Cote divoire report by International HIV/AIDS Alliance

Case study

The HIV response in political conflicts: Lessons learnt from Cote d’Ivoire 2002-2010

IDP Camp, Cote d’Ivoire (2011).

About the International HIV/AIDS Alliance We are an innovative alliance of nationally based, independent, civil society organisations united by our vision of a world without AIDS. We are committed to joint action, working with communities through local, national and global action on HIV, health and human rights. Our actions are guided by our values: the lives of all human beings are of equal value, and everyone has the right to access the HIV information and services they need for a healthy life. Acknowledgements We would like to acknowledge the lead writers of this case study, Madiarra Coulibaly Offia (Executive Director of ANS-CI), Alain Manouan, Caroline Perraut, consultant Jane Johnson, and copy editor Hester Phillips.

© International HIV/AIDS Alliance, 2014 Information contained in this publication may be freely reproduced, published or otherwise or used for non-profit purposes without permission from the International HIV/AIDS Alliance. However, the International HIV/AIDS Alliance requests that it be cited as the source of the information.

Unless otherwise stated, the appearance of individuals in this publication gives no indication of either sexuality or HIV status. Cover photo: IDP Camp, Cote d’Ivoire (2011) © Alliance

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Contents

Summary

Key lessons

The Alliance in Cote d’Ivoire

Background and context

Post-electoral crisis 2010-11

The experience of ANS-CI and partners

Good practices, lessons learned

Gaps, unmet needs, missed opportunities

Current situation, future priorities and needs

Summary Cote d’Ivoire has endured a military-political crisis for over a decade. Government elections in 2010 and a wave of military offensives in 2011, has resulted in 3,000 deaths and the internal displacement of one million people. This period of conflict saw the provision of food; water and sanitation prioritised over other, more long term needs. It has caused huge disruption to healthcare and other public services. Despite having a more developed public health system than many of its neighbours, many gains in Cote d’Ivoire are now being reversed. What does this mean for the 450,000 people living with HIV in the country or those people more vulnerable to HIV infection, many of whom are now living in camps where HIV risk is thought to increase? This case study examines the role Alliance Nationale Contre le SIDA (ANS-CI), an Alliance Linking Organisation, played in maintaining the country’s HIV response during the crisis. It examines the way in which the conflict has hindered essential aspects of Cote d’Ivoire’s HIV response such as data collection and the ability to access donor funds. It assesses the coordination between partners working on HIV and with the overall emergency response and identifies key learning to ensure HIV prevention, care and support services, informed by the experiences of PLHIV, are better integrated into disaster preparedness planning.

Key lessons

 Local organisations and networks including people living with HIV (PLHIV) networks can contribute to HIV and emergency response but they need to be better linked to national and local disaster preparedness training and systems so they are better equipped to respond to the needs of communities in crisis.

 Contingency plans need to be developed in countries at risk of conflict so that the needs of PLHIV are met during a crisis.

 HIV prevention, sexual and reproductive health (SRH) and gender based violence (GBV) need to be a priority focus in times of emergency.

 Co-ordination between UN, INGOS, government and local civil society needs strengthening. Local community organisations play an important role in a crisis (e.g. ‘watch committees’ to track displaced PLHIV). This role needs to be better communicated and acknowledged.

 Stronger integration of HIV treatment and prevention into emergency planning is required.

 Alliance Linking Organisations are well placed to establish a sub-regional network to provide HIV services to refugees coming from neighbouring countries.

The Alliance in Cote d’Ivoire The Alliance is a global network of nationally based, independent, civil society organisations united by a common vision of a world without AIDS. The Alliance is committed to joint action, working with communities through local, national and global action on HIV, health and human rights. Alliance Nationale Contre le SIDA (ANS-CI), the Linking Organisation of the International HIV/AIDS Alliance (the Alliance) in Cote D’Ivoire, has been supporting community groups to respond to HIV since 2005. By strengthening and developing community networks ANS-CI, is helping to link people living with HIV to treatment and care, prevent new HIV infections and reduce AIDS-related deaths. Currently, ANS-CI, with funding from Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and US President’s Emergency Plan for AIDS Relief/Centre for Disease Control (PEPFAR/CDC), is providing financial and technical assistance to HIV focused community-based and civil society organisations and networks in order to strengthen their capacity to provide comprehensive, gender specific HIV prevention, care and support to key populations at high risk of HIV infection and other vulnerable populations. ANS-CI has developed a range of innovative programs including the Community Participatory Initiative (ICOP), which creates synergy between community actors at local level to improve access to services and continuum of care, and better use of resources. ANS-CI has played an important role in previous emergency response in Cote d’Ivoire including HIV cluster participation, essential service delivery, advocacy for needs of people living with HIV, enhanced security planning and strategic communication with the Ministry of Health and other external stakeholders.

1) Background and context Cote d’Ivoire has endured a military-political crisis for over a decade. The number of people living in poverty has increased sharply, rising by more than 10% in seven years (38.4% in 2002 to 48.9 % in 2009). There is a high mortality rate and once eradicated diseases such as cholera, bacterial meningitis and yellow fever have resurfaced. Tuberculosis is experiencing resurgence due to HIV infection. AIDS is the leading cause of death among adult men and the second cause for women after death due to pregnancy or childbirth. In 2011, Cote D’Ivoire was ranked tenth in the Global Fragility ranking and is also a fragile state as defined by the World Bank and DFID. The prolonged crisis has disrupted and restricted access to health and other public services. Despite having a more developed public health system than many of its neighbours, the system is still weak and gains have been reversed by the crisis. Blood screening services and treatment for sexually transmitted infections (STIs) and TB are currently limited. Regions that have not been under government control during the crisis have experienced a complete and prolonged disruption of public-sector services and an exodus of skilled professionals. Major disparities exist between urban and rural services, with a paucity of health professionals outside the major cities.

HIV prevalence and trends in Cote d’Ivoire  The country has a mixed epidemic (generalised in the general population and concentrated in key populations).  In 2012 the number of PLHIV was estimated at 450,000.  The number of women aged 15 and over living with HIV is 220,000.  The number of children aged 0 to 14 living with HIV is 63,000.  The number of deaths due to AIDS is 31,000.  The number of orphans due to AIDS aged 0 to 17 is 380,000.  Around 51,820 of PLHIV are on antiretrovials (ARVs)1.  The number of people receiving treatment increased from 32.30% in 2006 to 48% in 2009 and 56% in 20112.  Access to ARVs has been free since 2008 (109,926 people, of which 5,579 are children, received ARV treatment in 2012).  HIV prevalence in the general population declined from 4.7% in 2005 to 3.7% in 20123.  HIV rates are higher in urban areas (5.4%; 6/1% in Abidjan) than rural areas (lowest rate is 4.1%). 1

UNAIDS, July 2009 and Annual Report HIV / AIDS in Côte d'Ivoire health sector 2007-2008 UNGASS 2012 3 UNAIDS estimates 2

 Women are disproportionately affected. HIV prevalence in women aged 15-49 stands at 6.4% compared to 2.9% among adult men4.  Young women (aged 20-24) are approximately 15 times more likely to be HIV positive than their male counterparts (4.5 % compared with 0.3 %). Despite huge efforts, Cote d’Ivoire remains one of the most HIV affected countries in West Africa. The conflict has hindered the collection of national HIV-related data, resulting in a seven-year gap between comprehensive surveys (the most recent of which, La 3ème Enquête Démographique et de Santé en Côte d’Ivoire, took place in 2012). Despite increased efforts in prevention of motherto-child transmission (PMTCT), the number of women accessing various services is low. Significant risk behaviours are evident in young people (aged 15-24)5. Sexual violence is common with 25% of interviewed women and 14% of men having been sexually abused. People most at risk to HIV infection include sex workers, their partners and clients, men who have sex with men (MSM) and injecting drug users (IDUs). Other at-risk populations include transportation workers, uniformed services personnel and their partners, young people, orphans and vulnerable children (OVC), migrants and seasonal workers, internally displaced persons (IDPs), prisoners, and victims of sexual violence. The latest research finds 28.6% of sex workers to be HIV positive6.

HIV response since the Peace Agreement in March 2007  Coordinated, decentralised and multi-sectoral response under the National Strategic Plan (NSP) 2006-10.  Mobilisation of civil society around abstinence and fidelity.  Support for correct and consistent condom use.  Increased access to voluntary counselling and testing (VCT) and PMTCT.  Reduction of HIV related stigma and discrimination.  Antiretroviral (ART) programmes scaled up and access to services improved.

Remaining challenges  Prevention strategies are inadequate due to low capacity at public health centres and poor community systems.  Interventions are not always well coordinated, leading to gaps in services.  Technical and financial partners do not always align support with national priorities.  Limited financial resources allocated to HIV response, both internally and externally. 4

AIDS Indicator Survey (AIS) 2005 AIS 2005, KAP surveys 2009 by the INS 6 PAPO, 2012 5

Since 2006, development partners, particularly PEPFAR, have provided the majority of funding for Cote d’Ivoire’s HIV response. This funding is then augmented with public (9%) and private money (3.8%). In this context, the sustainability of the country’s HIV response remains a constant challenge. Most donors have greatly reduced their support to the country since 2007, reflecting the global downturn in funding between 2007 and 2008. Since their first disbursement in 2003, the Global Fund has approved a total of US$110.4 million to combat HIV in Cote d’Ivoire, US$3.8 million of which was designated to prevent and manage HIV in conflict situations between 2006 and 2008. In August 2010, a ninth-round grant of US$56.2 million was approved from the Global Fund to strengthen the national response to HIV. Programme activities funded by this grant will scale up prevention and comprehensive care, factoring in gender and key high-risk populations. Through the US Agency for International Development (USAID), Cote d’Ivoire has also received more than $189 million between 2007 and 2010 for essential HIV programmes and services, with more than 60% of funding allocated to the provision of ARVs and to strengthening the country’s national supply chain management system.

Knowing your Rights Campaign: Group discussion with young people on HIV and Rights within an IDP Camp in the West of Cote d’Ivoire (Nov 2011)

2) Post-electoral crisis 2010-11 Timeline of events The current military-political crisis began in September 2002 after a failed coup led to the partitioning of the country into the Southern zone, known as the government area, and the North, Central and West (CNO), known as the besieged area. Conflict and atrocities in the CNO area caused displacement of a large number of people to the Southern zone. The consequences on HIV work were:  A scarcity of trained healthcare providers  Looting of health facilities whose technical and human capacity had been reduced  Temporary suspension of prevention work by NGOs  Disruption in ARV treatment for some patients who could not leave the CNO area. This first period of conflict took the actors in the HIV response by surprise, and they were not prepared to respond quickly to the needs of the population. A second period of conflict began in October 2010 following contested presidential elections. The already fragile socio-political situation deteriorated rapidly. Ensuing violence, mainly in the South and West, caused more than 3,000 deaths7, led to one million people becoming displaced and 161,000 becoming refugees in Ghana, Liberia and Guinea. Instability continued between October 2010 and March 2011 with some areas completely inaccessible. Sporadic outbreaks of violence occurred mainly in the capital Abidjan. In March 2011, a wave of military offensives led to besieging of key urban targets. An estimated 450,000 Ivorians left the country of which 370,000 were from Abidjan. International organisations reported numerous human rights violations.

Impact on the general population  Electricity and water in the northern half of the country were cut.  Widespread pillaging and destruction occurred.  Families were separated and/or displaced; many physical and sexual violations occurred.  Due to the closure of some private and international banks, most partners (including ANSCI) could not access funding to continue activities. 7

Please note that estimates vary from between 3,000 deaths (ICC) to 5,000 (International Federation for Human Rights, FIDH, http://www.fidh.org/en/africa/cote-d-ivoire/14477-ivory-coast-post-electoral-crisis-special-investigation-unit-term-extended)

 The cost of living significantly increased and people were unable to afford basic needs.  There was a lack of medical supplies.  Fearing for their lives, many personnel abandoned health centres.  Disruption of HIV prevention, care and treatment services and pharmaceutical supplies, especially in the western part of the country.  The western region experienced more degradation in socio-economic indicators relating to HIV, food security, health, water, sanitation, hygiene and shelter.

Impact on local NGOs Organisations continued to work but at essential operations only. Between October and May 2011, NGOs and the government took the following actions:  Development of an emergency response plan under the leadership of the Ministry of Health, building on lessons from the 2002 crisis (actors involved in the HIV response developed a contingency plan to meet the needs of key populations and PLHIV). Seminars on emergency preparedness were held by UNICEF, SCF and MSF, attended by national NGOs and public the sector.  Systems were strengthened to monitor medical stocks at health centres, provide early warning systems and pharmacy networks.  Government-contracted humanitarian organisations such as IEC/CCC supported activities on ARV adherence (three month supply of ARVs), home visits and monitoring committee.  Prevention interventions continued in IDP camps and where possible, HIV interventions were linked with GBV.

The humanitarian response By May 2011, a number of IDP camps had been established. The camps were overcrowded and the priority of most humanitarian actors was to ensure adequate provision of food, water and sanitation. With few prospects many young females resorted to selling sex for survival; rape was also commonplace.

HIV was not considered a priority, and was not on the government’s agenda. The focus was on the adequate provision of food, water and sanitation. The health system slowly started to function again, restocking equipment and materials. NGOs restarted activities and, in the field of HIV, reinitiated prevention programmes. Humanitarian activities were coordinated under a cluster arrangement. There were sub-clusters on HIV, GBV, health and protection. But there was lack of coordination within the HIV cluster. The merging of Ministry of Health with the Ministry for HIV following the crisis hugely impacted the

multi-sectoral, decentralised response. In effect, due to the suppression of the Technical Support Cells for Local Initiatives, the functioning of decentralised committees almost ceased. Additionally, in 2012, the collection of non-health information relating to HIV faltered due to the continued existence of two monitoring and evaluation departments (at the time of writing this case study, a restructure was in progress to address this issue). ANS-CI regularly communicated with and updated donors (PEPFAR/CDC, UNAIDS, World Bank, Global Fund) about the unfolding situation and outlined alternative means to get funding to the country, given the closure of the banks.

Impact on ANS-CI and its implementing partners All ANS-CI partners interrupted their programmes during the crisis. ANS-CI was strongly dependent on large institutional donors including PEPFAR, the World Bank and the Global Fund who froze funds to reduce risk and to focus on ARV treatment. As a result, capacity building programmes were interrupted, Global Fund funding was frozen and PEPFAR activities suspended.  ANS-CI halted activities from April to June 2011 due to the conflict.  ANS-CI’s implementing partners stopped the majority of work, although some developed innovative approaches that enabled crucial activities such as prevention and adherence work to continue.  Discussions took place with implementing partners to establish what could be done with no funding during the interim period. Regular updates on assets were also established and maintained.  With support from the Alliance Secretariat, ANS-CI developed an emergency security plan that enabled key staff to work on a rota basis and respond to demands as needed. ANS-CI benefited from the regular Alliance security information and risk assessments provided by third party sources  Alliance funding flexibility enabled ANS-CI to redirect funds to cover staff salaries and other immediate operational costs. The money was sent via the Alliance Linking Organisation in Burkina Faso, using a mechanism set up by a private company operating between the two countries, showing the strength of being part of the global Alliance network.  Importantly, ANS-CI provided vital local information on the ARV shortage on the ground to Save the Children to assist in their proposal to the EC.

3) The experience of ANS-CI and partners Due to the insecurity, the ANS-CI offices were closed for three months from 1 April 2011. The offices reopened in June 2011 but travel was limited due to the security situation. By the beginning of July, operations were back in full operation. ANS-CI conducted assessments of all VCT centres to measure the impact of the crisis. Five ANS-CI VCT centres in the south had been looted and the majority of equipment and materials stolen.

Impact on service delivery by ANS-CI and its partners When ANS-CI was established in 2005 the country was still divided in two. Despite this, the situation in the CNO had mainly stabilised and NGOs had resumed activities. This enabled ANSCI, with funding from PEPFAR, to carry out activities in the south as well as the CNO area. Sporadic outbreaks of violence were occurring and staff members were trained in security. ANS-CI centred its work on the NSP 2006-10. The organisation carried out activities with functioning local NGOs and local administrative and health authorities. They also coordinated with the Ministry help establish a community database. When the post-electoral crisis broke in 2010, ANS-CI’s PEPFAR/ CDC grant had finished and its Global Fund programme was not yet operational, leaving minimal operating resources. Given its non-humanitarian status, ANS-CI had not been involved with the development of the emergency plan in the period before the crisis. ANS-CI and their sub-grantees continued their activities until the security situation forced them to suspend their actions.

ANS-CI’s responded to the post election crisis by:  Advocating for the needs and highlighting the vulnerabilities of key populations  Highlighting human rights violations  Mobilising funding from UNFPA to evaluate the vulnerability of key populations (interventions related to income-generating activities, reproductive health, GBV)  Strengthening its partnership with the UN peacekeeping mission (UNOCI) to ensure the safety of staff who travelled to conflict areas  Conducting security training with the support of the Alliance Secretariat  Developing an emergency contingency plan with support from the Alliance. ANS-CI’s status as a development organisation working on HIV acted against it when applying for funding, as international humanitarian NGOs had broader experience on a range of conflict-related issues such as social cohesion and demobilisation of ex-combatants.

Learnings  Coordination is key in a disaster setting and should be prioritised. Although the UN set up clusters around specific themes there was disorganisation within the HIV cluster impacted by the unification of two government health ministries.  It is important in any future situation to support national NGOs working on HIV to be involved in disaster preparedness at the national level. ANS-CI was not sufficiently prepared for the changes brought about by the 2010 crisis and had not taken part in the development of emergency plans nor taken specific steps to ensure continuity of care.  ANS-CI’s status as a development organisation rather than as a humanitarian organisation strongly influenced and limited its actions.

4) Good practices, lessons learned Positive learnings from the Cote d’Ivoire crisis Coordination is key in ensuring an organised response to a crisis. The government, UN agencies and NGOs all worked to support national implementation structures in the provision of HIV services in prevention, care and treatment. However, this coordination was not optimal. UNICEF surveyed beneficiaries after the crisis and found that training and emergency contingency planning at national and regional levels, organised by UNICEF and partners such as Save the Children and MSF, proved crucial in emergency management and implementation of interventions8. For example, the established pharmacy network enabled a supply of drugs to be passed from one health centre to another when one had been looted thus avoiding a break in supply. An early warning tool developed by UNICEF enabled NGOs to report in a timely manner. This was important for coordination purposes and for finding solutions. The joint UN teams and donors such as PEPFAR and the Global Fund played a crucial role at the national level. They enabled ARVs to be available in districts and provided support at a distance. ‘Watch committees’ were established by NGOs to help monitor and identify those in need of treatment. Through these means many PLHIV were reached.

Challenges emerging from the crisis With the exception of medical staff, public service officials who attended emergency training did not replicate learning operationally. Training on emergency humanitarian law was lacking. This needs to be strengthened to enable public services to better engage with emergencies. During the crisis, services were disrupted between one to three months, depending on location. By March 2011 around 50 to 75% of the country’s medical personnel were no longer in situ. Many health centres were abandoned. Shortages of medical equipment, vaccines, and essential treatment for children, pregnant women and PLHIV were rife. Medical surveillance systems and epidemiological surveillance were no longer functioning in combat zones to the west and in Abidjan. HIV was not a priority for humanitarian organisations.

Strengthening national responses to HIV and adolescents in Emergency Situations: Lessons learnt from Cote d’Ivoire and Haiti April 2013

Learnings Specific conditions need to be met in order for the ANS-CI to effectively intervene in future emergencies. This includes strengthening procedures for the management of finances, materials and personnel before, during and after a crisis. Active participation with humanitarian action coordination teams to develop emergency response planning is key. This applies to clusters and sub-clusters. Local NGOs need to be repositioned through strategic partnerships with UN and other humanitarian agencies to be closely connected to humanitarian responses. Expertise in integrating HIV prevention with the provision of water, sanitation, food, and social cohesion activities needs further development.

5) Gaps, unmet needs, missed opportunities Cote d’Ivoire has experienced chronic problems since 2002. Emergency responses, by their nature, focus on short-term needs, which can create problems when the emergency abates and governments and communities need to rebuild sustainable services and infrastructure. The link between emergency and development contexts is crucial and needs to be considered at an early stage. Service provision on HIV needs to be seen within the socio-economic context of the country. The health system had many challenges prior to recent crises9. In an emergency, steps need to be taken to strengthen the health system for the long term rather than focusing solely on short-term inputs.

Learnings  Disaster preparedness is of utmost importance, yet the capacity of many organisations in disaster response planning is under-resourced and needs strengthening.  Connections between networks and platforms working on HIV need strengthening so that the needs of PLHIV are better tracked, considered and advocated for.  An approach that integrates HIV response with services for IDPs, demobilisation and disarmament of combatants and social cohesion needs developing.  As poverty increases so does transactional sex. It is important to develop and strengthen HIV work with sex workers and their clients including those more recently involved in transactional sex and with a focus on IDP camps.  Further development of approaches that include GBV, stigmatisation towards sexual minorities and sex trafficking is needed.  Coordination, monitoring and evaluation in line with national programmes are needed.  Alliance Linking Organisations are well placed to establish a sub-regional network to provide HIV services to refugees coming from neighbouring countries.

USAID Cote d’Ivoire (2010): HIV/AIDS Health Profile

6) Current situation, future priorities and needs The current conflict in Cote d’Ivoire has exacerbated issues already in existence in the country, not least vulnerability to HIV particularly for young people. Instances of early sex, forced sex, low condom use, and negative gender attitudes – all of which give rise to HIV, STIs, early unwanted pregnancy, illegal abortion and maternal death - have been amplified by conflict. Health and education services have disintegrated, as have many social and family ties. Transactional sex, rape and sexual violence have all increased as has alcohol and substance use10. Three years after the post electoral crisis, humanitarian actions are muddied with those relating to recovery and development. HIV programmes are being taken up again, and a new strategic plan covering the period 2012-15 has been elaborated in a participative manner. However, the 2015 presidential elections are approaching and could constitute another period of insecurity. If unrest occurs, those who currently benefit from the work of ANS-CI must not lose their services. Crucially, ANS-CI must be enabled to work in the west of Cote d’Ivoire, the most unstable part of the country given its proximity to Liberia.

UNICEF, ONUSIDA, UNFPA, PUMLS (2011) – Analyse de la vulnérabilité au SIDA et de la réponse chez les adolescents et les jeunes en Cote d’Ivoire, Rapport de Synthèse