Côte d’Ivoire

Côte d’Ivoire is one of the countries most severely affected by the HIV/AIDS epidemic in West Africa, with an estimated HIV prevalence in the adult population of 3.9% and a two-fold to five-fold higher prevalence in female sex workers.

The HIV prevalence among female sex workers is estimated to be 26.6% in Côte d’Ivoire. Although data are scarce for male and transgender sex workers, a study conducted among male sex workers in Côte d’Ivoire identified an estimated HIV prevalence of 50% which stands in stark contrast with the HIV prevalence of he general male population of 15-49 years olds which was 1.9% in 2017.

Structural factors that may increase risk of HIV acquisition among female sex workers includes extreme poverty, concomitant lack of familial and social support, gender inequality, stigma, discrimination, physical and sexual violence and legal and regulatory policies penalizing sex work. Sex work is illegal in most west African countries. Structural risk factors associated with arrest and incarceration indirectly heighten risk for HIV infection by restricting access to preventive HIV/ STIs care and treatment services

Information on migrant sex workers is sparse. No information was found on HIV incidence or prevalence among migrant sex workers.

Decades after the first reported case of AIDS, sub-Saharan Africa continues to be the most heavily affected region in the world. West and Central Africa is home to 6.1 million people living with HIV, 500,000 of whom are children. This is equivalent to 17% of the global population of people living with HIV, despite the region making up just 7% of the global population.

In West Africa, international migration among fishermen, traders, farmers, other migrant workers and refugees is common. An estimated 3% of West Africa’s population live in temporary housing while they are away from their communities and families. This is important because housing, migration, economic status and education are associated with HIV infection. Most of the migrant population in West Africa are males and HIV is predominantly spread through heterosexual contact. Less than half of those living with HIV in West and Central Africa are aware of their status which means they are unknowingly passing on HIV infection and that they do not access treatment services.

Cote d’Ivoire, the main country of immigration, has the highest HIV prevalence in West Africa. Infection is widespread throughout the country, with larger concentrations of HIV infection in the most attractive destinations for migrants: Abidjan and the agro-industrial centers of Daloa and Bouake. Côte d’Ivoire also has the highest HIV incidence rate in West Africa. Although interventions such as the promotion and distribution of condoms among female sex workers has been effective at averting infections, low coverage of antiretroviral therapy and low prevention of mother to child transmission continue to drive HIV incidence. HIV is the leading cause of death for men and second leading cause of death for women in Côte d’Ivoire.

The Ivorian health care system is mainly provided through the public sector and is divided into three levels:

1. The primary level is composed of primary health care institutions such as health centers, specialized health centers and clinics. There are 1,870 public primary health care institutions in Côte d’Ivoire.
2. The secondary level is composed of health facilities such as general hospitals, regional hospitals and specialized hospitals. There are 66 general hospitals, 17 regional hospitals, and 2 specialized hospitals in Côte d’Ivoire.
3. The tertiary level is composed of health facilities such as teaching hospitals and specialized national institutes. There are 4 university teaching hospitals and 9 specialized health institutes in Côte d’Ivoire.

In order to guarantee health access to its citizens, Côte d’Ivoire has started on reforms by developing a National Health Development Plan. The new 2016-2020 National Health Development Plan (PNDS) envisions a high-performing, comprehensive, responsible and efficient health system that guarantees the best possible standard of health for all people living in Côte d’Ivoire, especially the most vulnerable.

Public health policy in Côte d’Ivoire does not guarantee access to health services for migrants. There do not appear to be any national policies or coordination mechanisms between migration or immigration and HIV.

Migration is often motivated by economic, social, political and human rights reasons. The AIDS epidemic in West Africa is in large part shaped by international migration. In rural areas of Burkina Faso, AIDS appears to be widespread among families of seasonal temporary workers.  Ghanaian female sex workers travel between Ghana and Cote d’Ivoire to work and unusually high levels of HIV and AIDS have been found in the rural areas of Ghana. A regional approach to meet the needs of migration throughout their entire journey, before, during and after migration is needed to both manage an curb the spread of HIV. Closing borders and restricting migration flow is a short-sighted policy intervention that  may do little to prevent the spread of HIV and may instead increase economic and social hardship. Seasonal migration will continue to be a part of the West African experience. Policies that provide access to free health care, fair employment standards and ensure adequate housing for migrants regardless of their legal status will likely result in a curb in HIV incidence, among other impacts.

Policy interventions that affect key populations are another important tool in curbing HIV incidence. In Côte d’Ivoire adolescent girls (aged 15-19) are five times more likely to acquire HIV than adolescent boys. The HIV response in Côte d’Ivoire should prioritize girls and young women. In West Africa, girls and women face high level of gender inequality, gender based violence and sexual violence, which increases vulnerability. According to demographic and health surveys, 80% of married adolescent girls in Côte d’Ivoire do not have the final say on their own healthcare.

Between 2011-2018, HIV prevalence in Côte d’Ivoire declined to 3.7% but remains substantially higher among men who have sex with men and female sex workers, both of whom are identified as key populations in the country’s most recent national strategic plan. Côte d’Ivoire has emphasized anti-retroviral therapy as a response to HIV emphasis which has resulted in funding declines for condoms and prevention activities for key population. Even if the United Nations’ 90-90-90 objective was reached by 2020, 27% of infected individuals with unsuppressed viral load would still contribute to HIV transmission in the population.

Although immigration policies in Côte d’Ivoire do not have not have provisions for deporting persons living with HIV, sex workers, men who have sex with men and transgendered persons, they do not include any supportive policies either. Planning, coordination and political will along with legal frameworks that prioritize public health and human rights are needed to ensure HIV prevention, care and treatment programming for key populations in Côte d’Ivoire are accessible to all those living with HIV and for key populations. Given that Côte d’Ivoire is a hub for migrants and seasonal workers, labour policies that protect the rights of both documented and undocumented migrants is necessary to ensure that access to health, housing and fair labour practices are provided to migrants and key populations.