Low HIV prevalence has its own challenges

Madagascar has a low level of HIV prevalence, and managing its AIDS programme should present no major difficulties. But the apparent advantage of a low infection rate, combined with the ongoing political crisis, has brought its own challenges.

Madagascar, and the neighbouring islands states of Comoros, Mauritius and Seychelles, are anomalies in the context of HIV/AIDS in Africa. Prevalence is very low - around 0.37 percent, or 24,000 confirmed cases - and restricted to a few sections of the population.

Recent research has revealed that the groups most infected are men having sex with men (14 percent), intravenous drug users (7 percent) and prison populations. HIV prevalence among female commercial sex workers is relatively low.

The UNAIDS Inter-Country Coordinator, Dr Mamoudou Diallo, says the low prevalence makes it a challenge to carry out a concerted national programme. "In the Indian Ocean islands, HIV and AIDS is a condition very few people have seen. It's not like the African mainland, where everyone knows someone who has it. As a result, many people here are not convinced of the danger of AIDS. This includes the leaders."

Getting antiretroviral (ARV) drugs to the 472 patients who need them is not easy, and recent stock-outs have sometimes left patients without treatment for months, exposing them to the risk of developing drug-resistance.

The Malagasy Ministry of Health and its private sector distributor, Salama, have problems placing orders because suppliers are not interested in providing small quantities, making it difficult to keep adequate supplies of ARVs in stock. "We try to use a supply station in Denmark and place the order through UNICEF [UN Children’s Fund]," Diallo told IRIN/PlusNews. The expensive drugs can't be given to patients for months in advance and must be held in stock.

One possibility being explored is putting in place a central purchasing mechanism for the four Indian Ocean countries. This facility would fall under the oversight of the High Level Partnership Forum, which is expected to be set up after discussions with the Indian Ocean Commission, an inter-governmental cooperation group.

The forum would include Ministers of Foreign Affairs, Ministers of Health; Networks of people living with HIV, support groups, and various financial partners.
 

In the Indian Ocean islands, HIV and AIDS is a condition very few people have seen ... As a result, many people are not convinced of the danger of AIDS. This includes the leaders.

Donors warn that although the spread of HIV/AIDS in Madagascar has been limited until now, the potential for an epidemic still exists. The country’s growing industries, mining, and tourism are all potential sources of rising HIV infection, while its young people are among the groups most vulnerable to HIV infection.

Madagascar's 2008/09 Demographic and Health Survey (DHS), notes that more than half of the young men and women 15 to 24 years of age had their first sexual encounter before the age of 18. Nearly one out of five young men had more than one sexual partner in the past year, but only 8.8 percent used a condom. In the adult population the percentage of condom use was even lower: 7.4 percent for men and 7.6 percent for women.

Diallo sees a real but hidden threat of escalating HIV/AIDS infection in this behaviour. "Since men having sex with men is not accepted in Malagasy society, a third of these men are also married, potentially passing the virus on to wives and the wider society," he said.

Low condom usage has already caused one of the highest rates of sexually transmitted infections (STIs) in the world: syphilis prevalence is as high as 4.4 percent among pregnant women and 12.1 percent among female sex workers, according to government figures. "We need a system of vigilance, and to carry out a prevention plan to help fight HIV at every level and with everyone involved," Diallo said.

But AIDS prevention work has been complicated by the political instability of the last three years. Madagascar last carried out a national AIDS prevention plan during the administration of President Marc Ravalomanana.

In early 2009, Andry Rajoelina, the opposition leader and mayor of Antananarivo, the capital, ousted Ravalomanana but the move was widely condemned and donors halted all but the most basic humanitarian funding. Promised elections have yet to be called and although funding has improved, the levels remain low.

The National AIDS Control Committee (Conseil National de Lutte contre le SIDA - CNLS) is attached to the President's Office and facilitated by international donors. Work is now mostly done by the Forum of Partners, which operates under the CNLS with participation by the UN, international donors, civil society and the private sector.

"[Around] 90 to 95 percent of all AIDS-related work is financed from abroad, while this should be about 60 percent. However, the ministers here don't have AIDS on their agenda," said Diallo, who is looking for funding to improve and expand HIV/AIDS data collection.

"It's hard, because other countries have millions of patients, and here there are 826 monitored people living with HIV, of whom 472 are treated. But on the other hand, studies on the low prevalence reasons here can help everybody."

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