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Côte d’Ivoire is one of only two “focus countries” in West Africa (the other being Nigeria) selected by the President’s Emergency Plan for AIDS Relief (PEPFAR), a five-year, $15 billion U.S. initiative to fight AIDS abroad. It is bordered by Burkina Faso, Ghana, Guinea, Liberia and Mali, with its southern coast on the Atlantic Ocean.

A former French colony, Côte d’Ivoire gained its independence in 1960. At one time a prosperous tropical country, today it is torn by a civil war that began in September 2002 after an attempted coup. The northern part of the country is held by rebels, the south is controlled by the government and the middle is a buffer zone controlled by the United Nations.

The country is divided into 19 regions with Yamoussoukro as the official capital since 1983. Abidjan, the largest city and former capital, remains the commercial and administrative hub where the U.S. maintains its embassy.

There are about 60 ethnic groups in Côte d’Ivoire, the largest of which is the Akan people. French is the official national language, but each ethnic group has its own dialect and most Ivorians are multilingual. According to the U.S. Embassy Web site, almost one-third of the population is comprised of immigrants from nearby countries.

Côte d’Ivoire is the leading producer of cocoa beans in the world, with 68 percent of its labor force working in agriculture. It also has a large business sector.

The face of HIV

Côte d’Ivoire has the highest HIV infection rate in West Africa, and its worst impact is in the western part of the country. Jyoti Schlesinger, the country’s PEPFAR coordinator, said that the overall rate is about 4.7 percent, according to a new demographic and health survey.

Looking at just adults, UNAIDS, the Joint United Nations Program on HIV/AIDS, estimates a 9.7 percent infection rate in the urban areas and 5.8 percent in rural areas, where just over half the population lives. HIV is the leading cause of death among adults.

Challenges to fighting the HIV epidemic

Political instability is perhaps the greatest challenge to fighting the epidemic. According to PEPFAR, the ongoing civil war has disrupted vital services, such as delivery of supplies for treatment and blood screening, in certain regions of the country.

The rebel-held north has virtually no health care providers. About 80 percent of health care organizations are no longer operating there, an area encompassing about half of the country.

Because of the threat of violence, it is difficult to find people willing to come to the country to work. Also, the work is “backbreaking and you feel like you’re working 24/7,” Schlesinger said.

The political unrest has also caused many other donors and embassies to withdraw from the country, including the U.S. Agency for International Development and Centers for Disease Control and Prevention offices except those maintained through PEPFAR. In other countries, collaboration among donors is common; in Côte d’Ivoire, PEPFAR operates virtually alone.

The war has also made poverty more widespread, as well as created new vulnerable groups, such as intravenous drug users. About 800,000 people have been displaced by the fighting, which has disrupted HIV programs, contributing to the spread of the epidemic.

PEPFAR is focusing on rehabilitating and strengthening the health care system. According to Schlesinger, the U.S. brings in equipment and resources, such as computers and electricity, to outfit health clinics.

Ivorian government response

In 1999, the government announced its National Strategic Plan Against AIDS. The plan outlines strategies and programs to fight HIV/AIDS and includes activities that focus on human rights, gender issues, orphans and mother-to-child transmission of HIV. It also lays out programs that target youths, women and commercial sex workers.

In 2000, the Ivorian government created the Ministry of AIDS, which coordinates the efforts of other government ministries as well as civic and faith-based organizations to combat HIV/AIDS.

According to the fiscal 2005 Country Operational Plan for Côte d’Ivoire, the minister of health and population has made HIV/AIDS a priority and has initiated changes within the Ministry of Health aimed at expanding the national response to the epidemic. In 2001, the National HIV Care Program was created to ramp up voluntary counseling and testing programs, enhance treatment programs and support innovative partnerships with the private, public and NGO sectors.

In its 2005-2007 national strategic plan, which solicited input from the public and private sectors including people living with HIV/AIDS, the government devised a plan for fighting the epidemic. It focuses on creating innovative prevention efforts using the components of the so-called ABC approach (for Abstinence, Be Faithful, and correct and consistent Condom use) which are a “central pillar of the current national HIV/AIDS response.” Another five-year plan is in the works, with many of its components to be funded by PEPFAR.

U.S. government response

In fiscal 2005, Côte d’Ivoire received $13.3 million for prevention activities, or 35 percent of the country’s total PEFPAR funding for prevention, care and treatment. Another $6.8 million — or 18 percent — went to care, while treatment activities were allocated $17.8 million — or 47 percent.

As one way to reach young people in Côte d’Ivoire with its HIV/AIDS message, the U.S. government has turned to sports. “This is a huge way to tap into youth,” Schlesinger said. “We’re using professional soccer players as spokesmen, spreading … behavior change messages. They teach boys the value of a real man; a real man doesn’t beat his wife or rape his girlfriend.”

Working closely with the Ministry of Sports and Culture, the U.S. is also helping to start basketball and soccer teams, including soccer teams for girls to help empower them.

PEPFAR is also working with parents. Hope Worldwide, a PEPFAR partner, promotes abstinence and fidelity programs, working through churches to encourage parents to talk to their children about sex, as well as the importance of getting an education, especially for girls.

The U.S. is also looking into forming more health care partnerships with the billion-dollar industries in Côte d’Ivoire, Schlesinger said. Many businesses have their own clinics and health care professionals, but the workers are often not trained in HIV/AIDS treatment and care. Businesses have approached PEPFAR for assistance, and each collaboration is tailored to the business’ needs and resources. U.S. funds have paid for clinics, schools and sensitization programs as well as mandatory training to reduce the stigma of AIDS.

Côte d’Ivoire is one the best performing of the PEPFAR focus countries in terms of results. According to Schlesinger, it has hit every target except voluntary counseling and testing, which is a difficult area for most countries.

Schlesinger said she is still frustrated with the way Congress moves money around, without necessarily increasing funds. “Congress’ heart is in the right place,” she said. “But they’re not [in the field] working on issues, and earmarking [for abstinence programs] can be harmful.” Any responsible public health official would set up abstinence programs anyway, she said.

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