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HIV and AIDS in West and Central Africa Overview

2018 UNAIDS statistics for West and Central Africa
KEY POINTS
  • Despite a relatively low HIV prevalence across West and Central Africa, only around 65% of people living with HIV in the region are aware of their status, which means that half of all HIV positive people are not accessing treatment.
  • Insufficient antiretroviral treatment provision means that a fifth of all AIDS-related deaths in the world each year occur in West and Central Africa.
  • Less than a third of children living with HIV in the region are on treatment; the lowest coverage rate for this age group in the world.
  • The poor economic status of many countries in West and Central Africa has hindered the investment that is necessary for expanding HIV services.
  • Conflict, insecurity and humanitarian crisis such as Ebola are putting further strain on health systems, weakening many countries’ HIV responses further.

Explore this page to read more about populations most affected by HIV, testing and counsellingprevention programmes, antiretroviral treatment availability, civil society’s role, HIV and tuberculosis (TB), barriers to the response, funding, and the future of HIV in West and Central Africa.

West and Central Africa is home to 5 million people living with HIV, of whom 450,000 are children.1 HIV prevalence among adults is 1.5%, which is relatively low when compared to East and Southern Africa. There is wide variation between countries, ranging from 0.2% in Mauritania to 7.1% in Equatorial Guinea.2

In 2018, 64% of people living with HIV were aware of their status. Of those who were aware, 79% were accessing antiretroviral treatment (ART). Of those on treatment, 76% were virally suppressed.3 The number of people accessing treatment rose significantly from 860,000 in 2010 to 2.6 million in 2018. However, because so many people are unaware of their status, this equates to just half (51%) of all people living with HIV being on treatment and 39% of people living with HIV being virally suppressed.4 

In 2018, 160,000 people died from AIDS-related illnesses, around a fifth of the total number of AIDS-related deaths in the world. AIDS-related deaths are also high among children (aged 0-14), with around four out of every ten children who die from AIDS-related illnesses dying in the region.5 Overall, it is estimated that 3.4 million 0-17-year-olds in West and Central Africa have been orphaned by AIDS since the epidemic began.6 Good progress is being made on new infections among children, which decreased by 29% between 2010 and 2018 due to the availability of more prevention of mother-to-child transmission services.7 New infection rates among adults are declining more slowly, having fallen by 13% overall over the same period (280,000 new infections in 2018), with some countries experiencing rising infection rates of more than 10% over this time period.8 9 Nearly 60% of new HIV infections and 54% of AIDS-related deaths that happen in the region each year occur in just three countries (Cameroon, Côte d’Ivoire and Nigeria).10

Women in West and Central Africa are disproportionately affected by HIV, with 2.8 million adult women living with HIV compared to 1.8 million adult men. In 2017 HIV prevalence stood at 2.3% among adult women, compared to 1.6% among adult men.11

Adolescent girls and young women (aged 15-24) are almost twice as likely to acquire HIV than their male counterparts, with 58,000 young women acquiring HIV in 2018, compared to 27,000 young men.12 West and Central Africa’s HIV epidemic is driven by heterosexual sex. Although it is generalised, meaning it affects the population as a whole, certain population groups such as sex workers, people who inject drugs and men who have sex with men are even worse affected. New infections among these groups, also known as ‘key populations’, and their sexual partners accounted for 64% of all new infections in 2018, despite these groups representing a small proportion of the overall population.13 Yet programming for key populations remains insufficient, and stigma, discrimination and legal barriers prevent many people from these groups from accessing services.14

In addition, many countries are in conflict, facing post-conflict situations or dealing with the impact of other humanitarian crises. This further complicates the region’s HIV response.15

West and Central Africa 90-90-90 (2019)

Key affected populations in West and Central Africa

Young women

The annual number of new HIV infections among adolescents and young people (aged 15–24) in the region now greatly exceeds that of children. These new infections mostly occur through unprotected sex.16

Every day, UNAIDS estimates that around 160 young women in West and Central Africa acquire HIV.17 HIV prevalence among women aged 20–29 is above 3% in Cameroon, the Congo, Côte d’Ivoire, Gabon and Liberia, and is consistently higher in most countries among young women than among young men.18 In Côte d’Ivoire, the Gambia and Ghana, for example, young women are between five and nine times more likely to be living with HIV than young men.19 In 2016, UNAIDS named Cameroon, the Central African Republic (CAR), Côte d’Ivoire, the Congo, the Democratic Republic of Congo (DRC), Gabon, Guinea-Bissau and Nigeria as countries where HIV responses for young women should be prioritised.20

The reasons why young women are disproportionately affected by HIV in the region are numerous and complex. Girls and women face high levels of gender inequality, gender-based violence and sexual violence, all of which increase vulnerability.21 In Burundi, the Congo, DRC, Mali and Sierra Leone, a third of ever-married or partnered women (aged 15–49 years) experienced physical or sexual violence from a male intimate partner in the past 12 months.22 Additionally, in conflict situations, sexual violence, particularly against women, is commonly used as a strategy of war, with younger women being especially vulnerable.

Other reasons for the disparity between genders are high rates of voluntary medical male circumcision, which has helped to prevent men from acquiring HIV from women. At the same time, low acceptance of condoms, low levels of HIV testing and low uptake of antiretroviral treatment among men heightens the risk of men living with HIV passing the virus on to their sexual partners.23

Age-disparate sexual relationships between young women and older men are common, as is adolescent marriage and pregnancy.24 The power imbalance between genders also means that many young women are not able to make decisions about their own lives. For example, more than 80% of married adolescent women in Senegal, Niger, Burkina Faso, Côte d'Ivoire and Cameroon do not have the final say on their own healthcare, according to demographic and health surveys.25 In Mauritania, married women must obtain consent from their husbands to access sexual and reproductive health services.26

Knowledge about HIV among young people in the region is alarmingly low, with fewer than 35% of young people able to display comprehensive and correct knowledge of how to prevent HIV in all countries except Burundi, Mauritania and Sao Tome and Principe. Young women display lower levels of HIV knowledge than young men in the majority of countries.27

Children

Nearly three-quarters (72%) of the 450,000 children now living with HIV in West and Central Africa are not accessing ART because the majority have not yet been diagnosed. Every year, an estimated 38,000 children die of AIDS-related illnesses in the region, and 58,000 are newly infected with HIV.28 Some countries are making progress in preventing HIV among children, with 11 reporting a reduction in new infections among this age group of more than 35% between 2010 and 2017. However, new infections in other countries are not falling. This includes Nigeria, which has the largest HIV epidemic in the region.29

The main route of HIV transmission to children is through birth (see later section on preventing mother-to-child transmission). However, West and Central Africa also has high levels of underage, child and forced marriage.

Across the region, three out of 10 girls become pregnant before the age of 18, and four out of 10 get married before that age. The region is home to the three countries with the highest rates of child marriage in the world: CAR (68% married before the age of 18), Chad (68%) and Niger (76%),30. However, this is not uniform across all countries in the region, for instance, in Benin, Burundi and Cameroon, the majority of girls (75% or over) are unmarried by the age of 18.31

Females who marry as minors are more likely to suffer domestic violence and rape than those who marry later; they also find it harder to negotiate safer sex.32 These factors all increase HIV risk.

Sex workers 

In 2018, HIV prevalence among sex workers in West and Central Africa differed greatly between countries, ranging from 4% to more than 30%, with nine countries reporting prevalence of 10% or more.33 In the same year, sex workers accounted for 14% of all new HIV infections occurring in the region, while the clients of sex workers (and the sex partners of other key populations) accounted for 25%.34

Reported data suggests sex workers and their clients are likely to use condoms, with usage levels at above 70%, except Burundi at 52%, Guinea Bissau at 22% and Sierra Leone at 15%.35 However, in some cases sex workers cannot access condoms, are unaware of their importance or have condoms confiscated by police.36

Sexual violence, which often involves forced unprotected sex, has been documented among sex workers in the region, including while being arrested and in detention. A study in Benin found increasing violence against female sex workers to be associated with increasing HIV prevalence among this group.37

A 2015 study of female sex workers in Burkina Faso and Togo explored the relationship of sexual violence with unprotected sex. Among 684 participants, one in three (33%) reported a history of forced sex. Over half of those experiencing sexual violence had experienced it on multiple occasions and almost 70% reported experiencing it before the age of 20. The study found these experiences to be associated with high-risk sexual behaviour, specifically unprotected sex with clients. Less than 5% of those who experienced sexual violence reported the event to an authority figure.38

We are abused by clients, by law enforcement agents, and even at the market the police stop and harass us, asking for money and health cards. Every month we contribute 10,000 CFA so that we can practise our activities at the weekend freely.

– Debo Sow, President of Karlene (an association of sex workers living with HIV in Senegal)39

Men who have sex with men

In 2018, the median HIV prevalence among men who have sex with men (sometimes referred to as MSM) was 13.7% across the region, and in six countries it was more than 20%.40 However, data is limited, as not all countries in the region report on this population.41It is common for men who have sex with men to be married or in long-term relationships with women. A 2015 study of men who have sex with men in Abidjan, Côte d’Ivoire, for example, found the majority of respondents identified as bisexual.42

Those countries reporting data suggest condom use among men who have sex with men is relatively high with around half the countries that collect HIV data on this group reporting use above 75%. Countries where use falls below this level are Benin (66%), Burundi (45%), Cabo Verde (58%), the Congo (64%) Guinea (66%) and Guinea-Bissau (12%).43

People who inject drugs

Côte d’Ivoire, DRC, Ghana, Liberia, Nigeria, Senegal, Sierra Leone and Togo all have populations of people who inject drugs (sometimes referred to as PWID).44 Overall, in 2017 is was estimated that 6.5% of people who inject drugs who live in the region have HIV.45

Although data on people who inject drugs is limited, where recorded, HIV prevalence ranges from 1.6% in Senegal to 8.5% in Sierra Leone.46 Nigeria has the highest number of people who inject drugs in the region, estimated at 45,000 in 2017.47 HIV prevalence among women who inject drugs is much higher than among men who inject drugs. For example, in Senegal in 2016 HIV prevalence among women and men who inject drugs was 28% and 7%, respectively.48

Often times, as a female you wait for your partner to inject you after he has already fixed himself. So we share needles.

– Female drug user, Nigeria49

infographic showing distribution of new HIV infections among population grops by region, west and central Africa (2014)

Prisoners 

HIV prevalence among people who are in prison in West and Central Africa is thought to be high, with female prisoners most affected, experiencing HIV prevalence that is almost double that of men (13.1%, compared with 7.1%). High prevalence is due to a number of factors including the continued criminalisation of key population groups, limited access to healthcare, drug use, unsafe injecting practices, sexual violence, unprotected sex and tattooing.50

Transgender people 

Despite the lack of data, transgender people are thought to be hugely affected by HIV in West and Central Africa. Only Sierra Leone has reported on HIV among this group, estimating HIV prevalence to be 15%.51

HIV testing and counselling (HTC) in West and Central Africa 

HIV testing and counselling (HTC) services in West and Central Africa have increased in the past decade but still remain largely inadequate with only 64% of people living with HIV aware of their status as of 2018. Even among groups that are usually prioritised, such as pregnant women, HTC remains low.52 UNAIDS describes the lack of diagnosis of people living with HIV as the “single biggest challenge” to the HIV treatment cascade in the region.53

Stigma and discrimination, test kit stock-outs, staff shortages, insufficiently trained health workers and user fees at clinics all undermine progress.54

Provider-initiated HTC at healthcare facilities, where clinical staff offer patients an HIV test, is the main testing approach in the region. However, alternative approaches to testing are needed and, where they are being implemented, are showing results. For example, the involvement of civil society organisations and the use of peer-led community approaches has led to relatively high testing coverage among female sex workers in many countries, with Benin, Burkina Faso, Cameroon, Côte d’Ivoire, Gambia, Guinea and Togo reporting HTC coverage among this group of 60% or above in 2018.55 As of June 2018, Benin, Burkina Faso, Burundi, Côte d’Ivoire, DRC and Ghana had all introduced supportive policies relating to HIV self-testing although were yet to implement self-testing widely.  Cameroon, CAR, Chad, Gabon, Guinea, Guinea-Bissau, Liberia, Mali, Senegal, Sierra Leone and Togo were developing policies.56 Access to HTC remains low among adolescents across the region, although girls have better access than boys. Barriers to HIV testing among adolescents include age-of-consent laws and parental consent requirements; adolescents’ low perceived risk of HIV, and negative attitudes of healthcare providers.57 As people age, the disparity between genders continues, as women are more likely than men to be aware of their status.58

CASE STUDY: Increasing HIV diagnosis rates among key populations

An ‘enhanced’ peer outreach approach, implemented in Burundi, Cote d’Ivoire and DRC, has been shown to significantly increase diagnosis rates among HIV positive female sex workers and men who have sex with men.

The approach involved paying peer outreach workers and providing other performance-based incentives, and only recruiting those with medium to large social networks who could demonstrate certain characteristics such as good communication, leadership and motivational skills. The approach was implemented by existing community-based organisations that already had established outreach programmes in HIV ‘hot spots’ such as karaoke bars and massage parlours.

The intervention resulted in a significantly higher proportion of HIV positive sex workers and men who have sex with men becoming aware of their status. For example, in Burundi the diagnosis rate among female sex workers rose to 10.8%, compared to 4.1% during standard community-based outreach. In Cote d’Ivoire, the diagnosis rate among men who have sex with men rose to 15.4% compared to 5.9%.59

HIV prevention programmes in West and Central Africa

There were 280,000 new HIV infections in West and Central Africa in 2018, 13% fewer than in 2010. However, over the same period new infections have risen by more than 10% in Equatorial Guinea, Gambia, Mali and Niger.60 In contrast, Burundi, Burkina Faso, Mauritania and CAR have seen new infections fall by 40% or more.61

Countries in the region have committed to a combination approach to prevention, although certain interventions within this approach are stalling.

Condom availability and use 

Condom programmes are a priority across the region. Social marketing, including through civil society organisations and in healthcare facilities, is the main strategy for distribution. However, few countries have comprehensive condom programming plans and often where they do exist they are not implemented.62 Individual country progress reports show that condom distribution is particularly low in Burundi, Chad, Guinea and Mali. It has also been estimated that Nigeria needs US$22 million a year to close its condom procurement gap.63

Half of the 12 countries reporting data from population-based surveys found low levels of condom use among adolescent boys and young men, with less than 50% using a condom the last time they had high-risk sex. Among adolescent girls and young women condom use is even lower still.64

HIV education and sex education 

Delivering comprehensive sexuality education (CSE) in schools in West and Central Africa is hampered by the low levels of children and young people accessing education in the first place, with gender disparities widening as children advance through the education system. In 2010, close to 17 million children aged 6–11 in the region were out of school, 52% of whom were girls.65 Enrolment to secondary education across the region stands at 37% for males and 30% for females.66

For those in school, good quality CSE is compromised by resistance from parents, teachers and decision-makers, resulting from misunderstandings about the nature, purpose and effects of sexuality education.67

However, some countries are making progress in this area. For example, Benin has accelerated efforts around CSE, developing a national programme that will be integrated into existing subjects without affecting school schedules. Teachers’ guides and student handbooks have been designed to accompany the programme to support teachers to introduce CSE effectively.68

Case study: MTV Shuga

MTV Shuga is a mass-media behaviour change campaign that aims to improve the sexual and reproductive health of young people, with a particular focus on young women. It is funded by a range of international and national donors and centres around an awarding-winning TV series, supported by radio, digital, social media and mobile elements. It began in 2009 in Kenya, with Series 3 (2013) and Series 4 (2015) set in Nigeria. It has been viewed in countries across the region.69

In 2016, a study conducted by the World Bank in Nigeria found a 35% increase in HIV testing among those who watched MTV Shuga for up to six months, and over half for those who watched the series for longer. The series was also found to improve viewers’ knowledge and attitudes relating to HIV, sexual and reproductive health, and risky sexual behaviour.70

Prevention of mother-to-child transmission (PMTCT) 

Antiretroviral treatment for pregnant women in the region has expanded since 2010 but has shown a worrying decline in recent years. In 2018, 59% of pregnant women living with HIV received ART to protect their health and prevent their infant from acquiring HIV, compared to 64% in 2016.71 In Nigeria alone, the proportion of women receiving ART during pregnancy has fallen by nearly 20% (from 63% to 44%) between 2014 and 2018.72

There is variation between countries with Benin, Burkina Faso, Burundi, Cameroon, Côte d’Ivoire, Liberia and Togo all reporting PMTCT coverage of 80% or above in 2018.73 At the other end of the scale, the Congo, Mali, DRC, Nigeria and Guinea Bissau all have low coverage of between 24% and 48%..74 User fees for antenatal clinics or other health services are stopping many women and children in the region from accessing PMTCT services. The impact of this is can be seen by the disparity in coverage between countries. For instance, in 2018 less than half of HIV positive pregnant women in Cameroon, CAR, DRC, Mali and Nigeria, where user fees exist, were receiving ART. By comparison, around three-quarters of HIV positive pregnant women were on ART in central African countries where user fees do not apply.75

Just 27% of babies born to HIV-positive mothers in the region are tested for HIV within two months of their birth, compared to 68% in East and Southern Africa.76Of the 52,000 babies born with HIV in West and Central Africa in 2016, 15,000 died from AIDS-related illnesses before their first birthday.77

Children younger than 18 months who are born to HIV-positive mothers require virological testing yet there has been limited progress on this in the region.78 However, it is increasing in Cameroon and Côte d’Ivoire,79 and Ghana is in the process of piloting programmes.80

Voluntary medical male circumcision (VMMC) 

In 2007, the World Health Organization (WHO) and UNAIDS recommended voluntary medical male circumcision (VMMC) as a key component of HIV prevention in countries with a generalised epidemic, following the discovery that it could reduce the risk of sexual transmission of HIV from females to males by 60%.

Male circumcision is common in West Africa.81 One of the reasons for this is that circumcision is a common practice within Islam and many countries in this part of the region are predominately Muslim. A 2016 study found countries that report on both the proportion of Muslim men who were circumcised and the proportion of the population who are Muslim show a close match.82

Male circumcision is less common in Central Africa. UNAIDS has identified CAR as a high priority for VMMC.83 However, conflict has severely disrupted HIV services there since 2013, including the implementation of VMMC.84

Harm reduction 

Despite the region having significant populations of people who use drugs, harm reduction interventions, which help prevent HIV transmission through injecting drug use, are scarce.

The only harm reduction programmes in the region are in Senegal, Côte d’Ivoire and Mali. Senegal has the most advanced programme, although it is still relatively small, as it offers  needle and syringe programmes (NSPs) and opioid substitution therapy (OST), both of which are government-run and community-based. Côte d’Ivoire offers OST only, while Mali only implements an NSP.85

In November 2016, the Global Fund awarded Alliance Nationale des Communautés pour la Santé (ANCS), a civil society organisation in Senegal, with a regional harm reduction grant. The grant is being used to support Côte d’Ivoire, Cape Verde, Burkina Faso, Guinea-Bissau and Senegal to generate better data about people who use drugs, create and strengthen harm reduction programmes and policies, and advocate for a more supportive legal and policy environment.86

Progress among other countries in the region is stalling. For instance, in 2014 Ghana began collecting data on people who inject drugs to establish an evidence base for future programming. In 2017, this programming was yet to be implemented.87 While Nigeria’s National Strategic Plan 2010–2015 established a goal of reaching at least 80% of key affected populations, including people who inject drugs, with group-specific interventions, harm reduction interventions are not included, mainly due to political resistance.88 89 Despite this, 71% of people surveyed who injected drugs in Nigeria reported using sterile injecting equipment between 2005 and 2010 due to widespread availability via pharmacies.90

Pre-exposure prophylaxis (PrEP)

Although the World Health Organization (WHO) now recommends pre-exposure prophylaxis (PrEP) – the use of antiretroviral drugs to protect HIV-negative people from HIV before potential exposure to the virus – the region has been slow in implementing these guidelines for people at substantial risk.91 Two regional projects are underway. One is operating in Burkina Faso, Côte d’Ivoire, Mali and Togo in order to assess how feasible it would be to introduce PrEP, both nationally and regionally. The second is an implementation project in Côte d’Ivoire, DRC and Nigeria, supported by the United States President’s Emergency Plan for AIDS Relief (PEPFAR).92

Testing a preventive HIV method, PrEP, in Burkina Faso

Antiretroviral treatment (ART) in West and Central Africa

As of 2018, 51% of people living with HIV in West and Central Africa were on ART. This means that around 2.5 million people living with HIV need treatment but are not receiving it.93 As of 2017, 12 countries in the region had adopted the WHO ‘test and treat’ (or ‘treat all’) guidelines, which recommends that all people diagnosed with HIV be started on immediate treatment, regardless of the level of virus within their body.94

However, treatment coverage varies widely between countries. More than 60% of people living with HIV in Benin, Burkina Faso, Burundi, Cabo Verde, Gabon, Senegal and Togo were accessing ART in 2017. Cameroon, Chad, Côte d’Ivoire, DRC, Mauritania, Niger and Nigeria are in line with the regional average, with 50% or more people living with HIV accessing treatment. However, as Nigeria is home to the largest population of people living with HIV in the region (1.9 million), this still means around 900,000 people in the country are without treatment.

Access to treatment is particularly poor in CAR, Gambia, Ghana, Guinea Bissau, Liberia and Mali where around two-thirds of HIV positive people are without ART.95

The region’s coverage rate is well below that of East and Southern Africa at 67%.96 Conflict and other disease epidemics are partly responsible for low ART coverage, although the high number of people who do not know their status is a key barrier. Underlying factors such as the lack of national and international political will, weak health services, and lack of support for community organisations exacerbate the situation.97

Men are less likely than women to start treatment, and those who do begin ART are more likely to have advanced HIV progression. This disparity is thought to be due, in part, to harmful gender norms that lead men to view seeking HIV testing and treatment as a sign of weakness.98

Treatment services for children are also poor, as only 28% of the 450,000 0–14-year-olds living with HIV in the region received ART in 2018.99 This is the lowest paediatric ART coverage rate of any region in the world.100

Among the limited number of countries reporting retention-in-care data in 2018, most estimate that between 60-80% of people were still on HIV treatment after 12 months. However, in Equatorial Guinea and Niger this rate is extremely low at 36% and 27% respectively.101 MSF found that patients who interrupt ART do not necessarily disclose this when they re-enrol. It cites data from a 2014 study in Kinshasa, DRC which found that 70% of people with HIV who attended a health clinic due to a severe illness had previously been on ART, of whom 52% had interrupted their treatment for longer than three months. The consequence of insufficient retention data, coupled with health staff’s often-limited knowledge of how to manage treatment failure, means the need to shift to second-line treatment is often missed. This is further compounded by second- or third-line ARVs being either scarce or unavailable.102

As a result of low testing, low ART coverage and issues with care retention, in 2018 only 39% of people living with HIV in West and Central Africa had achieved the viral suppression necessary to prevent onward HIV transmission.103 However, as few people can access a viral load test, the real picture on viral suppression is uncertain.

The situation in the region reflects the fact that global prevalence of HIV drug resistance (HIVDR) is rising, mainly due to resistance to first-line antiretroviral treatment regimes. Weak health systems and low levels of adherence are the main drivers.

Civil society’s role in West and Central Africa

In West and Central Africa, many non-government organisations (NGOs) concerned with protecting the rights of people living with HIV have seen a decrease in funding since the 2008 global recession. As a result, some have had to scale down or stop activities. For instance, since the World Bank ended support to the HIV projects in CAR in 2012, civil society associations of people living with HIV have been struggling to survive.104

Additionally, the fragmentation of civil society organisations into distinct language-speaking groups (primarily English and French) leads to constraints in exchanging experiences and support between countries in the region.105

This is of a particular concern for people from populations most affected by HIV, such as sex workers and men who have sex with men, as these groups often rely on civil society organisations for HIV prevention services.106

People don’t understand HIV. They have a fear of taking the test because they think that if it’s positive, they will die straight away.

- Albert, 55-year-old president of an MSF peer support group in Bukavu, South Kivu, DRC

HIV and tuberculosis (TB) in West and Central Africa

In 2016, six countries (DRC, Nigeria, CAR, Congo, Liberia and Sierra Leone) were classified by WHO as being among 30 with the highest tuberculosis (TB) burdens.107 Overall, 72,000 people with HIV died of TB-related deaths in 2017.108

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Barriers to HIV prevention in West and Central Africa

Stigma and discrimination

HIV-related stigma and discrimination remains a major barrier to tackling HIV in West and Central Africa.

In 10 countries reporting recent population-based survey data to UNAIDS, 50% or more of adults said they would not buy vegetables from a shopkeeper living with HIV. This proportion rose to two thirds of adults in Benin, Ghana, Guinea, Mauritania and Sierra Leone. In seven countries, more than a third of adults felt that children living with HIV should not be allowed to attend school with other children.109

Some countries in the region are working with healthcare workers and police officers to reduce human rights violations in these settings, but often programmes are small, with only a quarter of the countries implementing such nationwide programmes.110

The region remains a difficult place for key populations such as men who have sex with men. This hostile environment often prevents people from accessing HIV prevention, testing and treatment services. For example, following the passage of the Same-Sex Marriage Prohibition Act in Nigeria in 2014, a greater proportion of men who have sex with men in the country reported being afraid to seek healthcare.111

Legal barriers

The criminalisation of sex work, drug use, and same sex practices, as well as the lack of legal recognition of gender identity, compounds key affected populations’ inability to access HIV services.

In Mauritania and Northern Nigeria, the death penalty exists for men who have sex with men. Homosexuality is also illegal in Cameroon, Gambia, Ghana, Guinea, Senegal, Sierra Leone and Togo.112.

Homosexuality is legal in Benin, Burkina Faso, Cape Verde, CAR, Chad, Côte d’Ivoire, DRC, Gabon, Guinea-Bissau, Mali and Niger.113

Sex work is illegal in most countries in the region.114 However, in Senegal, women over the age of 21 may register and work legally as sex workers if they submit to periodic medical examinations. Male and transgender sex workers are not allowed to register. In addition to heavy regulations on legal sex work, Senegal retains criminal penalties for solicitation, brothel ownership, and procuring sex work. However, when sex workers register their files are sent to the police, which sex workers say facilitates harassment, abuse, and extortion at the hands of authorities.115

Sex work is also legal in Burkina Faso, although profiting from others engaging in sex work is illegal.116

In many countries in the region there are laws criminalising people who expose others to HIV or transmit the virus sexually. This fuels HIV-related stigma, which can cause significant barriers to accessing HIV prevention, treatment and care services.117

Data issues

Monitoring of HIV-related information is weak in West and Central Africa. As a result, there are data gaps, questions about the validity of existing data, and a lack of quality available data, all of which hamper adequate programming.118 Data on key populations is also lacking, as many countries do not record consistent, national level data on these groups.

Weak healthcare systems

In 2018, 35 countries in sub-Saharan Africa were classified as ‘fragile states’ by the Organisation for Economic Co-operation and Development, a large proportion of which are in West and Central Africa.119 These countries are experiencing conflict, insecurity and humanitarian crises, such as the Ebola outbreak. All these circumstances put a strain on already weakened health systems, while also creating poverty and violence that can, in turn, increase both risk behaviours and HIV transmission. 120 121

The over-medicalisation of HIV service delivery, and inadequate decentralisation of healthcare services with little focus on community participation and community service delivery, pose further significant barriers to accessing HIV services and the quality of care.122 However, as of 2017 13 countries in the region had implemented task-shifting guidelines to enable nurses or community lay workers to take on tasks that previously only physicians could carry out, such as HIV testing.123 Weak supply systems in the region often result in stock-outs of ARVs, equipment and other commodities such as HIV testing kits. Up to 77% of healthcare facilities in Kinshasa, DRC reported stock-outs of at least one ARV during the previous three months in 2014. In addition, stock-outs of test kits over a three-month period resulted in an estimated 4,000 patients not being tested at their request. Although most of the commodities were available at central level, these stock-outs resulted in 68% of people living with HIV being sent away without the necessary medication.124

User fees, whereby people are charged for accessing HIV testing and treatment services, are also a major issue in a number of countries. For example, in DRC in 2012 households contributed 38% of all HIV spending. In Nigeria this figure stood at 31%, with 14.5% of annual household budgets spent on HIV services.125 However, some countries are aiming to rectify this. For example, in 2019 Cote d’Ivoire announced its intention to increase domestic funding on HIV by US$ 10 million, some of which will be used to ensure HIV services are free of charge.126

Funding in West and Central Africa

Funding for West and Central Africa’s HIV response remains challenging. In 2018, less than half of the resources needed to reach UNAIDS’ 2020 Fast-Track Targets were available. In real terms, funding for the region’s HIV response has fallen by 13% between 2010 and 2018.127

International investment accounts for the majority of funding, at 62% of the total resources available, but overall this has declined from US$ 1.5 billion in 2010 to US$ 1.2 billion in 2018. The Global Fund to Fight AIDS, Malaria and Tuberculosis provides the greatest share of financial support for the region’s HIV response, and although it has increased its investment by 40% during this time, an overall decrease of 75% from other international sources has created a significant funding gap.128

In 2010 domestic resources supported 30% of the region’s HIV response; as of 2018 this proportion had risen to 38%. Nigeria alone has increased its domestic public investment in HIV by more than 30% over this time.129

The downturn in international funding for the HIV response in West and Central Africa has led to an increased focus on domestic sources. However, there is concern that pressure to increase in-country contributions, particularly among fragile states or those countries with low income status, could lead to policies that increase out-of-pocket expenses for people through the introduction or expansion of user fees.

The future of HIV in West and Central Africa

Tackling the HIV epidemic in West and Central Africa is a long-term task that requires sustained effort and planning from both domestic governments and the international community.

In 2016, the African Union and political leaders in the region endorsed the West and Central Africa ‘catch-up’ plan, which aims to drastically improve HIV treatment for adults and children by 2018 in order to meet UNAIDS 2020 Fast Track targets.130

Among the key strategies of the catch-up plan are increasing community involvement in care delivery; improving country ownership and political leadership for domestic HIV responses; task shifting; and investment in strengthening supply chains for commodities such as test kits, ARVs, early infant diagnosis kits and viral load kits.131

The plan has seen 10 countries (Benin, Cameroon, CAR, Côte d’Ivoire, DRC, Guinea, Liberia, Nigeria, Senegal and Sierra Leone) implement country operational plans to implement these strategies.132 Results from 2017 and 2018 suggest some national HIV responses are showing improvement but insufficient political will and frail health systems are continuing to hold back progress.133Without addressing fundamental barriers to treatment, particularly HIV-related stigma and discrimination, HIV-specific criminal legislation and user fees, the number of people getting tested for HIV and seeking treatment will remain compromised.

Girls and young women must also be placed at the centre of the response if the region is to reduce HIV. This involves meaningfully addressing gender inequality, tackling harmful traditional practices such as child marriage, and increasing educational opportunities.134

Last full review: 
05 November 2019
Next full review: 
05 November 2022
Last updated:
05 November 2019
Last full review:
05 November 2019
Next full review:
05 November 2022