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HIV and AIDS in West and Central Africa Overview

Western and Central Africa_23August2016.png

inforgraphic showing HIV statistics for West and Central Africa (2016)

West and Central Africa is home to 6.5 million people living with HIV of whom half a million are children.1

HIV prevalence in most of the countries is relatively low compared to East and Southern Africa. HIV prevalence among adults across the region overall stands at 2.2% although there is wide variation between countries, ranging from 0.5% in Niger and Senegal to 4.9% in Equatorial Guinea.2

Most countries struggle to offer antiretroviral treatment (ART) to those who need it. It is estimated that 72% – around 5 million people – are without treatment.3 As a result, one in four AIDS-related deaths worldwide occurs in West and Central Africa, while four in every ten children who die from AIDS-related illnesses die in the region.4 This equated to 330,000 AIDS-related deaths in West and Central Africa in 2015.5

In the same year, 410,000 people became infected with HIV. An estimated 60% of new HIV infections occurred in Nigeria, and another 30% occurred in Cameroon, Chad, Côte d’Ivoire, Democratic Republic of the Congo (DRC), Ghana, Guinea and Mali.6

New infections among children decreased by 31% between 2010 and 2015, reflecting the scale-up of coverage of prevention of mother-to-child transmission services from 23% to 48%.7 However, the region still accounted for 45% of the global total of new HIV infections among children in 2015.8

Women are disproportionately affected by HIV in West and Central Africa, accounting for 54% of adults living with HIV. HIV prevalence was at least twice as high among women than men in Cameroon, Central African Republic (CAR), Congo, Cote d’Ivoire, Ghana, and Guinea in 2012.9 In 2015, 64% of new infections among young people (15-24 years) in the region occurred among young women.10

Although West and Central Africa’s HIV epidemic is generalised, meaning it affects the population as a whole, HIV prevalence among sex workers, people who inject drugs and men who have sex with men is significantly higher than prevalence among the general population. In 2014, new infections among key populations and their sexual partners accounted for more than a quarter of all new infections, despite these groups representing a much smaller proportion of the overall population.

Despite these statistics, programming for key populations remains insufficient and stigma, discrimination and legal barriers prevent many people from these groups from accessing HIV services.11  

In addition, many countries are in conflict, facing post-conflict situations or dealing with the impact of other humanitarian crisis such as the 2014-2016 Ebola epidemic, which further complicated the region’s HIV response.12

Key affected populations in West and Central Africa

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

Young women and HIV in West and Central Africa

In 2015, 64% of new HIV infections in West and Central Africa among 15 to 24-year-olds were among young women.13 The difference between young women and men is especially striking in Cameroon, Côte d’Ivoire and Guinea where adolescent girls aged 15–19 are five times more likely to be infected with HIV than boys of the same age.14
In 2016, UNAIDS named Cameroon, CAR, Côte d’Ivoire, DRC, Gabon, Guinea-Bissau and Nigeria as being countries where HIV responses for young women should be prioritised.15

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 and gender-based violence, both of which increase HIV vulnerability. For example, in Cameroon in 2014 more than 35% of 15-24 year old women had experienced spousal physical or sexual violence by their current or most recent partner in the past 12 months.16 Additionally, in conflict situations sexual violence, particularly against women, is commonly used as a strategy of war, with younger women especially vulnerable.

Age-disparate sexual relationships between young women and older men are commonplace, as is adolescent marriage and pregnancy.17 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 15-19 year-old women in Senegal, Niger, Burkina Faso, Côte d'Ivoire and Cameroon do not have the final say on their own healthcare, according to recent Demographic and Health Surveys.18

Knowledge about HIV among young people in the region is alarmingly low: with only 24% of young women and 31% of young men able to display comprehensive and correct knowledge of how to prevent HIV.19 West and Central Africa also had poor educational levels more generally, especially for adolescent girls. The United Nations Children’s Fund estimates that 18.8 million children in the region are not in school. Girls are particularly disadvantaged: just over half (54%) of young women in the region are literate.20

Children and HIV in West and Central Africa

The main route of HIV transmission for 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.

In 2015, 42% of girls in West and Central Africa were married by the time they were 18. Brides not Girls locates eight of the world’s ten child marriage ‘hot spots’ in the region.21

Females who marry as minors are more likely to suffer domestic violence and rape than those who marry later and also find it harder to negotiate safer sex.22 These factors all increase HIV risk.

Although child marriage is prevalent across West and Central Africa, there are marked differences between countries. For example, in Chad 29% of women are married before they are 15, compared to 10% in Burkina Faso, while 68% of women are married between the ages of 15 and 18 in Chad compared to 52% in Burkina Faso.23

Sex workers and HIV in West and Central Africa

In 2015, HIV prevalence was estimated at 16.5% among sex workers in West and Central Africa.24 In the 15 countries that reported data, prevalence ranged from 4% in Mauritania to 24% in Mali.25 In Nigeria and Ghana, HIV prevalence among sex workers was eight times higher than for the rest of the population in 2014.26

Data on condom use by sex workers and their clients in the region is limited. In some cases, sex workers have no access to condoms or are not aware of their importance. In other cases, condoms are confiscated by police.27

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 types of violence against female sex workers (defined as any combination of physical, sexual, and/or psychological violence) to be associated with increasing HIV prevalence among this group.28

A study published in 2015 of female sex workers in Burkina Faso and Togo explored the relationship of sexual violence with unprotected sex. Of the 684 female sex workers who took part in the study, 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 experiences of sexual violence were 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.29

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. We are stigmatised by the community and also within our families we have no voice. There is no confidentiality within the police if we take our ARVs [antiretrovirals] in front of them. If they arrest a sex worker who is on ARVs…we have to intervene very often on behalf of other sex workers who are arrested.

– Debo Sow, President of Karlene (an association of sex workers living with HIV in Senegal)30

Men who have sex with men (MSM) and HIV in West and Central Africa

It is estimated that 17% of men who have sex with men (sometimes referred to as MSM) who live in West and Central Africa have HIV, although prevalence differs between countries.31 For example, in 2015 prevalence ranged from 3.6% in Burundi to 37.2% in Cameroon. However, data is limited, with only 12 countries in the region reporting on this population.32

In the region, it is common for men who have sex with men to also 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.33

Regional data on condom use among men who have sex with men are limited. A 2011 study in Togo found 78.4% of respondents reported condom use at last insertive anal sex and 81.2% of respondents reported condom use at last receptive anal sex. This equates to one in five men in the study not using a condom the last time they had anal sex. At the time of the study, HIV prevalence among men who have sex with men in Togo was estimated at 19.6%, compared to 3.4% in the general population.34

People who inject drugs (PWID) and HIV in West and Central Africa

Burkina Faso, Côte d’Ivoire, Gabon, Ghana, Nigeria, Senegal and Sierra Leone all report populations of people who inject drugs (sometimes referred to as PWID).35

Nigeria has the highest number of injecting drug users in the region, estimated at around 11,700 in 2014, whereas Senegal reported 1,320 people who inject drugs in the same year.36

Although regional data is limited, country surveys among people who inject drugs suggest HIV prevalence stood at 6.5% in 2015.37 HIV prevalence among women who inject drugs is much higher than among men who inject drugs. For example, HIV prevalence in Nigeria among female and male injecting drug users was 14% and 3% respectively. Similarly, in Senegal HIV prevalence among female and male injecting drug users was 28% and 7% respectively.38

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, Nigeria39

Senegal implements small-scale, community-based needle and syringe programmes (NSPs). This is the only government-run harm reduction programme in West Africa. In 2014, Ghana began collecting data on people who inject drugs to establish an evidence base for future programming.40

While Nigeria’s HIV/AIDS 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 by 2015, harm reduction interventions are not included.41 However, 71% of surveyed injecting drugs in Nigeria reported using sterile injecting equipment between 2005 and 2010 due to widespread availability via pharmacies.42

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

HIV testing and counselling services in West and Central Africa have increased in the past decade but still remain largely inadequate. Even among groups which are usually prioritised such as pregnant women HTC remains low.43 As a result, 64% of people living with HIV were unaware of their status in 2015.44

Additionally, the Ebola epidemic in West Africa resulted in HIV testing services being suspended or heavily reduced in Liberia, Sierra Leone and Guinea for much of 2014 and 2015.45

The most recently available survey data suggest that more women than men, and more adults aged 25 years and older than young people, know their status.UNAIDS (2016) 'Prevention Gap Report'[pdf] By contrast, 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, with the majority of countries having coverage of 60% or above.46

Provider-initiated testing, when HIV tests are offered by health workers rather than being requested by patients, is often preferred over community-based voluntary testing and counselling although HTC is rarely offered systematically. For example, a Médecins Sans Frontières (MSF) study of hospital inpatients in three DRC hospitals in 2012 found 90% reported never being offered an HIV test before.47 Various barriers also hinder HTC uptake including test stockouts, patient fees, a reluctance on the part of staff to propose testing and a lack of counselling availability. Additionally, health workers tend to reserve HIV tests for diagnosing people who are already ill.48

HIV prevention programmes in West and Central Africa

Condom availability and use in West and Central Africa

Condom programmes are a priority across the region. Social marketing, including through civil society organisations and in health facilities, is the main strategy for distribution. However, few countries had comprehensive condom programming plans and often where they do exist they are not implemented.49

Individual country progress reports show condom distribution was particularly low in Burundi, Chad, Guinea and Mali in 2014/2015. It is also estimated that Nigeria needs US $22 million a year to close its condom procurement gap.50

Available data for 2010–2014 from 18 countries in the region indicate that condom use at last sex with a non-marital, non-cohabiting partner was higher among men than among women.51 The most recently available survey data suggested that condom use among female sex workers remained high within most countries in the region at above 80%, while among men who have sex with men it varied between 32% in Sierra Leone and 85% in Benin.52

Prevention of mother-to-child transmission (PMTCT) in West and Central Africa

In 2015, only 48% of pregnant women living with HIV in West and Central Africa received effective ART to prevent mother-to-child transmission of HIV (PMTCT).53 However, there are significant differences of coverage between countries. For example, Burkina Faso, Burundi, Cameroon, Cape Verde and Guinea all had PMTCT coverage of 80% or above in 2015. At the other end of the scale, Mauritania, Niger and Mali all had low coverage, at 12%, 28% and 33% respectively.54

An estimated 45% of global new HIV infections among children in 2015 occurred in West and Central Africa. This is despite the infection rate having reduced by 31% between 2010 and 2014.55 Just 10% of babies born to HIV-positive mothers in the region are tested for HIV within two months of their birth, compared to 50% in East and Southern Africa.56

The situation is particularly challenging in Nigeria, which in 2015 experienced the highest number of new HIV infections among children in the world (an estimated 41,000), roughly equivalent to the next eight countries combined. There has only been a 21% decline in new HIV infections among children in the country since 2009, compared to an average decline of 60% among other priority countries.57

In 2015, the region was home to half a million children (under 14 years) living with HIV, of whom just 20% had access to ART.58

Voluntary medical male circumcision (VMMC) in West and Central Africa

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 male circumcision could reduce the risk of sexual transmission of HIV from females to males by 60%.

Male circumcision is common west Africa.59 One of the reasons for this is that circumcision is a common practise within Islam and many countries in this part of the region are predominately Muslim. A 2016 study found that, 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: Gambia (90-99% vs. 95.3%), Guinea (96% vs. 84.2 %), Mali (86% vs. 92.4%), Mauritania (77% vs. 99.2%), Niger (92 -99% vs. 98.3 %) and Sierra Leone (96.1% vs. 71.5%).60

Circumcision is less common in Central Africa. UNAIDS has identified CAR as a high priority for VMMC.61 However, conflict has severely disrupted HIV services there since 2013, including the implementation of VMMC.62

Case study: #PutYoungPeopleFirst

In 2016, the United Nations Population Fund (UNFPA) launched #PutYoungPeopleFirst to give young people from West and Central Africa a voice at key regional consultations such as the 5th UN Pan-African Youth Summit in Libreville and the Banjul +10 Summit on the African Youth Charter. In June 2016, UNFPA ensured that young people from the region played a key role and were given a high level of visibility to make their call – on behalf of young people from the continent – for commitments from decision makers to invest in them.63

In July 2016, the #PutYoungPeopleFirst campaign saw the UNFPA and the United Religions Initiative - Africa (URI-Africa) sign a regional partnership agreement to help to bring together faith-based organisations (FBOs), traditional leaders and policy makers to protect and empower young people. The agreement focuses on the prevention of child marriage, avoiding early pregnancies, ending female genital mutilation and establishing a regional mechanism between religious leaders, FBOs, interfaith and traditional leaders to address young people’s reproductive and maternal health.64

 

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 but Series 3 (2013) and Series 4 (2015) were set in Nigeria and it has been viewed in countries across the region and engaged with widely on social media.65

In 2016, a study conducted by the World Bank in Nigeria found a 35% increase in HIV testing for those who watched MTV Shuga for up to six months, and by over half for those who watched it for longer. The series was also found to improve knowledge and attitudes of viewers relating to HIV and sexual and reproductive health, as well as reducing risky sexual behaviour such as having multiple sexual partners. It also had an effect on reducing the rate of new chlamydia infections by 58%, a common sexually transmitted infection among young people in Nigeria.66
 

Programmes for key populations in West and Central Africa

There are a number of regional programmes providing multi-country combination prevention programmes for key populations. These include:67

Case study: Abidjan-Lagos Corridor Organization (OCAL)

This is the first multi-sectoral, multi-country initiative of its kind. It specifically targets sex workers, men who have sex with men, people who inject drugs, truck drivers and mobile populations. The programme works on behaviour change communication, condoms and lubricant distribution, HIV testing, management of sexually transmitted infections, and referral to treatment.
As of 2014 OCAL had achieved the following:

•    80,583 truckers, trucker apprentices, female port users and other port users sensitised on HIV
•    196,328 condoms distributed
•    4,685 truckers and other port users tested for HIV, out of which 49 tested HIV positive and were referred to care sites
•    World AIDS Day 2014 was celebrated in all ports involved in the intervention in order to raise awareness about HIV68

 

Case study: Regional HIV/AIDS Prevention Project in Western and Central Africa (PACTE – VIH)

PACTE-VIH is a US $13.5 million programme funded by USAID, which is being implemented by FHI 360 between August 2012 – August 2017. Working in Burkina Faso and Togo, it focuses on female sex workers and their clients and men who have sex with men. Its core aim is to strengthen the human and institutional capacity of national and community-based organisations to plan, coordinate, deliver and monitor service delivery for these target key populations.

As of 2015, PACTE-VIH had achieved the following:
• Conducted advocacy workshops for the police and religious and traditional leaders to build an enabling environment for interventions targeting key populations
• Provided services to more than 51,500 people from key populations, including HIV testing more than 18,000
• Distributed more than 4.2 million condoms (male and female) and lubricants
• Established four Drop-in-Centers for key populations
• Organised advocacy training for journalists
• Trained more than 600 health care workers69

Antiretroviral treatment (ART) in West and Central Africa

An estimated 28% of people living with HIV in Western and Central Africa in 2015 were on ART.70 This means that just under 5 million people living with HIV in the region need treatment but are not receiving it. Of these, 2.5 million live in Nigeria and half a million live in Cameroon.71 There is variation in coverage between countries. For example, in 2015 Gabon and Burkina Faso reported 40% coverage, while CAR, Congo, Guinea-Bissau and Mauritania all reported coverage below 25%.72 Conflict and other disease epidemics are partly responsible for low ART coverage, although 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.73

The number of people starting treatment in West and Central Africa is still outstripped by the number of new HIV infections. Only Senegal, Benin, Burundi and Gabon bucked this trend, reporting more or an equal number of people initiating ART than new HIV infections.74

Figures are scarce for the number of people who initiate ART and are successfully retained in care. In 2016, MSF released data from its own health facilities that suggest retention varies widely, ranging from 75% in Guinea (2013) to 78% in DRC (2014) and 63% in CAR (2014).75

MSF found that patients who interrupt ART do not necessarily disclose this when they re-enroll. It cites data from a 2014 study in Kinshasa, DRC which found 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 antiretorvirals (ARVs) being either scarce or unavailable.76 Drug resistance as  a consequence of non-adherence to ART is a growing global challenge.77

As a result of low testing, low ART coverage and issues with care retention, in 2015 only 12% of people living with HIV in Western and Central Africa had achieved the viral suppression necessary to prevent onward HIV transmission. However, viral suppression data in the region are extremely limited. Only 2% of people living on ART had received a test for viral load, bringing these statistics on viral suppression into question.78

I have seen a number of people die because they didn’t have the money to buy their ARVs. It breaks my heart to see others suffer, getting sick and dying. I would like to have the government support us. I would like to have a place where we can get treatment.

A woman living with HIV from Kinshasa, DRC.79

Pre-exposure prophylaxis (PrEP)

Although pre-exposure prophylaxis (PrEP) – the use of antiretroviral drugs (ARVs) to protect HIV-negative people from HIV before potential exposure to the virus – is not available in the region, both Benin and Nigeria were investigating the uptake and impact of PrEP in 2016. The Benin trial is looking at the effectiveness of PrEP for HIV prevention among female sex workers while the study in Nigeria is focusing on serodiscordant couples, which is when one person has HIV and the other doesn’t.80

Barriers to HIV prevention in West and Central Africa

Weak healthcare systems

Although domestic funding for health has been rising in countries across the region, the provision of health service remains weak. This is particularly true of those countries that are repeatedly exposed to humanitarian crisis such as CAR, DRC and Nigeria. In CAR, even prior to the onset of civil unrest in 2012, the health system was categorised as ‘non-existent’ and in a state of ‘chronic medical emergency’.81

During the 2014-2016 Ebola epidemic in West Africa, fear kept people away from health centres and HIV services were highly disrupted in the three high-transmission countries (Guinea, Liberia, and Sierra Leone) as a result.82

An analysis in Sierra Leone found that the Ebola epidemic weakened already inadequate supply systems, causing severely reduced access to ART for people living with HIV. In Guinea, a study by the organisation Solthis documented a significant decrease in healthcare use among people living with HIV enrolled at Conakry’s Donka hospital during the Ebola outbreak in 2014 with an estimated 42% of those on ART lost to follow-up.83

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 health 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.84

Social and cultural barriers

Stigma and discrimination

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

Data from People Living with HIV Stigma Index surveys conducted in the region between 2011 and 2015 show that stigma and discrimination against people living with HIV is high. These surveys report that insults, harassment and threats were common, with the proportion who had suffered ranging from 15% in Sierra Leone to 70% in Cameroon. Many people also reported being forced to change their place of residence or being unable to rent accommodation (53% of those interviewed in DRC, 12% in Ghana, 10% in Mali). People reported being denied access to health services and reproductive health services because of their HIV status, with the proportion reporting such discrimination ranging from 1% in Benin to 21% in Nigeria. The proportion of people living with HIV who reported self-stigmatising ranged from 16% in Chad to 67% in Liberia.85

Although Burkina Faso, Côte d’Ivoire, Guinea-Bissau and Niger began to implement the recommendations of their national Stigma Index surveys in 2015, funding for this work remains limited.86

The region remains a difficult place for men who have sex with men, sex workers, transgender people and people who use drugs. This hostile environment often prevents people from accessing HIV services.

The status of women

Gender assessments of national HIV epidemics and responses were conducted in Burundi, Burkina Faso, Cameroon, Chad, DRC, Gabon, Nigeria and Senegal in 2016. These found that women and girls in the region are more vulnerable to HIV—in part due to laws and policies that maintain traditional gender roles—and that women in key populations had limited access to services.87 Despite this, the responsiveness of HIV programmes and strategies to meet women’s needs remains uneven in. Although Nigeria had several strategies on gender equality and HIV, budget allocations for these interventions were less than 1% of the total expenditure on HIV in 2015.88

In emergencies, women and girls are particularly vulnerable and have specific needs that are often ignored, including services for safe pregnancy and childbirth and protection from gender-based violence. Additionally, emergencies often cause a disruption to HIV treatment and services, increased food insecurity and destruction of livelihoods as well as heightened exposure to HIV vulnerability and risks.89

For example, a survey of internally-displaced families living in three camps in Sierra Leone found that 9% of female respondents reported having been victims and survivors of sexual violence related to the war and 13% of all households reported some member (male and/or female) having experienced sexual violence.90

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.91In Nigeria, the adoption in 2014 of harsher legislation on same-sex relationships is thought to have resulted in increased harassment and prosecution based on sexual orientation and gender identities.92

Homosexuality is legal in Benin, Burkina Faso, Cape Verde, CAR, Chad, Côte d’Ivoire, DRC, Gabon, Guinea-Bissau, Mali and Niger.93
Sex work is illegal in most countries in the region.94 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.95

In many countries in the region there are laws criminalising people who expose others to HIV or transmit the virus sexually. Supporters of criminalisation often claim they are promoting public health or justify these laws on moral grounds.96 Yet the criminalisation of people living with HIV fuels stigma, which can cause significant barriers to accessing HIV prevention, treatment and care services.97

Funding the HIV response in West and Central Africa

The majority of countries in West and Central Africa are reliant on international funding for their HIV response. In 2015, 8 out of 12 countries reporting data relied on international funding for at least 75% of care and treatment costs. HIV spending on care and treatment per person living with HIV differs widely in the region, from US$65 (Chad) to US$436 (Burundi). Six out of these 12 reporting countries spend less than US$100 on ART per person living with HIV.98

The Global Fund to Fight AIDS, Malaria and Tuberculosis tends to be the major donor in the region, particularly for the provision of ARVs. This reliance creates a potentially precarious situation. In 2016, the United States President’s Emergency Plan for AIDS Relief (PEPFAR) funded programmes in Cameroon, Côte d’Ivoire, DRC and Nigeria.99

Many countries in the region are working with international partners to improve HIV programmes efficiency and funding. In 2015, studies in Burundi, Cameroon, Côte d’Ivoire, DRC, Ghana, Nigeria and Togo were underway to establish a baseline from which to measure national progress towards sustainable HIV responses. Pilots of innovative financing mechanisms, such as taxes on imports, tobacco, transport, hotels and tourism and levies on telephone calls, have also been undertaken.100

There is concern that the pressure to increase domestic funding could lead to policies that increase out-of-pocket expenses for people in the region through the introduction or expansion of user fees. Patient fees already represent one of the main barriers to care in West and Central Africa. For example, in DRC in 2012 households contributed 38% of all HIV spending. In Nigeria this figure stands at 31%, with 14.5% of annual household budget spent on HIV services.101

The future of HIV and AIDS 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.
To meet UNAIDS’ 90-90-90 targets by 2020, in 2015 the region needed to diagnose more than 3.5 million people living with HIV, start an additional 3.4 million people on ART, and ensure an additional 3.9 million people living with HIV achieved viral suppression.102

Innovative HIV testing strategies are needed, including self-testing options, community-based testing, and provider-initiated testing and counselling for priority groups.103
Girls and young women must be placed at the centre of the response if the region is to reduce HIV, this means meaningfully addressing gender inequality and inequity, tackling harmful traditional practices such as child marriage, and increasing educational opportunities.104

As the HIV epidemic develops, countries will need to assess how to allocate what are currently limited resources, by, for example, increasing linkages between sexual and reproductive health (SRH) and HIV services.
However, fundamental barriers to treatment, particularly HIV-related stigma and discrimination and HIV-specific criminal legislation, must also be overcome. Removing such barriers would encourage more people to get tested and seek out treatment, reducing the burden of HIV across the region. Civil society and community-led responses will be vital to this work.

A renewed focus on proper supply chain management must also be addressed in order for HIV-related commodities such as ARVs and testing kits to reach people in need. Out-of-pocket payment and fees for services act as a major barrier to HIV treatment and prevention. This needs to be urgently addressed.105

Without significant international support, sufficient and sustained funding for HIV remains uncertain. Moreover, there is a lack of technical capacity, human resource availability and coordination in some countries, which prevents effective data from being collected.106 These systems must be strengthened to enable the region’s HIV response to effectively tackle the challenges ahead.

Last full review: 
24 April 2017
Next full review: 
24 April 2018

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Last updated:
08 May 2017
Last full review:
24 April 2017
Next full review:
24 April 2018