The future at stake

The island nation of Madagascar, off the coast of Southern Africa, has so far been spared an HIV/AIDS epidemic, unlike its continental neighbours, but health officials have warned that the country cannot afford to be complacent.

The next decade presents a window of opportunity; a chance for the government to take action to prevent HIV prevalence from climbing. Madagascar's National Committee for the Fight Against AIDS (CNLS) has estimated that the country rate in 2005 was 0.95 percent, considerably lower than other countries in the region, where rates hover around 20 percent.

"There are two tendencies that can explain this rate," said Dr Minarivolona Andrianasolo, project manager at the CNLS. "Either the epidemic hasn't had time to spread, or the behaviour of the population has helped avoid it."

Several studies had pointed to unsafe sexual behaviour on the island, she commented. For instance, the syphilis infection rate has risen to over four percent, reaching over nine percent in pregnant women in some regions.

The CNLS has described HIV as "invisible yet rapidly spreading". Before 2000, prevalence was well below 0.1 percent, but has been steadily rising since then and Madagascar "is in a transitional stage, going from having a concentrated epidemic to one that is generalised".

Opening the doors to tourism

The fact that "Madagascar is an island, limiting exchanges with other countries in the region", may have acted as a natural barrier against the disease, remarked Kaba Setou, coordinator for the United Nations Joint Programme on HIV/AIDS (UNAIDS) in Madagascar, the Comoros, the Seychelles and Mauritius.

Male circumcision has also been cited by many involved in the fight against AIDS as a possible factor contributing to the low incidence of the disease. Recent studies in South Africa, Kenya and Uganda found that the removal of the foreskin on the penis can reduce the risk of HIV infection in men by half. This is because the inner surface of the foreskin is porous, making it more susceptible to sexually transmitted infections (STIs), including HIV.

Madagascar's isolation is shrinking, particularly with the growth of tourism in the last decade. According to national figures, 170,000 tourists visited the island in 2000, reaching almost double the number in 2006, and half a million are projected to visit in 2007.

Chronically poor but rich in natural resources, Madagascar is ranked at 143 out of 177 countries in the United Nations' Human Development Index. It has embraced the economic benefits of tourism, but there have also been negative side effects.

A 2004 Surveillance Study on Behaviour (SSB), funded by international donors and conducted by the National Statistical Institute, found that "prostitution has proliferated over the last years", and that "Madagascar seems to have become a destination for sex tourism".

Means to continue the fight

Faced with the potential spread of HIV/AIDS, Kaba Setou of UNAIDS said Madagascar was nevertheless equipped with several assets to help it mount an effective response, most notably the commitment of civil society, religious institutions and political leaders.

President Marc Ravalomanana, his wife and members of his government took a public HIV test in 2005 to encourage the population to do the same.

Madagascar also has financial support from international partners, including the World Bank and the Global Fund for the Fight Against AIDS, Tuberculosis and Malaria. The Global Fund has approved several HIV/AIDS grants to Madagascar for programmes targeting vulnerable groups, and has provided financing for the fight against tuberculosis, the main opportunistic infection in HIV-positive people.

The financial resources have provided free testing and antiretroviral treatment, and although fewer than 100 people are receiving treatment, the authorities said they had the means to handle more patients. According to the CNLS, 111 districts have voluntary counselling and testing centres, and there are 15 ARV distribution sites throughout the country.

UNAIDS estimates there are about 39,000 HIV-positive people living in Madagascar.

Keep up efforts

Despite these efforts the authorities have warned that the threat of the disease becoming generalised was real. "The epidemic is still concentrated amongst vulnerable groups, but there exist several means of transmission between these groups and the general population," said Dr Andrianasolo. "We can still halt the transmission chain of the epidemic, as long as we keep focusing on HIV prevention amongst these groups."

Local NGOs have targeted youth, sex workers, men who have sex with men, military personnel and truck drivers with education campaigns to raise awareness of the risks and the role they could play in transmission.

Sex workers have banded together in the fight against AIDS for several years now, with promising results. The 2004 SSB report found that they were the most frequent users of condoms, some even using them consistently.

"The situation appears reassuring, but we don't think it is," said Dr Andry Rasoloarimanana, national coordinator of 'Sisal' ('Sambatra izai salama' - Happy are those in good health), a local NGO that runs prevention campaigns and offers psychological support to people living with HIV.

Although the HIV prevalence rate might only be 1.3 percent amongst sex workers, there were high STI rates in this group, including a 17 percent infection rate for syphilis, the CNLS said.

Rasoloarimanana at the Sisal centre also pointed out that that the HIV patients visiting the centre, mostly women, were younger and younger. The 2004 SSB report revealed that one-third of people aged 15 to 24 had their first sexual relationship before the age of 15. About the same proportion said they had multiple partners, but fewer than 30 percent had used a condom at least once; another 17 percent said they had experienced symptoms of an STI in the last twelve months.

"You can't just look at what happened over the last 15 years," said Dr Rasoloarimanana. "What is crucial is everything that will take place within the next ten years: that will determine if the epidemic will spread within Madagascar or not."

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