Marguerite and Victory (not their real names) are two nurses who care for HIV-positive people in the besieged north-west region of Cameroon. Their daily routine often includes scanning hospital records to find out which patient is coming to pick up their antiretroviral therapy (ART). The two then make reminder calls to the patients. But reminding them is one thing, but getting them to come is quite another, as they face a host of challenges, including not being able to afford transport, HIV-related stigma and the risk of being caught in the crossfire. conflict ravaging Cameroon Since late 2016, a civil war has raged between separatists in the English-speaking regions and the government.
They have been like this for eight years. “Some patients have died as a result of the conflict, others have moved to safer areas, and others have stopped taking antiretroviral therapy because of the influence of their pastors or because of doubts about their condition,” says Marguerite, who follows up patients at the Bali District Hospital in northwestern Cameroon, as part of the HIV Free Projectfunded by the United States. “Constant lockdowns and insecurity sometimes make it difficult to deliver medicines,” she explains by phone. “If there are attacks, bullets go through the hospital walls and grenades explode inside. When this happens, we throw ourselves to the ground.” Because of the insecurity, there are patients who have developed very high viral loads because they have not taken their medicines, says the nurse. The health centre currently takes care of more than 700 people with HIV.
Victory, who follows up with patients at Tubah District Hospital, also in the north-west region, explains that to ease the physical and psychological burden, she and her colleagues have resorted to delivering antiretroviral therapy to people’s homes. “The conflict has aggravated the trauma of HIV patients. We have documented cases of armed men forcing their way into homes or farms and raping women and girls,” Victory laments during a call. “We tell the sick not to be discouraged and to take their medicines. Sometimes, I even lie to them by telling them that I am also a patient who is living thanks to antiretroviral therapy, just to get them to accept their condition.”
Sometimes I lie to them and tell them that I am also a patient who lives thanks to antiretroviral therapy, just so that they accept their condition.
Victory (not her real name), nurse at Tubah District Hospital (Cameroon)
She adds that stigma among patients is widespread: some who come to the hospital for treatment stop at the door and wait for the nurses to attend to them there, discreetly. “And if they don’t find any willing to do so, they prefer to turn back without picking up the medicines,” says Victory. Similarly, some turn back as soon as they discover that there are residents on duty. “Some newly diagnosed patients even give false numbers or names so that they won’t be called to pick up the prescriptions.”
Most hospitals in conflict zones have embarked on diagnostic testing to detect as many infected people as possible. “Once we diagnose a patient with the virus, we ask about their sexual contacts to test them as well. But we don’t tell them that they have been referred to us by their partners,” explains Marguerite. “This has helped us get many more people tested and treated. We still have partners on antiretroviral treatment who try to hide their status from their partners.”
A public health problem
HIV remains a major public health problem in Cameroon, where an estimated half a million people are currently living with the virus. But a 2018 Demographic and Health Survey —the most recent one available in the country— points to progress over the last 14 years, with a 50% decrease (5.4% in 2004, 4.3% in 2011 and 2.7% in 2018) in the prevalence of HIV among people aged 15 to 64.
The World Health Organization (WHO) attributes this decline to a combination of factors including increased access to antiretroviral therapy, a “test and treat for all” strategy, and changes in risky sexual behavior, such as delaying the initiation of sexual relations, decreased sexual violence, and increased condom use.
Cameroon’s National AIDS Control Committee, established in 1998 to coordinate, oversee and manage the multisectoral AIDS control programme, aims to end HIV as a public health threat by 2030 by reducing new HIV infections, deaths and stigma. The country is on track to meet the global “95-95-95” target: 95% of people living with HIV know their HIV status, 95% of those who know their status are on treatment and 95% of those on antiretrovirals have a suppressed viral load. The rates in 2022 were 95.8%, 92.3% and 89.2% respectively, according to the National AIDS Control Committee.
Despite these advances, political instability in Cameroon’s predominantly Anglophone North-West and South-West regions has had a significant impact on the response to the disease, contributing to health inequality and threatening progress in controlling the epidemic. The civil war in Cameroon’s North-West and South-West regions began in late 2016, when Anglophone lawyers and teachers in the regions took to the streets to protest the appointment of Francophone teachers and judges in English-speaking schools and courts. More than 6,000 people have been killed in the conflict, which has since escalated. More than 730,000 have been displaced from their homes, while another 2.2 million (one in two inhabitants) are currently in need of humanitarian assistance. Frontline health workers in the two regions acknowledge that the ongoing political instability has hampered the development and advancement of an effective local response to HIV/AIDS in the two affected regions of Cameroon.
Inaccessible ghost towns
In the beleaguered English-speaking south-west region, several nurses caring for HIV patients who spoke to this newspaper on condition of anonymity say they start their days with reminder calls to patients, checking on the availability of antiretrovirals, receiving patients, counselling, collecting viral load samples and documentation. This is not without its challenges. “Patients complain that they do not have money to pay for transport,” explains a nurse working at a health centre in Buea, the capital of the south-west region. “To avoid this, we give them medicines that can sustain them for up to three months or more. We also anticipate ghost towns.” [periodos de confinamiento obligatorio] and we make reminder calls, rescheduling appointments so they don’t fall on those days,” he says.
Some patients contacted by this newspaper do not hide their ordeal of dealing with the virus and the conflict. Elisa (fictitious name), 26, who has been taking antiretroviral therapy since 2006, says she has missed her hospital appointments on numerous occasions due to financial difficulties and insecurity. “There are days when I can’t pick up my medicines because of the closure. [Pero a veces] The nurses give them to me,” explains this young woman, who lost her father shortly before she was born, and her mother in 2008.
There are days when I can’t pick up the medicines because of the lockdowns.
Elisa (fictitious name), patient on antiretroviral therapy treatment since 2006
One patient who has been on ART since 2013, after being diagnosed with the virus three years earlier, says that repeated shootings sometimes discourage her from collecting her medication, leading to a deterioration in her condition. “I have been so traumatised by the crisis that I have had to move to a safer place. And leaving my new location to collect medication is difficult,” she explains. Another patient says that the numerous atrocities during the conflict have caused her to feel “panic”. “I always stay at home during ghost town days for fear of the unknown,” she says.
The present Republic of Cameroon has its origins in a complex colonial history, the distortion of which has fuelled the current conflict. The territory initially annexed by the Germans in 1884 was later divided and governed as separate entities by the French and British following the German defeat in World War I. With independence in 1960–1961, the two territories were reunited and formed a federal state, in which the Francophone section constituted about 80% and the Anglophone section about 20%, both in terms of land and population. However, the federal structure guaranteeing the rights of the minority Anglophone section was dissolved in 1972 following a controversial referendum.
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