The importance of interdisciplinary collaborative research in ...

African Journal of AIDS Research 2009, 8(4): 433–442 Printed in South Africa — All rights reserved

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AJAR

ISSN 1608–5906 doi: 10.2989/AJAR.2009.8.4.7.1044

The importance of interdisciplinary collaborative research in responding to HIV/AIDS vulnerability in rural Senegal Roos Willems Department Social and Cultural Anthropology, Catholic University of Leuven, Dalemstraat 2 bus 6, B-3078 Everberg, Belgium Author’s e-mail: [email protected] HIV prevalence in Senegal is less than 1%, a success generally attributed to the country’s quick response to the nascent epidemic of the 1980s and its continued efforts to curtail the spread of HIV. However, as the bulk of the healthcare infrastructure and support for HIV-positive individuals and AIDS patients are located in urban areas, there remains limited information on HIV and AIDS prevalence in rural areas. Several focus group discussions held with small-holder farmers in 2006, in the regions of Kolda and Tambacounda, Senegal, in the framework of a regional food-security development programme, revealed the growing vulnerability of rural populations to HIV and AIDS. Because current HIV/AIDS campaigns are strongly influenced by generalised, internationally formulated guidelines that fail to take into account the cultural particularities of the Senegalese context, the initial positive impact of these campaigns has dramatically decreased and at-risk behaviour in rural Senegal has been found to be on the increase. The article argues that in order for HIV/AIDS campaigns to have an impact there is an urgent need for evidence-based approaches built on a deeper understanding of the local socio-cultural situation through interdisciplinary research and collaboration. Keywords: cultural factors, food security, government health policy, Islam, prevention and control, socio-cultural aspects, West Africa

Introduction Senegal is often cited as a model for other countries on the African continent, sometimes for its democratic political system, other times for its proactive and timely action programme in response to the HIV epidemic. While West Africa as a whole, with an average HIV prevalence of about 2%, has been less affected than the rest of sub-Saharan Africa (about 5% HIV prevalence), the level of HIV prevalence in Senegal is still one of the lowest in the region (Lowndes, Alary, Belleau, Bosu, Kintin, Nnorom et al., 2008). According to official statistics, only 0.7% of Senegal’s population is HIV-infected (Comité National de Lutte contre le SIDA [CNLS], 2007). Yet the future may hold unpleasant surprises: HIV/AIDS experts predict the number of persons with HIV infection in Senegal will have increased by 22% by 2010, thereby increasing national prevalence from 0.7% to 0.9% (CNLS, 2007). This forecast is based on recent surveys among young urban populations who display a decreasing interest in avoiding HIV-risk behaviours in spite of a near universal knowledge of the virus and methods of prevention. In view of the fact that 41% of Senegal’s population is urban, and almost 64% are younger than age 25 years (Initiative Prospective Agricole et Rurale [IPAR], 2007), the influence of this particular group on the rest of society can be significant. In addition, in a country where 90% of agricultural activities take place during the threemonth rainy season, large numbers of seasonal migrants contribute to the inextricable link between urban and rural phenomena. And, even though Senegal’s agricultural

sector contributes only 15% to the gross national product, its contribution to national food security is crucial, especially in the context of the current global food crisis. The bulk of this food supply (about 90%) is generated by small-holder farmers, who represent approximately 60% of the national population (IPAR, 2007). Yet research into HIV and AIDS in Senegal’s remote rural areas has been fragmentary and remains small-scale, while the accessibility of rural populations to HIV/AIDS-related infrastructures — despite the recent decentralisation of all public services from national to regional or local authorities — continues to be difficult for a variety of reasons. On the basis of published research and the results of focus group discussions with male and female Senegalese small-holder farmers, held in different parts of the country in 2006, in the framework of a regional food-security development programme, this article argues that only interdisciplinary research efforts can succeed in identifying the elements necessary to reinforce the impact of current HIV/ AIDS measures. An evidence-based approach focusing on a deeper analysis and understanding of the local social context is needed to stave off an up-turn of the epidemic in rural Senegal, which could further endanger the country’s already precarious food security situation, thereby seriously affecting its future economic development. Historical background of HIV and AIDS in Senegal1 A series of social, historical and political factors are said to have contributed to the fact that Senegal did not suffer from

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a generalised HIV epidemic, in combination with the particular epidemiological characteristics of the virus in the West African sub-region. The first six cases of AIDS in Senegal were discovered in 1986 by Senegalese researchers, and the patients were diagnosed with the less virulent strain of the virus, HIV-2. HIV-2 is less pathogenic and has a longer incubation period than HIV-1, yet from its first discovery it was acknowledged to pose as much of a threat to public health as the HIV-1 strain (Le Guenno, Pison, Enel, Lagarde & Seck, 1992). Later penetration of the HIV-1 virus is attributed mainly to the presence of infected migrant workers (Kane, Alary, Ndoye, Coll, M’boup, Guèye et al., 1993), particularly those from elsewhere in West or Central Africa. However, from the onset of the epidemic, Senegal showed distinctly lower levels of HIV prevalence when compared to its West African neighbours, such as Mali, Burkina Faso or Côte d’Ivoire (Meda, Ndoye, M’boup, Wade, Ndiaye, Niang et al., 1999). The relative proportion of those infected with HIV-1 among those HIV-infected, however, has risen rapidly: from 4% in 1990, to 37% in 1995 (Diop, Pison, Diouf, Enel & Lagarde, 2000), and to 68% in 2004 (Hamel, Sankale, Eisen, Thakore Meloni, Mullins, Guèye-Ndiaye et al., 2007). Other contextual factors generally considered as conducive to the slow evolution of the HIV epidemic in Senegal include the country’s political stability since independence in 1960. This stability, consisting of three democratically elected presidents covering a four-decade period, has been conducive to limiting abrupt displacements among the population. At the same time, it has encouraged the up-keep of traditional institutions, thereby reducing violent conflict to a minimum level. From the colonial period, independent Senegal inherited a well-regulated sex industry in which the licensing and inspection of sex workers has helped to control sexually transmitted infections (STIs).2 From the late 1960s onwards, sex workers over the age of 21 were able to register and acquire the legal status of prostitute, entitling them to general surveillance through quarterly medical checkups as well as free treatment for STIs. The expansion of the number of health clinics beyond the capital Dakar to the 11 national regions was accompanied by the establishment of a culture that encouraged people to seek medical treatment for STIs through the launch of a national programme (Putzel, 2006). In addition, blood banks had been established as early as 1943, and in 1970 the Senegalese government instituted a policy of safe blood transfusions by controlling for immunological and infectious risks (ONSIDA [UNAIDS/Senegal], 2001). Another contextual factor often quoted by observers as having substantially contributed to preventing the spread of the virus in Senegal is that over 90% of the population is Muslim and male circumcision is generally widespread. A rather late median age for sexual debut, observed to be at around 18 years of age for men and women in Dakar in the late 1990s (Meda et al., 1999), is generally attributed to widespread and generally respected conservative Muslim values. At the same time, Muslim leaders contributed to the national HIV/AIDS awareness campaigns from the late 1980s onwards, and discussed the disease and higher-risk

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sexual behaviour in regular sermons. Contrary to a number of Christian churches elsewhere on the continent, “Islam has a tradition of leaving moral judgments to God and of rejecting stigmatisation for those who were HIV-positive” (Echenberg, 2006, p. 94). Evidently, the contextual factors described above would themselves never have been sufficient to curtail the HIV epidemic to its current proportion in the West African country. The very proactive approach that the Senegalese government took towards the disease from the onset is often quoted as an example to other countries on the continent (Putzel, 2006). As early as 1983, Senegalese universitybased researchers had already started working on HIV/ AIDS in collaboration with foreign academics. (In 1984/5, Dr Souleymane Mboup, the leading researcher, together with his team of academics and scientists, had discovered the HIV-2 strand, which was different from that in Europe. The resultant international recognition of Dr Mboup played a major role when the doctor, accompanied by several senior academics and scientists, visited President Diouf to convince him that an HIV/AIDS campaign was needed.) It is widely acknowledged that Senegal’s lead role in the international research on HIV and AIDS helped build political consensus behind the national campaign (Becker & Collignon, 1999). The Comité National Pluridisciplinaire de Prévention du SIDA (Multi-disciplinary National Committee for the Prevention of AIDS), the CNPS, was founded in 1988 and launched its first HIV/AIDS campaign, which focused on prevention measures such as: 1) prevention of transmission through blood by means of systematic HIV screening of all blood used for transfusion; 2) prevention of sexual transmission through awareness campaigns for responsible and safer sex; 3) widespread screening and treatment of sexually transmitted infections; 4) promotion of condom use and provision of affordable, good quality condoms; and 5) special interventions for groups at higher risk of exposure to HIV, such as female sex workers (Meda et al., 1999). The establishment of a transfusion policy centred on the prevention of transmission of HIV through blood and the compulsory screening of every batch of blood for HIV evidently benefited greatly from the well-functioning pre-existing public health infrastructures (albeit to a far lesser extent in rural as compared to urban areas). In addition, the existing screening and treatment services for STIs served as entry points for HIV/AIDS information and counselling as well as for condom provision and promotion of safer sexual behaviour, especially among sex workers (ONUSIDA [UNAIDS/Senegal], 2001). In 1988, the National AIDS Control Programme reached out to the religious leaders, in a concerted and effective effort to include religious and community leaders and politicians at all levels in HIV-prevention activities. Widely publicised national conferences, held by both Muslim and Christian leaders, lent considerable moral support to the provision of universal information about HIV infection and other STIs, as well as to efforts to promote responsible sexual behaviour (Putzel, 2006). In 1989 the World Health Organization assisted Senegal in establishing its sentinel surveillance system in those four

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cities that together accounted for 78% of the country’s urban population: Dakar, Ziguinchor, Thiès and Kaolack. And by 1992 the Ministry of Education had included sex education with an HIV component in the school curriculum for children aged 12 and over. Teachers were trained and educational brochures were included in the curriculum. In the course of 1997, over 130 000 school manuals devoted to information, education and communication (IEC) on HIV/AIDS were distributed in public and private teaching establishments (ONUSIDA [UNAIDS/Senegal], 2001). Whereas it is not possible to know what course the HIV epidemic in Senegal would have taken in the absence of these early prevention efforts, observers did attribute the successful containment of the spread of the virus to the country’s comprehensive interventions to increase knowledge and awareness of HIV and AIDS and to promote safer-sexual behaviour (Meda et al., 1999). UNAIDS even published a report on the Senegalese HIV/AIDS prevention programme and listed it among best practices (ONUSIDA [UNAIDS/Senegal], 2001) in spite of observed doubts on the equal participation of civil society actors in the national coordination committees and the efficient use of internationally financed resources (Kerouedan, 2004). National KABP (knowledge, attitudes, beliefs and practices) surveys were launched from 1993 onwards through the AIDSCAP programme (Family Health International, 1997) while the newly established sentinel system started collecting data in 1997. When comparing the results of the 1997 social behaviour survey with baseline data from 1993, significant changes in individuals’ sexual behaviour were noted (ONUSIDA [UNAIDS/Senegal], 2001). An overwhelming majority of the 1997 respondents (90%) was able to identify at least two methods of HIV prevention after having participated in an educational programme. Over two-thirds (70%) reported having used a condom at their last sexual encounter with a casual partner. Between 1997 and 1993, the number of persons having had at least one casual sexual relation during the preceding 12 months had fallen to half; and there was an 80% increase in the number of people who said they were able to access condoms. During the same period, the number of persons seeking treatment for an STD at the health centres increased substantially. The survey also showed that 90% of school girls and 79% of female university students reported never having had sexual contacts, while 84% of school boys and male students reported having changed their sexual behaviour by using condoms more systematically. Among the adult population, 80% responded in the same sense. The UNAIDS reports also mention that the sale of condoms increased exponentially between 1995 and 2000 (ONUSIDA [UNAIDS/Senegal], 2001). By 2003 the sentinel surveillance system had expanded from the initial four regions in 1989 to all 11 regions, hence covering the national territory. During the same year, the 6th International Conference on Home and Community-Based Care for People Living with HIV or AIDS was held for the first time in Africa, in Dakar, under the theme ‘More Care for Better Living,’ and it highlighted the priority needs of people living with HIV or AIDS (PLHIV) at a time when antiretrovirals were becoming increasingly available in developing

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countries. And in 2004, the Senegalese government made confidential HIV-testing free: currently there are some 87 voluntary testing sites, and close to 150 000 persons (1.5% of the total population) were tested in 2006 alone. In addition to free confidential HIV testing and medical care, certain voluntary counselling and testing (VCT) sites provide a more comprehensive package of care that includes counselling, psychosocial support, home visits, and follow-up services (CNLS, 2007). Structural inequality in access to medical services In spite of the timely and proactive efforts of the Senegalese authorities in the national response to HIV and AIDS, the ethical aspect, in terms of the legal protection of persons with HIV or AIDS, is seriously lagging. At the 2001 forum IH/SIDA et Droits de l’Homme en Milieu Médical Sénégalais (HIV/AIDS and Human Rights in the Senegalese Medical Environment), one report summarised the situation as follows: Even if, in general, the care of those living with HIV is relatively good in Senegal, there have been reports of cases of abuse, discrimination, refusal of care, screening tests without informed permission from those affected, and research carried out without taking into consideration the international norms contained in the Helsinki declaration (Atchadé et al., 2001, cited in Becker, 2006, p. 213). According to one longstanding HIV/AIDS researcher in Senegal, it is not only the lack of political interest in the ethical aspects of the epidemic but also “the feeble or absent reflection on the basic problem” that are at the basis of the lacunae in legal protection of the HIV/AIDS affected (Becker, 2006, p. 210). In a recent article he points out one of the root problems for the current HIV/AIDS programmes in Senegal, namely the historically structural inequality in access to healthcare services in the West African country (Becker, Dhiakhaté & Fall, 2008). During the colonial period, Senegal together with Cote d’Ivoire were the best equipped in terms of hospitals, dispensaries, and medical staff compared to other countries in the region; however, the high cost of this medical infrastructure brought with it a structural imbalance in access to health services from the very beginning (Becker et al., 2008). This situation was exacerbated in rural areas because the bulk of the medical infrastructure was based in and around Dakar and the Peanut Basin3 — the two regions carrying the major economic interests of the colonial authorities. Even if, from the mid-1970s onwards, the government’s health budget increased steeply in nominal terms, its percentage within the overall state budget decreased from 9% to a mere 5% by the 1990s. Recent statistics indicate that the capital Dakar, where only 22.5% of the population lives, currently disposes of 74.4% of all general medical practitioners, 91.4% of specialists, 83.7% of private doctors, and 58.7% of all pharmacies (Becker et al., 2008). The structural problems of the accessibility of health services in rural Senegal due to lack of personnel (e.g. approximately one health worker for every 8 700 persons and one medical doctor for every 17 000 inhabitants) are further exacerbated by poor road

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infrastructure (Heyen-Perschon, 2005). Over 60% of rural communities are only accessible via sand tracks that become all but completely impassable during the rainy season or during harmattan,4 which makes medical visits even more costly and time-consuming for rural residents than for the urban population. Within the context of a generalised unequal access to health services, HIV/AIDS patients become doubly vulnerable. In 1998, Senegal became the first sub-Saharan country to propose an antiretroviral treatment (ART) programme (i.e. Initiative Sénégalaise d’Accès aux ARV), and is currently one of only a handful of African countries that provide antiretrovirals (ARVs) free of charge.5 Free ART is currently available in 17 of the 20 hospitals nationwide, and around one in every ten HIV-infected persons is receiving ART; albeit with a somewhat lower success rate than in European countries (Etard, Ndiaye, Thierry-Mieg, Guèye, Guèye, Lanièce et al., 2006). However, the fact that only the ART is provided for free and not the medical expenses that are related to the treatment, continues to make it unaffordable for a large portion of the population, the overwhelming majority of whom do not participate in medical insurance plans (Mbodj, 2008). To complicate matters further, the recent increases in HIV/AIDS-care sites are concentrated in urban facilities, with rural areas entirely lagging behind. Of the ART centres, for example, 53 are located in Dakar and only 26 in the rest of the country (CNLS, 2007). Until recently, only doctors could prescribe ARVs, while many rural clinics were staffed with nurses only. Reportedly, there are also often problems with the delivery of ARVs to rural areas. According to one rural healthcare worker: ‘We are always having drug shortages. ARVs are free but there are problems with procurement. Sometimes we go for a month where there are no drugs available’ (quoted in Diouf, 2007, p. 34). Hence, rural residents risk being particularly hard hit when found HIV-positive because of the lesser availability of HIV/ AIDS services, and because of complicated and expensive accessibility (both in terms of money and time) to the existing health sites. The result is that many HIV/AIDS-affected patients decide that the benefits are not worth the extra cost (Desclaux, Lanièce, Ndoye & Taverne, 2002). With regard to the free and confidential HIV-testing programme launched in 2004, one of the major findings of a recent evaluation by the Enhancing Care Initiative from Harvard University was “the marked disparity in available HIV and AIDS care services between the capital city of Dakar and rural regions. Communities outside of Dakar were found to have limited access to voluntary testing and counselling and other related services” (Enhancing Care Initiative [ECI], 2006). In addition to lack of training in the technical capacities of staff and poor confidentiality of test results, there is an urgent need for more laboratories equipped to carry out the tests (Diouf, 2007). Because laboratories exist only in large cities, people in rural areas have to travel long distances to get tested for HIV. Hence, fewer people go for a test, which means many may not learn their HIV status early enough to benefit from treatment and to adapt their behaviour. Apparently, behind the Senegalese HIV/AIDS success story lurks a different reality; the situation in the rural areas

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is worrisome. A possible HIV epidemic in rural Senegal will impact all layers of society because of the importance of the agricultural sector to the country’s already precarious economic and food-security situation. The link between HIV/AIDS and food security Senegal’s economic growth has been rather stable over the past decade, with an annual growth rate of around 5%, and inflation rates (at least until very recently) have never exceeded 2%. However, due to the uneven distribution of the country’s economic results, the majority of the population (57%) still lives under the poverty line (Government of Senegal, 2004). Within the list of human development indicators, Senegal ranked 156 out of 177, after Mauritania and Haiti, and just before Eritrea and Rwanda (United Nations Development Programme, 2006). According to the latest official report on national food security, the 2008/9 agricultural campaign will provide only 77% of the country’s food needs, necessitating 23% to be imported from elsewhere (Comité Permanent Inter-Etats de Lutte contre la Sécheresse dans le Sahel [CILSS], 2009). This situation has been heralded as ‘much better than previous years’ by the Senegalese government who attributes the improvement of the food-security situation to its recently launched, yet overly ambitious, ‘Grand offensive agricole pour la nourriture et l’abondance’ (‘Great agricultural offensive for nutrition and abundance’). The food deficit has been ongoing since the late 1980s, and the subsequent pressure on the country’s financial reserves has severely handicapped the economic development of the entire nation. Within the context of precarious food security, which has been consistently worsening for the past two decades, the monitoring of the prevalence of HIV and AIDS becomes of the utmost importance. Earlier studies in African countries6 and elsewhere have long since established the direct link between HIV and AIDS prevalence among a country’s farmers and national food security. A 2001 collaboration between the World Food Programme (WFP) and the International Food Policy Research Institute (IFPRI) proposed the following categorisation of HIV/AIDS impacts on individual, household, community, national and regional levels (see Gillespie, Haddad & Jackson, 2001): • Human capital: Sickness and premature deaths will affect the productivity of household labour as well as the fact that healthy individuals have to care for those personally affected by HIV or AIDS. Because of stigmatisation, those affected may keep secret their HIV status or medical situation and so not seek treatment nor adapt their behaviour, thereby putting their social environment at risk. Children will be affected not only psychologically, but because of labour shortage may be forced to leave school early, resulting in lower levels of education. Premature deaths of adults also mean a loss of the indigenous knowledge transfer between generations. • Financial capital: Medical costs and funerals will affect a major financial burden, while HIV-affected households (because of depleted human resources but also because of stigmatisation) risk increased difficulties in getting loans from banks. In addition, HIV-infected/

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affected adults may no longer be able to work, resulting in depletion of financial resources and capital. • Physical capital: The depletion of financial resources is often met with the sale of land. HIV-affected households are often forced to sell other productive assets and livestock, while the loss of productive traction animals will further reduce agricultural output. In addition, land inheritance patterns, combined with stigmatisation, will make widows more vulnerable to becoming homeless and may cause the disinheritance of children where dwelling or land rights are linked to physical presence. • Social capital: When increasing numbers of households become affected, social networks within communities fragment, not only because of premature deaths but also because of high levels of stigmatisation. With the progression of the epidemic, the capacity of government and social institutions to provide formal safety nets will decrease because of increasing costs and diminishing revenues due to illness and death of populations in productive age groups. • Political capital: Political participation of members of HIV-affected households will be hampered by illness and diversion of time to tasks related to survival. Additionally, HIV-affected families are often deliberately excluded from the political process due to stigma and discrimination. While according to official statistics the prevalence of HIV in Senegal’s rural areas is still very low, male and female farmers participating in focus groups to discuss issues related to a regional food-security development programme appeared well aware of HIV and AIDS and its potential consequences. In 2006, three focus group discussions were held, each with 15 to 20 randomly chosen male and female members of farmers’ grassroots organisations in two different regions: Kolda in south Senegal and Tambacounda in southeast-central Senegal.7 During discussions on the respective regional food-security situation, the participants listed HIV/AIDS as one factor possibly affecting their level of food security. All participants reported that they personally knew no one with HIV infection and most said they were well aware of the existing modes of prevention and treatment facilities. One woman farmer explained: ‘Yes, I know the AIDS services here, and I know they organise information sessions and organise awareness campaigns, because I know of some of the young people in our village who have participated. Even when we go for a medical visit to the doctor, he gives us plenty of information. That’s how we know that AIDS is transferred not only by sexual means. Thanks to this awareness-raising almost all the shops of our village now sell condoms.’ Another male farmer confirmed: ‘Me too, I didn’t participate directly in the information sessions but I got my information from my doctor who made me aware of the dangers. That was a good thing, because now we have all the information on how the illness is transferred and how we can avoid it.’ When asked what the effects that HIV disease could have on day-to-day life, the informants were very clear-headed

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about the possible consequences. According to one male farmer, the whole area would suffer: ‘When AIDS strikes in an area, the economic growth will be affected, because if someone is sick he won’t be able to take care of his work anymore, especially in the fields. And then, if the illness spreads and affects more and more persons in the active population, work will stop and we won’t have an economic growth. And the illness will also attack the younger people, the population won’t grow, will even diminish. Yes, I think that those are the major consequences.’ One female participant described the effects of HIV at the level of the household: ‘Me, I think that AIDS is like half of death. And everyone knows that when death comes into a house, happiness goes away and the family falls apart. If it is the man who gets the disease and the woman cannot find anyone to talk to and who will help her, yes, for sure the couple will break up.’ Another female farmer compared HIV and AIDS to poison: ‘AIDS in a region is like poison creeping in. Because of the illness, the active men won’t be able to work in the fields anymore, and that will have effects on the economy. If the younger people are affected, then the population will no longer increase. If in our village the field owners fall ill, who will plough their plot? Who will do their work?’ From the above interview excerpts, both male and female farmers in the focus groups appear well informed about the virus, its modes of transmission and prevention methods, and they seemed aware of the disastrous consequences of an epidemic. And yet recent surveys in certain rural communities indicate a decrease in HIV-protective attitudes and an increase in at-risk behaviours (e.g. Wade, Enel & Lagarde, 2006). In order to situate these recent observations and apparent contradictions correctly, we need to first contextualise them by looking at the current national picture of HIV and AIDS in Senegal. Current trends in HIV/AIDS prevalence, knowledge and attitudes in Senegal According to the 2005 Senegal Demographic and Health Survey executed by the Ministry of Health, 97% of all Senegalese have heard of HIV/AIDS, with a slight preponderance in urban areas (99%) versus rural areas (95%) (Government of Senegal, 2005). Yet, there were discrepancies between the numbers of urban versus rural respondents with regard to correctly answering that a person who looks healthy can have the HI virus and who also correctly rejected the statement that HIV can be transmitted by mosquito bites or supernatural means. Only 18% of rural persons answered that question correctly, compared to 39% of urban respondents. Among younger persons, the high level of HIV/AIDS knowledge appears to fail to translate into safer behaviour, especially among young women. Comparable to the situation found in many other countries, only 5% of the women respondents between the ages of 15 and 24 said they used a condom during their last

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sexual encounter, compared to 48% of male respondents in the same age group. When considering that 96% of the unmarried women between the ages of 15 to 24 said they practiced abstinence (compared to 65% of young men), it is worrying to note that HIV prevalence among young women in Senegal is four times higher than it is among young men (0.4% versus 0.1%).8 While according to recent Comité National de Lutte contre le SIDA (CNLS) statistics there is no significant difference between HIV prevalence in urban versus rural areas (both are at 0.7%), the report notes however: …Significant intraregional differences in prevalence rates. Both among men and women, there are higher rates in Ziguinchor (3.4% for women and 0.8% for men) and Kolda (2.7% for women and 1.1% for men). On the other hand we note lower than average rates in Diourbel (0.01% for women and 0% for men) and in Thiès (0.4% for women and 0.3% for men) (CNLS, 2007, pp. 12–13).9 The sentinel surveillance system that generates the national statistics, and which currently covers all 11 regions that make up the Senegalese territory, has been criticised for being limited to the regional urban centres. The collected data are often simply extrapolated from these regional capitals to entire rural regions, hence possibly masking local serious epidemics. Until now, no large-scale survey has been undertaken to investigate the effective incidence of the virus in rural Senegal, where close to two-thirds of the population lives. Over the past two decades, several small-scale research projects at the village level took place in certain regions, probing into the level of HIV/AIDS knowledge and the evolution in at-risk behaviours.10 One of the earliest of these surveys administered in a rural community in southern Senegal essentially confirmed the general trends observed by the sentinel surveillance system in urban areas during the same period. While the level of HIV/AIDS knowledge had significantly increased among men and women, the level of at-risk behaviour had significantly decreased only among males between 1990 and 1994 (Lagarde, Pison & Enel, 1997 and 1998). In a context where only 38% of the population is literate (and only 28% of women), HIV/AIDS-information campaigns in rural areas in particular have had to rely on non-written communication channels. According to the same survey, it appeared that men largely drew their HIV/AIDS knowledge from listening to the radio (61%), while women found the local health centres to be their best source of HIV/AIDS information (52%). Both sexes mentioned the television as a second important source of information, as TV was accessible to them during periods of migration into local towns (42% of men, 33% of women).11 The researchers also noted the different patterns of behaviour among widowed or divorced women and seasonal male migrants. Both groups were more likely to declare having engaged in casual sex and have a lower rate of condom use (Pison, Lagarde & Enel, 1996).12 Young unmarried women, on the other hand, were found to be very unlikely to engage in higher-risk sexual behaviour, even when away from the social control of their village during seasonal out-migrations to the cities (Pison et al., 1996).

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Ten years later, the findings of another comparative study in rural central Senegal were less encouraging and seemed to confirm the disturbing trends in at-risk behaviour, in spite of the high level of HIV/AIDS knowledge observed by the sentinel surveillance system in the more urban areas (Wade, Enel & Lagarde, 2006). The proportion of respondents having heard of HIV and AIDS rose from 76.7% in 1997 to 88.3% in 2003, and that of persons having heard of condoms from 43.8% in 1997 to 56.4% in 2003. However, the proportion of those who estimated their personal risk of becoming infected with HIV as high or very high fell drastically from 49.1% in 1997 to 17.2% in 2003. In addition, the number of persons who reported having changed their behaviour to protect against HIV infection fell from 56.3% in 1997 to 24.9% in 2003. Also, only 58% of the respondents in 2003 reported fidelity as an HIV-protective method, compared to 93% in 1997. In short, a dramatic weakening of HIV-prevention attitudes was found in spite of the increases in knowledge of the virus and prevention methods over the past decade. The same survey also found that stigmatisation of PLHIV appeared to be widespread in this rural community in 2003. While 73.9% of the interviewees were of the opinion that PLHIV should not be allowed to mix with other villagers, only 65.1% were found to be ready to provide care to someone with HIV or AIDS (Wade et al., 2006). Among the participants of the previously mentioned focus groups held by the author in 2006, opinions on how to deal with the HIV infection or AIDS illness of a family member were divided, and apparently so along gendered lines. The way one male farmer saw it: ‘If AIDS comes to a family, I know that the couple won’t be able to have any children anymore. And the only future for the couple will be divorce.’ This was readily confirmed by another male participant: ‘If I were to announce to my wife that I have AIDS, then I’d like to have information on how I can still live with her. If I don’t have that information then for sure the divorce will separate us.’ Women, on the other hand, seemed to have a somewhat different take on the matter. One female participant assured the others that: ‘If my husband would be infected that I’d first of all do the test to know if I’m infected too and the children. But in any case, I’d continue to love my husband and take care of him.’ This statement led another woman to conclude that: ‘AIDS brings disagreement in the couple and death. But women are better able to cope with the situation than men.’ Stigmatisation of PLHIV substantially complicates the provision of care and counselling, not only by family members and friends, but also by government infrastructures and civil society organisations. At the individual level, HIV-positive persons may conceal their status out of fear, as testified to by a focus group participant: ‘Me, as a married man, if I were to have AIDS, my main problem would be how to announce it to my wife. How will she react when I tell her? I think the first pain of the disease is in that moment. Actually,

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I also think that those organisations that work in the area of fighting against HIV/AIDS should teach infected persons how to break the news to their spouses.’ At the same time, stigma is very likely to result in counterproductive behaviour, such as low attendance at voluntary HIV counselling and testing facilities. Relatively few people will openly seek care and support services, while many may take measures to keep their status secret, even to family members, thereby lacking basic support such as assistance for treatment and proper nutrition (Sane, 2009). The combination of increasing stigmatisation and decreasing risk-avoiding sexual behaviour is evidently a lethal one, particularly, but not solely, in areas that lack the necessary medical infrastructure. The need for more effective HIV-prevention messages The above-mentioned studies and analyses have shown that Senegal’s apparent success story in keeping the prevalence of HIV and AIDS low has its gaps and that the struggle is not yet over. Still, the bulk of HIV/AIDS research has focused on identifying problems in providing treatment for HIV/AIDS-affected persons, such as: the lack of ethical standards and the legal rights of the people affected; the unequal access to medical facilities and the inadequacies of medical services, particularly in rural areas; the costs related to the free ARV treatment, which are unaffordable to the majority without any type of medical insurance; and the shortage in technical knowledge and facilities for free and confidential HIV testing. These are to name but a few. The more startling observation is that after two decades of HIV/AIDS campaigns in Senegal, and a virtually universal knowledge of the virus as well as of many HIV-prevention modes, higher-risk behaviour among both rural and urban men and women is on the increase. It has been suggested that the availability of ART may be responsible for higherrisk sexual behaviour (e.g. Olley, 2008). However, given the sparse availability and difficult accessibility of ART (particularly in rural areas of Senegal) this seems to be not very likely. One HIV/AIDS health worker in the Kolda region, interviewed by the author in 2006, said: ‘People here think that those with AIDS will drop dead. They do not have knowledge of ARVs, and that a person can still be active if on treatment. For them, when the husband is HIV-positive, the family basically disintegrates.’ In view of the fact that the decrease in risk-avoiding behaviour has been noted throughout the country, and that there is a proven link between HIV prevalence in rural areas and people’s mobility between urban and rural areas (Lagarde, Van der Loeff, Enel, Holmgren, Dray-Spira, Pison et al., 2003), there is an urgent need for research into the causes of this recent phenomenon. An ongoing study is looking at the influence of religion on the stigmatisation of PLHIV in Senegal (Ansari, 2008). Perhaps religious perceptions also play a role in the recently observed changes in HIV/AIDS-preventive attitudes? As mentioned earlier, religious leaders were involved in HIV/AIDS-awareness campaigns in Senegal virtually from the start. In 1988,

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the Islamic NGO Jamra joined forces with the government in sensitising religious leaders and traditional authorities to discuss the epidemic, and by 1995 it published a guide in French and Arabic with factual information about HIV and AIDS, explaining how applying Islamic principles in daily life can prevent the spread of HIV (Sayagues, 2004). The Jamra guide also advised against female genital cutting, wife inheritance, premarital sex, anal sex, and sex during menstruation, while allowing use of condoms within marriage. As mentioned earlier, various researchers have rightfully attributed the containment of the virus to Senegalese conservative attitudes towards sex, low levels of alcohol consumption, and universal male circumcision. However, a small-scale survey in a rural area during the late 1990s seemed to suggest that religion was negatively linked with HIV-preventative behaviours. The researchers at the time suggested that: Religion may give men a protective feeling, whereas for women it may be associated more with submission and the lack of control over their personal risk of HIV infection. These women may feel unable to intervene about their partner’s behaviour (Lagarde, Enel, Seck, Guèye-Ndiaye, Piau, Pison et al., 2000, p. 2032). This suggestion appears to be corroborated by a more recent survey showing that 48.5% of a sample of 2 600 secondary school pupils in Dakar believed that HIV and AIDS is a divine punishment (Mbengue, 2008). These findings are not surprising to Senegal observers: Religious and traditional leaders often reinforce the belief that HIV is linked to sin and punishment, although a growing number of religious leaders promote acceptance and help raise awareness about HIV/AIDS and fight stigma and discrimination (Diouf, 2007, p. 21). On one occasion, the author observed how the suggestion that a 35-year-old Senegalese woman who died may have succumbed to AIDS, was vehemently met by a friend’s assertion that the woman was not a prostitute but decently married under Muslim law. The underlying argument was that, a person who lives according to Islamic principles and respects Islamic law will not be affected by the virus. In other words, HIV and AIDS seems to be perceived rather as an external threat than as something under an individual’s control, hence there is no need for individual preventative behaviours when one abides by religious prescriptions. Related to this observation is the finding that still a full third of young people (ages 15–25) believe that HIV or AIDS may be contracted through witchcraft or other types of supernatural means (ONUSIDA [UNAIDS/Senegal], 2008). Among unregistered sex workers as well, there are many who blame HIV and AIDS on “black magic and marabouts” (Homaifar & Wasik, 2005, p. 128).13 Within this context, considering HIV and AIDS as a divine punishment appears to imply that living by religious principles is protection enough against the virus. Hence, something may have gone awry in the formulation of HIV-prevention messages in spite of the early and active involvement of the religious establishment. Evidently, more in-depth research is necessary to ascertain this line of investigation so that research results

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can be utilised to formulate more effective HIV-prevention messages and stave off the current trends. Conclusions As recently shown in studies in Kenya, Lesotho, Swaziland, Uganda and Mozambique (UNAIDS, 2009), there is a general lack of evidence-based HIV/AIDS-related policies and programmes. The United Nations reports recommend that each country’s HIV epidemic and response to date should be better understood and efforts should be made to identify how HIV prevention might be more effective if it is evidence-based. Too often, HIV/AIDS programmes in sub-Saharan Africa have been strongly influenced by internationally formulated guidelines, without paying enough attention to the local social context (Hanson, 2005). This seems to be the case in Senegal as well. Despite relative success over the past two decades in keeping the epidemic contained, the efforts should not cease. Unless effectively controlled and prevented, the forecast is that HIV prevalence will triple to 2.2% by 2010 (CNLS, 2007). Hence, there is an urgent need to take into account socio-economic elements specific to Senegal’s particular context; interdisciplinary collaboration could allow a better understanding of the root causes of the failure of currently used HIV-prevention messages and the recent increase in higher-risk behaviour. The most effective way of channelling HIV/AIDS messages to rural areas has long since been known: men being more influenced by informal discussion or radio and women by public meetings and school education. The new strategic plan of the Comité National de Lutte contre le SIDA (CNLS) for the period 2007–2011 does foresee an increase in HIV/AIDS-information and prevention efforts in national campaigns (CNLS, 2007). However, as long as education messages are not culturally nuanced and grounded in interdisciplinary understandings, there is a risk that they will continue to have limited impact on Senegal’s rural populations. If that is the case, the HIV epidemic will sooner or later adversely affect the country’s food-security situation, and indeed, its entire economic development. Notes 1

2

3

4

5

6

For a comprehensive bibliography on the history of HIV/AIDS in Africa, see Becker & Van Houten (2006). For an overview of the colonial history of sexually transmitted infections in Senegal, see Becker & Collignon (1999). The central part of Senegal is the so-called Peanut Basin, where during the colonial days the peanut cash crop was introduced and is still grown. The Peanut Basin comprises areas around Bambey, Diourbel and Kaolack. The harmattan are sandstorms from the Sahara Desert which blow often during the dry season. See Mbodj (2008) for a detailed overview of the historical context and debates accompanying the introduction of a free ARV treatment programme in Senegal. See for example Van Liere (2002), for some telling examples from East and West Africa. The author does point out however that “there is a clear need for more knowledge on the impact of HIV/AIDS on nutrition and food security in West Africa,

7

8

9

10

11

12

13

specifically on the identification of the most vulnerable farming systems and the most vulnerable households” (Van Liere, 2002, pp. 9–10). The author worked for a European NGO in the field of Food Security and Access to Markets for Small-Holder Farmers in Senegal, from 2004 until 2009, through partnerships with grassroots farmers’ organisations. All focus group discussions were transcribed and translated from Wolof into French by a Senegalese NGO worker, and from French into English by the author. Other neglected groups at higher-risk of HIV exposure are sex workers, with an estimated HIV prevalence of 20%, and men who have sex with men (MSM) of whom an estimated 21.5% are infected. For interesting research on sex workers, see Homaifar & Wasik (2005); for the results of a 2005 survey among MSM, see Niang, Moreau, Bop, Compaoré & Diagne (2004). For an overview of the situation of orphans and children affected by HIV/AIDS, and the recommendations to the CNLS, see Mbaye, Becker & Tounkara (2005). Ziguinchor and Kolda are located in southern Senegal, while Diourbel and Thiès are located in the central part of the country. See Loenzien (1996) for an interesting overview of the methodological problems researchers are confronted with when administering KABP surveys in rural milieus. These gender differences in the channeling of HIV/AIDS information and knowledge have been confirmed by a later study in three other rural communities in central and southern Senegal (see Wade et al., 2005). Seasonal migration had been identified as a risk factor for HIV infections in rural Senegal in earlier studies (see Pison, Le Guenno, Lagarde, Enel & Seck, 1993). Already in 1989, 27% HIV prevalence was observed among a group of male expatriate migrant workers (and 11.3% prevalence among the females) in a rural community in northern Senegal (Kane et al., 1993). A marabout is a personal spiritual leader in the Islam faith as practiced in West Africa, and is often a scholar of the Qur’an. They preside at ceremonies and may actively guide the life of their followers. Some marabouts also make amulets for good luck, yet it is also not uncommon for followers to appeal to certain marabouts when they wish to put a spell on someone through means of ‘black magic.’

The author — During the 1990s, Roos Willems (PhD, 2003, University of Florida) worked with refugee and migrant organisations, such as the International Organization for Migration and the United Nations High Commissioner for Refugees, in both East and West Africa. From 2004 to 2009 she was the regional representative of a European NGO for Senegal and The Gambia. She is currently affiliated with the Institute for Migration Researches and Intercultural Studies at the Catholic University of Leuven (Belgium). She has published articles on forced migration, development and culture issues, and clandestine migration from West Africa to Europe.

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