The inhabitants of Sam Ouandja, an isolated diamond mining town in the northeast of the Central African Republic (CAR), were exposed to their first ever HIV awareness campaign in 2007. The focus was on HIV testing, but more than a year later, those who tested positive are still waiting for the arrival of HIV/AIDS services.
Issa Mohamed, president of the Health Management Committee (COGES) in Sam Ouandja, told IRIN/PlusNews that about 200 people came to be tested during the campaign led by the National AIDS Council (CNLS).
"We gave them their results; in some cases no explanation was given. As many people here are illiterate, they had to ask their neighbours to read them their results, so everyone in the neighbourhood knew if they were HIV positive," he said.
"These people didn't receive any counselling or medication. They [CNLS] said they were going to come back, but it's been more than a year and we're still waiting. People feel like they have been abandoned."
CNLS is well aware of the lack of HIV/AIDS services in Sam Ouandja and many other regions in CAR. The goal of the awareness campaign was to gauge local needs in each of the country's 16 departments, said Yacynthe Wodobode, the national CNLS coordinator. Only Vakaga, in the north, has not yet been visited due to security issues.
"Each prefecture now has a voluntary [HIV] testing centre, but counselling is not yet available at all centres and when the test results arrive, the biggest issue is providing ARVs [antiretroviral drugs] and treatment of opportunistic infections," she told IRIN/PlusNews.
"Even if a prescribing doctor at a [local] hospital can dispense ARVs, there is the issue of regular supplies of stocks," she added. "In many centres the shelves are empty."
Extent of HIV unknown
The HIV-prevalence rate in CAR is the highest in central Africa: 6.2 percent according to the government. The infection rate among Sam Ouandja's 20,000 inhabitants is not known, but Haute-Kotto, the department where the town is located, has a prevalence rate of 7.4 percent.
"The inhabitants of Sam Ouandja are very mixed," noted Mohamed. "There are lots of men who have come alone from all over the [African] continent in search of diamonds, and there are lots of [sex workers]." A refugee camp with around 3,000 Sudanese refugees from Darfur is also located in the town.
|Single men come to Sam Ouandja in search of diamonds|
Despite the potential for HIV to spread in such a community, the closest HIV testing and treatment services are hundreds of kilometres away in the towns of Bria, to the south, and Birao, to the north. The journey to either is long and expensive - costing up to 25,000 CFA (US$52) - and only possible during the dry season. During the rainy months, Sam Ouandja can only be reached by light aircraft.
Staff from the International Medical Corps (IMC), which runs the town's only hospital and is one of just two humanitarian organisations working in Sam Ouandja, believe there are many undiagnosed HIV cases.
The lack of testing services mean their suspicions are based on clinical signs, such as the high prevalence of tuberculosis and other opportunistic infections linked to HIV, but because they cannot confirm whether someone is HIV positive or offer treatment, health workers have to be cautious about telling patients.
"There are lots of cases of shingles [a common skin disease among people with compromised immune systems] in both women and men. When we come across cases, we can tell patients [that they may be infected]," said Rosalie Manché, a midwife at the hospital. "Some of them listen, but others do not take it well. All we can do is treat the [opportunistic] infections and give advice."
Infections are often fatal in people who have become weak due to malnutrition and waterborne illnesses caused by a lack of clean drinking water. "Since July  we have had four deaths of malnourished children, which we suspect were HIV/AIDS-related," said Félicien Djamby-Sangui, a nutrition assistant at the hospital's therapeutic nutrition centre, which is also run by IMC.
Need for government action
Despite the challenges, IMC has begun putting various initiatives in place, with support from donors such as the UN Children's Fund (UNICEF) and the UN Population Fund (UNFPA).
Trained community workers are visiting neighbourhoods to do awareness-raising and distribute condoms, said Dr Kossingou Niva, the IMC head in Sam Ouandja.
The hospital has a limited supply of ARV drugs, provided by UNICEF, to prevent the transmission of HIV from pregnant women known to be positive to their babies. The problem is the lack of testing equipment to confirm infection, and the risk of putting people on treatment unnecessarily.
Guy Yogo, the IMC head of mission in CAR, believes an effective and sustainable HIV/AIDS programme in the region requires commitment from the authorities, which is not disputed by Wodobode from CNLS.
She said the decentralisation of HIV/AIDS services to provincial areas had been held up by various factors, including problems managing a grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria, and emphasised the need for government to find ways of getting around funding shortfalls.
"The ministries do not have the [necessary] resources, but they are not exploring all available avenues either," she commented.
"For example, there are lots of AIDS cases in mining areas [like Sam Ouandja]; they could regulate it so that some [of the mining resources] stayed in the region and were used towards developing [HIV/AIDS] services." She said civil society should also become more involved.
Mohamed from COGES pointed out that there were no organisations for people living with HIV in Sam Ouandja. "If there was a system for bringing [people living with HIV] together, they could be helped but this is not the case," he said. "People are all alone in the town."
See also: Mabelle Kpawilina, "AIDS in Sam Ouandja is worse than in Bangui"
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