02/04/2005

Contact: Sarah Martin
ri@refugeesinternational.org or 202.828.0110

“AIDS is going to be a big problem in Liberia,” said the doctor in Nimba county. “We are seeing full blown cases of AIDS but there is nothing we can do for them. We can’t test them to see if they have AIDS since the nearest testing facility is a 14-hour drive away. We don’t have the facilities to treat them and we certainly don’t have drugs to help them. We feel helpless in the face of this epidemic.”  While the official prevalence HIV rate is 8.2%, health providers and others believe that the HIV infection rate is much higher. There hasn’t been a survey since before the war but all indicators of a problem are evident.

The civil war in Liberia was characterized by gender-based violence, forced abduction of women and girls to act as sex slaves for the fighting forces, and large numbers of rapes.  Former combatants are returning to their communities to start over. “During the demobilization process, we provided reproductive health services to the former combatants. We screened them for sexually transmitted infections (STIs),” said one health provider. “For male combatants, 93% had at least one STI; the female prevalence rate was 83%.  Most had multiple partners. They suffer from gonorrhea, syphilis, and chlamydia.” For a young sexually active population already weak with STIs and malnutrition, the onset of HIV infection could be devastating. Child protection agencies have reported some former female combatants turning to prostitution because of lack of opportunities since the demobilization trust fund has dried up. But the problem is not only one for former combatants, a relatively small group of people. It also impacts the general population.

According to health care agencies, the sexually transmitted infections rate in the general population is around 75-80%. There is inadequate treatment of STIs. Health clinics don’t have a steady supply of medicines or condoms. According to a local NGO, “We tell people to go to the clinic to get medicine to treat their infections and there is nothing there, so the people are very frustrated and do not trust the clinics to help them.”  One Liberian woman told Refugees International, “If I go to the clinic and there are no medicines for me, why should I come back? I have to walk a long distance to come here. They treat us for everything as if it were malaria.” A member of the Liberian Ministry of Health (MOH) also complained bitterly that “the international communities are interested in numbers rather than providing good care. They may substitute inappropriate drugs or send you home with nothing.” There are four testing centers for HIV in Monrovia but these are not nearly enough.

Another problem with treating STIs and providing health care is that Liberia is suffering from a shortage of health care workers. The Ministry of Health has problems paying salaries and must rely on international NGOs to provide stipends to health workers. There is no standard stipend, however, so health workers “shop around” for the best paid job, leaving many areas severely under-served. The rural areas are suffering the most from the health care crisis. Many clinics that RI visited were crowded with people but had few staff.

While there are billboards warning about HIV lining the streets of Monrovia, there is little evidence of real education about HIV infection.  Teenage pregnancy is high, with girls as young as 13 getting pregnant. “This is an indicator for HIV,” said an official of the Liberian Ministry of Health. “The people are very uneducated about HIV. It is very difficult to talk to them about something as abstract as HIV. They refuse to use condoms or accept that they will die. Death has been a reality for them and telling them that having sex without a condom will kill them does not make sense to them.” UNFPA reiterated this concern, “I’ve never seen so many pregnant teenagers! We’re talking about very young girls – as young as eleven. One wonders if the sex they are having is consensual.”  Another problem is the lack of options for youth. There are no schools, no jobs, and not many activities for this young sexually active population. While many would like to start cultivating the fields for agriculture, there are no seeds or tools. Returning displaced persons find little in the communities to assist them with recovery. The lack of money generating activities can lead women to enter commercial sex work to support themselves and their families.

In addition to the problems with lack of access to good health care and HIV prevention education, Liberia is next to countries such as Cote d’Ivoire and Guinea, which face continuous conflict and have high HIV prevalence rates. The borders between these countries are very porous; people move back and forth quite freely. While it would be impossible and foolish to try to close borders to prevent the spread of HIV, the response from donors should be regional rather than country-specific. For example, the U.S. government has targeted Côte d'Ivoire for the President’s AIDS Initiative, but Liberia and Sierra Leone do not get similar programs. According to UNFPA, there has been a rapid development of a sex industry along the border towns in response to the influx of truck drivers, uniformed personnel, and ex-combatants.

The concern about the peacekeepers is not new to post-conflict countries. Sexual exploitation in Liberia is rampant. There has been a boom in commercial sex work. In Monrovia, brothels and discos target UN peacekeepers as preferred customers while in the rural areas, many of the African peacekeeping troops live intermingled with the community. According to one local NGO, “We are also concerned about peacekeepers from sub-Saharan countries. No one is testing them to see if they have HIV. The young girls in the villages where they live receive money and food from their ‘boyfriends’ in the peacekeeping missions. They do not see it as a problem so no one is reporting it.” A recent article in the New York Sun reported that three Namibian peacekeepers stationed in Liberia died of AIDs recently.

While the UN does draw peacekeeping troops from countries with high HIV rates, some of the countries, such as Nigeria, have mandatory testing policies and do not deploy HIV-positive soldiers. The UN also provides medical facilities for its troops, but RI is concerned that peacekeepers will not use these facilities if they fear that they have HIV. Health care providers in neighboring Sierra Leone told RI in April 2004 that they had treated peacekeepers with obvious symptoms of AIDS who refused to seek treatment from UN facilities for fear of being repatriated and losing their stipends.

According to a recent study by International Crisis Group, nations with high or near-high AIDS prevalence contribute 37% of all U.N. peacekeepers. UNMIL has a unit solely dedicated to HIV/AIDS training and has the full backing of the mission’s force commander. But behavior change takes time and cannot be addressed simply by training during the soldiers’ deployment. HIV prevention needs to be fully mainstreamed into standard training for national and military personnel. Pre-deployment training is essential to change behaviors and attitudes in the troop contributing countries.

An UNMIL officer told RI that “it is a waste of time for me to attend these events [HIV awareness and prevention sessions]. My men obey orders and do not fraternize with the locals. I do not worry about them becoming infected with HIV.” But expecting peacekeepers to remain celibate while on mission is unrealistic. Until there is a better way to prevent HIV transmission and protect both the peacekeepers and the local population from infection, condoms are the only viable prevention method.

Therefore Refugees International recommends that:

• Donor governments provide increased funding for HIV education programs and more HIV testing centers;
• Donor governments provide increased funding for community-based development programs geared to young women and men;
• Donor governments and UN agencies develop a regional approach to HIV, with Guinea, Côte d'Ivoire, and Sierra Leone included along with Liberia;
• Donor governments find ways to fund more aggressive treatment for STIs and programs for HIV awareness and treatment, particularly in rural areas and border towns;
• Donor governments fund follow-up reproductive health services for former combatants;
• International non-governmental organizations provide more funding to local NGOs to build grassroots ability to address HIV;
• Donor governments increase funding to UNFPA to support current peer counseling programs for vulnerable groups such as ex-combatants, young people, and uniformed personnel;
• Troop-contributing countries increase pre-deployment training in HIV education for peacekeeping troops.
• UNAIDS and donor countries increase funding to programs that target uniformed services in countries with high HIV prevalence rates.