PRB

(September 2001) Now that the tragedy of AIDS in Africa has finally captured the world’s attention, the international media is spotlighting a few of the continent’s success stories. In Uganda, where the epidemic struck early and hard, aggressive public health campaigns seem to have now brought prevalence rates down to their lowest levels in years. Senegal, on the other hand, has maintained relatively low rates since the first case of AIDS was diagnosed in the mid-1980s.

AIDS experts are now sifting through data to explain how this West African country has managed to maintain its low rates. As Alpha Wade, data management specialist at the U.S. Agency for International Development (USAID) and formerly a statistician at the National AIDS Program in Senegal, said, “In the 1990s, the difference between Senegal and Côte d’Ivoire was not that extreme. Nowadays, prevalence rates in Senegal are still relatively low while in Abidjan, AIDS is the number one cause of death among young people.”

Emphasis on Public Health

One often-cited factor for Senegal’s success is that the government has made AIDS a priority since the mid-1980s. At the 1992 summit of the Organization of African Unity, Senegal’s president at the time, Abdou Diouf, led the way by asking other national leaders to make a commitment to fighting AIDS. The leadership of the National AIDS Program (Programme national de lutte contre le SIDA, or PNLS) has also been stable since its founding in 1986, an exceptional continuity compared with other African states where this key position has been a revolving door for political appointees, making it impossible to design and follow through on coherent strategies.

Senegal also has a long history of public health initiatives, which laid the foundation for their AIDS program. Since 1969, sex workers who are at least 21 years old can register at local clinics where they undergo regular and free testing for sexually transmitted infections (STIs). Rigorous blood screening policies, too, have been in place since 1970. In 1987, the PNLS started a program for the systematic use of the Elisa test on donated blood, according to a presentation by Dr. Ibra Ndoye, head of the PNLS.

Broad-Based School and Community Programs

These public health initiatives have been reinforced by broad-based education programs offered in schools and communities. While the government, spearheaded by the PNLS, has promoted policies to limit HIV transmission, their efforts have been accompanied by a country-wide mobilization of nongovernmental organizations (NGOs), ranging from international groups to small, community-based associations, such as ANBEP (Association Nationale pour le Bien-Etre de la Population) in the Dakar suburbs.

ENDA Tiers Monde, an international NGO with a large office in Dakar, carried out a study on AIDS as early as 1986 that was published the following year as “SIDA et Tiers Monde.” In 1989, ENDA launched its “AIDS Mobile,” a white station wagon with brightly painted images of condoms and information on AIDS that circulated in Dakar and the suburbs distributing AIDS information and condoms. Since then, ENDA has initiated a host of AIDS prevention activities among youth, street children, sex workers, and residents of the capital’s poorer neighborhoods. Another Dakar-based NGO, Africa Consultants International, has developed training programs to raise HIV/AIDS awareness among members of parliament, community leaders, and the media. The NGO has also developed a long-term program that supports HIV/AIDS awareness activities among dozens of community-based associations throughout the country.

Religious Leaders Lend Support

Religious leaders, too, have joined the movement. The head of Jamra and a popular conservative figure, Abdoulatife Gueye, responded to the appeal of local NGOs in the early 1990s to take a stand on AIDS. His organization is now well known for its anti-AIDS activities. Other leading Muslim leaders who talk publicly about AIDS may stop short of promoting condoms, but their open discussions have helped convince followers that AIDS really does exist, not always an easy task in populations where rumors circulate that AIDS is an invention of the West or that it afflicts only unbelievers and homosexuals.

Senegal’s social organization and cultural practices may also have helped keep HIV prevalence low. In this largely Muslim country, the emphasis on avoiding alcohol, which often leads to casual sex, may be a factor. A growing body of scientific literature also points to a relationship between a reduced risk of HIV infection and male circumcision in sub-Saharan African countries. Circumcision is widely practiced in Senegal.

Experts believe that the response of the government and community organizations to the epidemic as well as conservative Muslim beliefs and cultural practices have contributed to keeping Senegal’s AIDS prevalence rates low. They continue to warn, however, that Senegal is not out of danger and that increased vigilance may be needed to prevent the sort of explosive growth in HIV rates that has occurred elsewhere. Emmanuel Lagarde, a researcher at the Centre national de la Recherche in Paris, has noted that Senegal’s prevalence rates are low only in relation to its neighbors to the south. Estimates by the Joint United Nations Programme on HIV/AIDS (UNAIDS) show that HIV prevalence among Senegalese adults 15 to 49 years old was 1.77 percent at the end of 1999. In Côte d’Ivoire, which is among the 15 worst affected countries in the world, the rate is 10.76 percent. On the other hand, Mauritania to the north, which shares many of Senegal’s cultural and religious values, has a reported rate of 0.52 percent.

Areas of Concern

Dr. Abdel Kader Bacha, coordinator of the Department of Community Health and Vulnerability at ENDA Tiers-Monde, warned, too, of the danger that the Senegalese public could become complacent. “People here will see the figures and the guy on the street is going to say, ‘No problem here.'”

Another concern is that prevalence rates are, in fact, higher than the official figures. While the country’s sentinel surveillance system is composed of seven sites in urban and semi-urban areas, it is possible that rates are higher in rural regions. According to Professor Souleymane Mboup, the head of the Bacteriology-Virology Laboratory in Dakar, the sentinel system has been limited to urban areas because of the lack of high-quality laboratories in the countryside. While in most countries, prevalence rates are higher in cities and towns, Senegal’s high rates of migration could mean that returning migrants are bringing the virus home with them and that rates in their home towns are higher than those found in the sentinel sites. While the government plans to extend testing to all regions, HIV prevalence rates now cited for the general population do not include data from any rural regions.

A recent report by Family Health International praised Senegal for its HIV/AIDS policies and also included recommendations to improve sentinel site testing. An important concern is that the testing of pregnant women, who constitute an important indicator of prevalence in the general population, contains some bias. In Dakar, the capital city, and Mbour, a popular tourist resort on the coast with high rates of HIV infection among sex workers, pregnant women must go to a distant laboratory for the blood test, according to Professor Mboup. In Dakar, the women must pay for the test themselves, an obstacle that could well discourage all but the most motivated women, who are likely to be the most educated and possibly not at the greatest risk of HIV infection. Pregnant women will soon have a choice of more centrally located centers, according to Pape Moussa Ndoye, statistician and data manager at the National HIV Sentinel Surveillance Program.

Sentinel testing of sex workers in Senegal, another important record of the epidemic’s patterns, may also not provide the most accurate figures possible. The country’s policy to provide free STI testing and treatment and HIV testing for registered sex workers has been effective in tracking the epidemic among that group. But the legislation on sex workers restricts registration to those who are at least 21 years old. Only they are eligible to register and benefit from free testing for HIV, testing and treatment for STIs, instruction on HIV/AIDS prevention, and free condoms that are distributed by clinic staff. This means that sex workers under the age of 21 work clandestinely without access to benefits that could significantly decrease their chances of HIV infection. The prevalence rate among this group could well be higher than that cited for registered sex workers.

The conventional means of calculating an average prevalence rate for the general population or specific groups may also inadvertently mask important internal fluctuations that could be cause for alarm. When Senegal reports that the prevalence rate among sex workers has remained stable at 15 percent for several years, it is following an accepted practice, found in UNAIDS country reports, of citing figures that represent an average of all data.

Plans for Improving Anti-AIDS Programs

The National AIDS Program is working on plans to correct some of the biases in the data. Procedures for testing pregnant women in Dakar should soon be improved; treatment and testing facilities may become available for sex workers under 21 years old; and surveillance testing is planned for all regions. In addition, the National AIDS Program is planning behavioral and epidemiological studies of certain key groups — migrants, factory workers, and truck drivers — who are potential “bridges” between groups with high HIV prevalence rates, such as sex workers, and the general population. Once this additional information is integrated into prevalence figures, many of the doubts about prevalence rates may be laid to rest. More important, it may be clearer what needs to be done to protect people.

Victoria Ebin is a freelance journalist and consultant to PRB, based in New York City.

For More Information

UNAIDS Epidemiological Database:
www.unaids.org/en/HIV_data/Methodology/epidatabases.asp