Francoise Ndayishimiye, right, HIV-positive herself and a focal point for civil society at the CNLS, picks up drugs for her patients.
Photo by MERCEDES SAYAGUES
BUJUMBURA (AlertNet) - A decade of civil war in Burundi has boosted HIV infection rates, but local initiatives are helping thousands carry on with life in the shadow of the disease.
The conflict has forced hundreds of thousands from their homes, spreading the disease across the country and putting young people at risk in squalid refugee camps where sexual violence is endemic.
"Burundi was making solid progress on AIDS but it crumbled with the war and the crisis, " said Thomas Munyuzangabo, HIV/AIDS officer in Bujumbura for the U.N. Children's Fund, UNICEF.
Since 2000, a partial peace process has brought some hope. Power is now shared between former rivals, even as the government continues to battle a hold-out rebel group that has shunned negotiations.
Before Burundi's civil war erupted in 1993, HIV was mostly confined to towns, where infection rates stood at 11 percent. In the countryside, where 90 percent of the population lives, less than one per cent of people were infected.
Ten years later, HIV rates have stabilised in towns but have more than doubled in rural areas.
"It's alarming because rural people have the least access to information, health and social services," said Gaston Legrain, country coordinator for the U.N. AIDS body, UNAIDS.
"By destabilising and impoverishing rural people, until then the least affected by the epidemic, the war that exploded in 1993 has likely played a key role in the epidemic's expansion," said a recent study by the National Council for the Fight against AIDS in Burundi (CNLS).
This is the second national HIV survey, the first one dating from 1989. NGOs and U.N. agencies pulled out of Burundi or reduced staff in 1993.
Even today, since the start of the peace process in 2000, aid workers operate under strict rules because of continued attacks and banditry. For security reasons, travel in the provinces tends to be between 9 a.m. and 3 p.m. with armed military escort
MODEL SCHEMES
Burundi is one of the world's poorest countries, where GDP is $103 per person and life expectancy is around 40, according to the U.N. Development Programme’s Human Development Report 2003.
And yet two model schemes for community-based prevention and support of HIV-positive people have been in operation since the early 1990s -- the Society of Women Against AIDS (SWAA) and the National Association of Support for People with HIV and AIDS (ANSS).
SWAA provides medical, economic and psychological support to 2,500 HIV-positive people in Bujumbura and another 2,000 in six provinces.
"Most of our members are war-affected women with infections dating from the first years of the conflict through displacement, poverty and rape," said Isabelle-Lise Barema, Bujumbura SWAA coordinator.
Prudence Nayisabo is HIV-positive, freshly widowed with three children, and a SWAA member.
She has been twice displaced, once in 1993, fleeing attacks in her village near the border with Rwanda, then again in the capital fleeing local militiamen.
Her family died during the war. Her in-laws shun her and the children because she was not legally married and the landlord wants her evicted.
"I don’t know what to do," she said softly.
SWAA helps her with drugs for tuberculosis, school fees for the children, legal advice and emotional support.
SPREAD BY WAR
Experts say that war sometimes contains the AIDS epidemic by restricting movement and isolating regions. This happened in Angola and Mozambique.
In other countries like Burundi, soldiers and displaced people spread infection, while reduced access to health care and sufficient food lower people's resistance to the disease.
During the 10-year-old civil war, civilian massacres and rape were so common that the League of Human Rights Organisations in the Great Lakes Region said in a 2002, "(These) acts should be considered war crimes and crimes against humanity."
SWAA national coordinator Josephine Niyonkuru agreed.
"During attacks, women -- from the young to the old -- get raped by soldiers, rebels and bandits," Niyonkuru said, adding that husbands often reject wives who have been raped.
"The reasons are cultural and now, fear of HIV," said Niyonkuru.
Those factors make it harder for women to tell others they have been raped and seek help.
Last year, a survey by the U.N. Population Fund found 282,000 internally displaced people living in camps in Burundi. Niyonkuru described such camps as "sources of HIV, promiscuity, rape and misery."
UNICEF surveyed young people in the camps and found that one in 10 had been raped.
"With family and community structures under stress, gender-based violence is becoming widespread," said UNICEF.
TAKING ACTION
Today, exactly 20 years after the first AIDS cases were detected in Burundi, the government is stepping up its response with a $233 million action plan.
"It may be ambitious but we hope to have 10,000 people on free anti-retrovirals by 2005," said Joseph Wakana, CNLS executive secretary.
The treatment plan will gradually cover all 17 provinces, and is funded by the World Bank and the Global Fund to fight AIDS, Tuberculosis and Malaria.
With 80 voluntary counseling centres run by the government, NGOs and the Catholic church, and 200 health personnel trained on administering ARVs in place, Wakana said the roll-out could start as early as this year.
"With peace, decentralisation and increased funding, Burundi is moving very fast," said UNICEF representative Malick Sena.
Because the rate of HIV-positive women is twice that among men -- 13 percent among women against 5.5. percent among men in urban areas -- SWAA emphasises prevention among young women and girls.
HIV rates are low among boys and girls aged 12 to 14. Infection rises sharply among urban and semi-urban girls aged 16 and over, whose HIV rates are respectively six and three times higher than boys.
In rural areas, rates are low among both sexes until age 20.
Studies on social behaviour note that urban and semi-urban girls tend to have sex earlier, and with older men, putting them at higher risk.
A 2002 survey found that 17 percent of young people between the ages of 10 and 14 had had sex. HIV rates continue to rise among women in their twenties, suggesting they get infected in marriage.
One reason is that many men refusal to use condoms with spouses even when they know that they or their partners are HIV-positive.
CHEAP DRUGS
The combined lobbying of Burundi Network of People Living with HIV (RBP+), ANSS and SWAA reduced the price of ARVs and other AIDS-related drugs and tests by pressing the government to seek discounts from pharmaceutical companies, cut taxes on drugs and use generics.
The government subsidises ARVs for civil servants through a fund that covers 145,000 affiliates and their dependents.
Treatment costs a dollar a day, with the patient paying one-third.
This benefit was extended to widows and children of deceased soldiers after lobbying by Women of Military Men against AIDS (AFMS), which works to raise awareness and prevent infection among soldiers and their families.
"The military community is terribly exposed to HIV, very vulnerable," said RBP+ President Seconde Nsabimana, a founding AFMS member who has been HIV-positive since 1988.
In Bujumbura, ANSS has just moved into sprawling premises suitable for the many services it offers, from a day hospital and a community pharmacy to medical consultations, orphan support and projects to enable people to earn a living.
ANSS was set up in 1993 by professionals living with HIV, including a doctor, who could no longer stand denial and disclosed their status on TV. Their testimonies marked a turning point in the public perception and the national response to AIDS.
Today, ANSS helps thousands of HIV-positive people, including 550 members on anti-retroviral treatment.
But demand outstrips capacity.
UNAIDS estimated in 2000 that of Burundi's population of 6.9 million, 360,000 adults and 19,000 children were living with HIV.
But ARVs do not solve all the problems, said ANSS coordinator Marie-Josee Mbuzenakamwe.
"Stigma, psychological needs, rent, food, and school fees must be sorted out," she said.
BACK FROM THE BRINK
Her staff is grappling with a new problem.
"For people who come back to life and health after many years of being sick, incapacitated, filled with low self-esteem, unable to assume family or work responsibilities, it can be difficult to re-position their lives," said Mbuzenakamwe.
People with jobs find the transition easier but the unemployed find it hard, she said.
Many people pulled from the brink of death by ARVs become activists with the Burundi Network of People Living with HIV (RBP+).
With 800 members, mostly in the capital, RBP+ is setting up provincial branches to identify HIV-positive people and help them manage the disease.
Nsabimana said: "This new life that God has given me, I will use it to improve the life and health of every person living with HIV."
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