "combat" in Arabic, a youth association for people living with HIV, established in March 2007.

"When we come across someone who is sick and weak, and we still have some money left in the organisation's fund, we help them with their medical treatments," he said. In spite of their efforts, he felt that the huge obstacles to obtaining treatment were causing the health of HIV-positive people to decline and their life expectancy was falling.

In the largely Muslim eastern and northern areas of Chad, AIDS organisations have noted that it is much more difficult to raise awareness of issues linked to sexuality and AIDS.

"It seems that people ignore the fact that bad things happen," said Sirrobe Ignabaï. "For many people here, it is blasphemous to speak of sexuality and AIDS. We are trying to raise alarm bells, but people refuse to listen to us."

Of the 16,415 people screened across the country in 2006, only 3 percent took the test in the east and north, compared to 66 percent in the south and 31 percent in the capital, according to official statistics.

Difficulties recognised

The government has also found it difficult to decentralise healthcare. Besides problems with the management of HIV/AIDS funding from the World Bank and the Global Fund to Fight AIDS, Tuberculosis and Malaria, which led them to suspend funding for many months during 2006 and 2007, and delayed the expansion of HIV/AIDS services in the provinces, Chad is also struggling with a lack of health workers.

"There are no more than 300 doctors in the whole country and less than 200 of them have received ARV prescription training," said Dr Djouater Barou, coordinator of the National Programme to Fight AIDS (PNLS). "And they are not everywhere: at the general hospital in N'Djamena there are thirty-odd, but in certain areas [of the provinces] they only have one."

To alleviate staff shortages and inadequate training in the provinces, PNLS and its partners have started training nurses to write repeat ARV prescriptions, while those managing ARV stocks will be trained this year.

PNLS is also attempting to combat myths about the illness and develop infection prevention programmes in high-risk areas of the south, and in the isolated areas of the east and north, which are most exposed to insecurity due to tensions with neighbouring Sudan.

Lowering the chances of an HIV positive mother passing the virus onto her child is a simple case of giving mother and baby one dose of the antiretroviral drug, nevirapine. Implementing a national prevention of mother-to-child HIV transmission programme, however, is far less simple.

"When the fight against AIDS began, children were not an issue, it was only adults," noted Dr Souam Nguélé Silé, a paediatrician at the National General Reference Hospital (HGRN) in N’Djamena, the capital and Chad’s national PMTCT coordinator. “Then the pandemic set in and [HIV-infected] children appeared, which made people stop and think. Today the demand [for PMTCT services] is very high.”

Chad's first PMTCT services were set up at HGRN in 2005, but it was only in 2006, that a PMTCT programme was properly launched, with funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria and with support from other partners, such as the United Nations.

Uncertain funding and staff shortages

Suspensions of HIV/AIDS funding by both the World Bank and the Global Fund, between 2006 and 2007, however, slowed down the expansion of PMTCT services. Funding has since been reinstated, but a lengthy healthcare workers strike in 2007 further interrupted services. For the four-month period of the strike, which was due to non-payment of salaries, women could not always access antenatal consultations, let alone PMTCT services.

Healthcare workers are, in any case, in short supply. Only around 20 gynaecologists, three quarters of whom work in the capital, serve a country of around 9.5 million inhabitants.

Perhaps the greatest obstacle preventing more pregnant women accessing PMTCT are the low numbers who give birth in hospitals. According to a 2004 national health survey, 43 percent of pregnant women attended an antenatal clinic at some point during their pregnancy, but only 13 percent delivered their babies in a medical facility.

“The women have reasons [for not coming]. Generally they say it is because they have to pay for consultations and they don’t have the means. The wait at the hospital also puts the women off,” explained Silé. “There is also another issue: in certain cultures, the women cannot be touched. It is very difficult.”

In 2006, only about 6 percent of the 170,000 pregnant women who visited antenatal clinics in the country’s six main towns were given information about PMTCT, according to official statistics. Of the 49 percent that agreed to an HIV test, 7.7 percent were HIV positive.

Dr Tharcienne Ndihokubwayo, who runs the HIV/AIDS programme of the UN Children’s Agency (UNICEF)in Chad, refuses to be daunted by these hurdles.

"We will never have enough, but you always have to start somewhere,” she argued. “First we are resolving the issue of service provision: providing training for staff in PMTCT, a testing laboratory and antiretrovirals (ARVs). We cover at least the women who come for antenatal consultations; we're not expanding our work, we are working with the women who come.”

“I am sure that with effective community work and by carrying through the PMTCT work, we will increase the number of antenatal consultations,” Ndihokubwayo told IRIN/PlusNews.

Still a lot of work to be done

A lack of regular medical check-ups for children born to HIV positive mothers is another consequence of inadequate healthcare workers and services. At HGRN, check-ups for such babies only take place on Thursdays.

"It is hard for some mothers as you have to be there at 7 in the morning to get a [consultation] ticket and if you are a bit late, your ticket gets redistributed,” said Claire M’Darangaye, who has an HIV-positive son. "Some mothers come from far away and haven’t got the money to pay for a taxi [to get there on time]...If your child’s life is important to you, the only solution is to arrive the day before and sleep outside the hospital, but without a mosquito net, you and your child are at risk of catching malaria.”

Silé is well aware of such problems, but has no solution. "I’ve got other sick children in the paediatric ward and there are only two of us - my assistant and myself - for all these children and the current 130 [HIV-exposed] children,” she said.

Although the number of health facilities providing PMTCT has increased from one in 2005, to 22 in 2007, covering 15 of the country's 18 districts, Silé commented that there is still a lot of awareness-raising work to be done. Outside of the capital, providing PMTCT services is even harder, she noted.

"The crucial problem is that women cannot do anything without their husband’s permission ... when women agree to take the HIV test, the men come and harass the healthcare workers," she said.

Source: PlusNews

People living with HIV in Chad risk becoming victims of the explosion of violence in the capital, N'Djamena, in early February. During clashes between the army and groups of rebels from the east of the country, health services were damaged and many organisations working to fight the epidemic were looted.

FOSAP, a social support fund that manages HIV/AIDS money from the World Bank and the Global Fund to Fight AIDS, Tuberculosis and Malaria, and AMASOT, a local social marketing organisation working to reduce HIV infections, did not escape unscathed: their offices were emptied of computer equipment, supplies and even furniture and doors.

"We had [just] installed computers to allow young people to go on various [internet] sites ... to get information on AIDS and STIs [sexually transmitted infections]," Dr Kadah Dokblama, internal controller and interim director at AMASOT, told IRIN/PlusNews.

"We have lost everything; they only left us boxes of condoms and Orasel [water for rehydration]," said one of the organisation's employees.

The National General Reference Hospital in N'Djamena, which provides HIV/AIDS services, was hit by artillery shells and automatic weapons fire during the fighting. Although the shots were not intentionally directed at the facility, the intensity of the fighting drove patients out of the hospital in panic and some did not return.

Insecurity is an ongoing obstacle to the fight against AIDS in Chad, which has an official prevalence rate of 3.3 percent. The country has experienced regular explosions of violence for several decades, distracting attention from anti-AIDS efforts, but over the last few years the political engagement of the authorities and the arrival of donors have made it possible for HIV/AIDS programmes to be launched.

"The government has made an incredible effort by trying to mobilise resources and including it [the fight against AIDS] in their budget ... [but] insecurity remains a constraint - it prevents decentralisation [of HIV/AIDS services]," said Claire Mulanga Tshidibi, UNAIDS country coordinator in Chad.

Enock Nodjikwambaye, FOSAP's administrative manager, is well aware of this problem. "Insecurity holds us back," he told IRIN/PlusNews. "We don't dare send staff [into risk areas], where we could lose people and vehicles. We have already lost one vehicle [stolen by armed fighters]; we cannot risk sending someone into a living hell."

He said around 240,000 Sudanese refugees and 180,000 displaced Chadians were living in the east of the country, but ongoing insecurity in the area was a major obstacle to the development of FOSAP's programmes.

"We finance an HIV/AIDS sub-project in Abéché [the main town in eastern Chad, about 150km from the Sudanese border] but we haven't got anyone to go and supervise it."

Some of the young people who seek help at the Youth Information and Orientation Centre for Reproductive Health (CIOJ) in N'Djamena, capital of Chad, do not understand how they became pregnant or contracted a sexually transmitted infection (STI). Workers at the centre blame the high levels of ignorance on the failure of parents to talk to their children about sex.

CIOJ was set up by a local non-governmental family welfare organisation, the Chadian Association for Family Well-Being (ASTBEF), to provide young people with a user-friendly family planning, STI and HIV service. The centre is supported by several international partners, including United Nations agencies and the International Planned Parenthood Federation (IPPF), of which it is a member.

Although principally aimed at youth between the ages of 15 and 24, boys and girls as young as 10 come to the centre in search of information and treatment. "At nine or 10 some young people have already had sexual relations, girls in particular," said Hassane Haoua, a project coordinator at ASTBEF.

"Pregnancies at this age are rare but there are young mums in the 14-to-15 age group." In the first half of 2007, the centre, located in a working-class area of N'Djamena, saw more than 3,000 young clients, most of them girls.

Young Chadians tend to have a very poor knowledge of sexual matters. "They often know how to protect themselves against HIV, and what puts them at risk of contracting it, but some of them have never heard of contraception," said Dada Nandeh, the centre's social worker. "They don't know how to recognise the symptoms of STIs, and the girls don't know how to manage their menstrual cycles."

Although abortion is illegal in Chad, and people caught performing it can face up to five years in prison, this does not prevent young girls who become pregnant from sometimes taking desperate measures to hide their condition from their parents. "The girls go and get illegal abortions and end up dying of a haemorrhage," said the centre's midwife, Célestine Dagaïe.

A taboo subject

The subject of sexuality is so taboo in Chad that often even the most basic reproductive health and hygiene issues are not discussed in the family home.
"It was even hard to tell my mum that I'd had my first period," said Ndari Gebbe, 22, who began visiting the centre in 2003 and is now a peer educator and president of the IPPF's Youth Action Movement (MAJ). "When I first had it, I knew what it was because I'd read about it in a women's magazine, but I didn't manage to tell my mum for two years."

By contrast, young people feel comfortable talking about such issues at CIOJ, said Gebbe. "I came here because I was isolated; I didn't know anything about STIs or HIV, and I didn't talk to anyone about it, even at school. Here even the youngest ones talk about it - they're not scared."

What the centre's young female clients tell her is sometimes difficult to hear. "I've listened to girls who are traumatised; girls who had sex at the age of nine - often cases of rape," she told IRIN/PlusNews. "The girls tell us their secrets, but if it's too much for us, we take them to the centre's social worker."

Gebbe believes the lack of parent-child dialogue is at least partly to blame for incidents of sexual abuse. "If parents don't tell their children what to be careful of, they are [in danger]," she said. "Since the centre exists, [parents] may at least point their children towards it if they don't want to talk to them [about sexuality]."

In reality, said ASTBEF's Haoua, "some parents forbid their children from coming."

Before the CIOJ youth clinic opened in 2006, young people needing treatment were referred to the main ASTBEF clinic, in another district of N'Djamena, but many did not go.
"The young people were scared of bumping into their parents, especially when there were long waiting times at the clinic," said Nandeh, the social worker. "They were also scared of people being hostile, especially the girls, because boys can talk more freely. Here they can come at quieter times, between [school] classes, and they often come with friends."

Young people who come to the centre for treatment of STIs are offered an HIV test; if it is positive, they are taken to the ASTBEF clinic for psychological support and treatment of opportunistic infections, and then referred to an antiretroviral (ARV) treatment centre. In the first six months of 2007, 136 young people were tested for HIV at the centre, with 39 having a positive result.

Aside from HIV, one of the biggest worries at the centre is the resurgence of certain STIs. "We are finding STIs that had disappeared [in N'Djamena] have come back in young people", said Nandeh.

Despite these concerns, the number of visitors to the centre is growing. Some of CIOJ's young clients have even formed their own anti-AIDS organisations and are educating other young people about HIV, sexuality and reproductive health. "If they practice what they preach, we will have won the fight," said Nandeh.