HIV help at back of queue in war-battered east

When doctors testing blood in this remote town in eastern Liberia discover that a donor is HIV-positive, they keep the information to themselves. There is nothing else they can do. "Probably about two out of ten donors for blood transfusions are HIV positive and it’s very frustrating not to be able to tell people," said Karolina Claesson, the head nurse from the Medecins Sans Frontieres (MSF) Belgium team that runs Zwedru's main hospital. "But we cannot do anything because there’s no available counselling and treatment," she explained. "Telling them in these circumstances would only make me feel better. They couldn’t do anything about it, they probably wouldn’t be able to talk to anyone about it because of the stigma and they wouldn’t suddenly start using condoms because that would draw attention to themselves," Claesson said. With so much of Liberia's infrastructure destroyed during 14 years of civil war, international aid agencies and the government are focusing on restoring the most basic of health facilities. That inevitably means HIV/AIDS support gets pushed towards the back of the queue. And Zwedru is no isolated case. According to Liberia's National AIDS Control Programme (NACP) there is just one voluntary counselling and testing centre (VCT) outside the capital, Monrovia. That is in Gbargna, a provincial market town 200 km to the northeast. "There is a dire need to reach people in rural areas who are HIV positive and need care and support," Lwopu Bruce, the number two at the NACP, told IRIN. "It's a major concern." No-one really knows the scale of the HIV problem in Liberia. The latest figure from UNAIDS puts the prevalence rate at 5.9 percent of the adult population. But that estimate dates from 2003 when fierce fighting at the end of the civil war made much of the country inaccessible. Zwedru was formerly the headquarters of the Movement for Democracy in Liberia (MODEL), one of two rebel groups that waged war against former president Charles Taylor in this heavily-forested country. It also lies about 30 km from the porous border with Cote d'Ivoire, which has one of the highest HIV prevalence rates in West Africa. "I think the prevalence here is quite high. It’s quite close to Cote d’Ivoire, it’s post-war, there are lots of refugees and other people crossing the border, there are lots of ex-combatants. The prevalence rate here in Zwedru is probably about 10 percent," said Claesson. MSF has been discussing the possibility of setting up services for people living with HIV/AIDS. But Claesson explained that given the total devastation of hospitals and clinks during the civil war, MSF had to start off with basic health treatment in Zwedru for more widespread diseases such as malaria and tuberculosis. Even officials from Liberia's national programme agree that HIV/AIDS is not the number one health concern as the country struggles to rebuild. "Malaria is the leading cause of mortality in this country," Bruce, the deputy head of NACP said. "Of the US $24 million dollars granted to Liberia by The Global Fund, half of it has gone on malaria and the rest is split between HIV/AIDS and tuberculosis," she noted. Lack of doctors and nurses Claesson, in Zwedru, told a similar tale. "Our biggest problem is malaria," she said. "MSF has been putting its resources into the hospital because basic health care is what you need here. It’s a post-war country, there had been no proper healthcare in Zwedru until we came in. There are hardly any doctors and nurses up here. All the educated people are in Monrovia.” It has been almost two years since peace finally returned to Liberia in August 2003. But the capital Monrovia is still without mains electricity and running water and those in rural areas know they face an even longer wait for public services to reach them.

The guns have been handed in but there remains much rebuilding to be done in Zwedru

"We hope that the moment we have basic health services really working again, we can start to strengthen the HIV/AIDS programmes," Bruce said. But Liberia still has a long way to go before that happens. If MSF were to pull out of Zwedru, for example, health care in the town would most likely shudder to a halt. The 2,500 outpatients treated free-of-charge at the hospital each month would have nowhere to go. “Money-wise the government is not in a position to run the hospital. They would not have enough money to pay salaries or buy drugs,” Claesson said. Until Liberia's health infrastructure has been repaired and funds become available for testing, counselling and treatment, the fight against HIV/AIDS will focus on prevention, rather than treatment. But again, resources are limited. In Zwedru there are two billboards emblazoned with pictures and slogans promoting condom use, but the one in the market square has fallen off its hinges and its message faces the ground. And talking to local residents, the scale of the task facing AIDS campaigners becomes clear. "This sticking to one partner, what's that all about? We go all around here, we don't stick to one place, we move about," said one 45-year-old man who would only give his name as Jalue. "I use a condom in some cases, but sometimes you like flesh on flesh contact." Aid workers acknowledge they have their work cut out, even at the education level. “MSF hands out free condoms, but only maybe about five percent of people take them and I don’t know how many of those actually use them," Claesson said. There is also a limit to the extent that you can educate people if you can't offer them more substantial support, she noted. “You can start to talk to people about sexually transmitted infections and using condoms, but you cannot go into detail about HIV when you can’t follow it up," Claesson said. "It’s a tough call.”