Battling third highest HIV-rate in West Africa

Togo lies smack bang in the middle of West Africa's main trade and transport corridor and health experts say the tide of people passing through this narrow strip of territory have helped to land it with the third-highest HIV prevalence rate in the region. According to government statistics, six percent of Togo's five million people are HIV positive, putting the country just behind Cote d'Ivoire with 10 percent and Liberia with an estimated eight percent. But one bright spot is condom use. Packets of six can be found by the bedside in many a hotel room and according to Togo's national AIDS programme, there are now some 11 million condoms being sold a year compared to just seven million in 2002. However that still works out at less than four per person per year for Togo's adult population. And since this former French colony is one of the world's poorest countries, with the economy generating just US $291 per inhabitant each year, not everyone can afford to protect themselves against HIV infection and pregnancy every time they have sex. This problem will soon be aggravated because Togo's current source of cheap condoms is set to dry up next year. USAID recently announced that its condom donations to the country would stop at the end of 2005. Now the race is on to ensure a steady and affordable alternative supply of condoms to keep the safe sex momentum going. At its last board meeting at the end of June, the Global Fund To Fights AIDS, Tuberculosis and Malaria approved a $33 million funding request from Population Services International (PSI) to help plug the condom gap. PSI will use some of the new funds to buy a stockpile of condoms. It will gradually increase the retail price so that when USAID condom donations cut out in 2006, people in Togo will be psychologically used to paying an amount that covers the basic cost of producing, packaging and shipping the contraceptives. "We either have to gradually increase the prices or provide nothing," explained Manya Andrews, PSI's woman on the ground in the capital Lome. PSI condoms, sold by street hawkers whose wares include everything from tomato paste to soap, still dramatically undercut those on sale in private pharmacies. Today you can buy a PSI condom for 25 CFA (5 US cents), whereas unsubsidised equivalent products retail for 290 CFA (53 US cents) - more than 10 times the price. Andrews hopes that local consumers will take the gradual increase in the price of PSI condoms in their stride. "My driver said to me the other day 'Well I remember the day I paid 50 CFA for a beer. Today it cost me 500 CFA but I'm still drinking'," she said. But Leon Adom, the head of Togo's national AIDS programme, is worried. "Already there are people who can't afford to buy condoms. It could disrupt the whole programme and ruin what we've achieved," he told PlusNews. Sanctions clipping wings In this small West African nation, poverty and meagre inflows of international aid are taking their toll. The European Union has withheld aid since 1993 in protest at what it calls poor governance by President Gnassingbe Eyadema, who has been in power for 37 years and is Africa's longest serving head of state. These sanctions have limited the government's ability to spend money on social services and have hurt the fight against AIDS. According to World Bank data, the Togolese government spends just $9 per capita per year on healthcare. That compares to $19 in neighbouring Ghana and $12 in Benin. "The sanctions against Togo have definitely discouraged the traditional donors. Until the Global Fund came in, the donor situation had been extremely difficult," Andrews explained. National statistics show there are some 200,000 HIV-positive people in Togo, which lies in the middle of the coastal highway between Lagos, the commercial hub of Nigeria, and Abidjan, the main city in Cote d'Ivoire. Kossi Attisso, a doctor working for United Nations Development Programme (UNDP), says Togo's position at the centre of this busy trade corridor has been a key factor. "The mobility of the population plays an important part. Togo is a pretty much a crossroads," he explained. "Many foreign truckers make stopovers in the country and the economic crisis at home has pushed more and more women into prostitution which makes for a lethal cocktail." Civil war broke out in Cote d'Ivoire two years ago, seriously disrupting the port of Abidjan's traditional import-export traffic with landlocked Burkina Faso, Mali and Niger. Much of the external trade of these countries now passes through the port of Lome instead. The main road running north through Togo to the Burkinabe frontier has become crowded with heavily laden trucks plying to and from the Sahel. And health experts believe the development of this new trade corridor could have aggravated Togo's AIDS problem. "It's impossible to know because we haven't got before and after data, but the conditions that tend to favour the spread have definitely intensified," PSI's Andrews explained. "There are more... men far away from their families with a bit of money in hand and women who are increasingly desperate. More risky encounters are inevitable." Getting the message out However, some progress is being made in getting the message out to ordinary people. "Two years ago we had just 2,000 people coming forward for voluntary (AIDS) testing. Now's it's in the region of 5,000," said Adom, the coordinator of the government's national campaign against AIDS. He said the government had opened seven news testing centres in the interior, thanks to grants from the Global Fund, which has to date approved $53 million worth of AIDS funding for Togo. By 2005, the Global Fund aims to cut HIV transmission by 40 percent among Togo's sex workers and their partners and by 25 percent among young people aged between 10 and 25 years old. It also wants to improve the medical and psychological counselling services available to those living with the disease and implement measures to make blood transfusions safer. Another important target is increasing access to antiretroviral drugs (ARVs), which improve the quality of life and prolong the survival of people living with AIDS. At present, there are an estimated 2,000 people on ARV therapy in Togo, but the government will shortly launch a drive to make the drugs cheaper and more widely available. Last month, the government took delivery of $2.8 million worth of antiretroviral drugs purchased by the Global Fund. The delivery will be enough to treat another 1,500 people living with the disease, although officials cautioned there may be some overlap with current ARV users. Under the new scheme pregnant women and children under 10 with HIV-positive mothers will be offered free treatment. Officials said other people living with AIDS would pay around 5,000 CFA francs ($20) for a month's treatment, compared to 16,000 CFA ($32) at present. But for Augustin Dokla, who coordinates several associations of people living with HIV in Togo, the main battle to be fought is not over drugs, but against people's prejudices. "If we keep quiet then people are happy to eat and drink with us. But as soon as we say openly that we are HIV positive then we face the stigma everyday," he told PlusNews. "It's not easy living with HIV." Humanitarian workers note that even efforts to destigmatise the disease can sometimes end up reinforcing inaccurate stereotypes. Schoolchildren skits often include portray the person living with AIDS as someone who is continually vomiting or having diarrhoea. And a local NGO recently put out a comic book where the main character was portrayed as a heroine because she turned out to be HIV-negative. Some people living with HIV want laws to be drawn up to prevent stigmatisation, but aid workers said all the drafts of such protection laws were languishing in government offices, unable to get onto the parliamentary floor for discussion. "Everyone is willing to talk the rhetorical script but every effort to get to the personal level runs into a wall of resistance," PSI's Andrews said.