|HIV Prevention Needs and Successes: a tale of three countrie (UNAIDS, 2001, 25 p.)|
Much has been written about the need to intervene early to stop the spread of HIV before it gets a grip on a population. Obviously, however, if a country intervenes early and HIV infection rates stay low, it is difficult to say that the low rates were definitely the consequence of the intervention.
Nevertheless, Senegals HIV prevention programme has been extensive and contains the elements of an effective programme. There is good evidence that Senegal has maintained one of the lowest rates of infection in sub-Saharan Africa by changing the behaviour of many of its citizens.3
Like Uganda, Senegal is not a rich country. It has 9 million people, with 44% living in towns. Per capita income is below US$ 600 a year. Total HIV prevalence among adults is estimated at about 1.8%.
Senegal has long emphasized prevention and primary health care. Reproductive health and child health are well-established priorities. In addition, registered sex workers are required to have regular health checks, and are treated for any curable sexually transmitted infections (STIs) that are found.
What was the response in Senegal?
As in Uganda, politicians in Senegal were quick to move against the epidemic once the first cases appeared in the second half of the 1980s.
Since 93% of Senegalese are Muslims, the government made efforts to involve religious leaders. HIV/AIDS became a regular topic in Friday sermons in mosques, and senior religious figures talked about it on television and radio.
Many other levels of Senegalese society joined in. By 1995, 200 NGOs were active in the response, as were womens groups with about half a million members.
HIV prevention was included when sex education was introduced in schools. Parallel efforts reached out to young people who are not in school.
HIV voluntary and confidential counselling and testing were made available.
Programmes were immediately put in place to support sex workers to persuade their clients to use condoms.
STIs moved up the list of health priorities. Senegal was one of the first countries in Africa to establish a national STI control programme that integrated STI care into regular primary health services.
3 For more detailed information, see Acting early to prevent AIDS: the case of Senegal. UNAIDS Key Material, June 1999. Those were the actions. What happened in epidemiological terms?
Fig. 5: HIV seroprevalence trends in different populations in Dakar, Senegal, 19891997
Again, sentinel surveillance was the best option for monitoring the disease, but with more groups than in Uganda. In Fig. 5, the bottom line shows that HIV prevalence among pregnant women was just over 1.4% at the end of 1996, with no significant trend over time.
The next line represents male STI patients. Their HIV infection rates are higher, but remained under 6%.
Female sex workers are probably at highest risk. The top line shows their HIV prevalence levels rising significantly after 1989. Since 1993, however, especially in the capital Dakar, they have remained stable at around 17%.
Some changes in behaviours resemble the changes seen in Uganda.
Fig. 6: Median age at first sex for women in six African countries, 1997
Fig. 6 tracks age at first sexual experience for women in five African countries.
The line that falls most steeply is that representing women in Senegal. In 1997, most Senegalese women in their early 20s did not have sex until they were almost 19 or older.
For their mothers generation - the women who were between 40 and 49 in 1997 - the median age was closer to 16.
What about condom use? From virtually zero before the HIV/AIDS epidemic, consistent condom use with casual partners in Senegal rose to 68% among men having casual sex in 1997 (Fig. 7).
The national HIV/AIDS programme has overcome the checks posed by some traditional religious teachings. The programme achieved a dramatic rise in condom sales and distribution.
Fig. 7: Condom use with casual partners, reported by men, Dakar, 1997
Fig. 8: Condom distribution in Senegal by the National AIDS Programme, family planning services, and the condom social marketing programme, 19881997
Annual condom distribution rose from 800,000 in 1988 to 7 million in 1997 (Fig. 8).
Most were distributed free but some were sold at a social marketing price.
It is unlikely that this rise would have happened without the education and condom promotion campaigns to which men were exposed.
Fig. 9: Rates of STIs among women in Dakar, Senegal, 1991-1996
Fig. 9 is from a study of STIs among pregnant women in 1991 and 1996. It shows big falls in infection rates for all STIs measured, especially trichomoniasis, from 30% down to 18%.
This shows that HIV infection has remained low in Senegal since the start of the epidemic and shows no signs of an upwards trend. But why?
Three major factors can be identified, namely:
People are choosing to have their first sexual experience at a later age (there is also evidence that extramarital sex is relatively limited).
Condom use during extramarital sex, and especially during commercial sex, is high.
STI control programmes are apparently quite effective.
The first two factors are strongly linked to the countrys HIV/AIDS prevention efforts. And the change in social norms, which is evident in delayed sexual activity, is probably being reinforced by the AIDS prevention programme.
Clearly, much in the social structure and health services of Senegal before AIDS favoured a successful response. In addition, strong political commitment and the implementation of effective prevention activities helped keep Senegals rates of HIV infection among the lowest in sub-Saharan Africa.