Document Sample

                            CENTRAL AFRICA

            A REPORT OF THE WEST,

           HELD IN DOUALA FROM THE 11th TO THE 14th
                        OF JULY 2005

Organise by The Pan African Treatment Access Mouvment

   On the Supervision of the Network of Cameroon’s
 Associations of People Living with HIV/AIDS (NeCAP+)

      On the Coordination of: Sylvanie Laure DJUECHE
              Coordinnator of PATAM Central Africa
        Représentant ISG – ITPC for West and Central Africa

                                            Report Douala version of July 23, 05



2- Introduction of the participants
3- Historic of PATAM, Tides and TAG
10- HIV and TB Research – Old Questions, New Drugs

                                        Report Douala version of July 23, 05


This conference was held in Douala in Cameroon from the 11 th to the 14th of July
2005. It was regroup the West, North and Central Africa to gain access to the
treatment of HIV/AIDS.

In all, it had more than a hundred participants from twenty-three countries.

The conference was organized by the PATAM (Pan-AfricanTreatment Access
Movement) in partnership with the RECAP+ (Network of Cameroon‟s Association of
people living with HIV/AIDS) on the financing of Tides Foundation in the setting of the
fund of collaboration and TAG (Treatment Action Group).

PATAM is a social movement composed of individuals and organizations hired for the
mobilization, of the political leaders, all sectors of the society to assure the access to
the ARVS treatments, as fundamental component for complete care for all HIV+
people in Africa. The steering group members and the Regional Representant are all
democratically elected. The movement is coordinated by the steering Committee
elected by the members of the branch countries of five African regions; East, South,
Central, North and west.

The objectives of the conference were the following:

       1. Education: Educate the community representatives concerned with HIV on
          research, prevention, and treatment; in order to make them capable to
          distribute information on the HIV; to provide them some necessary
          qualifications to help them to understand the involvement of these
          communities in the programs of research and treatment.

       2. Reseautage: to Provide opportunities to the community representatives to
          develop partnerships with the organs of public health (national and
          regional), the administrators of programs of HIV/AIDS, WHO, and other
          donors‟ organization.

       3. Advocacy and mobilization of the ressources: to Provide opportunities to
          the community representatives to develop the plans and strategies in order
          to mobilize the community, the decision-makers, and resources, to better
          fight and to conquer the HIV at the national and regional level, and to
          participate in the world political initiative.

In order to carry this conference successfully, the international planning committee
was put in place following the Harare conference in Zimbabwe. Composed of ten
members, the international planning committee before departure composed of the
regional Representatives of PATAM (West, Center and North). Four members, North
Africa by two members and the coordinator of PATAM in Africa represent the Central
and West Africa.

                                                         Report Douala version of July 23, 05

The mission of the international planning committee is to coordinate the organization
of the conference while defining the country of organization; the criterias of selection
of the participants is on the basis of the enrollment demands.

It also has as mission to define the criterias of selection of the members and the
coordinator of the panel of selection of the community projects (CRP). The approval
of the budget, of the conference, the demands of enrollments. All activities of the
committee are based on the transparency and the individual respect.

The ReCAP (Cameroon Network of the Associations of People Living with HIV) has
been chosen by the international committee of organization to welcome the shop.
The ReCAP+ has load of logistics and all others organizations before and during the



Five sequences marked this part: the word of welcome of the regional Coordinator of
PATAM, the speech of the Chairwoman of the RECAP+, the introduction to the
meeting, a word from the Tecnical Counselor in the Ministry of the Public Health.

   1.1.   The spefique objectives of the conference

   -   To develop five main community priorities to be addressed for the access to
       treatments in the region.

   -   To share at least 3 successful strategies of activism for the treatment that the
       participants will be able to use, in order to develop their own strategic plans.

   -   To develop a means of better writing of the propositions based on real needs,
       to develop an efficient and feasible solution, a meaningful action plan.

   -   To develop a plan for the process of subsidies of the Panel of community
       magazine of collaboration funds.

It is necessary to note that the conference started before the official launching was
held due to delay accused on the Cameroonian authorities.

   2. Introduction of the participants

This session is been enlivened by Brandford Yeboah of Ghana, it consist of every
participant to present himself according to the following model: every person
presents himself and answers the following questions: Where do you come from?
Where do you work or what do you do? Why did you come to the summit? For what
do you hope to benefit from the summit?

   3. Historic of PATAM, Tides and TAG

                                                        Report Douala version of July 23, 05

   3.1.    Historic of PATAM

With this presentation, we can keep the following elements:
This movement was inaugurated August 22 nd, 2002. The CO–founding of the
movement are two world activists ringleaders for the advocacy on the AIDS : Zackie
Achmat of « Treatment Action Campaign (T.A.C) », in South Africa and Milly Katana,
of « Health Rigth Action Group » in Uganda and member of the coucil of the World
Fund for the fight against AIDS, TB and Malaria. PATAM is conceived to be an
open network, with a minimum general expense in the aim to dedicate a big
proportion of resources in the advocacy

It doesn't have any office therefore nor salaried personnel. All the members of
PATAM offer their services and their appraisal voluntarily. Nevertheless, PATAM
coordinates its activities at the regional level through geographical formations that
have each of its organs of coordination that work in relation with the directing
committee of PATAM–biggest organs decisions.

The Strategies of the Advocacy of PATAM

PATAM uses a complementary set of tactical strategies that goes either in the sense of the
partnership or in the one of the confrontation according to the circumstances. Some of these
strategies imply:

The development of an answer at community basis to the HIV/AIDS pandemic , that places
the PLHIVs in the center of discusion and assure their implications in the most important
procedures of decisions that will be able to affect our lives.

The mobilization of the communities, the political leaders and all sectors of the society
through out the continent to assure the access to the ARVS treatment to all those who need
it, while starting with the immediate implementation of the objective of the WHO to assure the
ARV treatment to at least 3.Millions of people in the developing countries from now to 2005.

To work with the governments as far as possible, in order to develop the national plans of
treatment, that include the ARV treatment like an integral part of health cares, with a
concrete objective the providing of ARV to at least 10% to the number of PLHIV from now to

To advocate for a local production and the generic medicines, the regional acquirement of
the medicines, as well as for other strategies in order to assure an equitable and long
access to the medicines and cheaper diagnoses of quality and, so as to follow-up materials.

To consider as responsible the governments, donors, international agencies and the
deprived sectors, particularly the pharmaceutical industries, in the setting of the good
politics and programs that will reach the targets identified objectives while supervising the
progress carefully, and while raising our voices in the protest so necessary, together with our
international allies.

To promote education on the treatment for the PLHIV, the communities and the medical staff
while developing and scattering the simple and accessible information on all aspects of the
cares and the treatment of the HIV/AIDS.

To share information and the appraisal between us, to sustain the reinforcement of the
capacities in order to increase the access to the treatments at the local, national and regional

                                                             Report Douala version of July 23, 05

level, to mobilizing the action of mass to underline the challenges in the access to the
treatments for the PLHIV.

   3.2.   Historic of the collaboration fund

The objectives of this session were to give:

   -   A brief historic of the collaboration fund
   -   A brief summary of the development of the fund as well as the process of

The themes to discuss in this session were:

   -   The Tides Foundation and the fund of collaboration
   -   ITPC (the International Coalition for the Preparations to the Treatments) and
       the fund of Collaboration
   -   What is the role of theTides Foundation in ITPC
   -   The strategy of theTides Foundation in the process of development and
       distribution of funds

   3.2.1. The Tides Foundation

The mission of theTides Foundation is to search for financings in order to sustain
initiatives of promotion of the social justice. The Tides foundation is based in San
Francisco with offices in New York, through the years, Tides to demonstrate that it
was an institution with slight progress to the eyes of the international community with
25 years of experiences in research, the use and the management of funds.

   3.2.2. The Collaboration Fund        in the financing of initiatives and
          preparations to the treatments

The objectives are:

   -   to establish a global mechanism of financing the collaboration fund
   -   to develop the distribution process of funds to finance local and regional
   -   to look for a way of always financing research

   3.2.3. ITPC (International Treatment Preparedness Coalition)

ITPC is an activist's international coalition that is created itself in Mantle Town in
South Africa following the first International summit on the preparations to the
treatments.It is an international organ of advocacy for the preparations to the

   3.2.4. The strategy of Tides in the process of development and distribution
          of fund

The strategy is the following:

                                                        Report Douala version of July 23, 05

   -   To establish a committee of scheduling at the international level
   -   To facilitate through this committee the selection of the important points at the
       regional level such as :
          o The problems and the obstacles in the access to the HIVs treatments at
              the local and regional level
          o The strategy of advocacy at the local level and the plan of action
          o The creation of development and financing process
          o To facilitate the development of the capacities of the activists for the
              treatment throw the financing of the communal interventions
   -    To facilitate the creation of a community panel of magazine and the
       recruitment of a regional coordinator with a task: ,:
          o To develop a regional process of development and financing
          o To select the financing criterias for the region
          o To develop a call to proposition
          o To value and to select the demands that must receive financings
          o To facilitate the setting up of a technical support, of a process of follow-
              up and assessment of the financed programmes.

   3.3.   Historic of the advocacy of HIV/TB/TAG

   3.3.1 What is TAG?

TAG (Treatment Action Group) was created in 1992 and is based in New York. Its
research on the AIDS and the advocacy for the treatment consists:

   -   To accelerate the distribution and development process of the strategies for
       the access to the treatments including the vaccine and germicide
   -   To include basic science concerning HIV, opportunist infections, co -
       infections, tuberculosis, vaccine and germicides
   -   To increase the research of fund by the public and private institutions for the
       support of the programs of treatments
   -   To improve the programs and to increase the understanding and the
       involvement of the community in the research and treatment programmes.

   3.3.2 TB/HIV global vision

On the world plan, the number of persons suffering from tuberculosis increases every
year of 1%. The increase is due to the HIV (SSA), MDR (EE). The tuberculosis is the
main opportunist infection that causes the death of people living with the HIV/AIDS.
The death rate of the HIV–TB is 30% in Africa in the South of the Sahara (SSA)
during the first year of treatment. About 2/3 the HIVS cases–TB is especially negative
in the ETB test at the children. 70% of African HS that have tuberculosis don't have
access to the treatments. Only a number lower than 5% of the PLHIV/TBS have
access in the ARVS.


The TAG/HIV project has as task.

                                                        Report Douala version of July 23, 05

    •   To build global community of TB/HIV advocates
        - Community mobilization/education workshops (IUATLD, IA, etc.)
        - Int'l Treatment Preparedness Coalition (ITPC) TB/HIV WG
        - Integrate TB/HIV community into Stop TB Partnership WGs and Coordinating
        - US Federal AIDS Policy Partnership
    •   TB/HIV support advocacy in developing countries
            - Osi Advocacy Grants In Partnership Tag With (34 Funded, $5-15k,
               One-Year Projects)
            - Develop Tb/Hiv Advocacy/Education Materials (Tb Drug Pipeline;
               Plwha Tb Manual)
-       Integrate Tb Hiv Into Community Treatment Literacy Projects And Workshops
    •   Work w / TB research & technical agencies to integrate community & address
        its needs: NIAID, TB Alliance, WHO, DFID,
    •   Stop TB Partnership Advocacy & Communications, DOWRIES Expansion,
        New Diagnoses, New Drugs, New Cowpoxes, MDR - TB, TB/HIV WGs–
        support community involvement


      - IPT uses where INH - Resistance high (EE)
      - Optimize algorithm to exclude activates TB
   • Cotrimoxazole (CTX) preventive therapy (CPT)
      - Role CPT of + ART / WTS CPT (+ / - ART)
      - WTS ART IN TB PTS (+ / - CD4 TESTING)
      -    Optimize     community     treatment      literacy/support  to       enhance
   • Intensified places management
      - Evaluate diff. approaches earlier & intensified places finding
      - Improve dx algorithm SN heart - & ETB in HIV+ adults & children
      - Develop new dx tools heart uses in field settings–dx, tx response,


    •   Full funding heart TB/HIV activities by 2010
    •   Massive funding increase heart research one treatment / new diagnosis tools
        heart TB


                                                       Report Douala version of July 23, 05

   4.1.   BENIN


   •   Introduction
   •   The circuit of the ARVs medicines in Benin
   •   The therapeutic diagrams proposed to the patients
   •   Experience of HES NGO concerning access to the treatments
   •   Recommendations and Conclusion
   •   ANNEXES : list of the Medicine ARVs used in Benin


The HIV/AIDS is the most serious sanitary crisis to which the world is confronted
today. In two decades, the pandemic provoked close to 30 millions death. One
estimates today to 40 millions the number of people living with the HIV, of which 95%
in the developing countries and to 14 000 the number of the new infections recorded
everyday. Although the Sub-Saharan Africa, account only 10% of the world
population, close to the 2/3 of the PlHIVs live there, either about 25 Millions. No
means of recovery and the potential vaccines exists currently won't be available
before several years. Yet, the clarification of antiretroviral medicines permitted to
save lives and brought a real hope. With its 5,5 Millions of people soliciting the
access to antiretroviral therapy to outlive, about 7% of the world have access in the
ARVs medicines. In the Sub-Saharan africa , the burden of the HIV is therefore the
most elevated because 150 000 people out of 3.8millions people have access in the

In Republic of Benin, The Beninese initiative of access to the antiretroviral (IBA/ARV)
is the program that introduced the ARVs officially. It knew a pilot phase from 2001 to
2002 (Cotonou) then a passage to the scale from the 11/02/02 with a progressive
growth of the sites. On this day, all departments count at least one (1) site. The
IBA/ARV has been financed successively by: F.S.T.I, Global Fund, ESTHER.
Medecins Sans Frontières and Action for the humanity, are the only non state-
controlled structures authorized to import and to give up the ARVses. 2767 people
Living with the Virus (PLV) were under ARV at the date of the 31/05/05, and more of
3 000 are in waiting of treatment. This number only takes account of the people who
are taken in account by (IBA/ARV).


The National Program of the fight against the AIDS (NPFA) identified Twenty two
Sites of transfer of the ARVses on the whole Beninese territory. These sites distribute
themselves as follows :


   •   National Hospitable Center and Academic HKM
   •   Camp Guézo Hospital
   •   Ami des Malades‟s hospital

                                                        Report Douala version of July 23, 05

   •   Arc en ciel
   •   CTA


   •   Departmental Hospitable center (DHC) Ouémé
   •   Louis Pasteur‟s Clinic
   •   Amour du Rédempteur's hospital


   •   MSF DOGBO
   •   Pro Humanitate Action
   •   Hospital of Zone Aplahoué


   •   CHD
   •   Saint Camille de DAVOUGON‟s Hospital
   •   Zone de Savalou‟s Hospital


   •   CHD
   •   Hospital of Boco
   •   Guéré hospital of Bembemrèkè


   •   CHD
   •   Hospital of zone of Natitingou
   •   Ordre of Djougou malt

These sites received of the NPFA an initial stock of 4 months of ARV. Every month
end they make the point between the ARVS given to the patients and the remaining
stock and send to the NPFA an evaluation of the quantity of the products they need.
The NPFA centralizes the needs in ARVs of the 22 sites, then it is sends to the unit of
management of the World Fund the UGFM who passes the commands by
pharmaquick (Beninese factory industry of medicine) or of CIPLA (Laboratory ) or
solicits the contest of the local Office of the UNICEF to pass the orders to
COPENHAG. All commanded medicines are delivered and are stocked to the Central
Pourchassing Agency of the Essential Medecines(CPAEM). Once delivered to the
CPAEM , the NPFA distributes the ARVs on the sites in accordance with their


                                                       Report Douala version of July 23, 05

3 lines of treatment for the adults
2 lines of treatment for the children (Several possible combinations)



-3TC+D4T+ (IDV/r or NVP)
-3TC+AZT+ (IDV/r or NFV)

2nd LINE

.ddI+ABC+1IP(SQV/r or IDV/r or NFV), So trithérapie with IP in first line,

3rd LINE

. ABC (or 3TC)+TDF+LPV/r

- 2nd LINE


. (D4T or AZT)+3TC+NFV




.(D4T or AZT)+NFV(ou EFV) NB: to Avoid NVP or EFV, so mother PTME with only


   -   1000f CFAs to 20.000CFAs passing by 5000f and 10 000f for the adults after
       social in0vestigation. (February 2002 to December 2004)

   -   Exemption from payment (January 2005)

                                                        Report Douala version of July 23, 05


The project on AIDS in schools

In 3 years, 122 colleges and primary schools have been visited, 4.567 pupils and
892 teachers were infected. More than 1200 free and anonymous tests of voluntary
tracking have been achieved.

The Centers of healths friend of the young’s project

24 sittings of advocacy have been achieved from the sittings of IEC/CCC twice_daily
in the 42 villages and hamlets of the township of Kétou (department of the
compound). More than 1500 youngsters benefitted from the project and 246 local,
administrative or religious authorities.

The project of teenage health and Development in Africa

It lasted for 6 months and financed by the World Bank. This project led to the
realization of a video - conference that has served as an instrument of advocacy for
the access to the treatment in March 2003 with the help of persons responsible of all
institutions of the United Nations in Benin and the government's representatives


The advent of the ARVS in Benin, after having given a lot of hope to the PLVS in
general, and a little profit at the health level to those who already follow the course of
treatment; is cause of concerns at this moment. These fears especially found on
these questioning:

People under ARV since the beginning have been wondering
   - What fate is reserved to those who were victims of the stock shortage?
   - What solutions for those who are in thérapeutic exhaust ?

New candidates to know :
  - How to honor expenses of inclusion exams?
  - Is it necessary to come to the big cities to follow the treatment?
  - How long will it be necessary to wait to take finally this famous cachets again?

To remedy this situation, and to reach the objectives fixed by the authorities (6000
PLVS before end 2005), we propose:

   -   The exemption from payment of the exams for an adequate biologic follow-up;
   -   The possibility to achieve all exams in accordance with the service„s note of
       the MSP        on the minimum packet                  of    health cares (NFS,
       Creatinine,Transaminase GO and GP,Glycémie, Triglycérides, CD4 and Viral
   -   The decentralization of the sites of hold in charge by the ARVS inside the
   -   The setting up of a real and flexible politic for the inclusion of new people.

                                                         Report Douala version of July 23, 05

It is only after this work that the access to the treatments anti AIDS will be a success
for the recipients and for the countries.

1 - DUOVIR (AZT+3TC)                           12 - Videx (ddI) 200 B/60S mg
2 - LAMIVIR S30 (D4T+3TC)                      13 - Zerit (D4T) 30 B/60S mg
3 - LAMIVIR S40 (D4T+3TC)                      14 - Zerit (D4T) 40 mg syrup,
4 - RÉTROVIR 300 (AZT)                         15 - Nevirapine (Viramune) 200 B/60S
5 - AZT RETROVIR 300 B/60S                     mg
6 - AZT Retrovir 100 syrup                     16 - Nevirapine Pédiatrique
7 - LAMIDUDINE (EPIVIR) 150 B/60S              17 - Strocrin (EFV) 600 B/30S mg
8 - Lamidudine (Epivir) 150 syrup              18 - Strocrin (EFV) 50 B/30S mg
9 - Videx(ddI) 50 B60S mg                      19 - Viracept (NFV) 250 B/270S mg
10 - VIDEX (B60 DDI)100                        20 - NORVIR (RITONAVIR) 100 B/84S
11 - Videx (ddI)150 B/60 mg

   • INDINAVIR 400 B/60S
   • Abacavir 20mgml 240 ml syrup
   • Lopinavirritonavir 80 + 20 ml (Kalétra)300ml drinkable solution
These four (4) last molecules will only be available from the month July 2005.

   4.2.   BURKINA FASO


   -   Introduction
   -   The number of people under ARV in Burkina
   -   The existing types of ARVs treatments
   -   The sources of ARVs provision in Burkina
   -   The distribution process of the ARVS in Burkina
   -   Experience of the RAME concerning the access to the treatments
   -   The actions concerning access to the treatments
   -   The acquirements
   -   The difficulties
   -   The perspectives
   -   The experience of the Hope and Life association (HL) concerning access to
       the treatments


Burkina knew an regressive evolution of the prevalence from where the rate of
seroprevalence of 2,7 in 2004. The HIV/AIDS is a sanitary emergency, a problem of
public, economic health, and development. The difficulty of the hold in charge by the
ARVS, financial and geographical inaccessibility, political orientations, coordination

                                                        Report Douala version of July 23, 05


   -   Number of PLHIV 345 600 (end 2004)
   -    PLHIV WHO need the ARV treatment:: 50 000
   -    PLHIV actualy under ARV: 4 220 (8,44%)
   -   Important part of the associative world: AIDSETI: 727; CIC-Doc: 250; etc.


Treatment of first line:
2 IN + 1 INN

Treatment of second line:
2 IN + 1 P


   -   Main source: CAMEG
   -   Other sources: partners of the North of the associations


   -   The associations distribute most often free
   -   Ambulatory Treatment center ( ATC) of Ouagadougou
   -   Decentraization at the National Hospital (03) and CHR (09) level
   -   Price: contribution of the patients : 8 000 FCFA/month/ infected persons
       of which 5 000 FCFAS + 3 000 for the ARVS and the test
   -   Adoption of national programs of PECM of the PLWHA. and a plan of passage
       to the scale of the access in the ARVS
   -   Distribution by some partners: MSF, Saint Camille, etc.
   -   Dispensation by the CAMEG
   -   Several initiatives are in progress: ESTHER, PPTE, World Bank, FM,   TAN
       ALIZ, PRSS, TAP, Society Rakièta, etc.

Advantages: PEC of hundreds of patients


   -   Financial inaccessibility
   -   Problem of agreement of the associations
   -   Difficulty of follow-up trançability of the ARVS
   -   Slowness of the process
   -   Insufficient of coordination and of legibility of the possibilities of access


RAME = network of physical people, network of advocacy for the access to the
essential medicines, informal functioning: since 2001, formalisation and recognition:
July 2003 and September 2003

                                                           Report Douala version of July 23, 05

The actions undertaken:

Technical advocacy:

   -   Compilation and diffusion of information on the access to the medicines:web
       site with forum of debates (, edition of a newspaper,
       confection and distribution of posters, press pack and positions;
   -    Creation of a technical center for animaton,dialogue and advocacy of the
   -    Propositions of initiatives to better adapte the authorities and partners.

Popular advocacy:

   -   Information and education campaigns (public conferences, etc);
   -   Creation of setting of expression of the populations: US - AIDS with more than
       230 structures (Charter US - AIDS asking “ the health state of emergency and
       the taking of exceptional measures for the HIV/AIDS), petition addressed to
       the National assembly;
   -   RAME= national guarantor of international campaigns for the access the
       medicines (WHO, UNICEF, MSF, etc.)
   -   RAME = to cause the legitimizing reactions on bottom of national reality, the
       international battle for the right of all to health

The acquirements:
  - Gathering of more than 230 structures around the US - AIDS concept
  - Existence of a free ARVS
  - Mastery of information on the access to the medicines


   -    Human resources:permanent insufficiency of formation well_disposed
   -   Logistics :lack of seats and equipment,
   -   Partnership: incomprehension of the authorities on our actions


   -   Development of programs for adoption of the better policies of access to the
       essential medicines (EM)
   -   Development of promotion and information programs on the ME
   -   Execution of actions of advocacy and lobbying for sufficient resources in the
       hold in charge of the PLWHA
   -   Development in partnership with the CGD and the RENLAC, program of good
       governance in the structures of the fight against the AIDS
   -   Execution of an advocacy programs for the access of the populations in the
       MEGS, in partnership with the RAM,


                                                      Report Douala version of July 23, 05

      -   HL = group of auto support of infected and affected people. 307 patients
          of which 102 are under ART and 297 OEVS
      -   Creation: 1996 and officially recognized June 19, 1997
      -   HL is the founding member of REGIPIV, member of the AIDSETI network,
          member of organization of PATAM in 2003

The actions undertaken

      -   Prevention (tracking, etc.)
      -   Communal and medical taken in charge of the PLWHAS and vulnerable
          children (VAD, VAH, group of speeches, community meal, small jobs,
          groups of therapetic observance, ART)
      -   Advocacy and relations of partnership for access to the treatments

   4.3.   BURUNDI

Plan of presentation

      -   Seroprevalance in Burundi
      -   Number of PLWHA under ART
      -   Types of existing treatements
      -   Sources of ART and provision
      -   Process put in place
      -   Experience of our organization

National Seroprevalance
      ≥ 15 years: 6%;
      - Urban regions: 9,5%;
      - Semi urban regions: 10,5%;
      -   Rural regions: 2,5%.
      - PLWHA 250.000
      - Adults 220.000
      - Women130.000
      - AIDS: 1st reason of death;
      - 2003: lost of 25.000 PLWHA

PLWHA under ART end February 2005: 3585

Distribution by sectors:

- 4 public hospitals: 993;
- 2 private polyclinics: 112;
- 6 associations and NGOs: 1922;

 In 8 hospitals: 558.
- Mother to child prevention program:
- 573 women T3 prophylactic ARVs;
- 470 newborns ART prophylaxis.

                                                    Report Douala version of July 23, 05

-   The clinical and biological care of the PLWHA under ART is insured.

Drugs and the biologic follow-up are free.

     Types of ARV treatment: generic and few specialties of the 1st and 2nd

         order’s   The available and used                    Conditioning
    number         ARV
    1.             Abacavir gel 300 mg                       B/60

    2.             Amprenavir cp 150 mg                      B/240

    3.             Didanosine cp 100 mg                      B/60

    4.             Didanosine gel 200 mg                     B/60

    5.             Didanosine cp 400 mg                      B/60
Types of ARVs treatment: generic and few specialties of the 1st and 2nd

    6.             Duovir cp                                 B/60
    7.             Duovir- N cp                              B/60
    8.             Duovir-N cp                               B/30
    9.             Efavirenz gel 5o mg                       B/30
    10.            Efavirenz gel 100 mg                      B/30
    11.            Efavirenz gel 200 mg                      B/90
    12.            Efavirenz cp 600 mg                       B/30
    13.            Indinavir gel 400 mg                      B/180
    14.            Lamivudine cp 15o mg                      B/60

                                                      Report Douala version of July 23, 05

Types of ARVs treatment: generic and few specialties of the 1st and 2nd

  15.               Lamivudine sirop 5o mg/5ml          Fl 100 ml
  16.               Lamivir-S 30 cp                     B/60
  17.               Lamivir- S 40 cp                    B/60
  18.               Lopimune gel                        B/60
  19.               Nelfinavir gel 25o mg               B/60
  20.               Nevirapine cp 200 mg                B/60
  21.               Nevirapine sirop 50 mg/5            Fl 100 ml
  22.               ml
                    Ritonavir gel 100 mg                B/ 84
  23.               Stavudine gel 30 mg                 B/60
  24.               Stavudine gel 40 mg                 B/60

Types of ARVs treatment: generic and few specialties of the 1st and 2nd

  25.               Stavudine sirop 1 mg/1ml            Fl 200 ml
  26.               Triomune cp 30 mg                   B/60
  27.               Triomune cp 40 mg                   B/60
  28.               Trisivir cp                         B/60
  29.               Zidovudine gel 100 mg               B/100
  30.               Zidovudine cp 300 mg                B/60
  31.               Zidovudine sirop 100                Fl 100 ml
B = Limps
Fl = small bottle

Sources of provision in ART:

Currently Financing of the Global Fund since March 2003. The global        care for
PLWHA articulates on:
   - Clinical care including the access to ART;

                                                 Report Douala version of July 23, 05

   -   Backing of the PTME program;
   -   Psychosocial and nutritionna taken in chargel
   -   Clinical and biological care.

The orders are made in the setting of the RIBUP financed by GF. In the future it will
be completed by the PMLSO financed by the World Bank. The partners: AEDES-
SIDACTION-AIDSETI-CASSOM-BRARUDIS. This project relieved the local
initiatives. In 1999, a national Fund of therapeutic solidarity put 100 million of francs
to fournish the ARV: Cost of the bitherapy from 1999 to 2002: 96 USDS. Present cost
of the tritherapy 2002-2003 until today: about 30-70 USDS.

The process put in place for the distribution of the ART: 24 sites of distribution

                                   Ordered by RIBUP

                               Distributor : CAMEBU

              A stock of structures of care: pharmacy and or hospital and

               A structure in charge of social services and observation
                                        of treatment


   •   The patient's circuit to reach ART:
           – Medical consultation
           – Three session of therapeutical observance
           – Prescription by physicians
           – Pharmacy for treatment
           – Nutritional support for the resourceless cases (Association only)
   •    Every prescriber follows a simplified diagram of ART, standardized according
       to the norms of the WHO.

   •   Difficulties:
           – Problem of evaluation of the needs
           – Insufficiency of Human resources
           – Complexity of the procedure of market transfer;
           – Disfonctioning of the heath system;
           – Insufficiency of the devices for the biological follow-up;
           – A treatment for life: the fear of the stock shortage

                                                          Report Douala version of July 23, 05

    •   Positive points:
          – Treatment saves thousands of human lives;
          – Efforts are not scattered;
          – The management of these data is easy
          – The non payment of these services shows evidence of fairness and
          – Decentralization of the initiative;
          – Setting up of new cases of therapeutic solidarity;
          – High demand is need in advice, voluntary tracking, in care and

The experience of our organization


    -   The Network of Burundian People Living with HIV/AIDS
    -   ASBL accepted on the 29th of March 2002;
    -   To promote the visibility and the openness;
    -   To promote the rights of the PLWHA
    -   To improve their quality of life;
    -   Account 6500 members
    -   Distribution in 17 provinces and 129 communities;
    -   Office of national coordination and 4 regional offices
    -   Member of the organs of decision and dialogue in the struggle against

Contribution of the RBP+ concerning access to the treatments

-   Advocacy of the political decision-makers and financial backers for an easy
    access to free treatment;
-   Decentralization of information
-   The setting up of the focal points;
-   Facilitation for a real access to treatment
-   Struggle of priorisation of the cares to many people
-   Organization of a round table on the advocacy by the high personalities
    responsible of the emergency to make available these ART;
-   Participation/Formulation of the strategies of the implementation of «RIBUP »;
-   Facilitation to the identification of the recipients requiring the treatment
-   Reference and orientation of the P LWHA toward the treatment centers;
-   Organization of the groups of speech and exchanges of experience;
-   Accompaning to the observance of the treatment
-   Backing of the capacities of leaders PLWHA and communities;
-   Testimonies of the P LWHA under ARV;
-   Setting up of partnership of the RBP+ and the treatment centers;
-   Sensitization of the enterprises for the setting up of the therapeutic solidarity
    cases for the follow up of the initiatives;
-   Other actions: Petitions, advocacy and broadcast broadcasts


                                                      Report Douala version of July 23, 05

   4.4.   CAMEROON

THE HIV TREATMENT IN CAMEROON: present situation and new challenges.

Present in +70 countries, +/-500 projects,
    Support to the populations in the zones of conflicts, epidemy, hunger, natural
      disasters trough the medical aid.

   •   In Cameroon, MSF takes care of people who have the ulcer of Buruli (120
       patients in 2004) to the district hospital of Akonolinga, and people living with
       HIV/AIDS (+3500 PVVSS of which +/-1712 ARVS coins) in the cities of DLA
       and YDE

    MSF works in Cameroon since 1984


                             Number of peole on ART in MSF projects

          60000                                                                                    60'000

          30000                                                                        33'942
          10000                                                  11'000
                                         2'700        5'000
              0    600        1'500
              January  July 2002    January    July 2003    January   October       March    December
                2002                  2003                    2004     2004         2005       2006

   1. HIV/AIDS vertical projects: to Increase the cover (scaling up) and to simplify +
      to decentralize (Mozambic, Cameroon: Douala)
   2. HIV/AIDS vertical projects: process of transfer and disengagement /strategy of
      exit in (Guatemala: Roosevelt, Honduras: Tela, Cameroon: Yaounde)
   3. Partnership: How to improve the local commitment (Angola): NGO, civil
      society …etc,
   4. To put in place the commitment to take care of the PLWHA (Laos, Burma:
   5. To proceed to the inclusion of the PLWHA in the present projects of
      emergency: Kajo Keji (SS), Dungu (RDC)

                                                            Report Douala version of July 23, 05

SERVICES 18.233 = total Number of patients recorded and follow-up at least
once in the MSF - HP services

PATIENT UNDER TREATMENT : 6.171 either 33,8% = Number of patients who
started the ARV treatment and who have presented themselves at least once in
the MSF - HP services

SOME DATA OF THE HIV PROJECT - MSF CH : Actualization of the data of
Fuchia THIN MARCH 2005

Patients recorded:                             18.233
Patient who started the ARV treatment:         6.171
Children under ARV treatment:                         200 (3.2%)
Patient under ARV followed currently:          4.973 (80%)
Death of the patients under ARV:                      361 (5.8%)

                                                Report Douala version of July 23, 05

Lost of view:                                          521 (8.4%)


                        1'356                         Mozambique - Alto Mae
                                                      Mozambique - Lichinga
                                                      Cameroun - Yaounde
                                                      Cameroun - Douala
                323                                   Laos - Savannakhet
                                                      Dawei - Myanmar
                                                      Guatemala - Roosevelt
                                                      Guatemala - Coatepeque
                                                      Honduras - Tela

MINIMUM PACKET OF HIV ACTIVITIES: In the context of high prevalence (>1%)
and in the places where MSF is in charge of a curative medical service

   -   CDV
   -   Prevention and treatment of the OI (TB included)
   -   MTCT
   -   ART
          o Tained personal
          o Continuous provision in medicines
          o Support to the systems of adhesion and observance
          o Therapeutic nutrition
   -   Functional research


   -    In September 2004, the MSF gave the amount of 3.000 FCFA/ month for the
       1st ARV line and 16.000 FCFA/6 months for the cost of the medical follow-up,
       for a total of 68.000 FCFAS or 103,66 euros for each person per the year.
   -   In 2005, only 17.000 people had access to treatment in Cameroon
   -   By 2007, Cameroon foresees to offer 35.000 treatments to people in need…
   -   However 71.000 patients over the 500.000 PVVSS already need ARV!
   -   In spite of the efforts and the political will for the decrease of the prices, the
       cost of treatment is still high when one considers the offer of cares necessary
       to treat these patients
   -   The logic of cost recovery must not be solely a commercial logic; it must also
       take into account the public health objectives.
   -   The policy of pricing adopted must be made in such a way that the medicines
       are accessible from an economic point of view for the patients.
   -   It is necessary to ascertain the minimization of the costs in order to guarantee
       the possible lowest prices and a better access to the essential medicines for
       the poorest.

                                                         Report Douala version of July 23, 05

  -   Ex.: In Senegal, the ARVS are free and the minimum package has reduced
      the prices, which increases the access to the cares and the cover (scaling up)


At the multilateral level: WTO (+ADPIC)

  -   The creation of the WTO (signed in 1995) and the signature on the ADPICS
      (Aspects of the Intellectual Property Rights which deal with Trade) had as
      result the revision of the agreement of Bangui in 1999. When Cameroon
      became a member of the WTO, he has been integrated to the agreement of
      Bangui = national Legislation
  -   Cameroon became member of the WTO in 1994 and signatory of the
      declaration of Doha on the Public Health in November 2001.
  -   The countries in development, who are also member of the OAPI (Cameroon,
      Ivory Coast, Gabon, Senegal) had to be in conformity with the ADPIC
      agreement before the 01/01/00, unlike the less advanced countries having one
      transitory period until 2006.

   Up to then, these agreements do not forbid the parallel importation of drugs of
    common origins; this indicates that if a medicine is worth 2 USDS in
    Switzerland by ex. and 1 USD in India, Cameroon has the right to buy in India
    because it is more competitive.

At the regional level: OAPI

  -   The OAPI (African Organization of the Intellectual Property) and the
      agreement of Bangui (1977) regroup 15 member countries: Benin, Burkina,
      Cameroon, Congo Brazza, Ivory Coast , RCA, Gabon, Guinea, Guinea Bissau,
      Mali, Mauritania, Niger, Senegal, Chad and Togo.
  -   In West Africa, the patents of medicines are delivered by the OAPI whose seat
      is in Yaoundé and controlled by the agreement of Bangui.

Bangui accord of 1999

  -   In 1999, the Bangui agreement was reviewed but it will be applied for all OAPI
      members only in 2002.
  -   The new agreement analysis revealed a backing of the rights of the holders of
      the patents to the detriment of the public interest of the States of the region.
  -   It bestowed a protection that went beyond the minimum required by the ADPIC
      agreement; it became more restraining because it obliged the member
      countries to buy only in the country of production.

Bangui reviewed 99 = ADPIC +

  -   Besides, the patents on the medicines are now aged 20 years (Art. 9). In
      1977, the period was only of 10 years + 5 years renewable twice, they are all
  -   Appendix 1: Limits the conditions to offer an obligatory license (non volunteer
      license) and ex - officio license (gouvernamental)

                                                       Report Douala version of July 23, 05

   -   Do not allow the licenses obligation to the import if the patent is officialized on
       the territory of a member country (Art. 49) = impossible imports
   -   Only allow the parallel imports between the member states of the OAPI in
       spite of the fact that the least expensive medicines are out of the regions of
       the OAPI (Asia, Latin America…)

Reminder 1: Article 4 : Declaration of Doha

   -   « We agree that the agreement on the ADPICS does not prevent and should
       not prevent the Members to take some measures to protect the public health.
       Consequently, while reiterating our attachment to the agreement on the
       ADPICS, we affirm that the aforesaid agreement can and should be
       interpreted and put in lace in a way that pushes the right of the Members of
       the WTO to protect the public health and, in particular, to promote the access
       of all to the drugs ».

Remider 2: Bangui 99 & Doha

   -   Art. 17 of Bangui: “In case of divergence between arrangements contained in
       the present agreement or in its annexes and the rules contained in the
       international conventions to which the member states are legally binding,
       these last preceedings will prevail”
   -   The position of the OAPI: “The member states can undertake some measures
       to protect the Public Health… and to facilitate the access to the medicines on
       the basis of the Declaration of Doha”

Some MSF - HP data on the indigence to the Military hospital of Yaoundé and
the hospital of Nylon district in Douala

   -   June 05: On 116 patients transferred to the CTA of the MHY, 28 patients
       answered the national criteria of indigence, representing either 24%
   -   May - June 05: On 1215 patients came to look for their ARVS in the pharmacy
       of the HDN, 198 patients answered the criterias of indigence, either 16,3%
   -   The budgetary line assigned to the paupers has risen to 15%, no - efficient on
       this day, let us believe that with time, it will be comfortable to demonstrate that
       the number of exclusions due to the financial gates is again too high.


The accord of Bangui reviewed reinforces the rights of the holders of the patents:

   -   While lengthening the stay_life of the patents
   -   While recognizing that the import is sufficient to exploit a patent.
   -   While putting stricter conditions to the obligatory license concession.

This new arrangements are not auspicious to encourage the necessary technology
transfers to the development of the pharmacitical industry in the region, and the
dependence of these countries opposite the imports of medicines risk to increase

                                                         Report Douala version of July 23, 05


To use the existing mechanisms in order to pursue the efforts for the access to the

   -   To reduce the prices while improving the agreement of Bangui and so to have
       the right to buy the least expensive medicines that means implantingr the
       agreement of Bangui according to the mind of the declaration of Doha (as
       notified by the OAPI) in order to use flexibilities and so to permit to continue to
       reduce the prices of the treatments.

   -   At the terms of the ADPIC accord, the least advanced countries benefit from
       one period of transition of 11 years, until 2006, bound to their level of
       development, to allow them to get ready to the consequences of the setting in
       place of the accord.It is recommended to the member countries to use this
       period fully to get ready to assume the consequences of their engagements,
       esepecially for the pharmaceutical sector.
   -   Cameroon should push the members of the OAPI so that they do not introduce
       any patents for the medicines before 2016 (Doha para.7)

   -   With these policies, the increase in the number of patients having access to
       free treatment will indrease though a greater proporton will remain excluded
   -   Health should be a universal right and not only to the speculation of a private


The access to the antiretroviral in Central African Republic (Experience of the GA)

 Presentational plan

   -   General context of the country
   -   Types of ARV treatment in RCA
   -   Sources of provision of the ARVS in RCA
   -   Processes of distribution of the ARVS in RCA
   -   Situation of people under ARV in the country
   -   Experience of the GA association in the ARVS

Context of the CAR

 Area:                           623 000Km2
General population:               3,8 m
Urban population:                 39%
 Rural population:                61%
10th world ranked of the countries the hardly hit by HIV/AIDS
PLWHA:                            240 000
Prevalence:                       15%
Epidemic generalized:              (4–40%)
Orphans of the AIDS:               110 000

                                                         Report Douala version of July 23, 05

Needs in ARV:                     40 000

The types of ARV treatment in CAR

The molecules kept by the national program of access in the ARVS are:

Didanosine (ddT) Stavudine (d4T)
Saquinavir(SQV) Lopinavir+Ritonavir

The protocols kept by the national program are:

1st line: 3TC + D4T + NEV (TRIOMUNE)

2nd line: NELFINAVIR + AZT + 3TC

Sources of provision of the ARVS in CAR

2 main suppliers at the national level:

   -   A public supplier (The unit of Transfer of the medicines / UCM)

   -   A supplier deprives (the CENTRAPHARM)

In the setting world fund project, provision in medicines made by by the UNICEF

Processes of distribution of the ARVS in CAR

The national program of access in the ART has just started in CAR. Presently only
680 PLWHA are under ART. The entire process is taking place in Bangui, the
national capital.

The number of eligible patients for the ART is estimated about 40 000. With the
support of the world fund, the national program intends to decentralize the activities
of the programme in the province. In the program of access in the ARVS, the Circuit
of provision of the medicines is assured by:

   -   The CARITAS (Catholic National Organization)
   -   The world fund.

For the PVVIHS that are not covered by the program, they buy their ARVS directly
either from the UCM or from the private pharmacies.

Situation of people under ART in CAR

                                                       Report Douala version of July 23, 05

The National Program of access in the ART was created in September 2004. Thanks
to the financing of the CARITAS and the World Fund of the struggle against AIDS,
tuberculosis and malaria, 680 PLWHA of which 75 children are currently under ART
in the country. Worthy to note is the fact that ARVS does not.

Experiences of the GA association concerning access TO the ARVS

GA = Grouping of social aid, for help to the infected or affected women and
children by HIV/AIDS.


   - 1 strong ministerial office of 8 members with 06 P LWHA
   - 4 cells at the strong operational level of 32 members with 23 LWHA
   - Efficient of people taken in charge for the hour = 200 people
Goal of the GA: to contribute to the reduction of the social impact caused by
the infection in HIV/AIDS to the communIity level.

Specific objectives

    -   To imply answers to the women in the community
    -   To develope the mind of partnership in charge of AIDS patients and orphans
        of AIDS
    -   To develope the community initiatives of generating income.


-   Sensitization of the population,
-   Support of the targets incomes generating activities,
-   Nutritional, psychological and medical hold in charge
-   Support to the schooling of orphans,

Methodology of access to PLWHA and other group targeted in the ART:

    1. Declaration of the case to the GA,
    2. Meeting of the office of the GA for hold of decisions,
    3. Sensitization and orientation of the case toward the structures in charge of
    4. Psychosocial follow_up (weekly visits at home, distribution of supplies)
    5. According to the case, social rehabilitation (advice and implementation of a
       generating activity of incomes)

Access of the GA in the ARVS:

46 people of the group target are infected. 9 people under ARV of which:

    -   2 people are taken in charge by their societies
    -   3 people buy their ARVS
    -   4 people are taken in charge by the World Bottom (2 deaths among the 4)

                                                       Report Douala version of July 23, 05

Strong points:

   -   Will of the members of the office of the GA
   -   Supports of the partners (PAM, private benefactors, NGO Friends of Africa,
   -   Good cooperation and solidarity within the people in charge by the GA

Weak points:

   - Insufficiency in competent material, financial and human resources, necessary
     for the implementation of the activities of the GA,
  - Abrupt stop of the support in supplies by the PAM
  - Weak access of the P LWHAS of the GA in the ARVS (number reduces some
     cases took in charge by the world bottom, cost of the ARVS very elevated in
     the private pharmacies)
Recommendations to the actors against HIV/AIDS in CAR:

   -   To reorganize the system of eligibility of access in the ARVS so that a quota is
       allocated to the network of the PVVIHS
   -   To take over the support of nutrition from the P LWHAby the PAM
   -   To make an advocacy by the partners for a necessary financial and material
       support to the implementation of these activities of the GA and a backing of
       the capacities of the members of the association

   4.6.   CHAD


 Area:                   1.284.000 Km2s
Population:              6.000.000 hbt
1st case of AIDS         in 1984
Rate of prevalence       5,4%
Number of infected people:     18000 according to the National Programm
                            300.000 according to the UNAIDS investigation (2004)

Number of patients under ART; since the introduction of the therapy in 1985 the
Number of patients put under ARV equivalent to 189 people. Left in 12 cities. It exists
in Chad ten (10) ARV treatments namely:

AZT + 3TC + EFAVIRENZ (05)                     LAMIVIR 40 + EFAVIRENZ (02)
AZT + 3TC + NELFINAVIR (01)                    LAMIVIR 40 + NELFINAVIR (02)
AZT + 3TC + NEVIRAPINE (01)                    Triomune 30 (129)
DDI + 3TC + EFAVIRENZ (01)                     Triomune 40 (17)
LAMIVIR 30 + EFAVIRENZ (26)                    Non specified (03)

There is only one (01) source of provision of ARV it is the central pharmacy of
purchases that throws its orders by the businesses pharmaceutical strangers

                                                        Report Douala version of July 23, 05

(CIPLA)-STRIDE ARCOLAB. The Regional pharmacies get a stock by the
pharmaceutical central purchassing agency and put the medicines at the disposal of
the patients.

The advantage is that the products are controled as regards to the hold.

The inconvenience is that the Associations of the PLWHA cannot obtain the
medicines for the entire member.

The national Network of the Associations of the P LWHA participates in the Meeting
of the therapeutic group. It is informed of the deliveries and is held informed of the
stock ruptures. It is part of the committee of setting under treatment.



Population of Congo:              3.110.000
Maternal mortality                1100 for 100.000 NV
Infant mortality:                 108 for 1000
Prevalence rate in 2003:          4,2 (disparities between the cities)
Number of PLWHA                   110.000 of which (69.000 women
                                  70.000 orphans of the AIDS


Republic of Congo is touched by the epidemic of the HIV/AIDS to the general stage:
4,2% of prevalence rate and near 110.000 people living with the VIH/SIDA. In end
2002, the total number of case of AIDS notified was of 13.837 cases. Currently more
than 8.000 HIVS patient are followed regularly at the level of the Ambulatory
Treatment Centers (ATC) situated in the two bigger cities of the country: Brazzaville
and Pointe - Noire. In the setting of the medication of the HIV/AIDS infected people,
the Government put the congolese initiative in place for the access to ART (ICAARV)
that permitted to about 2.300 people living with HIV to reach the ARVS treatments.

It is necessary to note that inspite of the reduction of the prices of the ARV, caterers
ARV remain inaccessible to the biggest majority of the patients because of the
extreme poverty that hits them globally, the access in the ARVS was very weak until
the beginning of the year 2005.Only 1,6% of the HIVS patients on the 110.000
people living with the HIV/AIDS have access the ARVS treatments.


The adherence of the country to the program Access, and the opening to the markets
of the generic permitted a widened provision in ARV. Provision and the consumption
of the ARVS to the national level are organized relatively well by the state through a
National Central Purchassing Agency of Essential medicine purchase (CENAMES).
The different sources of provision in ART are: CIPLA, GLAXO, and very lately IDA.

                                                        Report Douala version of July 23, 05

It is necessary to note that the contracts have been realised with these two
laboratories for non-payment of the invoices. A new contract has been signed with
the IDA laboratory to remedy the recurrent ruptures of the ARVS.

Processes put in place for the distribution of the ARVS.

For the regular distribution and the prescription of ARVS in the whole country, the
state put the Congolese initiative in place to the access to ART (ICAARV). It has
three (3) operational commissions namely:

   -   The commission of treatment decision
   -   The commission of assessment and socioeconomic follow-up
   -   The commission of management of the medicines and reagents.

The setting up of l ' ICAARV gave the advantages and the following inconveniences:


   -   The medicines are only ordered by one central purchassing agency of drugs.
   -   The ARVS medicines are sold only by pharmacies with the authorization of
       ICAARV, to follow the traçability of the products.
   -    Only the patients whose medical prescription has been signed by a physician
       can buy the ART.


   -   The orders of the ART are made in an irregular way; sometimes provoking
       ruptures of some molecules,
   -   All the physicians who prescribe do not make their work (hardly 20 on the 40
       recognized prescribe some orders on the ART).
   -   Some non authorized physicians who follow the patients don't prescribe and
       are often under the orders of the physician who prescribes
   -   Insufficiency of the prescribers physicians
   -   Change of treatment due to the shortage of the ART.
   -   Lack of observance to the treatments for certain patients.


The National Network of the Positives (RENAP+) is very implied in the access to the
treatments. Its members contributed to the success of two official dinners receptions
organized under the patronage of the First Lady, in partnership with the Agencies of
the System of the United Nations and the private sector, that permitted to collect a
sum of 130 Millions of CFA francs, that have encouraged since the beginning of this
year the free access to the ARVS treatments of 430 HIV patients. .


   The access in the ARVS is very weak in the Congo Brazzaville.Considerable
   efforts must be made for the setting under treatment of the biggest majority of the
   HIV patients. Since January 2005, the prices of the ARVS knew a reduction from

                                                       Report Douala version of July 23, 05

   80.000 francs to 20.000 CFAS francs for the vulnerable patients and from 10.000
   to 5.000 CFAS francs for the extremely vulnerable patients.

   4.8.   DRC

Presentation of the HIV/AIDS epidemic in DRC: prevalence up to 4,5%

Existence of a national politics document concerning struggle against the HIV/AIDS
and the STIS, existence of a strategic plan concerning struggle against the HIV/AIDS
and the STIS, existence of a scheduling a short time concerning struggle against the
AIDS, politics of hold in charge, promotion of the voluntary tracking and medical
advice, adequate hold in charge of the STIS and the IO, ARV treatment, 5713 people
under treatment out of 351000pvv of which 1100 in the free circuit with MSFb.

Cost of treatment: 39 $(+labo)

The types of the existing ART treatment in DRC

1st line: stadivune+lamidivyne+nevirapine

2nd line: abacavir+didanosyne+lopynavir+ritonavir

Source of ART provision

Government in a deprived/ public partnership. The firm cipla makes available the
ARV to the prescribers physicians in case of needs.

Process of the distribution of the ARV:

   -   Generic molecule acceptance,
   -   Setting up of a follow-up system and assessment of the arv
   -   Designation of the prescriber physicians and centers of prescription of the
       ARV: there are around 80 prescribers physicians.

Regulation of the disponibilisation of the ARV at one price in the whole country.
Para - medical material setting up in 4 big cities of the country: Kinshasa /
Lubumbash / Mbuju-mayi and Bukavu.


   -   no stock shortage
   -   reduction of the cost of the arv
   -   increase of the number of people under ARV

Disadvantages :

   -   the realisation of this programme is stopped in the big city
   -   weak subsidy of the state.
   -   notification of the prescribers not covering the whole country.
   -   monopoly of the CIPLA firm.

                                                         Report Douala version of July 23, 05

Experience of the woman foundation more concerned with the access to the

   -   Active involvement of its members after the study made in 2001 on the use
       of ARV treatment by the kinoise population .
   -   Active collaboration with MSF/b that elects its members in the free programme
   -   Organization of the support groups
   -   Organization of seminaries of dialogues with the members the follow-up of
       the treatments
   -   Formation of the group of volunteers and the social workers on the instruction
       of the ARV treatments .
   -   The social office organizes the visits in houses ,give the ARV and supervise
       the customers who are not able to follow_up their medication.
   -   Only 262 PLVS are under treatment on 4774 people.

  4.9. RWANDA
Socio Demographic Indicators

                 Indicators                   Value

       Total Population                       8.126 million
       Population Density                     306 inhab/km 2
       Life Expectancy (1991)                 52
       Life Expectancy (2002)                 47
       Infant Mortality                       107/1000
       >5 Mortality                           196/1000
       Maternal Mortality                     1,071/100,000 live births
       Pop aged < 15 years                    49%
       Doctors                                1/60,000 inhabitants
       Nurses                                 1/5,000 inhabitants
       Malnutrition rate                      30%
       Orphans                                250 000
       Women-headed households                34%
       Children born with HIV                 40,000 per year


• Rwanda is one of the least developed countries
• Nearly one million people were massacred during the genocide of 1994
   • Many highly-skilled people were lost
   • Infrastructure was lost
   • 64 % of the population lives below the poverty level now

Other problems:
   • High number of orphans

                                                      Report Douala version of July 23, 05

    • High number of female-headed households (34%)
    • Impact of sexual violence
    • Psychological trauma


Government Response :
  • 11 years of reconstruction:
  • Strategies for fighting poverty:
      a - Democratization
      b - Decentralization
      c – National Reconcilliation
      d – Process of participative justice -    GACACA

National Policy for caring for people living with HIV/AIDS

•   Improving links between TB and HIV/AIDS control (ex. Integrated VCT)
•   Integrating HIV/AIDS into all sectors (Umbrellas of NACC in all sectors)
•   Reinforcement of education in the community and a focus on prevention
•   PRSP / Vision 2020

Epidemiological Situation
• Prevalence rates :

 7-11% (urban)
 2-5% (rural) 91% of the population is in rural areas (DHS on going)


5,2% of the adult population

Rwanda National ART Plan

• Vision
   – Increased longevity and improved quality of life for people living with HIV/AIDS
     (PLWHA) in Rwanda
• Approach
   – Integration with existing health infrastructure
   – Community mobilization
   – Linkage between treatment and care and prevention
   – Procurement economies of scale
   – Rapid scale-up, including iterative learning

Philosophy of Rwanda‟s HIV/AIDS Program
• Ensure that patients have equal access to the drugs.
• Patients who cannot afford to pay should be able to get drugs.
• No discrimination on the basis of gender, income, age, ethnic group or Nationality.

                                                        Report Douala version of July 23, 05

• Ensure that patients on ART take their drugs properly so that resistance does not

The solution for Rwanda is a Ministerial Instruction on the Conditions and Modalities
for Health Care Delivery to Persons Living with HIV/AIDS

Patient Criteria
• Medical Criteria
   – Enter ART program through VCT, PMTCT, or other recognized program
   – Must meet clinical and biological criteria
• Social Criteria
   – Fixed residence for 6 months
   – Unable or partially unable to pay for ART
   – Agree to meet financial cooperation according to ability to pay
   – Agree to join mutual health insurance scheme, if available
   – Join association of PLWHA if not a health insurance scheme
   – Reveal status to one family member or friend; this person agrees to assist with
   – Consent to home visits
   – Consent to stay on medication long-term
   – Agree to practice safe-sex

Patient Selection Committees
•   Members: head of ART program at the facility, medical representatives involved in
    ART at the facility, laboratory rep, 2 reps from PLWHA associations, psychosocial
    support unit rep, matron of the service.
•   The Committee meets at least once a fortnight.
•   Doctors present their cases to the committee for selection.
•   Patients not selected can be presented repeatedly, or waitlisted. Appeals can be
    filed with the NACC.
•   Quarterly report submitted to the TRAC, MOS and NACC.

•   Patients are given ART if they meet the criteria as applied by the Patient Selection
    Committee. If there are not enough drugs:
     – Health workers at that facility meeting all medical and social criteria are
       selected first
        • Health workers can receive ART for post-exposure prophylaxis
     – Then all other patients are selected, first come, first served
Priorities, cont
•   Special issues, concerns
     – Should certain groups have priority – teachers, health workers, military,
       genocide widows?
     – Rwanda has decided no, but allows special programs to make exceptions if
       they bring their own funding, have clear rules, and the prioritization is approved
       by the Government of Rwanda

                                                          Report Douala version of July 23, 05


Patient Treatment and Care Targets: 380,000 by Year 5

Patients on ARV Therapy: 100,000+ by Year 5


•   NACC: sensibilisation (mobilisation)
•   CAMERWA: Procurement of ARVs
•   NRL: CD4 count, viral load, quality assurance
•   RRP+(Associations of PLWHA…)
•   Faculty of medecine and school of public health (reseach, studies,...)

RWANDA- Peadiatric treatment: approximative figures
•   ~ 60 000 infected children (1/2 should get ARVs = ~ 30 000 children)
•   ~ 500 children on ARV in Rwanda (0,01 %)

•   High demand of ART (10%)
•   Disproportion btwn ART and prevention structures(VCT/PMTCT).
•   HR problems (quantity and quality)
•   Staff Motivation
•   Nutritional support(problems of adherence)
•   Stigma
•   Social support
•   Poverty
•   Weaknesses on peadiatric treatement (500/60000)
•   Meanstreaming

    4.10. GHANA

Briefing on the 3 by 5 iniative, ghana

       In september 2003 who /unaids declared lack of treatment for plwhas a public
        health emergency requiring urgent action
       The 3 by 5 initiative was launched on december 1. 2003 in respondence to the
       The itiative aims to scale up art in deloping countries and targets to put 3
        million plwhas on art by the end of 2005

Hiv/aids situation in ghana

       The hiv prevenlence rate is at 3/6%(2003), an increase from 2.3% in 2000
       The prevalence rate is highest in the eastern region and lowest in the northern
        region. In all areas the prevalence rate is above 2%
       Total of 350,000 estimate to live with hiv/aids by the end of 2003
       Cumulative total of 72,000 cases reported as at september 2003
       Between january – sept 2003, 7,850 new cases were identified

                                                         Report Douala version of July 23, 05

      Present population on art 700

      Significant % hospital beds are occupied by aids patients
      Significant in 5 majors hospital in are due to aids

Response to hiv/aids 1

      There is a comprehensive multisectoral response guided by national hiv/aids
       strategic framework
      Health sector and other sectors have developed sector implementation plans
       for hiv/aids
      All key health sector hiv/aids responses are being implemented (sti
       management, pmtct,vct?hbc, care and treatment of plwhas, surveilance,
       condom promotion, iec)
      Dri is being implemented in 44 districts
      The hiv/aids response is supported financially by government and its partners
      Coverage for interventions range from limited awareness
      Scaling up of various interventions is in progress

Increasing access to treatment
     Reduces;
     -frequency of opportunistic infections
     -the number of hospital admissions and outpatient attendances
     -death among hiv/aids patients
     -improves significantly the quality of life of plwhas
     Increases demand for testing and counseling
     Changes hih/aids from a death sentence to chronic disease
     On treatment most patients are able to return to work
     Mitigates against the socio-economic effects of hiv/aids including the number
       of orphans

Prevention and treatment
    Prevention remains an important intervention in the control of hiv/aids
    --prevetion and treatment of sti
    --pmtct
    --vct
    --screening of blood for transfusion
    --iec
    --prevention and treatment must all go together

Current art programme

      Treatment started in june 2003 in manya-krobo district in the eastern region of
      So far about 700 plwhas are on art
      A small number of patients are accessing art through private prationers
      Entery points include vct? Pmtct, tb clinics,diagnostic testing and sti

Art delivery model

                                                       Report Douala version of July 23, 05

      Hospital based
      Physician led
      Initiation of treatment, prescription & follow up
      Counseling done by other cadres
      Adherance counseling done by nurses
       national art guidelines exist and used for training
      Government procures art and distribute to treatment sites

Art enhancing factors
     Appropriate art policies
     Implementation plans and programme management and coordination
     Procurement, supply and management systems for medicines and diagnostics
     Trained human resource, technical guidelines and training materials
     Operational research plans
     Documentation and sharing of implementation results with all stakeholders
     Monitoring and evaluation

Challenges for 3 by 5 iniative
   Weak health systems and limited human resource
   Poorly staffed and equiped health facilities, limited infrastructure and staff
   Most health workers are not trained on art and lack of training materials
   Shortage of health workers
   High cost and lack of user friendly arv formulations for children
   Too high overall financial burden of treatment
   Development of resistance
   Low treatment literacy
   Lack of laboratory policy

   Increase commitment by government and private sector

What needs to be done to scale up art
   Political leadership
   Stewardship-develpment of standards for practice
   Development of comprehensive care and treatment plan as parts of overall
   Procurement with negotiations(bulk purchasing)
   Local purchasing and public private- mix strenghten health systems,
      particularly laboratory capacity, monitoring and quality assurance
   Human resources
   Targeting hard to reach populations
   Partnerships

Recommendations 1
   Develop a plan for art scale up in line with the 3 by 5 iniative target
   Develop art training materials and initiate training of various community

                                                           Report Douala version of July 23, 05

      Broaden training to include all health workers and not just those involved in the
       art program
      Integrate comprhensive care into pre-service training of health workers
      Encourage training and use of lay counselors to support programs
      Review the art delivery model and consider the use of other workers than
       doctors for patients follow up etc
      Finalize and diseseminate the laboratory policy
      Iec for the general public for art and social moblization for art to address
       stigma as well as increase patient demand for art
      Moblization of additional resources for scaling up from health partners and
       ministry of health and other agencies
      Development of financing mechanism to guide the coordination of the support
       from various sources

Principles for action
     Decentralization of service delivery
     Mobilization of health workers and volunteers
     Taking emergency measures for supply of health workers
     Integration of plwhas in servvice delvery
     Strenghtening motivation of health workers
     Harmonization/coordination of human resource development and training
     Using operational research to improve service delivery and training

    Increase involvement
    Reliable supply of equipment and reagents
    Assistance to countries in selection of test, equipments
    Assist countries for bulk procurement of hiv/aids diagnistics
    Access to and effecient distribution of high quality low cost diagnosis


      Hiv/aids as a major threat to health and socio-economic development of africa
      3 by 5 intiative as a timely response
      Challenges and opportunities associated with the 3 by 5 initiative
      3 by 5 initiative should be used as an opportunity to strenghten the health
       sector response to hiv/aids
      Based on partnerships
      Each should contribute what they do best
      Need for shift in our thinking and actions for success of the inative



   -   Advocacy is an action aiming to change the policies, positions or programmes
       of an institution, whatever it is.

                                                        Report Douala version of July 23, 05

   -   Advocacy, is to take the speech, to draw the attention of a community on an
       important question and to orient the decision-makers toward a solution.

   -   Advocacy is the deliberated process to influence those who take decisions on
       the topics of the policies. (CARE)

An efficient advocacy can succeed to influence decision making and the
implementation of policies by doing as follows:

   -   to inform or/and to form the leaders, the decision-makers and those who
       apply the policies ;

   -   to reform the policies, laws and existing budgets, to formulate new

   -   to make the structures and the important procedures more democratic, open
       and «responsible». (Interaction, 1995).

The advocacy is not:

   -   Information, Education and Communication (IEC)
   -   To inform the government about his/her/its programs
   -   To sensitize the public opinion about his/her/its activities
   -   fund raising


To fix an objective of advocacy

The objective of advocacy must be based on the answers to the following questions:

   -   Is the theme able to unite several people or various groups to make a coalition

   -   Is it possible to achieve the objective?

   -   Will the objective really solve the problem ?

To use the data and research

   -    Data and research are essential to take controlled decisions while choosing a
       problem to which one will attack, while identifying some solutions to the
       problem and while fixing realistic objectives.

   -   Good data can represent in themselves the most convincing argument of the
   -    Considering the proposed data, can you realise the objective ?
   -   Which data can be used to efficiently sustain your arguments ?

                                                          Report Douala version of July 23, 05

To identify the publics of the advocacy

   -   the efforts of advocacy must be directed toward the people who have the
       power to take the decisions

   -   and, also toward the people who influence these decision-makers, as the staff,
       the counselors, the eldests who have the influence, the medias and the public.

   -   What are the names of the decision-makers      realise your objective ?

   -   Who and what influences these d ecision_makers?

To formulate and to bring the messages of the advocacy

   -   Different publics answer different messages:

          o A politician could be motivated more if he knows how many people, in
            his circumscription, worry of the problem in question.

          o A Minister of Health can take whichever measure when he is facing
            the detailed data on the prevalence of the problem.

   -   What message can push the public to choose to act in your name?

Setting up of pressure groups

   -   The power of the advocacy is in the number of people that sustains our

   -   The involvement of a big number of people representing various interests can
       provide a security for the advocacy and can create a political support.

   -   Even within an organization, the setting up of an internal coalition can help to
       achive a consensus for the action in question.

   -   Who else can you contact to join your cause ?

   -   Who else could be a partner?

To make convincing presentations

   -   The possibilities to influence the target publics are often limited.
   -   A politician will grant you a meeting maybe to debate your problem or a
       minister will be able to give you only five minutes of his time during an

   -   A good preparation and riched of convincing arguments and a good style of
       presentation can make of these rare opportunities a succeeded defense of the

                                                        Report Douala version of July 23, 05

   -   If you have luck to joind the decision-maker, what would you like to say and
       how would you say it ?

Mobilization of fund

   -   Most activities, including the advocacy, ask for resources.

   -   The maintenance of an efficient advocacy effort in the long term requires
       an early investment and energy to get funds or other resources sustaining
       your work.

   -   How can you get the necessary resources to handle succesfuly your effort of

To value the efforts of advocacy

   -   How will you know if you succeed to realise your objective of advocacy ?

   -   How can your strategies of advocacy be improved?
   -   Constant assessment and feedback are important aspects of an efficient


To analyze the problem and to formulate some requirements to solve it

   -   To describe the event or the situation that makes problem, and its most direct
   -   To agree on a common description of the problem

   -   To express the solutions to short and long term

   -   To express the principle that guides our requirements and the final objective
       that they serve

To understand the decision making process

   -   To familiarize with the decisional process that we try to influence.
   -   The more the process is known,the more the power to influence is important.

Survey of the targets publics

To target the institutions and people of critical importance for our success, rather than
to try to reach all decision-makers and all sectors of the society.
    - To make an detailed exam of the concerned public to understand its
        knowledge, attitudes and beliefs.
    - To regroup the decision-makers, the influents people, the NGO or the
        professional associations in subgroups with analogous characteristics.
    - To learn to know every subgroup and to target the messages in order to
        answer the preoccupations of these subgroups.

                                                         Report Douala version of July 23, 05

   -   To learn what are the internal norms, the informal rules or they «codes of
       conduct» that the group can have

To master arguments and those of the opposite camp.

   -   intern debate to develop the arguments and master/anticipate on the one of
   -   To redefine the objectives
   -   To elaborate a strategic position document

To forge some alliances

   -   Often, we can make together what a single personl can not do
   -   The networks and groups of pressure take time and energy, either to be
       created or maintained.
   -   To explore how to create and to maintain some networks, the coalitions etc.
   -   To examine the advantages and the inconveniences.


   -   To fix a calendar:

          o It is important to fix some delays at the departure, it is also important to
            keep to the mind that the political events escaping your attention can
            force you to modify them

   -   To prepare a budget:

          o The evaluation of the cost of an advocacy project can be difficult,
            especially for an initiative stretching into several years. More than with
            the other types of programmes, the corrections of short time will occur
            and can cause sometimes raised prices.

   -   To prepare a logical setting:

          o a useful material to summarize, of a logical way, the relations existing
            between your objectives, the results, the activities and the contributions.
            The logical settings permit you to visualize the relation that exists
            between the objectives of an advocacy initiative and the activities
            proposed to reach these objectives.

   -   To plan the follow-up and the assessment:

          o    Important activities to keep an initiative of advocacy on the good path
              and to value the changes that it reached on the base of specific

Indispensable tools

                                                        Report Douala version of July 23, 05

   -    Reference texts : Declaration of the UNGASS, Declaration of Amsterdam,
        Objectives of the Millennium, quotations of Chiefs of State…
   -    Mailing lists,reference Internet sites
   -    Management of files of data bases
   -    List of the referent people within the international organizations
   -    Press releases, files of press, newsletter,
   -    Petitions, mails,
   -    Demonstrations, marches, etc…
   -    Tracts, posters, streamers…


   -    To establish an agenda
           o The efficient negotiators always plan in advance.
           o What are the main messages that it is necessary to transmit and what
              are the topics to avoid?
           o What to do if our public do not agree with us?

   -    To know where we are
           o What do we want?
           o Why does the other camp accept to negotiate?
           o What to do if the other camp says no?

   -    Role of mediator


The practice is the best way to learn to advocate!

What you discover in an initiative is susceptible to help you to plan the
   6. Works in groups: to Develop the priorities of the advocacy

   -    What are the regional opportunities to seize to succeed the advocacy in our sub
   -    To identify five (5) common problems concerning the access to the treatments
   -    To identify the actors who must be involved in the advocacy
   -    Strategies to put in place to manage the advocacy successfuly




   I-      PROBLEMS :

                                                           Report Douala version of July 23, 05

-      No free from payment of the tracking
-      Few physicians prescribers
-      The governmental policies
-      Weak access of the children to ART(non availability of pediatric shape )
-      High cost of ART and the different tests
-      Weak spending power


-      P LWHA
-      Community leaders (NGO–religious Leaders, artists, etc)
-      Parliamentary (deputies)
-      Political decision-makers
-      Pharmaceutical firms


-      CEMAC
-      CEEAC
-       WHO/Regional
-      CBLT (commission of the basin of the lake - Chad
-      Initiative of the countries of the big lakes
-      IFCOC (Initiative of the streams oubangui-chari Seat b : Brazzaville
-      CANASO ( NGO Council of struggle against the AIDS Libreville seat)
-      OPEDAS (Operation of the 1éres Ladies of Africa Centrale. Libreville seat)

- To inquire
- To document itself
- To make the strenghtening of the capacities (to form and to recycle
- Coordination of the activities
- Mobilization of resources
- Example of plan of advocacy campaign
- Choice of the problem, of the stake (to describe it)
- Analysis of the problem% to the stake (the important documentation)
- Special objective: development for the country
- Determination of target people
- Assessment of resources (human, material, financial, etc. ;;;)
- Identification of the partners and adversaries
- Creation of a plan of action
- Setting of an consistent assessment

                                                       Report Douala version of July 23, 05


 Tech & tactical
  of advocacy                                    Audience Targets
                             Partners                 Media             Adversary
Sensitization      NGO          Leaders                       NGO      Leader Rél/p/trad
Mobilization                    Rel :P&/Trad.
                   X            X
Dialogues                X              X
Negotiations                            X                       X                 X
Debate                                                          X                 X
Petition                 X             X               X



Advocacy means actively supporting a cause and trying to get others to support it as
well. Advocates educate about year exit and suggest has specific solution. All
advocacy involves making has slot in favour of has descended particular, using skilful
persuasion and strategic action. Advocacy efforts are usually geared towards
changing public perceptions and influencing policy decisions and funding priorities.


The Pan African Treatment Action Movement (PATAM) is an advocacy group
launched on 24th August 2002 to mobilize our communities and continent to ensure
access HIV to AIDS and treatment heart all our people who need it.


    -   We are angry!
    -   Our people are dying!!
    -   Our leaders failed us!!!


    -   Many individuals hold and perpetuate myths about HIV transmission and
        treatment, which puts them and those they influences at risk of either being
        infected HIV with however dying prematurely from treatable infections
    -   PLWHA and their family members haggard no access to information one
        health care services and treatment heart opportunistic infections
    -   PLWHA and their care givers are often ignoring of the criteria to start ARVs
        and implications of starting therapy


    -   Medical examinations and physical, essential drugs heart treating Hears and
        Antiretroviral drugs are unaffordable

                                                           Report Douala version of July 23, 05

   -   The silence, shame and stigma HIV surrounding AIDS and created “Ghost
       PLWHA” and makes it almost impossible heart custom to visible be has
       activists and advocates in the fight heart access to treatment
   -   Our government's strategic framework to prevent new infections and mitigate
       the impact of HIV/AIDS in Africa are not clear one it's plane to make ARVs


   -   We are PLWHA and our partner/collaborating organizations are often unaware
       of, however uninterested in, our government policies, declarations and
       implementations of such policies
   -   There isn't enough collaboration and networking between countries,
       governments, NGOs and CBOs working one treatment, care and support.
   -   International politics and debates surrounding access to drugs is not
       understood by the majority of the people


Many of the set frameworks don't haggard SMART.Targets, stating which treatment
is to be made available, when, where and what resources are to be mobilized.

There's very little support heart PLWHA and Civil Society groups to contribute in
setting and implementing government's set targets.

Treatment Education is not included ace has tool to prepares communities heart
treatment and ensure success of treatment programs.


Promote treatment literacy PLWHA heart, communities and health care workers by
developing and disseminating simple, accessible treatment education materials one
all aspects of HIV/AIDS care and treatment.

   -   We will give treatment literacy workshops to ensure adhesion, VCT promoting,
       prevent new infections and promote openness.

What do we need?

   -   We need to get involved in and stick our noses in existing programs like the
       Global Fund, PEPFAR, 3 by 5, World Bank programs, DFID, country programs
   -   We need to stop the PHD (Sweater Him Down) business
   -   We need to become real partners and not competitors in the AIDS business
   -   People living with HIV need to become LEADERS in ART provision
   -   We must station wagon the barriers treatment access ace we carry out
       treatment education.

                                                     Report Douala version of July 23, 05

  -   Develop community-based responses to the AIDS pandemic Africa in that
      places PLWHA at the center and ensures our involvement in decision - making
      key process that will affect our lives.
  -   Share information and appraises with each other to capacity - building support
      heart increasing access to treatment at the local, national and regional level.
  -   Mobilize our communities, leaders & all sectors of society throughout the
      continent to ensure access to treatment, starting with the immediate
      implementation of the WHO 3 by 5 goalkeeper.
  -   Advocate heart local production & import of generics, regional procurement of
      medicines and other strategies to ensure equitable and sustainable access to
      the lowest cost quality drugs, diagnoses and monitoring tools.
  -   Continue to mobilize the business sector to take its share of the responsibility
      to address HIV/AIDS by implementing workplace policies that incorporated
      ARV PLWHA heart staff and family members
  -   We will be watch dogs of ourselves, our governments, NGOs international
      agencies and the private sector, particularly the pharmaceutical companies.

What should we do?

  -   Identify the specific descended and establishing your priorities.
  -   Identify target audiences.
  -   Define your message and tailoring it heart the audience.
  -   Network to expand your bases of support.
  -   Educate the public, often by working with the medium.
  -   Persuade the public and policy makers to support descended your.


  -   There's strength in number
  -   Haggard To has wider coverage
  -   To reduce cost
  -   To promote education
  -   To promote adhesion
  -   To form has strong lobbying block
  -   To strengthen implementation
  -   To Monitoring strengthen and Assessment


  -   There must be has common purpose
  -   Clear operational guidelines
  -   Clear targets
  -   Clear timeline
  -   Conflict resolution and arbitration procedures
  -   Cost sharing


  -   Families

                                                       Report Douala version of July 23, 05

  - Communities
  - Government
  - Health Workers (Orthodox, traditional and support service providers)
  - Organized Sectors private
  - Donors
  - Medium
  - Civilian Society Organizations
*We must look beyond our present CSOs


To conscious and voluntary coming together of actors one has project, to attain has
common purpose


   -   Strength in numbers
   -   Wider coverage
   -   Reduces cost
   -   Promotes adhesion


   8. ADHERENCE TO            THE    MEDICINES      AND     STRATEGIES               OF


   -   Definitions of the adherence to the medicine, compliance and observance.
   -   Adhesion to the medicine is the term used to describe that the patient takes
       his medicines correctly in terms of dose, frequency and moment
   -   The patient participates in the adherence while deciding to take or no the
   -   The observance means that the patient makes what the physician told him
   -   A bad adherence drives to a virologic failure, to an evolution toward a
       pharmacoresistance and to an immunological failure and ulterior clinic
   -   The compliance suggests that the patient respects and submits completely to
       the rules of the prescription.


                 a. Factors concerning the patient

   -   Oblivion
   -   Preparation and motivation of the patient
   -   Carelessness
   -   To be far from at home
   -   life style (excess of alcohol, etc.)
   -   Depression
   -   Cultural elements

                                                     Report Douala version of July 23, 05

   -   Socioeconomic elements (isolation, efficient support, use and rhythm of work,
       malnutrition, etc

                 b. factors concerning the beneficiary of cares

   -   Preparation of the beneficiary of cares (knowledge, expertise)
   -   Council
   -   Education of the patient
   -   Devices indicating that it is necessary to take the medicines, for example,
       pictures and diaries
   -   Team of cares concerning adherence
   -   Help to the beneficiary of cares

                 c. factors concerning the treatment and the medicines

   -   Number of tablets
   -   Frequency
   -   Side effects
   -   Food restrictions
   -   Medicinal interactions
   -    stock shortage
   -   Taste of the medicine
   -   Cost of the treatment and the follow-up


It is important to really advice the patients before starting an ARV treatment. It
implies the clinicians, the nurses, the pharmacists, the social and other agents. It is
important not to start an ARV treatment at the time of the first clinic visit. You must
advise the patient concerning the adhesion to the treatment in order to maximize it.
Once the statet,started , you must control it and must bring a permanent support.
The strategies have :

   To prepare and to motivate; to provide the information of basis concerning the
medicines, to debate the importance of the adhesion, as soon as to take the
medicines, of the medicinal interactions, etc.
  - To simplify the treatment
  - To adapt the treatment to the life style of the patient
  - To manage the side effects and to prepare the patient to these side effects
  - To form a team charged of the adhesion (cfr. module A session 4)
  - To personalize the hold in charge according to every patient's particularities.
  - Supplying of support devices to encourage the adhesion (I.E.C materials.).
  - To use a person relay (godfather) at home to sustain the adhesion


The advices concerning adhesion imply a capacity to transfer the technical aspects of
the adhesion and faculties to make so that the patient is relaxed, that he feels at
ease and that he has confidence in the beneficiary of cares. This last point needs
more time.

                                                       Report Douala version of July 23, 05


   -   Interview and autoevaluation of the patient: convenient and inexpensive
       means to count the tablets (demanding in labour)
   -   Interview with the godfather
   -   Files of the pharmacies/controle of the renewal of the prescriptions
   -   Directly Observed Treatment ( DOT) bound theoretically to an 100%.
       Adherence. Strict in labour and a little practical out of the institutional
   -   Assessment of the therapeutic answer (clinic, answer CD4): not a first
       assessment of the adhesion; auxiliary marker; can be useful when it is used
       with the patient's autoevaluation. If available, the viral load can be used.



TRAITEMENT- The process or manner of behaving towards or dealing with a person
or thing.

EDUCATION- A process of training and instruction which is designed to give
knowledge and develop skills

TREATMENT LITERACY can be a song about ARV, a drama on Malaria or a poster
on breastfeeding.


   -   Positive Living
   -   Good nutrition
   -   Use of supplements and vitamins
   -   Use of prophylaxis
   -   Treatment and management of OIs
   -   Use of ART
   -   Adherence and Compliance
   -   Side effects
   -   Monitoring and Evaluation


   -   Learning about the virus
   -   Self care- Seeking medical help whenever an illness arises
   -   Limiting the use of alcohol, tobacco & recreational drugs
   -   Getting enough physical exercise
   -   Getting enough sleep and rest
   -   Protecting others from the virus
   -   Eating a balanced diet
   -   Going for individual and/or group counseling

                                                      Report Douala version of July 23, 05

   -   Keeping busy and remaining productive
   -   Spending time with family and friends
   -   Planning for the future of loved ones
   -   Having hope and maintaining Spiritual health


Good nutrition is eating a balanced diet from all three basic food groups namely:
  - Body Building Foods- Protein (e.g. beans, Soya, eggs, milk, fish, meat,
      peanuts )
  - Energy Giving Foods- Carbohydrates (e.g. Rice, bread, maize, yam, oil, sugar)
  - Protector & Fighter Foods- Vitamins (e.g. Fruits and vegetables)


   -   Try to eat a balanced diet
   -   Eat enough – at least 3 to 5 times daily
   -   No forbidden foods
   -   Don‟t loose appetite by forcing yourself
   -   Expensive does not mean good
   -   As much as possible, avoid alcohol, smoking and recreational drugs


Healthy people usually get enough through balanced diet, but with HIV, we might
need more you can get through food.

Vitamins and Mineral deficiency needed by the immune system to fight infections is
common in PLHIV as the body cannot build micronutrients in sufficient quantity so
MINERALS (selenium, iron, zinc etc) and VITAMINS (e.g. A, B+, C, D E etc) are

Calcium, magnesium is needed IN REASONABLE QUANTITIES!!!


   -   These are drugs used to prevent a disease or infection instead of waiting to
       treat the infection.
   -   E.g. ARV for health workers in case of occupational accidents
   -   INH for the prevention of TB if there has been an exposure to the bacteria
   -   ARV to prevent HIV in rape survivors
   -   Daraprim (Sunday-Sunday) to prevent malaria.


   -   Nivirapine or AZT was used in the PMTCT programs, but now we have a
       minimum of HAART at last trimester.
   -   This is not treatment for the mother but a prophylaxis to prevent the baby from
       HIV infection.

                                                       Report Douala version of July 23, 05



PWHIV are at risk of getting some opportunistic infections like TB, PCP, Meningitis,
thrush, diarrhoea, herpes, syphilis, warts, skin infections, shingles etc.

Almost all opportunistic infections can be treated, managed or avoided, so we need
to know what drugs are needed.

Some other herbal remedies have been found effective in managing OIs.


   -   These are is the only class of drugs that attacks the HI Virus directly.
   -   ARVs stop disease progression
   -   Durable and sometimes complete viral load suppression, thus allowing
       immune recovery
   -   Persistent Increase in CD4
   -   Decreases hospitalization. Reduces morbidity (illnesses) and mortality


Before anybody is placed on medications, proper counseling is needed and this point
can never be over emphasized or over stressed. PLWHA who start medications
either as prophylaxis, in treating OIs or ARV need to be completely and absolutely
adherent, otherwise the body develops resistance and the drugs fail to work.

Note that some drugs have side effects, but all are treatable or the drugs changed to
a more tolerant one.


   -   Compliance is obedience to the Doctors‟/health workers‟ orders. Compliance
       does not require understanding or commitment - only „blind‟ obedience


   -   Adherence is a voluntary commitment made by the individual to „adhere‟ (stick
       to, loyal to, follow) the prescribed treatment, based on an understanding of
       the information given
   -   Taking all medications in the right quantities, taking the your pills at the right
       times and taking your pills according to instructions
   -    Checking for Interactions with other medications

Why Adhere?

   -   Key element in success of your treatment

                                                         Report Douala version of July 23, 05

   -   Reduction of chances of resistance
   -   Reduction in break down of immunity
   -   Important to understand the challenges of adherence
   -   Understanding that treatment is for long term

Factors affecting Adherence

   -   Level of involvement in treatment decisions
   -   Depression & mental health problems
   -   Costs and other support requirements
   -   What you think about your HIV treatment
   -   Alcohol and substance use

Adherence Support

   -   Support from everyone
   -   Support when starting or changing therapy
   -   Medication alerts
   -   Multi-disciplinary support e.g. Counselors, Nurses, Therapists, dieticians,
       social workers, etc

Adherence Tips

   -   Practice before hand - use of sweets/multivitamins
   -   Keeping a diary -avoid confusion & reminders
   -   Jogging your memory
   -   Storing & Transporting
   -   Holidays, travel, time off, going out


The only way to take advantage of all forms of treatment and know what to be on the
look out for is through regular monitoring tests. All forms of HIV Treatment would be
meaningless in the absence of tests which must be done at least once every 3 – 6
months irrespective of the stage of HIV infection


   -   It gives hope and removes the despondency of being HIV+
   -   It educates communities about HIV, thereby demystifying it and causing an
       understanding which helps reduce stigma
   -   It challenges the complacency of the government and care providers
   -   Makes the doctor‟s job easier
   -   Leads to advocacy and demand for better services
   -   Empowers the community & reduces infections


   -   In Clinics and hospitals

                                                      Report Douala version of July 23, 05

   -   In the work place
   -   In our homes and communities
   -   In support groups
   -   In schools
   -   In the media
   -   In places of worship

   10. HIV and TB Research – Old Questions, New Drugs

  - Why is research important?
  - What kinds of research are being done on HIV and TB?
  - What specific research questions are important now?
  - What research questions will be important in the future?

1. Why is research important?

   -   Well-designed research studies provide evidence about what works to prevent
       and/or treat infections such as HIV/AIDS or tuberculosis.
   -   All new drugs, diagnostics, and vaccines are studied in clinical trials (research
       in humans) to prove their safety, define their side effects, and determine
       whether or not they work (efficacy or effectiveness).

2. Pre-clinical research & clinical trials

   -   Research on new drugs, microbicides and vaccines takes place in five

   -   Pre-clinical -- research in the test tube and in animals;
   -   Clinical trials – studies in humans:
   -   Phase I -- early testing in humans to determine a dose and early safety;
       usually conducted in 30-50 people over days to months;
   -   Phase II -- intermediate testing in humans to further determine the dose, see
       whether the intervention is active, and see medium-term safety, usually
       conducted in 50-500 people over months to years

Phase III clinical trials

   -   Phase III -- definitive studies to determine whether the intervention works
       compared with placebo (inactive substance) or an already proved effective
       intervention (active control); usually conducted in >500 people over several
       years; after the results are in the drug is submitted to a regulatory authority --
       such as the US Food & Drug Administration -- every country has such a drug
       oversight authority, but not all drugs are submitted by their sponsors (drug
       companies) in each country -- for approval to sell the drug with full information
       on safety, side effects, dose, how to use) on the drug label;

Phase IV clinical trials

                                                         Report Douala version of July 23, 05

   -   Phase IV/post-marketing studies, conducted after the drug is approved and
       marketed, are done to define its use in specific settings such as pregnancy or
       childhood, or in complex situations like co-infection with HIV and hepatitis B or
       C virus, or to better define dosing options, such as moving from twice daily to
       once daily dosing.

Strategy trials
   - Strategy trials are done to look at, for example:
   - Different types of prevention behavior (condoms + counseling vs. condoms
      only, to prevent HIV transmission, for example)
   - When to start antiretroviral therapy (ART)

Operational research

   -   Operational research studies look at how different strategies and programs
       work in the real world:
   -   How do various ARV combinations work together with TB treatment?
   -   How do HIV testing programs work in antenatal clinics, TB programs, or
       STI (sexually-transmitted infection) programs?

Sponsors, ethical review, informed consent

   -   Every kind of research has sponsors who pay for, design, and carry out the
       studies, ethical review boards, who are supposed to review the study to
       ensure that it meets ethical standards for safe treatment of participants,
       including accurate and clear informed consent procedures and documents.

Study design

   -   Studies are described in formal written documents called protocols, which
       define the study's hypothesis, its design, its inclusion/exclusion criteria,
       and its endpoints (for example, CD4 cell changes, viral load changes, the
       development of drug resistance, and changes in clinical symptoms such as
       development of new opportunistic infections or death.

Study endpoints

   -   Study results are examined periodically and studies are supposed to be
       prematurely stopped if one arm is clearly more dangerous, or clearly more
       effective than another. Otherwise the study is continued to its planned ending,
       when the results are analyzed for statistical significance. Usually a study is
       described as "statistically significant" if the result is less than 5% likely to have
       occurred by chance (this is described in formal terms as "having a p-value
       less than 0.05". Then the results are presented at scientific meetings and
       published in scientific journals.

3. What questions are important?

When to start? / How to monitor HIV therapy.

                                                           Report Douala version of July 23, 05

      -   All studies and guidelines agree to start ART when a person has
              o AIDS
              o Symptomatic HIV (WHO stage III or IV)
              o CD4 count < 200/mm3
              o Some guidelines recommend starting ART when:
      -   CD4 count is between 200-350/mm3
      -   HIV RNA is >100,000 copies/mL (where viral load is available)
              o Most guidelines recommend deferring ART if CD4>350/mm3 and HIV
                  RNA <100,000
              o When to start ART if CD4 testing is not available?
              o How to monitor ART if CD4 testing is not available?
              o If HIV RNA testing is available, how should it be used?

The DART Study

3a.       The DART Study

      -   The Development of Antiretroviral Therapy in Africa (DART) study is a
          randomized trial of monitoring strategies and planned interruptions (after 24
          weeks) in 3,300 symptomatic ARV-naïve [never received ARV's] adults with
          CD4<200 cells/mm3 from 3 clinical sites (2 in Uganda, 1 in Zimbabwe).
      -   Participants take:
              o AZT (zidovudine) + lamivudine (3TC) + tenofovir DF (TDF) or
              o Nevirapine (NVP) + 3TC + AZT
      -   The study is examining whether it is better to start people on ART on clinical
          grounds (WHO stage III or IV, symptomatic HIV or AIDS) or on laboratory
          grounds (<200 CD4 cells/mm3)
      -   The study will also assess whether interrupting therapy for 3 months every six
          months after 24 weeks of therapy is safe, reduces side effects, and preserves
          efficacy (Mutuluuza 12th CROI abs. 22).

Cotrimoxazole (CTX) prophylaxis therapy (CPT)

What is known so far
  - CTX is cheap, safe antibiotic with a broad spectrum action against several HIV
      related and non-related pathogens including PCP, toxoplasma gondii
      encephalitis, many bacteria, and possibly malaria

Cotrimoxazole in HIV+ persons

      -   Reduced hospitalization by 43% in HIV+ persons with WHO stage II or III
          disease (Anglaret Lancet 1998)
      -   Reduced hospitalization by 43% and death by 46% in smear-positive HIV+ TB
          patients (Wiktor Lancet 1998)
      -   CTX prophylaxis (960 mg every other day) for HIV-infected adults and children
          in Africa with WHO stage 2,3 or 4 or CD4 < 500/mm3

TB therapy and ART

      -   WHO recommendations for ART when persons have TB disease:

                                                         Report Douala version of July 23, 05

   -   CD4<200. Treat TB; treat HIV with efavirenz + 2NRTIs
   -   CD4 200-350. Treat TB; treat HIV with efavirenz + 2 NRTIs either immediately
       or after first 2 months of TB treatment
   -   CD4 >350. Start TB treatment. Defer ART.
   -   CD4 not available. Start TB tx. Consider ART.

4. Important emerging research questions

   -   Second-line ART in areas where scale-up is occurring now.
   -   Most countries use WHO-recommended '3x5' 1st-line regimens:

             NNRTI                      +        2 NRTIs

             Nevirapine (NVP)* +        Stavudine (d4T)***
                                        or zidovudine (AZT) +
             or Efavirenz (EFV)**              Lamivudine (3TC)

       * NVP can cause life-threatening liver toxicity or rash; not recommended in
women with CD4>250 cells/mm3 or men with CD4>400/mm3 before starting therapy.
NVP with rifampicin- containing TB regimens only recommended if no alternatives
       ** EFV not recommended in 1st (and maybe 2nd) trimesters of pregnancy
because of neural tube defects seen in primates and humans; however EFV
preferred NNRTI for use with rifampicin-containing anti-TB treatment.
       *** d4T may cause pancreatitis, peripheral neuropathy (requires switch to
            AZT), lactic acidosis (requires cessation of NRTIs), or lipo-atrophy.

How to manage ART toxicity?

   -   d4T related neuropathy, lipoatrophy -> switch to AZT;
   -   d4T related lactic acidosis -> stop NRTIs
   -   AZT related anemia -> switch to d4T
   -   NVP related rash or liver toxicity -> switch to EFV
   -   EFV related CNS toxicity -> switch to NVP

New drugs needed in future guidelines

   -   Future guidelines need to add treatment options with lesser toxicity such as:
   -   Tenofovir DF (TDF)
   -   or (in children) Abacavir (ABC)****
       **** ABC can cause a fatal hypersensitivity
               reaction in <4% of recipients

Need for strong 2nd line regimens

   -   Clear, simple second-line therapy options are needed for people whose CD4
       count drops and/or develop another AIDS-defining infection after <6 months of
       ART; possible options include:

       Protease Inhibitor +       2 new NRTIs

                                                        Report Douala version of July 23, 05

       Lopinavir/ritonavir               didanosine (ddI) (Kaletra)
       +     abacavir (ABC)****

   -   However currently there is WHO-prequalified generic version of
       lopinavir/ritonavir; the drug requires a cold chain (refrigeration until the last
       before use); **** severe hypersensitivity in 4%



   -   To define the main possible domains of the plan of action of the collaborative
   -   To define the strategy used for the implementation of the collaborative fund
   -   To define the important actions for the implementation of the collaborative fund

The strategies and the targets of the plan of action

   -    Which could be the main possible domains of the plan of action of the
       collaborative fund?
   -    Which could be the strategy used for the implementation of the collaborative
   -   What could be the important actions in the implementation of the collaborative



   To sustain the local or regional initiatives in the figth against HIV/AIDS


    The education to the treatment
    Capacity building:

              -   the therapeutic education and the observance to the treatment,
              -   the new technologies of information and communication (Internet,
              -   thcommunity hold in charge
              -   the use of the follow-up materials and assessment

    The advocacy on:

          -   the free access to the offer of cares (minimum packet) of hold in charge
              concerning the HIV/AIDS (tracking of the HIV, ARV, IO, Exams,

          -   The mobilization of resources

                                                         Report Douala version of July 23, 05

          -   The commercial agreement impact on the access in the              HIV/AIDS
              medicines (Bangui 99, WTO)

          -   The efficient integration of the PLWHA in the organs of decision
              (CNLS, NACC, CCM, Parliament,…) for the relative questions in the

          -   The global integration of the hold in charge of the HIV

          -   Coordination of the actions in the sanitary structures (exemples :
              tuberculosis, hepatitis,…)


  -    Developments of the material of information (newspapers, unfolding, posters,
       spotlights, stickers…..)
  -    Development of the modules of training
  -    Creation of the Web sites and green line,
  -    Access to the internet
  -    Integration of the formation to the hold in charge of the HIV/AIDS in the
       medical, paramedical, administrators, pharmaceutical programme
  -    Mobilization of the PLWHA
  -    Yearly conventions of the PLWHA on the advocacy and the hold in charge
  -    Decentralization of the actions toward the rural areas
  -    Setting up of a dialogue structure to all levels
  -    Petition, demonstrations, pacific marches, rounds tables, medias…
  -    Regional and sub regional concertation/collaboration


  -    Distribution by country

                 5.000 us DOLLARS by project for the associations
                 10.000 us DOLLARS by project for the networks or national


  -    The advocacy for the free access to the offer of cares (minimum packet)
  -    strenghtening of the capacités

  -    The education to the traitement

                    NORTH AFRICA : Main domains of action

  •    Building capacities of the NGO
       To create a group/ or association of PLWHA


                                                        Report Douala version of July 23, 05

Salaried class - professionalisation so that they appropriate
the reason
Put PLWHA in the committees of the CCM

   • Advocacy
   - Inter - regional network strenghtening
Financing fees of functioning
Permanent salaries
Communication (fax - internet, etc…)
Expenses of mission for
Setting up mailing lists
Publication and diffusion doc references, investigations,
research, etc…

   • Education to the treatment
   - Educators formation
   - Development / guide
Ex : nutritional advices/ mothers_ children transmission (ex: nursings…)
- Development of a guide on the co - infections


   •    1/regional
Ex: common transversal themes: right of people / stigmatization / education to the
treatments / PI and patents
    • 2 / national
Ex: decentralization of the hold in charge / orphans and vulnerable children /
nutritional hold in charge
    • 3 / local
Ex: Strenghtening of the capacities of the NGO / and implementation of the
programmes / follow-up and assessment


   • 1/ To work on stigmatization and right of the PLWHA
To integrate PLWHA in association
To give the means to act
Promotion of a law defending the rights of the PLWHA

2 / advice and tracking
Mediatized countries
To link to the advantages the treatments
To guarantee the confidentiality and the anonymity

3 / problem of strenghtening of the intellectual property
To document the question: identification of the statements of repairs
To popularize the problematic, to give example, exchange experiences,
Organization of regional shops

                                                        Report Douala version of July 23, 05

Creation of regional coalition
Setting up of a FTA WATCH

4 / promotion of the condom
Action: to imply the religious leaders
To make posters of condoms
Documentation in scientific way of the advantages of the condom to
to place at disposal of the schools, association, etc…
To make the condom accessible at the level of the price
Charter of engagement on promotion of the condom


      The education to the treatment and community mobilization.
      Advocacy for the access to the treatment
      Capacity building for communities at the grassroot.


      It was not accepted that this fund is given to the country, but to the community
       organizations at the basis.
      To deliver funds to the associations through the networks. The essential
       criteria should be only their real work on the field
      To give a maximum to each organization and at this moment, the big
       organizations will move away from this financing. The committee has therefore
       proposed that the big NGO doesn't benefit from this fund.
      It was proposed to give funds to the NGO and to ask the networks to
       supervise the use of these funds
      it was proposed that the elected people here are not candidates to financing at
       least for one year
      The eligible associations are not only those of the PLWHA even though they
       must be at the fronts
      An association which is present in this shop could be delegated by PATAM to
       supervise and to coordinate the use of funds
      it is proposed that the big organizations in the country care about what the „S
       small 'S organizations make withfinancings.
      It is difficult to win a campaign of advocacy in 6 months that is why it is
       important to strenghten the capacities of the organizations and to give them a
       little time to make the setting up.


   -   Election of a selection committee–Thursday (Those who take part to this
       committee should not submit a project for 1 year)

   -   To write the selection criterias of offer. It will only be about the ideas of –
       criterias (each must be voluntary at this committee and no one must be co-
       opts). This regional committee should consist of 5 countries. August 1st

                                                         Report Douala version of July 23, 05

    -   Launching of invitation to tenders


    11.1. GUINEE : Situation of the access to ART in Guinea / Conakry


    -   CONTEXT


    -   West African Country
    -   7 million of inhabitants
    -   Prevalence Rate in 2005 = 2,8% (average)
    -   Characterized by a fast and generalized evolution of the epidemic

Context of the access in the ARVS

    -   Available ARVS in the country since 1995
    -    Average cost 100 000 in 1995
    -   Actual cost ARV 5000 / month
    -   No numbering of CD4
    -   Other assessment = 5000
    -   Several opportunities to sustain the access to the care:
    -   MAP = 20 millions
    -   FG = 13 millions
    -   SNU = 2 millions
    -   Cooperation: 25 millions
    -   Eligibility Committee put in place lately by the state
    -   Centers of hold in charge: 6 known
    -   Donka = FG / everybody but for 150 people
    -   Matam = MSF Belgian = 50 people
    -   Kissidou = idem
    -   Boulbinet = FHI but started not
    -   jean II paul = Idem
    -   Zerekore = idem
    -   Mamou = GTZ = 50 people new centers in opening in Faranah and Labé


-   Several source of provision and dispensation of products

                                                       Report Douala version of July 23, 05

-   Every partner has his circuit
-   Produced mainly in generic but availability of specialty product

Experience of AGUIP

-   Creation in August 2002 2
-   Members = 230
-   Of which 80 infected
-   AGUIP intervenes at the national level but especially in conakry and Mamou
-   Domain of intervention:
-   Advocacy
-   Medical care
-   Prescription, follow-up and financial support of the treatment for 30 people during
    8 months
-   Psychosocial hold in charge l
-   VAD, Accompaniment to the observance, counseiling, group of speech…
-    Nutritional support with the support of the PAM
-   Capacity building of the members
-   Small jobs/ sewing shop, Joinery, Brickyard, Center of leisure and restoration,


    -   To assure the continuation of programmes of the actual treatment
    -   To find adequate resources to strenghten the activities of AGUIP+
    -   To reduce the stigmatization and the discrimination toward the PLWHA
    -   To assure the availability of the tracking services
    -   To get a lucid political engagement


    -   Free of payment of the medicines for all
    -   To assure a bigger implication of the PLWHA in the national answer


In spite of important available resources in Guinea, it remains a lot to do to guarantee
the access to the treatments for all in guinea


  - Introduction.
  - Historic of the access to treatments
  - Mechanism of passage to the scale.
  - System of provision and distribution.
  - Experience of the RIP+ and the NGO.
  - Challenges and perspectives
  - Conclusion.

                                                         Report Douala version of July 23, 05


    -    Country of West Africa.
    -     Area: 322.462 km²
    -    General population: 16,8 millions
    -     AIDS prevalence =7%
    -    Increase of the infection rate because of the war
    -    Co - TB - HIV infection = 45%
    -    Important country in the 3x5 WHO
    -    Need of treatment from now to 2005 = 126 000 prs
    -    Historic of the access to the treatments
    -    1998:Initiative of UNOAIDS of the access to the treatments.
    -    1998-2004: 2105 patients hold in charge by the state.
    -    2004: several initiatives = World fund, 3x5 WHO, PEPFAR, MAP, CTB, Fund
         of collaboration,
    -    Operational objective: 23.000 patients to put under treatment from now to


-   2001: setting up of the National Program of Medical care of the PLWHA (NPMHC)
-   Adoption of deconcentration and decentralization plan of the hold in charge:


    -    Reseautage of the services

    -    Strenghtening of the capacities at the central and peripheral level.

    -    National instructions development (therapeutic protocols, accredited centers
         and of defined references)

    -    Implication and formation of community actors (world Fund, International

    -    2005: cost of the package to 5000 fcfa every term (biological follow_up +ARV)
         for everybody
             o In the setting of the PTME and children (0 TO 15 years) the treatment is


-   Provision in ARV by the state and the partners (World Fund, Pepfar, MAP) for the
    national program for the PPH (Pharmacy of the Public Health)

-   To guarantee the tracabilitY / WHO takes what and where

-   Coexistence of medicines of specialties and the generic.

                                                          Report Douala version of July 23, 05

-   Dispensation           only in the accredited centers

There are:

-   31 accredited centers
-   50 centers of PTME
-   20 CDVS
-   11000 people are under ART treatment

          - Forecastings per area i 2005
    PEC BOUAKE administrative center of the Region
(PTME Tanda Sanitary District )

                             MAL I
                                                                               BURKINA             FASO

                    DENGUELE                          SAVANES
                                                                     
                     ODI EN NE                     KOR HOG O
    GUI NEE                                                                                                  

                    BAFING        WORODOUGOU                   VALLE DU BANDAMA
                  TOU BA                                               Katiola
                                    SE G UE LA                                                               
                                                                                                     BONDOU KOU
                                                           Beoumi   BOU A KE                             Tanda
                                                                                                   
                      M AN
         Danané                                             Sakassou
                                                                 
          18 MONTAGNES               HAUT                           Tiebissou   N'Z
                                                                               BocandaI-CO O M E
                                  SASSANDRA           BOU A FLE
                                                                    LACS         
                                                                                           Daoukro        
                                                                YAMO U S SO UK RO              Agniblekrou
                                        DA LOA
                                                                                                      M YEN-COM E     O
                                                   A
                                                  M RAHOUE      Toumodi       DI MBOK RO
                                                                                                       ABE NG OUR OU
               GU IGL O                                               
                                                                              Bongouanou 
                   MOYEN                            FROMAGER                                     Adzopé
                                                                                                                     GH   ANA
                  CAVALLY                           
                                                GA GNOA         DI VO          Tiassalé     AG B OVIL LE
                                    Soubré              Lakota    
                                                        
     LI B ER   IA                                              SUD                              Alépé      ABO IS S O
                                                           BANDAMA DabouUNES

                             BAS-SASSANDRA                                     
                                                                                  ABIDJ AN 16 43             SUD
                                                                                                      CO O  M E
                                       Sassandra                     Gd-        Jacqueville     Gd-Bassam
                                                                 Lahou
                           SA N-PEDR O
                                                    OCEA N A TLA NTIQUE


-   Involvement of the PLWHA(RIP+) to all decisions processes on the treatments at
    the national level.
-   Education to the treatments of the actors, the PLWHA and the community
-   Advocacy for the reduction of the costs of the ARVS
-   Formation of basis of the communIity actors (associative members) on the
    ARVses by The International alliance / PEPFAR)

                                                                                      Report Douala version of July 23, 05

-   campaign medium for the promotion of the education to the treatments
-   Coordination of the advices at the national level.

Plan of the campaign medium for the promotion of the education to the treatments


-   Visit at home and to the hospital
-   Group of auto support
-   Hold in charge of the OEVS under treatments
-   Hold in chage of the Treatments of the actors and the resourceless
-   Accompaniment to the observance to the ttt
-   Food hold in charge and nutritional formation
-   AGR



-   To avoid the stocks shortage of the ARVS
-   To improve the observance
-   To reduce the discrimination and stigmatization
-   Adequacy of financial and human resources
-   To change the habits of the physicians


-    Strenghtening of the capacities of the RIP+ to play its role of support and
-   Mobilization of additional resource for the accompaniment to the observance and
    the education to the treatments
-   Advocacy by the decision-makers for the accessibility and the psychosocial
    follow-up of the patients on the national plan
-   Financial autonomy of the RIP+ and its NGO


-   The access to the treatment and the community accompaniment to the
    observance of the treatments is complementary and fundamental for the success
    of every programme of treatments.
-   The answers brought to the patients by the PLWHA, the associations and NGO
    are specific, efficient.
-   The community actors need subsidies and strenghtening of capacities to develop
    efficient systems to come with it the programs of treatment in their countries



                                                      Report Douala version of July 23, 05

A global view of HIV infection 33 million adults living with HIV/AIDS as of end


    -   POPULATION: 3,4 Millions
    -   Area: 111,370 sq Km
    -   Land: 96,320 sq Km
    -   Water: 15,050 sq Km
    -   +60% population are young (-30 years old)
    -   Age structure
    -   0-14 years = 43%
    -   15-64% = 52,8%
    -   65 & over = 3,7%


    -   5,9% BEFORE 2003
    -   11% - 2004
    -   PLWHA = 100 000 – 220 000 (Estimation 2003)
    -   HIV/AIDS death = 7,200 (Est. 2003)
    -   36,000 (15%) ARE ORPHANED BY AIDS
    -   42,000 DOUBLE ORPHANS


-   War
-   High level of poverty
-   Breakdown in Societal norms
-   Rape/forced early marriages/GBV
-   Invasive cultural practices, (FGM)
-   Migration/IDP
-   High level of stigmatization/discrimination
-   High level of denial of HIV infection


    -   Poor/lack of medical/Lab facilities
           o Kanweaken - transfusion without screening for HIV, River G County
           o Sinoe - blood collected based on previous donors HIV Negative result

    -   Lack   of or poor treatment of STIs
           o    STIs
           o    OI
           o    ARV

    -   Inadequate/Lack of VCCT services

                                                      Report Douala version of July 23, 05

           o Low knowledge levels of HIV/AIDS (Min Of Info)
           o Lack of HIV/AIDS experts



   -   OI & STI Prevalence not known

   -   Lack   of
          o    Appropriate care
          o    Health facilities
          o    Personnel well trained
          o    Lack of drugs
          o    Inaccessibility of drugs


   -   Since 2001, ARV are in Liberia
   -   Nowadays, less than 369 persons were under ARV in the all country (2004)
   -   ARV still expensive (more than 10 USD/Day)
   -   Some organization are supplying this drug to PLWHA (Firestone, ELWA,
       Catholic Hospital)
   -   ARV are available just in Monrovia
   -   ARV
   -   Triomune is the most common treatment for now in the country
   -   ARV are freely sold in the pharmacies
   -   Very few persons are qualified for ARV prescription
   -   There is no prescription coordination strategy
   -   No NEVIRAPINE/ No PPTCT site


POPULATION                                                      3,4
HIV PREVALENCE                                              5,9 – 11%
NUMBER PLWHA                                   100 000 - 220 000 (Est. NACP 2005)
NUMBER OF PLWHA IN NEED OF ARV                                  N/D

PLWHA CURRENTLY ON ARV                                          369

FRONT LINE DRUG REGIMEN                                    Triomune
GFTM: 2yrs approved funding (round 2):                    $7 658 187

                                                        Report Douala version of July 23, 05

    TOTAL FUNDS DISBURSED BY GFTM                       $1 032 753

    LIBERIAN PHYSICIANS                                      30

    ARV PRESCRIBERS                                           4
    VCCT SERVICES                                5 (Only 1 out of Monrovia)
    NEVIRAPINE/PPTCT                                         Nil
    SYSTEM OF COMPREHENSIVE CARE                             Nil


-    In the country, just 7 VCCT exist (6 in Monrovia)
-    Each provider is king
-    There is no CD4 counter in the country
-    There are few organizations of PLWHA (3)
-    There are few persons trained for psychosocial follow – up of PLWHA on ARV




           GLOBAL FUND                                HEALTH


                                                     Report Douala version of July 23, 05

                                  TO THE NTGL

STRENGTHENING                                                        SUPPORT TO
       &                                                            THE UN FAMILY
 EMPOWERMENT                                                         AGAINST HIV
   OF ASSO                             UNMIL

        SUPPORT                                                        AMONG PKF
        TO NGOs



-   Empowerment of „Light Association‟
-   Fight against stigmatization
-   Training of PLWHA for advocacy
-   Advocacy to the NTGL to lead the fight against HIV/AIDS & to provide free
    treatment for OI/ARV
-   Organize the route of distribution as well as the strategy of supply to maximize the
-   Train practitioners and prescribers
-   Make sure that money from GFTM is used properly

    11.4. NIGER

General information
Area =                                          1 287 000 km2
Population =                                    11 000 000hbts
Seroprevalence =                                0,87% (National investigation 2002)
 Number of PLWHA cared by the CTA =                          742
Number of people under ARV =                    352 of which 232 at the CTA level

Free ARV treatment since January 2005

Centers of care

-   Niamey = 5

                                                        Report Douala version of July 23, 05

-   Inside the country = 1 (hospital SIM Galmi)
-   7 trained physicians for the 7 regional hospitals for the ARV prescription
-   2 devices of dosage of the CD4S (CTA and Galmi)
-   Niger is beneficiary of the world fund of the fight against AIDS, TBC and the
-   THE ONPPC and some private assure provision in medicine.


Associations of hold in charge:

-   Better to live with the AIDS/CEDAV
-   Niger hope
-   The Network of the PLWHA
-   The RAIL Network of the actors who interven in the setting of the fight against
-   The Ambulatory Treatment Center (ATC) State and Cross red in France
-   Others NGO and associations of support and fight against AIDS
-   Collaboration with some Burkina associations
-   The Catholic church (BALD and CARITAS)

Difficulties at the national level

-   Concerning the hold in charge:
-   Transportation to join the 2 centers of prescription
-   Tests
-   The nutrition
-   The administrative heaviness in the financing of the projects submitted to the
    Global fund
-   Weak rate of tracking
-   Accomodation for the out on business people

Catholic Action Project in the fight against AIDS
- Creation
- Resources, profiteers, activities
- Programme of the formations
- Materials of follow-up of the activities
- Waitings
- Partners
- Difficulties


                                                     Report Douala version of July 23, 05
                                   Catholic church in Niger

                 BALD                                     CARITAS

        Partners in the fight agaist                     Partners in the fight against
                HIV/AIDS                                          HIV/AIDS

                                   Catholic Committee against

                                       Projet: A.C.L.S


-   HUMAN: 1 Animator Coordinator
-   IMOBILIERES: 1 Office of animation
-   LOGISTICS: 1 vehicle of service
-    COMPUTING: 1 portable computer, 1 printer,
-   FINANCIALS: 70 000 Euros (Caritas Italiana), 60s 000 Euros (Caritas Spain)
    quests in progress

The Targets of the Project

-   Hbt in a area of 10–15 km of the health centersf of the church
-   All user of these centers
-   All sick referred in these centers
-   The parishioners
-   The other structure recipients (training center, project of reinsertion etc.…)

The activities

    -      Advocacy)
    -     Prevention / PTME
    -     Therapeutical hold in charge: -(from June 2004 to June 2005, 75 patients of
          the AIDS are under treatment)
    -     Pshyco - Emotional
    -     -Nutritional
    -     Socioeconomic reinsertion
    -     Training

                                                          Report Douala version of July 23, 05

The points of support of the project:

    -   The centers of health of the Catholic church in Niger
    -   The of welcome medico - social center of Saga/NY
    -   (Béthanie)
    -   The Centers of Human Promotion
    -   The parishes / Committees Solidarity Development
    -   The groups and movements
    -   The CTA (ambulatory treatment center)
    -   The other projects of the Catholic mission
    -   The hospitals and regional maternity ward of reference

The Recipients of the formation programme

-   Personal of health and volunteers of the pastoral health
-   Important people of the parishes and the CSDS
-   Animators (trices) of the health centers and the CPHS
-   The catechists
-   The Teachers of the missionary schools
-   The coordinators and responsible of CARITAS shutters and BALD

Contents of the formations

-   The communication for a change of behaviour (C C B)
-   The therapeutic hold in charge
-   The counceling
-   The follow-up

The material of follow-up

-   Cards of discharges
-   Cards of management of funds
-   Card of counseling
-   Social file of the PLWHA
-   The reports


    -   Feedback on the activities of the parish sub- committees, of centers and
    -   The complete hold in charge of all patients referred by our structures
    -   The axes of the project are mastered
    -    The plans of action are élaboratet – committees of the regions

The Partners structures

-   The CTA
-   Network of the PLWHA
-   The regional hospitals
-   The hospitals of reference

                                                       Report Douala version of July 23, 05

       -   The maternity ward of reference
       -   The associations of hold in charge
       -   AAS. African Associationfor Solidarity of Ouaga Burkina F.


       -   Insufficiency in the financing of the project especially the AGRS
       -   More and more strong demand concerning the offer (on the hold in charge)
       -   Lack of physician for the Bethanie center of Saga
       -   Difficulties for the setting up of the network of the religious of the fight against

       The plan of actions (Exple)

ACTIVITIES         QUANTITY / Material      Human Means Financial means                      targets groups
                   Number     means

Sensitize      the 2 sittings   -Pagi voltes 2 animator        - Cool of taxicab X 2         Young     between
young of the FADA               -   Tea     & 1 PPHIV          - Cool of thé&sucre X 2       16–25 years (CUN)
LOBATOU                         sugar                          -Perdiems Animators x 4
                                                               -PERDIEMS 1 PVVIH X 2

           11.5. NIGERIA

       HIV/AIDS Care in Lagos The Challenges of Scaling up, Tobias Luppe, Lagos, May
       5th 2005

           MSF in Nigeria

           -   Started Activities in 1996
           -   2005: Bayelsa, Lagos, Borno, Abuja
           -   Epidemics

               HIV/AIDS Care in Lagos

           -   2003 Start in Lagos Island General Hospital
           -   2004 Start ART
           -   2005 Scaling Up

       Free Comprehensive Care

       -   VCT                                             -    Pharmacy
       -   Laboratory Services                             -    Adherence Counselling
       -   Peer Health Education                           -    Nursing Care
       -   Nutritional Support                             -    Universal Precautions
       -   Medical Care                                    -    Data Collection

                                                                      Report Douala version of July 23, 05

-   Networking                                  -   Access Campaign

The Patients

-   1000 PLWAs enrolled
-   70% present WHO stage 3 / 4
-   More than 50% on Cotrimoxazole Prophylaxis

ARV Treatment

    -   >500 patients on ARVs
           o d4T, 3tc, NVP (FDC)

    -   9 months follow up
           o mean increase in CD4: 309
           o undetectable Viral Load

Increasing Quantity Maintaining Quality
-   Integration LGH patients                            800

-   Drop Geographic Inclusion Criteria                  600
                                                                                                        ARV Patients
-   Streamlining processes                              400

-   Reinforce Staff                                       0
                                                              1st Qtr 2nd Qtr 3rd Qtr 4th Qtr 1st Qtr

Upcoming Challenges

-   Availability of ARVs
-   Treatment Experienced Patients
-   Adherence
-   Integration with LGH
-   Hand Over
-   Catalyst for Change


    -   42 million people living with HIV/AIDS
           o 95% live in developing countries.
    -   6 million people need ART
           o yet only 500,000 people receive ART

Catalyst for Change

-   4 – 5 Mio PLWHAs in Nigeria
-   500 000 in need of ART
-   Only 15 000 ART through Government
-   Apprx. 10 000 through private Initiatives

Pay or Die?

                                                        Report Douala version of July 23, 05

    -   US-programmes: 1000 Naira / month
    -   Government Programmes: 1000 Naira / month
        + lab. Tests, other medical expenses
    -   Private Sector????
    -   Average daily payment in Government Program: >100 Naira
    -   Daily Income of 66% of Nigerians < 132 Naira

Free Treatment

-   High Drop Out Rates
-   Non Adherence Leads to Treatment Failure
-   Adherence Comes with Understanding – Not with Payment
-   ART is Cost Effective

          (ART) in SENEGAL

REPUBLIC OF SENEGAL: “ one objective, one people, one faith »

-   National consultant of the fight against AIDS (NCFA)
-   Ministry of Health and the medical Prevention
-   National network of People Associations living with the VIH/SIDA (RNP+)
-   SENEGALESE initiative Of access in the Antirétrovirauxes
-   (ISAARV° 1998

PREVALENCE: 1,4%----------------1,5%

-   Senegal entered in 1998 into the Antiretroviral treatment
-   For it, the initiative of access in the ARVS is created with five (5) composantes:
-   Physicians Cliniciens
-   Physicians Biologistes
-   Physicians Pharmaciens
-   Social workers
-   National network of the PVVIH/SIDAS


-   A restricts technical Committee
-   A Committee of eligibility
-   (Selection of the patients to put under ARV)


-   Sensitization of the Government
-   Negotiation with the pharmaceuticals


-   Bitherapie

                                                         Report Douala version of July 23, 05

-   Tritherapie


-   Biological: 350 CD4S--------- 10.000 copies
-   Socioeconomic


-   1998----------- 250 millions CFAS------0 in 100.000 FS
-   2000----------500 millions CFAS------0 in 60.000 FS
-   2002----------1,6 billion CFAS 0 in 5.000 FS
-   2004--------- ARV exemption from payment (oh)
-   Number of Patients under ARV
-   Program                   2999
-   Out program 1000

- To improve the technical set
- Efficient hold in charge of the balances
- Purchases of medicines (some) the I.US.
- Nutrition level
- To take 7.000 patients in charge (2.00)
- To assure the transport


-   Heaviness of payment
-   The decentralization of the ARVS
-   The formation of the Health staff
-   The availability of the ARVS pediatric shape
-   To widen the Committee of eligibility (community)



 It is an association of PLWHA composed of infected and affected people, created in
1999. It is member of the national network of the P LWHA in Senegal (RNP+) and
members of the African network 2000 put in place by AIDES Paris federation. Implied
in charge in the accompaniment, the support and the hold of the PLWHAS: it assures
a daily permanence at the hospital of CTA, counsseling meadow and post - test,
counsseling meadow therapeutic backing of counseling organization of speech
group, therapeutic education, culinary tasting, visits at home and the hospital,
distribution of food commodity and kit food sensitization and advocacy involvement in
national and international conferences

    1) Number of people under ART: today, Senegal counts 2800 people under

                                                        Report Douala version of July 23, 05

   2) The types of ARV existing treatment: the nucleoside: the Didanodine (Videx),
      the Lamivudine (Epivir), the Zidovidine (Retrovir), the Stavudine (Zerit), the

   -   The non nucleoside: The Efavirenz (Avirens, Stocrin), Nevirapine (Viramune,

   -   The anti - proteases: the Indinavir (Crixivan), Nelfinavir (Viracept), The Kalétra
       (sponsors or grant)

   3) The sources of provision in ARV

   -   The Senegalese initiative of access to ARV (ISAARV)
   -   But also of the research of sponsors in the cases of resistances (Kalétra) that
       is not even available in Senegal.

   4) Processes put in place for the distribution of the ARVS: (the advantages and
      the disadvantages

Firstly, only Dakar had the ARVS. But now we have decentralization since 2003.

The advantages:

   -   The obtaining of the ARVS from the residence.region
   -   The improvement of the life quality
   -   Reduction of the stigmatization and the discrimination
   -   The acceptance of people living with the HIV by the families and their

The inconvenients:

   -   The constant shortage of the ARVS medicines.
   -   The non availability of the shape pediatrics in ARV
   -   The inaccessibility of the strangers to the free payment in the ARV.
   -   The unavailability of the balances of ARV follow-up
   -   Risk of nonobservance (resistance of most people under ARV)
   -   Nourishing and food means lack (nonobservance)
   -   Lack of autonomy of people living with HIV

    5) The experience of our organization concerning access to the ARV S
Since the first cases of AIDS in Senegal, the Senegalese state organized itself to the
setting up of the ARV treatment that is the Senegalese initiative of access to the
ARV? Thus, we passed below of three stages to have today free payment of the

   -   The contribution to the treatment (% paid)
   -   The involvement to the treatment (to give what we can give)
   -   The fee of paiement

                                                         Report Douala version of July 23, 05

 Till now, this contribution and this involvement are required to the strangers living in
Senegal. Before the exemption from payment, our organization led activities of
advocacy in the political decision-maker meadows for an availability of the ARVS, the
exemption from payment to the strangers, the access and the availabilities of some
anti - protéases (KALETRA) for cases of resistance that regularly appear. But also,
for the availability of the new molecule that must be taken once

    11.7. TOGO


HIV/AIDS, although it is so dangerous in the nature, and in spite of the limited means
of our poor States, but the more infected. The efforts don't plan with regard to the
So the last evaluations of the UNAIDS in December 2003 on the propagation of the
infection by HIV/AIDS worrying: 40 Millons of P LWHA in the world of which 26
Millions in sub-Saharan Africa. This situation doesn't save Togo.

Since the beginning of the epidemic, the number of AIDS accumulated cases
declared is of 14840, the number of seropositive People is estimated to 160 000 .on
a total of 487 P LWHA of the region of the Kara about 92% present some clinics
signs to the major people (opportunists infection and AIDS) but only 172 people are
under the ARVS in the Global funds project and 105 riched people take themselves
entirely in charge for fear of discrimination.

So for the therapeutic treatment we use different ARV types:

-   Triomine 30 (that means tablet composed of 3 molecules),
-   Triomin 40,
-   Avolam–stag (straridine),
-   Névipan (névirapine),
-   Stockrin.

Having noted that these products have negative effects, we record like advantages
the backing of immunity, the improvement of health, the improvement of the life
expectancy; the dissuasion of the discriminatory mind and the inconveniences of the
toxicity of the products, the lack of rigorous follow-up, the access to the ARVS
showed that the conditions of eligibility of the patients to be under ARV don't cause a
problem but rather it is the contribution of the patients to the purchases of the ARVS.

A. P (ASSISTANCE PLUS) is an association in charge the PLWHAS that asked in
the project of Global fund to all seek a contribution of 5000 FS in order to have the
product per month for 200 000 to 300 000F the real price of the availability of the
ARVS for a person that wants to take itself in charge. That permits the PLWHA to
have access to ARV.
Also note that this strategy of distribution is not so efficient especially as on this day
the P LWHA that don't find means for their own treatment and to make the analysis of
the CD 4 and to respect the treatment even they are eligible. Only one physician is
trained for the prescription of the ARVS in one circumscription. The constitution of the

                                                         Report Douala version of July 23, 05

files is difficult because it exist only one point for each prefecture (prefectorial
Direction of health).

 ASSISTANCE PLUS that is a structure less important on the financial plan, but the
institutional aspect and the backings of the member capacities concerning treatment
of the HIV make our strength. So we have a lot of expectations in the following

   -   Training, to begin in 2004 on the psycological treatment. This training is made
       by a health psychologist based in Lomé

   -    Training on the hold in charge of the PLWHA in the treatment of the
       opportunists‟ deseases in April 2002.
   -   Initiation and execution in 2002 „' to live with the HIV, it is to live with his the
       friend for life. ' '
   -   Formation on the cares at home assured by the non professional of the
       community health (agent) in 2004
   -   Setting up of a generic pharmacy in December 2003, to allow the PLWHA to
       have access to weak cost of the medicines for the treatment.of opportunist
   -   Setting up of a project on ARV of the P LWHA in of finalization phase

   11.8. MOROCCO

Country of North Africa

Population:                          30.000.000
1986:                                1st case of AIDS
1988:                                Creation of the PNLS
1988:                                Creation of the ALCS
Weak prevalence                      0.1%
Case of AIDS illness (Déc 2004)      1587
P LWHAevaluation:                    30.000 in 2003 (15.000 in 2004?!)
Nbre of grey. in need of ttt:        1.500
Nbre of people under treatments :around     900

  - Created in 1988 by H. Himmich
  - 1st NGO in north Africa and Middle Coast
  - 16 regional sections

  - Prevention of the infection in HIV/AIDS
  - Hold in charge of affected people by the HIV
  - Defense of the rights of infected people and of the vulnerable groups

Moroccan experience of access to the antiretroviral therapies and organization
of the hold in charge

                                                          Report Douala version of July 23, 05

Actors of the access in the ARVS

-   Ministry of Health
-   Infectious illness service
-   ALCS
-   FSTI–ESTHER - World Fund
-   Sidaction

Role of the Ministry of the health

-   Takes in charge expenses due to hospitalization and the tests of diagnosis
-   Budget for the purchase of ARV
-   Political engagement in favor of the access to the cares
-   Respect of the rights of people living with the HIV
-   Organization of the hold in charge

Role of the ALCS

Defense of the rights ofiinfected people

-   Right to the cares
-   Right to confidentiality
-   Right to the return in the country
-   Demand of grace

Advocacy for the access in the ARVS

At the national level

-   By the Ministry of Health
-   By the mutual and insurances
-   By the big companies

At the regional level

At the international level

-   FSTI - ESTHER–World Fund

The ALCS provides
- To provides 90% of the medicines for the treatment and the prevention of the I
     o French association grants
     o Collection of fund
- Financing of a part of the viral loads and the numerations of CD4
- Help to the observance

The ALCS finances
- Expenses of Tel Fax for the services of hold in charge
- Expenses of transportation of the patients

                                                       Report Douala version of July 23, 05

-   3 social workers
-   Construction of a day hospital in Casablanca
-   Secretary of the consultation and the hospital of day

Reduction of the cost of the ARVS

First   stage:
   -     Customs tax exoneration
   -     Negotiation of the prices
   -     1250 dhs/month            6450 dhs/ month

Second stage:
   -  Complex program ACCES (trop), 2000 dhs / month
   - Generic: 3000 to 6000 dhs/ year

Role of the financial backers
   - FSTI: pilot experience of treatment of 100 patients in 1998
   - ESTHER: partnership with French hospitals, formations, medicines for the
      opportunist infection treatment
   - World fund: financing of actions of prevention and ARV
   - Sidaction: Takes psycho - social in charge, and therapeutic education

Role of the Service of the Infectious Illnesses
   - Service of reference for the hold in charge of the infection in HIV/AIDS
   - Takes 70% of the patients in charge
   - Experience of the ARV since 1990
   - Nursing team trained and motivated

Previous conditions to a rational prescription of the ARVS
   - Availability of the diagnosis tests and respect of confidentiality
   - Treatment of the opportunist infections
   - Training of the nursing team
   - Material and psychological support
   - Implication of infected people
   - Regular provision in ARV


The treatment is recommended for the patients:
   - Symptomatic to the AIDS stage
   - Asymptomatic of less than 350 CD4S

Experience with the ARVS
1990:             MONOTHERAPIE AZT
1994:             Bitherapie
1996:             First diagram of tritherapie
April 1998:               ministerial Circular
June 1999:                Partnership Ministry of health / FSTI
2001:             Access program of the UNAIDS
2003:             Global fund

                                                        Report Douala version of July 23, 05

The nucleosidic inhibitors of the RT (INRT), nucleotidics (INtRT) and non
nucleosidics (INNRT)

                        INRT                                        INtRT

  AZT                    RETROVIR ®            TDF (TÉNOFOVIR)       VIREAD ®
  DDI                    Videx®
  DDC                    HIVID ®                                   INNRT
  3TC                    EPIVIR ®              Névirapine            VIRAMUNE ®
  D4T                    ZÉRIT ®               Efavirenz             SUSTIVA ® STOCRINE
  Abacavir               ZIAGEN ®

The inhibitors of the Protease

                                Inhibitory of the protéase
Saquinavir                                    INVIRASE® FORTOVASE ®

Ritonavir                                     NORVIR ®
Indinavir                                     CRIXIVAN ®
Nelfinavir                                    VIRACEPT ®
Lopinavir + Ritonavir                         KALÉTRA ®
Atazanavir                                    Zrivada®

Main associations of ARV used
                          +                                  +
        INRT                          INRT                             INNRT

                          +           INRT                   +
        INRT                                                                IP       /r

        INRT              +         INRT                 +                  INRT
Active line (February 2005)

    -    Cohort: 730 patients
           o 674 HAARTS

    -    Average of age: 34 years
    -    Sex:
            o Hs: 372 (55,2%)
            o F: 302 (44,8%)

                                                             Report Douala version of July 23, 05

   -   Urban origin: 80,3%

Experience with the ARVS

Since June 1999, 674 patients received a tritherapie

   -   Naive patients: 527 (78%)
   -   Average of the CD4S: 147 (5 - 611)
   -   Viral load average: 4,64 log10

Sources of financing of the ARVS
                                       N                       %
Ministry of health + World Bottom      489                73
Mutual and insurances                  68                 10
Employer                               7                   1
Country of origin                      71
Grants                                 2          0,3

Prescribed therapeutic diagrams (N=674)
                                                Nbre            %
2 IN + 1 INN                                    461             68,3
2 IN + 1 IP                                     211             31,3
3 INN                                                          2 0,3

Impact clinic of the tritherapies
Gain of weight (6.5 kg)               70%
Improvement of the life quality        73%
Resumption of work                     54%

To become patients under HAART (N=674)
                                 Nbre                          %
Tritherapie                      592                           85
Bitherapie                       1                             0,14
Stop of treatment                2                             0,3
Follow up in another country     7                             1
Lost of view                     21                            3,1
Death                            51                            7,5

Undesirable effects
                          Number          %
None                         61          13
Transient                   384          82,4
Critica                      21          4.5

Change of the 1st ARV treatment

Failure virologi immune    23 cases
Secondary effects:         19 cases
Pregnancy:                 2 cases
Tuberculosis:              2 cases

                                                        Report Douala version of July 23, 05

Therapeutic lightening:     2 cases

Contests and challenges

-   To succeed the process of decentralization (
-   To generalize the programms of therapeutic education
-   To assure the treatments for all IO (Antifongiques!)
-   Biologic exam price
-   To assure the availability of the 2nd and 3rd line treatments: implémentation of
    TRIPS, ALE Morocco United States)

    12. TB Prevention, Diagnosis, and Treatment

What is TB?

-   It is a mycobacterial infection, most often of the lungs (pulmonary TB)
-   It can also be in other parts of the body (extra pulmonary TB)
-   It is curable
-   Nearly 2 million deaths a year
-   Close to nine million people develop infectious TB each year
-   One of the biggest infectious killers of women
-   More than one third (2 billion) of the world‟s population infected with TB
-   TB incidence rate growing at 1% per year globally
-   80% of existing cases in 22 countries
-   95% of people ill- developing world
-   98% of people dying- developing world

Types of TB infection

-   Primary- When active infection occurs immediately after exposure
-   Secondary- When a person has a latent TB infection that progresses to active
    infection due to immune suppression or due to any other factor that results in
    progression of TB.

The Impact of TB/HIV Co-Infection


-   TB is a leading cause of death amongst PLWH/A (15% globally)
-   People with HIV are 50 times at greater risk of getting active TB
-   In sub-Saharan Africa:
        o 30% of PLWH/A die within 12 months of starting TB treatment
        o 1/3rd of all TB patients do not get a full course of medicines
        o Africa carries highest TB rates in the world
        o Annual TB incidence in Africa is growing at just less than 5% per year vs
           1% globally
        o The AIDS crisis in Africa is causing TB rates to rise dramatically

TB Prevention

                                                         Report Douala version of July 23, 05

-   Preventing and reducing exposure through improving ventilation and UV radiation
-   Through the early detection and treatment of infectious pulmonary TB
-   BCG vaccination prevents severe TB in children.
-   Through Isoniazid Preventitive Therapy (IPT)
-   Through access to ART to prevent immune suppression to delay onset of TB

Detection Challenges for PLWH/A

Sputum smear microscopy

-   Generally TB detection ranges between 20-60%
-   In HIV + the bacillary count is lower than in HIV -.
-   PLWH/A are more likely to be SS negative and extra-pulmonary.

Chest X-rays

-   Not easily available.
-   In immune suppressed patients cavitation in the lung can be less, so harder to


-   Not easily available and takes a long time (6 wks in standard media, liquid media
    in 3 wks).
-   The mortality of PLWA is up to 30% in the first year of TB treatment, so time is a
    crucial factor.


-   In immune suppressed people the reaction to the germ might be low so can lead
    to missed diagnosis

Smear negative diagnostic algorithm

What can be done?

-   If unexplained weight loss, fever, cough more than 2-3 wks, reach out for TB
-    Revise the diagnostic algorithm to shorten time of diagnosis
-   Should try all the previous diagnostic methods, but with speed and sensitivity
-   Advocate on global level for increased resources for research on rapid

Treatment of PLWH/A with TB

-   TB can be treated
-   TB drugs have interaction with PI and NNRTI
-   Recommendations from WHO are:
    - CD4 < 200. Treat TB and HIV together. HIV regimen is efavirenz + 2NRTI
       (D4T/AZT + 3TC)

                                                       Report Douala version of July 23, 05

    -   CD4 200-350. Treat TB first, treat HIV with same regimen as above
        immediately if the person is symptomatic or after first two months of TB
    -   CD4 > 350. Treat TB first, Defer ART.
    -   CD4 not available. Start TB treatment and consider ART depending on
        symptoms of PLWH/A.


5 Key Elements

-   Govt commitment to sustained TB control
-   TB case detection through sputum smear (SS) microscopy among people with
-   Uninterrupted/regular supply of anti-TB drugs
-   6-8 months of regular supervised TB (including DOT for first 2 months)
-   Systems to report and monitor Tx and program progress

Challenge for DOTS

-   Globally, less than half (45%) of new, infectious TB cases are detected under
    DOTS (2003); case detection is lowest in Africa
-   250-400,000 MDR-TB cases/ yr
-   Long Tx regimens (6 -18 months)
-   Not designed to address TB/HIV co-infection context

What can be done?

-   Advocate for efavirenz and rifabutin
-   Community education emphasising early detection
-   More research and funding for better treatment options for TB and HIV
-   Include TB advocacy and education in your Collaborative Fund proposals

        JOHNSON AAHU JUNE 23, 2004

What is an opportunistic infection?

An opportunistic infection (also called an OI) is an infection or condition caused by an
organism that the body‟s immune system would normally be able to hold off

When HIV weakens the immune system, these organisms take the opportunity to
cause disease

What is an opportunistic infection continued…

There are 26 infections & malignancies (cancers) currently listed in the Centers
for Disease Control’s (CDC) AIDS case definition

                                                        Report Douala version of July 23, 05

    The causes of OIs can be divided into six categories


    -   are small germs which infect host cells and use them to spread (CMV, Herpes,


    -   are cancers (Invasive Cervical Cancer, Kaposi‟s Sarcoma (KS), AIDS-related
        Non-Hodgkin‟s Lymphoma)

    HIV Specific Complications

    -   are conditions caused by HIV infection itself       (HIV Encephalopathy, Wasting


    - are simple plants (e.g., mold, mildew,                &     mushrooms)        (Candidiasis,
      Cryptococcosis, PCP, Histoplasmosis)

    -   are tiny single cell organisms (Bacterial Pneumonia, MAC, Pulmonary


    -   are single cell animals that can be parasitic (Cryptosporidiosis, Toxoplasmosis)

    CDC AIDS-defining opportunistic infections

   Opportunistic Infection    Type of          Common sites of problems                Danger t-cell
                                bug                                                      level[1]
Candidiasis*[2]              fungus   mouth, vagina, throat, lungs                  any (mouth, vagina), 75
                                                                                    (throat, lungs)

Cervical cancer, invasive*   virus    Cervix                                        any

                                                                Report Douala version of July 23, 05

Coccidiodomycosis                  fungus      lungs, brain                                              50
Cryptococcosis*                    fungus      brain, central nervous system                             100
Cryptosporidiosis*                 protozoa Intestines                                                   100
Cytomegalovirus*                   virus       eyes (retina), brain, central nervous system              50
Encephalopathy, HIV-related* virus             Brain                                                     any
Herpes simplex*                    virus       genitals, lungs, bronchia, liver, esophagus               any
Histoplasmosis*                    fungus      central nervous system, brain, intestines, blood 100
Isosporiasis                       protozoa Intestines                                                   75
Kaposi‟s sarcoma*                  virus       skin, mouth, intestines, lungs                            any

    [1] The risk for all opportunistic infections increase as the number of T-cells go down; the numbers listed below
    provide a rough guide to the level below which the particular bug is most common or most serious.
    [2] Opportunistic infections listed with an asterisk (*) are discussed in the main text.

  Lymphoma,       Non-Hodgkin‟s          (Burkitt‟s, some     forms: brain, b-cell, t-cell, central any (b-cell, t-cell), 100
  immunoblastic or other)*                           virus;  others: nervous system                 (brain, central nervous
                                                     unknown                                        system)
  Mycobacterium avium complex* or M. Bacteria                        lungs, skin, gut, liver, blood 75
  kansasii, or other unidentified species
  Mycobacterium tuberculosis*                     Bacteria            lungs, blood, bone marrow     any

  Pneumocystis jiroveci pneumonia*                Protozoa            lungs                         200

  Pneumonia, recurrent*                           Bacteria            lungs                         any
  Progressive multifocal leukoencephalopathy* Virus                   brain                         50

  Salmonella septicemia, recurrent                Bacteria            intestines                    any

  Toxoplasmosis of brain*                         Protozoa            brain                         200
  Wasting syndrome due to HIV*                    Virus               systemic                      any

    General HIV-Related Preventive Healthcare (no matter what your CD4 cell count
    or viral load)

    -   Regular visits to your primary care provider
    -   Regular dental visits (a minimum of every six months)
    -   Yearly eye exam
    -   Hepatitis A and B vaccines
    -   Yearly influenza vaccine
    -   Pneumococcal vaccine (this vaccine should be repeated every five years)
    -   Baseline TST to check for TB infection
    -   Annual Rectal/ Anal Exam with Smear
    -   For women, a baseline Pap smear (which involves taking tissue from the walls of
        the vagina to look for early signs of cancer); it is recommended that HIV-positive
        women have two Pap smears done six months apart to determined the baseline
    -   Monthly self breast exam for women
    -   Monthly self testicular exam for men
    -   Wash your hands often in lukewarm water using an anti-bacterial soap


                                                                                   Report Douala version of July 23, 05

    -   Is caused by an overgrowth of yeast normally found in the body, most
        commonly candida albicans
    -   Can affect the mouth, vagina, throat, windpipe, or lungs
    -   Can occur in the mouth or vagina of HIV-positive people at any CD4 cell count
    -   Is an AIDS-defining infection when it occurs in the esophagus, trachea, or
    -   Usually only occurs in the esophagus, trachea, or lungs when the CD4 cell
        count is below 75

Signs & Symptoms

-        in the mouth or throat: include creamy white patches or red spots on the
    sides of the mouth, the roof of the mouth, the tongue, the gums, or the throat;
    difficulty swallowing, change in taste, nausea, vomiting, and chest pain may occur

-      in the vagina (commonly called a yeast infection): frequently include a thick
    white curd-like discharge, which may have a foul odor; the vagina may become
    red and irritated

-       in the esophagus: usually include pain and difficulty swallowing

-       on the skin: generally include a red, itchy, and moist rash

Oral and Esophageal Candida
Diagnosis & Treatment

-   Diagnosis can usually be made by your healthcare provider by looking into your
    mouth or at your vagina to see if you have an overgrowth of candida
-   An endoscopy or bronchoscopy may need to be done to confirm candidiasis of
    the esophagus, trachea, or lungs
-   Treatment can be either localized (applied directly to the affected area) or be
    systemic (medications taken to affect the entire body):
-   Localized: among the many options, Femstat® (butoconazole), Lotrimin® or
    Mycelex®      (clotrimazole), Monistat® (miconazole), nystatin, Terazol®
-   Systemic: Nizoral® (ketoconazole), Sporanox® (itraconazole), Diflucan®
    (fluconazole), amphotericin B
-   Prophylaxis
-   There is no primary prophylaxis for candida since it is a part of our normal flora
-   Limit sweets & sugars
-   Acidophilus pills or powders to replenish other normal flora
-   Wear cotton undergarments
-   The same medications used for treatment are used for secondary prophylaxis

Side Effects of Therapy

-   Nizoral (ketoconazole) can cause rash, nausea, or abdominal cramps
-   Sporanox (itraconazole) can cause nausea, vomiting, diarrhea, tiredness, and

                                                         Report Douala version of July 23, 05

-   Diflucan (fluconazole) can cause nausea, vomiting, diarrhea, liver problems, and
    allergic reactions (such as rash and fever)
-   Amphotericin B can cause headache, seizures, loss of appetite, weight loss,
    diarrhea, and liver and kidney problems
-   Most of the local treatments can irritate the area to which they are applied but
    rarely cause more serious problems

Herpes (Simplex and Zoster)
- Simplex is caused by one of two viruses (Herpes Simplex I and II), while Zoster is
   caused by the Varicella-Zoster Virus, the same virus that causes chicken pox
- Is very common in the U.S., occurring perhaps in as many as three in four people
- May cause problems at any CD4 cell count

Signs and Symptoms

Herpes Simplex I:
Cold sores or blisters around the mouth and nose that can last from a few days to a
few weeks; fever, tiredness, swollen glands, and muscle pain often precede an

Herpes Simplex II:
Painful sores, mostly on the genitals and anus

Herpes Zoster also called shingles:
Appear as fluid-filled blisters anywhere on the skin, most commonly the chest, back,
neck, head, and behind
All herpes infections cause more serious outbreaks in people who are have HIV,
especially those with lower CD4 counts
Herpes Simplex I, II and Zoster

Diagnosis and Treatment

-       Simplex I/II is usually made by laboratory culture or zank smear (which
    involves looking for herpes cells with a microscope)
-       Zoster is generally made by having a doctor look at the lesions, although there
    is a test (called the direct fluorescent antigen test) and biopsies are also
    sometimes done
-       the same medications work against both Simplex and Zoster
-       Zovirax® (acyclovir) (taken orally or intravenously, or used as an ointment),
    Valtrex® (valacyclovir), and Famvir® (famciclovir) are all used
-       patients who don‟t respond to these treatments are given Foscavir (foscarnet)
-       Prophylaxis
-       Herpes Simplex I is found in very high percentage of populations and is
    spread through kissing, so it is very hard to prevent transmission
-       Herpes Simplex II is a sexually transmitted disease, so condoms help prevent
    transmission (however, because the sores can spread beyond the genitals,
    condoms may not cover the affected areas)
-       although avoiding contact during outbreaks helps prevent the transmission of
    both types I and II, both can be transmitted even without the presence of sores

                                                        Report Douala version of July 23, 05

-      The virus which causes Zoster is airborne, so there is no effective way to
    prevent transmission (avoiding people with active chicken pox helps)

-      Any of the drugs used to treat herpes may also be used as secondary
    prophylaxis (for people who have already had it)

Side Effects of Therapy

-      IV Zovirax (acyclovir) can cause localized inflammation of the veins
-      Valtrex (valacyclovir) and Famvir (famciclovir) both can cause headache
    and nausea

Bacterial Pneumonia

PCP (pneumocystis jiroveci pneumonia)

-       Most common opportunistic infection in people with AIDS who do not take
    preventive medication
-       Caused by a fungus
-       Causes infection mostly in the lungs, but can also cause disease in other parts
    of the body
-       Can be mild, moderate or severe
-       Occurs in HIV-positive people with CD4 cell counts under 200

Signs & Symptoms of PCP

-   fever
-   dry cough
-   tiredness
-   increasing shortness of breath
-   weight loss
-   night sweats

Symptoms increase over time rather than occurring suddenly

Treatment for PCP and Side Effects

-   Pentamidine (injection or IV) can cause pain at the injection site, nausea, loss of
    appetite, low blood pressure and blood sugar, fever, rash, and a metallic taste in
    the mouth
-   Aerosolized pentamidine can cause tiredness, a metallic taste in the mouth,
    dizziness, shortness of breath, loss of appetite, chills, nausea, vomiting, and night

Treatment for PCP and Side Effects

-   TMP/SMX, Bactrim®, Septra® IV or oral       (all are different names for the same
-    pentamidine IV or IM (intramuscular
-   trimethoprim and dapsone

                                                         Report Douala version of July 23, 05

-   Bactrim can cause allergic reactions (such as rash and fever), nausea, vomiting,
    loss of appetite, hepatitis, and headache

-   Dapsone can cause fever, jaundice, tiredness, rash, and allergic reactions
-   Mepron can cause diarrhea, rash, nausea, and headache

PCP Prophylaxis

-      Recommended for HIV-positive people who have a CD4 cell count of 200 or
    less or who are experiencing HIV-related fevers and thrush with a borderline CD4
    count and rising viral load
-      Bactrim is the first choice if tolerated
-      Dapsone or Mepron® (atovaquone) are used for people who cannot take
-      Pentamidine, given aerosolized or by IV, is sometimes used for prophylaxis
-      Studies have shown that PCP prophylaxis can be safely stopped when the
    CD4 count rises above 250 and is sustained for six months


-   is caused by a protozoa called cryptosporidium
-   is very contagious and most commonly transmitted through oral-fecal route; can
    also be present in drinking water
-   is often prolonged and causes severe diarrheal illness in HIV-positive people who
    have CD4 cell counts below 100

Signs & Symptoms

-   constant watery diarrhea
-   crampy abdominal pain
-   tiredness
-   nausea
-   vomiting
-   loss of appetite
-   weight loss
-   fever


-   TB co-infection 14 million, (10 million in Africa)
-   TB infection 2 Billion
-   VIH infection 42 million

In other words……..
HIV fuels TB in three ways

    -   Promotes progression to active TB disease
    -   Reactivates latent TB infection
    -   Increases rate of TB recurrence

                                                         Report Douala version of July 23, 05

 " TB is too often a death sentence for people with AIDS. It does not have to be
this way"

Nelson Mandela
15th International HIV/AIDS Conference, Bangkok,
Thailand July 15, 2004


-     Up to 50% of PLWHA develop TB
-     Cause of death of up to 50% of PLWHA (global average= 15%)
-     World wide 14 million PLWHA are co-infected with TB .

TB/HIV affects women with grave implications to their children

It mostly affects the poor…      and it incur dual stigma…

HOWEVER, TB is NOT in the agenda of the HIV community including in HIV and
AIDS advocacy of PLWHA. AND HIV is not yet FULLY in the agenda of the TB

What should be done

-   Implementation of Collaborative TB/HIV Activities by countries.
-   English, French, Russian and Spanish of policy available online

Collaborative TB/HIV activities
A. Establish the mechanism for collaboration

      A.1. TB/HIV coordinating bodies
      A.2. HIV surveillance among TB patient
      A.3. TB/HIV planning

                                                       Report Douala version of July 23, 05

       A.4. TB/HIV monitoring and evaluation

B. To decrease the burden of TB in PLWHA

       B.1. Intensified TB case finding
       B.2. Isoniazid preventive therapy
       B.3. TB infection control in health care and congregate settings

C. To decrease the burden of HIV in TB patients
      C.1. HIV testing and counselling
      C.2. HIV preventive methods
      C.3. Cotrimoxazole preventive therapy
      C.4. HIV/AIDS care and support
      C.5. Antiretroviral therapy to TB patients.

What African countries should do?

-   Should implement all 12 activities
-    Have national TB/HIV policy and national implementation plan through
    establishing national TB/HIV coordinating body that include communities
-   Should integrate TB and HIV services at the health facility level.

What community groups can do?
Community advocacy strategies

National level

-   Establishment of National TB/HIV CB
-   Inclusion of communities in the CB
-   National policy and implementation plan

Grass root (e.g. health institution)

-   Advocacy for HIV testing for TB patients
-   TB screening and treatment for PLWHA
-   ARV for PLWHA with TB

"One-stop shop"

Uganda –Actions

-   Networking among community groups
-   Stakeholders meeting
-   Well heard community voices
-   Bring together the HIV and TB managers
-   Met minister of health and national AIDS commissioner
-   Call for National TB/HIV coordinating body
-   Call for national policy and implementation plan

Uganda –Results

                                                        Report Douala version of July 23, 05

-   National TB/HIV Coordinating body established
-   Community groups well represented in the body and "stir-up" the process
-    Draft national HIV policy and implementation plan developed
-   Kenya-Actions and results
-   National stakeholders meeting
-   "TB/HIV Day" with media coverage
-   National TB/HIV body revitalised with communities
-   National guidelines developed
-   Sensitization of health workers
-   TB and HIV/AIDS services integrated in Eldoret hospital as "one-stop shop".


-   Community groups have indispensable role in TB/HIV advocacy
-   Priority areas:
    - National TB/HIV coordinating body with community members
    - National policy and implementation plans with resource allocation
    - Integration of TB and HIV services at health facility level



Communities are “systems composed of individual members and sectors that have a
variety of distinct characteristics and interrelationships. They can be defined by the
characteristics of its people; geographic boundaries; shared values, interests, or
history; or power dynamics.

Elements of community
Elements of community include:

    -   a sense of membership;
    -   common symbol systems;
    -   common values;
    -   reciprocal influence;
    -   common needs and a commitment to meeting them; and
    -   a shared history

Community Involvement & Participation

    -   Community participation can be defined as involvement in decision-making
        processes and implementation, as well as sharing the benefits of the program.
    -    Participation occurs along a continuum, from active involvement in all stages
        of the intervention, or "community development /organizing," to token or
        consultative involvement, or "community-based."

Models of community involvement

                                                       Report Douala version of July 23, 05

    -   The service consortium model focuses on involvement of local providers &
        professionals, with impact measured by access to services and quality,
        coordination, and utilization of services.
    -   The community empowerment model focuses on participation of
        nonprofessional community members in       the planning process via
        neighborhood-based groups, service-provision contracts with community-
        based organizations, employment of community members, and economic
        development initiatives.

Characteristics of Community Competence

    -   Ability to collaborate effectively in identifying the problems and needs of the
    -   Able to achieve a working consensus on            goals and priorities;
    -   Ability to agree on ways and means to implement the agreed-upon goals; and
    -   Able to collaborate effectively in the required actions."

Community Action

Community action is characterized by "a collective rather than an individual approach
to health, a social rather than a medical model of health and illness, a preventive
rather than curative orientation to health problems, and the participation of
community members in health care decisions."

Principles of community mobilization

-   Establish consistent visibility and ongoing relationships with opinion leaders.
-   Build consensus around a realistic and manageable agenda that recognizes the
    role of compromise in the community processes.
-   Involve new voices and leaders from other sectors. Note the importance of
    expanding support base for PLHAs and their families

Factors that Influence community Mobilization

-   Feelings of community
-   Awareness of issues and belief that issues need to be addressed
-   Positive expectations
-   Feelings of affiliation and belonging
-   Resource availability

Barriers to community mobilization

-   Perceived sensitive issues
-   Feelings of inadequacy
-   Social fear / shyness
-   Fear of conflict, repercussions
-   Inter-personal / Inter-group conflict
-   Members' lack of commitment
-   Too tight deadlines.

                                                        Report Douala version of July 23, 05

Recommendations for policy and practice

-   Building upon existing community resources is critical for meaningful mobilization
-   Successful mobilization requires multiple partnerships that facilitate skill and
    knowledge transfers and acquisition leading to credibility and visibility
-   Leadership skills, hired personnel, and commitment are essential to community


Methods for successfully mobilizing communities around HIV/AIDS responses are in
early development, requiring action- research to test and evaluate capacities.


-   Number of countries
-   Number of people by country
-   Cost by project or by country?
-   Representativity in the CRP (kind, languages…
-   Criterias of selection of the members of the crp
-   Role of the CRP (recall)



    -   Volontariat
    -   Availability
    -   Experience
    -   Accountability
    -   Transparency
    -   To have a community experience
    -   Knowledge of the sub region
    -   Activist
    -   To know to plan, to go up, to follow and to value the projects


    -   The members of the CRP have right to financing, but don't have to comment
        during the study of the project

    -   To be PLWHA

   - Attestation of the availability of the organization


    -   Honesty

                                                           Report Douala version of July 23, 05


-   Colette KOALA (Burkina)
-   Mohammed Farouk (Nigeria)
-   Kata OLUWOLE (Nigeria)
-   Jean Roger KUATE (Liberia)
-   Brandfong YEBOAH (Ghana)
-   Second NSABIMANA (Burundi)
-   Bertrand KAMPOER (Cameroon)
-   Amani HIIMANA (Rwanda)
-   Lucy ZAMBOU (Cameroon)
-   Ambroise Mamona (Congo Brazza)


    1-  Periods/durations of the mandate of the CRP
    2-  Plan of action
    3-  Criterias for the coordinator's selection (2 weeks July 30)
    4-  job a nnouncement (1 month August 14)
    5-  Canvas of the projects communautaire/Guideline of the community project
        September 15
    6- To throw the call to project (September 15)
    7- To select the projects (bilingual November 15)
    8- Report final shop of Douala (2 weeks)
    9- Networking (Internet)
    10- Bringing up financing by project
    11- Post card of the association
    12- Distribution of funds
    13- Survey (analysis of the projects)

The conference of Douala ended by a Galla organized by the hotel.

                                                     Report Douala version of July 23, 05

12.        ANNEXE

JOUR 1: 11 JUILLET 2005

 Heure                        Sessions                                                          Présentateur/Facilitateur
                              Président de séance :                                             Ministre de la Santé Publique
                              Vice – président :                                                Présidente du ReCAP+
                              Rapporteurs :                                                     Nigeria, Congo, Cameroun
 8.00 – 9.00                  Enregistrement
 9.00 – 9.10                  Bienvenue                                                         Laure Djueche
 9.10 – 9.25                  Introductions                                                     Cyriaque Ako
 9.25 – 9.40                  Attentes et objectifs                                             Bertrand Kampoer
 9.40 – 9.50                  Discours d‟ouverture                                              Ministère de la santé
 9.50 – 10.00                 Discours de bienvenue                                             ReCAP+
 10.00 – 10.15                            Pause café
 10.15 –11.15                 Présentation des participants:Chaque personne se                  Ambroise Mamona
                              présente et répond aux questions suivantes: D‟où venez
                              vous ? Où travaillez vous ou que faites vous Pourquoi             Brandford Yeboah
                              êtes vous venue au sommet? Qu‟espérez vous bénéficier
                              du sommet?

 11.15 – 11.30                Détente
 11.30 – 12.15                Historique de PATAM                                               Laure Djueche
                              Historique du fond de collaboration/Tides                         Moises Agosto
                              Historique du plaidoyer de TB/TAG                                 Javid, TAG
 12.15 – 13.15                Rapport des pays sur la situation en matière d‟accès aux          Délégués pays
 13.15 –   14.15              Déjeuner
 14.15 –   14.45              Qu‟est ce que le plaidoyer?                                       Othman
 14.45 –   15.15              Lier le traitement et le plaidoyer.                               TAC
 15.15 –   16.00              Plaidoyer Ouest Africain:Qu‟avons nous? De quoi avons             „Rolake
                              nous besoin ?
 16.00 – 16.15                                            PAUSE
 16.15 – 17.30                Travaux en groupes:                                               Mamadou
                              Développer les priorités du plaidoyer                             Thérèse

 17.30 – 17.45.               Evaluation                                                        NeCAP+, FISS-MST/SIDA Laure Djueche
 17.45 – 18.00                Cloture
 18.00 – 18.30                Reunion du Planning Committee                                     Laure Djueche

* Satellite sessions continue après le dîner

JOUR 2: 12 JUILLET 2005

 Heure                        SESSION                                                  FACILITATEUR
                              Président de séance :                                    Nigeria
                              Vice – président :                                       Maroc
                              Rapporteurs :                                            Sénégal, DRC, Cameroun
 8.00 – 9.15                  Récapitulatif jour 1                                     Rapporteurs
 9.15 - 10.00                 Accès aux traitements                                    MSF Nigeria,
                                                                                       MSF Cameroun
 10.00 – 10.15                Pause café
 10.15 – 11.15                Rapport des pays sur la situation en matière             Délégués pays
                              d‟accès aux traitements
 11.15 – 12.15                L‟éducation sur les traitements et les initiatives sur   Rolake
                              le plaidoyer.
 12.15 – 13.15                Adhérence aux traitements du VIH                         Amani Hitimana

 13.15 – 14.15                Déjeuner
 14.15 – 15.00                Recherches sur le VIH,                                   Javid, TAG

 15.00 – 15.15                Pause
 15.15 –16.00                 Travaux de groupes:Les stratégies et les cibles du       Laure Djueche
                              plan d‟action.
 16.00 – 16.15                Pause
 16.15 –17.00                 Travaux de groupes:Les stratégies et les cibles du       Laure Djueche
                              plan d‟action (suite)
 17.00 – 17.30                Evaluation et cloture                                    FISS-MST/SIDA,
 17.30 – 18.00                Reunion du Planning Committee                            Laure Djueche

                                                                                       Report Douala version of July 23, 05

     *Sessions satellites après le dîner

     JOUR 3: 13JUILLET 2005

Heure                    Sessions                                                                   Présentateur/Facilitateur/modérateur

                         Président de séance :                                                      Koala Colette
                         Vice – président :                                                         Othman Mellouk
                         Rapporteurs :                                                              Tunisie, Cameroun
9.00-9.30                Rapport du jour 2.                                                         Rapporteurs

9:30 – 10:45             TB et d‟autres IO:aborder la prévention, les diagnostiques et les          Javid
                         Panel sur les infections opportunistes communes chez les PVVIH

10.45 – 11.15            Traitements de TB/VIH, mobilisation communautaire,                         Javid, Heylesus,
                                                                                                    Amani Hitimana
11.15 – 12.00            L‟éducation sur les traitements et les initiatives sur le plaidoyer.       Rolake
12.00- 13.30             Rapport des pays sur la situation en matière d‟accès aux traitements       Délégués pays
13.30 – 16.45            Déjeuner et réunions satellites
15.30 – 18.00            Reunion du Planning Committee                                              Laure Djueche

               Sessions satellite continuent après le dîner

     JOUR 4: 14 JUILLET 2005

Heure                         Sessions                                                         Présentateur/Facilitateur/modérateur

                              Président de séance :                                            Moises Agosto
                              Vice – président :                                               Laure DJUECHE
                              Rapporteurs :                                                    Bertrand, RCA, Cameroun
8..00 - 8.30                  Rapport jour 3.                                                  Rapporteurs
8.30 – 9.30                   Rédaction de projet de financement: comment planifier et         Moises Agosto, Tides Foundation
                              rédiger un bon projet de financement (besoins de
                              documentation, proposer un projet qui soit faisable et qui
                              aborde les besoins réels, développer des mesures
                              d‟évaluation pour savoir si nous avons réussies ou si nous
                              devons apprendre de nos erreurs
9.30 – 10.00                  Procédures du panel de revue communautaire                       Cyriaque Ako
10.00 – 10.15                           Pause

10.15 – 10.45                 Développement des termes de référence du CRP                     Laure Djueche
10.45 – 12.15                 Election des membres du PRC                                      Moises Agosto
12.15 – 13.15                           Dejeuner
13.15 –14.00                  Prochaines étapes.                                               Laure Djueche
14.00 – 14.15                  Evaluation de l‟atelier                                         Bertrand

14.15 – 14.30                Cloture                                                           Lucie Zambou
18.00                        Soirée dansante                                                   ReCAP+, FISS-MST/SIDA
    * Sessions satellites continues après le dîner

                                                                                           Report Douala version of July 23, 05


   Nom et Prenoms            Réseau / Association         Adresse                   Tél                            Email
                                                           CENTRAL AFRICA
DJUECHE       Sylvanie   Coordonnateur PATAM         BP         16.629 +237 775.69.93      
Laure                    Afrique Central             Yaoundé
Bertrand Kampoer         FISS-MST/SIDA                                  +237 972.51.08     
Therese Omari            Femmes Plus                                    +243 991.32.57     
Ambroise Mamona          RNP+ Congo                                     +242 521-30-36     
                                                              WEST AFRICA
Cyriaque AKO             RIP+                        03    BP     1916 +225    
                         Côte d‟Ivoire               Abidjan            +225
Rolake NWAGWU            PATA Nigeria                20 B Brown Road +234 803.303.5895     
                                                     Aguda, Lagos
Yeboah Brandfort         Ghana                       AN 12471 Accra     +233 277.40.464    
                                                                        +233 212.48.565
Mamadou Sawadogo         REGIPIV Burkina Faso        09 BP 860 Ouaga    +226 503.696.98    
                                                                        +226 702.303.01
                                                             NORTH AFRICA
Othman MELLOUK           ALS Maroc                                      +212 22 99 42 42 / + 212
                                                                        22 99 42 43
Lobna El Tabei                                                                             
                                                              South Africa
NJOGU Morgan             TAC


     Noms et             Pays            Organisations              Tel                Fax                       Email
 Koala Colette     Burkina Faso      Espoir et Vie          +22676617866                 
 Seconde           Burundi           RBP+ Burundi           257-248.493          257.248.494
 Nsabimana                                                  C.832.388 977.314            
 Lucie Zambou      Cameroun          ReCAP+                 +237 955.35.93       +237222.30.38

 Bertrand          Cameroun          FISS-MST/SIDA          Tel 972.51.08                
 Ambroise          Congo Brazza      RNP+                   +242 521-30-36               
 Amani Hitimana    RWANDA            Forum des ONG sur le   +250 08449109        +250 574270
 Brandford         Ghana             Goodwill               +233 0277740464      +233 021244539
 Yeboah                                                     021248565
 Jean Roger        Liberia           UNMIL                                               
 Mohammed          NIGERIA           AIDS ALLIANCE IN       +234 803.304.69.72           
 Farouk Auwalu                       NIGERIA
 Kate OLUWOLE      Nigeria           PATA                   +234 802.318.38.96           

                                                                                     Report Douala version of July 23, 05