Final Report for the AIDSCAP Program in Cameroon: Background and Country Context

Table of Contents

Executive Summary

I. Background and Country Context (See Below)

II. Country Program Description

• Part 1
• Part 2

III. Lessons Learned

IV. Subproject Highlights

• Part 1
• Part 2

V. Attachments

Glossary of Acronyms

I. Background and Country Context

Cameroon with a surface of 475,000 square kilometers is located in Central Africa. In 1993, the estimated population of Cameroon was approximately 13 million inhabitants of whom 51 percent are women. The population is very young, with almost half under the age of 15. The sexually active population (15-60) represents 50.2 percent of the total population. Over a quarter of the marriages in the country are polygamous. This proportion reaches 42.7 percent in rural areas while Yaoundé and Douala only account for 18.2 percent of polygamous marriages. This means that there are far more unmarried men than unmarried women. In the high risk ages (15-39) there were (in 1987) 183 single men for every 100 single women. This imbalance naturally encourages irregular sexual contacts, which encourages the spread of HIV.

Cameroon's continued stagnant economic growth may also be another important factor behind the spread of the epidemic among specific populations. The poor economy makes it difficult for young people to marry and form stable relationships. In addition the economic constraints also push many (young) women into commercial sex or to exchange sex for goods and services.

A. Epidemiology of HIV/AIDS

The first AIDS case in Cameroon was reported in 1985. As of 1995, a total of 8,141 cumulative cases of AIDS have been reported in Cameroon. Of the reported AIDS cases in 1995, the average age was 32 for men and 29 for women. Half of the people were married (50.9 percent) and only 2.7 percent were homosexuals, 77.6 live in urban areas, 84.7 percent were illiterate, and 53 percent were women without a job. The most common clinical manifestations were tuberculosis (25 percent of the cases), weight loss, fever and diarrhea (22 percent of the cases). The 1993 report by UNDP on the Human Development in Cameroon estimates that the real number of AIDS cases is at least three times higher than the reported cases, and that over the course of the next five years, the number of infected persons with HIV and the number of AIDS orphans will increase.

Table 1 : Cumulative AIDS cases from 1985 through 1995

A system of sentinel surveillance was instituted in 1989 in Yaoundé, and later extended to cover most of the country. The 1991 Sentinel Surveillance Report covering the period 1989 - 1991, issued by the MOH, reported pregnant women presenting for antenatal care (ANC) in Yaoundé showed infection rates respectively of 0.8 percent, 1.5 percent and 1.6 percent over the three year period. In 1992, when additional sites were included, rates averaged 2.0 percent at three antenatal clinics in Yaoundé, 2.4 percent in Douala, 2 percent in Limbé, 3.5 percent in Bamenda and 7.9 percent in Bertoua. In Yaoundé, the seroprevalence steadily increased from 0.8 percent in 1989 to respectively 3 percent in 1994 and 2.7 percent in 1995. In Douala rates increased from 0.7 percent in 1989 to 4.4 percent in 1995 and 4.5 percent in 1996 and in Garoua from 1.5 percent in 1991 to 3.4 percent in 1995 and 3.3 percent in 1996. There is some evidence that these rates are stabilizing. In other urban areas rates have continued to rise with figures as high as 10 percent in Bertoua and Bamenda in 1994-1995. The primary mode of transmission is heterosexual and the epidemic primarily affects the young, sexually active population. The prevalence of HIV is higher in urban areas and there is nearly an equal proportion of male to female cases.

Cameroon has not carried out a national HIV seroprevalence survey, therefore there is no precise information on the level of infection in the general population. However, limited data from the sentinel surveillance sites have been used to provide an estimate of the prevalence of HIV infection in the general population, which according to the National AIDS Control Service is about 5 percent in the urban sexually active population. Compared to other African countries, it would seem that Cameroon is still a country with relatively low HIV prevalence levels. Although HIV prevalence has remained relatively low in the adult population, a high prevalence of HIV has been detected in Cameroonian sex workers. A seroprevalence study in 1990 found an 8.6 percent prevalence among sex workers in Yaoundé. A subsequent sero-survey in 1992 in Yaoundé and Douala found an HIV prevalence of 25 percent and 45 percent, respectively, indicating a dramatic increase in HIV infection in these groups. A survey conducted in 1994 among a random sample of sex workers (n=360) from Yaoundé found a 21 percent prevalence of infection among this population. The most recent prevalence data presented at the Vancouver AIDS conference from a study conducted among over 1,000 sex workers in Yaoundé and Douala indicated an overall prevalence of HIV of 16.8 percent.

B. AIDS Prevention and Control in Cameroon

The Government of Cameroon -- In response to the rising number of reported AIDS cases, the Government of Cameroon established a National AIDS Committee (NAC) in 1988. Subsequently the National AIDS Control Unit (ULS) was created within the Ministry of Health and later became the National AIDS Control Service. The NACS was given the mandate to establish a strategy for the prevention of HIV/AIDS in Cameroon.

The NACS developed the first Medium Term Plan (MTP) outlining Cameroon's AIDS prevention strategy for the period 1988-1992 with assistance from WHO. This MTP defined and prioritized responsibilities, structures, staffing and resources. The objectives of the plan were to assess and monitor the status of the epidemic, to decrease the transmission of HIV through blood transfusion and injections, sexual transmission, and from mother to child, and to improve clinical skills of health care providers. The second MTP, established for the period 1993 through the present, focuses primarily on prevention through communication strategies for behavior change, sentinel surveillance and counseling for HIV+ people.

National and international support for AIDS Prevention and Control in Cameroon -- In response to the AIDS pandemic, a number of international donors provided financial and technical assistance to Cameroon to support STI/HIV/AIDS intervention and prevention activities. The main donors are:

World Health Organization (WHO) -- WHO/GPA assisted in the development of the Medium Term Plan MTPI (1988-1992) and MTPII (1993-1997) and provided assistance in the management and coordination of the program. During the 1988 - 1993 period, WHO/GPA also provided two long-term resident staff, including an IEC specialist and an epidemiologist, to assist the ULS. In addition to providing general administrative support, WHO/GPA has provided assistance in AIDS-related policy development, educational materials, training, equipment, reagents, and vehicles.

United States Agency for International Development (USAID) -- USAID has provided support to the Cameroon AIDS Control Program from 1989 until 1996 through its bilateral program and through the centrally funded AIDSTECH, AIDSCAP and HAPA programs. After the USAID Mission closed in 1994, the AIDSCAP Cameroon program continued to operate with Africa Bureau funds. Collectively this support has provided: management assistance in the form of a long-term resident advisor; condoms; assistance in implementing a national sentinel surveillance program; assistance in implementing a comprehensive program of education, condom promotion and distribution and STI treatment targeted for high risk groups; technical assistance, supplies, and training to reduce transmission of HIV through blood transfusions; training to improve blood transfusion practices; training of counselors as part of a national counseling program; support for a study of the efficacy and acceptability of condoms and spermicide use among commercial sex workers; a condom social marketing program and support for international conference attendance. Under the AIDSCAP program, STI and AIDS prevention activities and condom social marketing were expanded countrywide, and the number of target groups increased to include university students, in-and out-of-school youth, the armed forces, CSWs and their clients, bar patrons, STI patients. In addition technical and financial support was provided to the Ministry of Health to develop national STI treatment guidelines and to maintain the sentinel surveillance program.

German Technical Cooperation (GTZ) -- GTZ is a major donor for HIV/AIDS prevention and primary health care in Cameroon. Its AIDS-related interventions include: training, counseling, social support, equipment and reagents for HIV and STI screening, and condom promotion. GTZ focuses its program in three provinces of Cameroon: the Northwest, Southwest and Littoral.

French Cooperation -- France has primarily provided support to the Centre Pasteur laboratory to strengthen capacity for accurate blood screening and safe blood transfusions by training staff and procuring test kits and related lab equipment. They also fund the Organisation contre les grandes endémies (OCEAC) for research, and a primary health care project and STI/AIDS prevention in the North Province.

European Community (EC) -- The EC supported the Central Hospital blood bank in Yaoundé through 1994. In addition, the EC has conducted training for laboratory personnel in HIV screening and provided equipment and reagents for HIV screening. The EC has also provided assistance to improve blood transfusion services. Their IEC work has focused on reaching first year secondary school students though the use of a specially designed brochure. This last program is currently under negotiation for renewal.

Other support is provided by bilateral agencies such as the Canadian International Development Agency (CIDA) and United Nations Agencies such as UNAIDS, UNDP, UNICEF and UNFPA. In addition to these international bilateral and multilateral donors, international NGOs have also played a major role integrating STI/HIV prevention in their activities and include, among others, CARE International, Save the Children, and Catholic Relief Services.

In addition to international support, Pan African, local NGOs and community based organizations have contributed to the fight against AIDS in Cameroon. The Society for Women and AIDS in Africa (SWAA) mobilizes Cameroonian women in fight against AIDS and STIs. Sidalerte targets youth in its prevention programs and provides counseling to HIV positive people and their families. The Association des frères et soeurs unis, AFSU is a local association of people living with HIV and AIDS. AFSU members mobilize HIV infected people, their families and communities, and provide them with counseling and assistance. The Action féminine de lutte contre le SIDA, l'exclusion sociale et la promotion de la santé de la mère et de l'enfant, AFLUSES, works at the village community level to mobilize women in the prevention of STIs and AIDS.

The Cameroon Health Program is a local registered NGO that was created by the AIDSCAP/Cameroon Resident Advisor at the end of the USAID funded FHI/AIDSCAP. CHP, staffed primarily with AIDSCAP/Cameroon personnel, builds on seven years of experience in HIV/AIDS prevention project design, management and evaluation. The mission of CHP is to support and promote health programs for Cameroon. CHP works with governmental and nongovernmental organizations to design and deliver HIV/AIDS prevention interventions, reproductive health, mother/child health and family planning projects. By leveraging funding and support for HIV/AIDS prevention activities, CHP will be able to sustain many of the behavior change interventions begun during AIDSCAP.

The Institut de Recherche et Des Etudes de Comportements (IRESCO) is a small local research organization that specializes in evaluation of STI/AIDS projects, design and testing of IEC materials, and operations research in Cameroon. IRESCO staff also provides technical assistance to other francophone countries in the region.