Executive summary of starting point analysis research in Burkina Faso

This report presents the summary of the findings and the recommendations resulting from the starting point analysis research carried out in Burkina Faso in June 2005. Work included a desk review, 10 focus groups, and 26 key informant interviews. Locations included: Ouagadougou, Bobo-Dioulasso, Koudougou, and Yako.

Please download:

• Full EPN HIV starting point analysis research in Burkina Faso [.doc 504KB] [.pdf 290KB]
• Summary EPN HIV starting point analysis research in Burkina Faso [.doc 64KB] [.pdf 52KB]
• (French) Summary EPN HIV starting point analysis research in Burkina Faso [.doc 72KB] [.pdf 55KB]

In Moré, one of the languages of Burkina Faso,
the word 'sida' means husband and truth,
and now also means HIV/AIDS (AIDS = SIDA in French).

“Limited knowledge and negative attitudes towards ARVs on the part of health workers and patients were the main limiting factors to ART uptake… Community education is also essential to ensure adherence, dispel unrealistic expectations, and avoid increasing risk behaviour.”
–Attawell K, Mundy J (2003) Provision of ART in resource-limited settings: a review of experiences up to August 2003. DFID/Health Systems Resource Centre. 

Consultants for EPN:

• Heather Budge-Reid (Kirkwood Communications) heatherbr@kclinfo.com
• Pastor Mathias Sawadogo (Translator/Interpreter) mathiassawadogo@yahoo.fr

HIV/AIDS and Burkina Faso: The numbers challenge

There is widespread debate over the figures for adult HIV prevalence in Burkina Faso, with some figures (and some choices of figures within ranges) indicating a dramatic reduction in seroprevalence rate over time.

• In 1997/98, levels of adult HIV prevalence in Burkina Faso were estimated at a rate of just over 7%.
• UNAIDS (2004) gives a 2003 estimation for adults aged 15 to 49 of 4.2% (270,000 individuals) with a range from 2.7% (170,000 individuals) to 6.5% (420,000 individuals).
• A survey carried out in 2003 and published in 2004 found an adult HIV prevalence rate of 1.8% (female 1.8%: male 1.9%; urban 3.6%: rural 1.3%) through a national household survey and HIV testing by consent. (Enquête Démographique et de Santé / Demographic and Health Survey – Institut National de la Statistique et de la Démographie; Ministère de l’Économie et du Développement, part of the MEASURE DHS+ programme).
• The Strategic Paper for 2006 to 2010 from the Conseil National de Lutte contre le SIDA (CNLS – National Committee Against HIV/AIDS) is not yet available.

There are three possibilities for the wide range of estimates:

1. It is possible that levels of prevalence have fallen dramatically. If they have, then the country is an extremely successful example of work against HIV/AIDS and more investigation is required to illuminate just how such a dramatic fall has been achieved, especially over such a short time.
2. It is possible that the prevalence rates were not as high as previously estimated, and that methods of measurement have become more accurate over time.
3. It is possible that those who work closest to the issue, the majority of whom informally and confidentially estimated a figure much closer to 10% prevalence, are correct and that this contributes to the confusion between official and unofficial estimates.

During interviews, it was reported that there is much discussion in the sector about why the government uses such low figures; some indicated that they think that the highest figures are used in relation to need and the lowest figures are used in relation to impact. Others refrain from comment.

Regardless of the actual figure for HIV prevalence, the numbers of people currently receiving ARVs are recorded to be 5,510 adults and 168 children (Comité Ministériel de Lutte contre le SIDA (CMLS) / Ministerial Committee against HIV/AIDS, June 2005). This figure is still very far from the estimated treatment needs. In 2003, WHO/UNAIDS estimated the total treatment need in 2005 to be 43,000 people, and the WHO “3x5” treatment target was calculated to be 21,500 people by the end of 2005, based on 50% of estimated need. Burkina Faso has set ART targets of 20,000 people by the end of 2005, 30,000 by the end of 2006, and 40,000 by the end of 2007 (WHO/3x5, Country Profile Burkina Faso, June 2005).

A predominance of late VCT and the self-diagnosis aspect of going for VCT means that, although VCT results can indicate a definite number of people who will need ARVs at some point, it cannot illuminate potential need. However, any campaign that encourages people to go for VCT (as early as possible) would contribute significant information to the debate on the level of ARV needs. Early VCT would also, of course, give the more well known benefits of people knowing their status, such as increased responsible behaviour, increasing positive and healthy living, and (with the advent of ARVs) timely access to treatment. It should be noted that the hope of ARVs can itself (alongside an appropriate community literacy campaign) encourage increased and earlier take up of VCT.

The danger of low estimates of seroprevalence is that not enough attention and focus is paid to the issue of HIV/AIDS in general and to the treatment of HIV/AIDS. This appears to be the case in many aspects of HIV/AIDS church work across the denominations. Apart from a few dramatic and dynamic examples, the churches maintain their prevention work based on early training messages without the new and important messages associated with ARVs.

The government and ARVs: The sustainable access challenge

The government has announced that people must make a monthly contribution of 5,000 FCFA (US$ 10) per month for a first-line ARV triple therapy. This price is out of reach of the majority of the Burkinabè population, especially if there are multiple needs in a single family. (The most recent data available from the WHO World Health Statistics 2005, covering the period from 1990 to 2002, are that 44.9% of the population live below the poverty line of less than US$ 1 per day.)

For adults requiring ARVs, there are no financial means testing mechanisms in place that would allow the poor to access these life-lengthening drugs. In contrast, ARVs for children are currently provided free of charge (where available), as is a standard two-dose PMTCT with Nevirapine (where available).

For the lucky few, ARVs are available for free, through a type of sponsorship mechanism where an organization pays the 5,000 FCFA per month on their behalf. MSF, for example, provides ARVs to 1,000 people (a list that is now full). There are a very small number of other ‘sponsorship’ opportunities. Some schemes only guarantee a limited period of free support – which raises the possibility of problems with non-adherence, virus mutation, and drug resistance.

The argument that the government puts forward is that, as it believes that free ARVs from donors cannot last forever, it needs to build a sustainable health care system. However, alongside arguments for free ARVs (see below), the local network RAME¹ and the US-SIDA campaign² point out that the 5,000 FCFA contribution bears no relation to the actual cost of the ARVs (which is much higher), and will not be sufficient to assure a sustainable ARV supply in the future. They also claim that there is no transparent scheme in place yet for where the money is being collected, or how it is being used. 

The WHO/UNAIDS report, Progress on Global Access to HIV Antiretroviral Therapy: An update on “3 by 5” (June 2005), says, without caveat, that treatment should be provided free at the point where it is given. It appears that some donors to the Burkinabè Government have accepted both the argument that charging fees creates a sustainable system and that the current level of charges is acceptable. 

There are four faith-based national committees for addressing HIV/AIDS issues in Burkina Faso (representing Muslim, Catholic, Evangelical, and traditional beliefs). Apart from the Muslim committee, none of them have put their full weight behind the free access to antiretroviral therapy campaign, citing a variety of problems, such as the name of the campaign, the fact that churches do not protest, and that it is not the churches’ role. For example, the Catholic Church has two hospitals (out of the three CHS hospitals in Ouagadougou) that actually provide ARVs, and yet they are not part of this campaign. There are a small number of examples of faith-based organizations that do support the campaigns, but the full weight of the denominations is not apparent.

The church health services: The impact challenge

The church health sector is extremely small in Burkina Faso. The annual statistics of the Direction des Etudes et de la Planification / Central Government Office for Studies and Planning (2004) only record 44 registered church-related health structures in Burkina Faso in 2003 (only an estimated 2.3% of all healthcare structures were run by faith-based organizations). The majority of these are thought to be small health posts. During the study period, only two structures were found that provide ARVs: CMA-St. Camille (Centre Médical avec Antenne chirurgicale / health centre with surgical department) and the Centre d’Accueil de Notre Dame de Fatima (CANDAF), both in Ouagadougou. The other hospital-level church structure in Burkina Faso did not provide ARVs. There is a need to develop a cross-denominational overview of the Burkina Faso church health service provision and its role in the supply of health care in Burkina Faso. 

While it is recommended that there be an effort to maximize the engagement of CHSs in ARV provision, this really only refers to one hospital with the potential to offer these services. The church-related health posts and clinics that exist could consider offering VCT provision and PMTCT provision where facilities allow, but overall the potential level of ARV delivery through CHS institutions in Burkina Faso is low.

The answer to the problem of both physical and affordable access to ARVs does not lie with the current CHS institutions. While various plans are being discussed to increase the number of, for example, CHS health posts, this alone will not solve the access problem either.

The church in Burkina Faso: The impact challenge

Given the very low potential impact that the church can have through its CHS provision, the church needs to look at the other types of impact it can have. It is noted that the current estimate for the Christian population of Burkina is between 10% and 20%³, but it is likely that the church can reach a much larger number of people through its work. While there is no doubt that all churches are, to some extent, involved in the dissemination of prevention messages, in the main these messages are out-of-date and not well adapted to local circumstances, and do not include the issues of ARVs or PMTCT. The church has not yet fully taken up its role in community literacy on ARV issues, nor, it seems, the necessity of addressing the potential impacts of ARVs in its work with congregations.

Apart from two notable exceptions encountered during the study, Vigilance in Ouagadougou and ACCEDES⁴ in Bobo-Dioulasso, there is little church work in the area of support groups for PLWHA, advocacy work on related issues, or the prioritization of ARV and prevention messages. It is really only through the auspices of the church structure itself that the Christian faith can have an impact on the issues of HIV/AIDS and its treatment. This means that the churches have to look much more carefully at their activities, their content, and the potential impact of their work.

Some elements of the church do have an important media-based capacity to reach out to audiences with messages. However, it is also clear that, for example, the TV CVK Canal Vim Koeega / Radio Lumière Vie et Développement broadcast organization requires more training and access to information and materials if it is to support the work of the church in this area.

Stigma: The denial challenge

Throughout the research work, people in senior positions indicated that stigmatization of PLWHA was not a problem anymore in Burkina Faso. At the same time, discussions with PLWHA and those closest to the issue indicate that social stigma (rather than institutional stigma) is still very strong, with the church in general not handling stigma issues very well, e.g., a lack of confidentiality.

A number of comments were made that indicated people used to believe that it was possible to catch HIV simply through touching or proximity. It may now be more widely understood (although not perfectly understood) that ‘normal’ contact is not a danger, but there is still a great deal of stigma against people with HIV, particularly those trying to prevent mother-to-child transmission and those taking ARVs. Why there is such a strong de-prioritization of the issue among some senior actors is unclear. However, there is a clear role for the church to play in addressing stigma.

A mistaken understanding of ARVs

The study indicates that there are areas around which the church needs a better and more up-to-date understanding.

• ARVs and their role in prevention
• The benefits of ‘knowing your status’ in the light of PMTCT and ARVs
• The availability and need for special ARV formulations for children
• An understanding of the gender implications of HIV/AIDS and treatment issues
• The existence of stigma and the role of the church in combating it and the impact of stigma on taking ARVs
• The confusion relating to ‘cures’
• The implications of indeterminate test results
• ARV messages in general
• Non-medical ARV treatment literacy and the role of the church
• The link between immorality and HIV as the primary cause of infection.
• The lack of recognition as potential PLWHA of those who are faithful to partners, those who are abused, those who are raped, children, etc.

Challenges for the church

Ten challenges for the church have been identified through this study.

1. There is a general (erroneous) feeling that ARV issues are medical issues only and that, as such, they do not fall within the domain of the church.
2. There is a lack of understanding as to why community literacy around ARV issues is important. It has been largely accepted that doctors inform patients on ARVs and that this is enough.
3. Community leadership for VCT is lacking, with existing messages focusing on behaviour issues and out-dated materials. The encouragement that the availability of ARVs can bring to knowing your status through VCT is lacking, as is the link between ARVs and responsible behaviour.
4. While traditional prevention messages dominate, along with some anti-stigma messages based around how HIV can be caught, the majority of churches do not make anti-stigma a leadership issue nor, it seems, train church leaders in addressing this issue.
5. With notable exceptions, the churches do not focus on the development of PLWHA support groups, which can have a number of roles, including personal witness; income generation; advocacy for access to ARVs for members; community literacy; encouraging adherence; etc.
6. There is a need for both pastoral and support group activities with hospitals. There are a few examples from associations that show how incredibly important support groups for PLWHA are to the work of understaffed and overwhelmed HIV/AIDS/ARV units in hospitals.
7. While the number of CHSs is low, there is a much larger number of faith-based schools in Burkina Faso, which are to some degree run by various churches. The church needs to look at the enormous opportunity that young people represent in the fight against HIV/AIDS, and should look at mirroring invigorated church-based activities in these schools.
8. None of the Christian-related national HIV/AIDS committees appear to make a sufficient impact at the national level. These coordinating functions are an important part of the response to HIV/AIDS and the new treatment opportunities, and the attendant information and leadership requirements.
9. National advocacy on the part of the combined church voice could have a significant impact on the current situation. Whatever the message the churches decide to advocate around (from the need for higher standards of testing, to access to free ARVs), the churches, with their strong media connections, congregations, and community work, can have a powerful and successful impact.
10. On an international level, there are some advocacy issues where the church could play an important role – for example, the provision of ARVs for children, and reducing the cost of reagents for VCT and CD4 counts.

It should be noted that the church in Burkina Faso is not alone in facing these challenges. Much can be learnt from existing and heartening examples from within Burkina Faso (from associations and church organizations) and also from church activities in other countries.