Freetown — Just two years after seeing off a bloody decade-long civil war, Sierra Leone is engaged in yet another battle: against the twin-scourge of poverty and AIDS.
Sierra Leone's poverty is well documented. The United Nations ranks this West African country as the least developed - or poorest - in the world. After the end of the civil war, the Sierra Leone government estimated that about four-fifths of the population was living in absolute poverty with incomes of less than a dollar a day, mostly in rural areas.
Information about HIV/AIDS is harder to come by. There is a general acknowledgment that the epidemic has worsened over the years and that it is slowly depleting the country's scarce human resources, eating into finances and energies just when they are most needed for nation-building.
Officials at the government's main AIDS prevention unit, the Sierra Leone HIV/AIDS Response Project or SHARP, say recent statistics indicate that about 0.9% of the population is infected with HIV - making up a total of some 45,000 people.
But UNAIDS, the umbrella UN body that leads the global fight against the pandemic, puts the figure many times higher. According to it, the total number of Sierra Leoneans with HIV, whether or not they had developed symptoms of AIDS, was 170,000 at the end of 2001. Of them, 150,000 fell in the 15-49 years age group, the majority (90,000) being women. The adult rate was 7%. As many as 16,000 children under 15 had the virus. Some 11,000 people died of AIDS in 2001 and the number of AIDS orphans in that year was 42,000.
Experts say the confusion over numbers is due to the fact that there have been no nation-wide surveys held to ascertain the real extent of the epidemic. The only estimates that are available were arrived at through diagnoses of those patients who turned up for AIDS tests at the few hospitals that are equipped to conduct such tests. Because of poverty and poor medical facilities, many patients are identified only when they develop full-blown AIDS and are on the verge of death.
Poverty and AIDS are linked closely in Sierra Leone - a fact that finds reflection in the government's main poverty-cutting strategy, the Poverty Reduction Strategy Paper (PRSP). Under the initiative, led by the World Bank and the International Monetary Fund, Sierra Leone - and 45 of the world's other poorest countries - have to draft their individual PRSPs. They, in turn, must be approved by the IMF for these countries to qualify for much-needed aid and debt relief.
"Poverty in Sierra Leone is endemic and pervasive." Those are the opening words of the Sierra Leone PRSP, drafted in July 2001. It goes on to note in the next paragraph that "endemic diseases, especially malaria and HIV/AIDS, loom as a menace."
The document, which forms the backbone of Sierra Leone's policies to fight poverty, points out that in 2000, the Central Statistics Office in collaboration with UN agencies concluded a Multi-Indicator Survey, which showed that 46% of women of childbearing age in the country were unaware of HIV/AIDS while very few knew where they could be tested for HIV. This, it says, shows the "potential consequences for the spread of the disease".
It also explicitly acknowledges that HIV/AIDS may be an "emerging and important contributory factor" to the high levels of infant and under-five mortality rates. In 2001, the infant mortality rate (per 1,000 births) was 182 and under-five mortality rate 316. The document lists a series of action plans to combat the pandemic, including intensification of education and information campaigns; condom distribution; and focusing on young people.
"The PRSP is very critical to the development of Sierra Leone as it enables us to move from an ex-post facto [retrospective] to ante-post [anticipatory] approach in poverty reduction, including HIV/AIDS," Deputy Minister for Development, Mohamed Sesay told Panos Features.
The task is by no means easy because HIV/AIDS is both a result and a cause of poverty. "The cost of treatment and care for people living with HIV/AIDS and other diseases impoverishes many families and communities," says Braima Josiah of the National Poverty Alleviation Strategy Coordinating Office.
"The need for care forces potential wage earners, especially women, to stay at home, children to miss school and family assets to be sold for treatment. The cost to the economy of HIV/AIDS is massive and HIV/AIDS must be mainstreamed throughout the PRSP."
On the ground, there are doubts over the government's AIDS prevention strategies. Some analysts say SHARP, which received $15 million from the World Bank and IMF this year, is highly centralised in Freetown, with little presence in those remote regions where poverty is most severe.
For instance, the south-eastern border has been witnessing large numbers of Sierra Leoneans returning from neighbouring Liberia and Guinea at the close of the civil war, as well as nationals of these countries. These returnees and immigrants are economically impoverished and vulnerable to HIV. Makeshift camps set up throughout the country are in a run-down, overcrowded condition, creating a base for sex work-related infections, including HIV.
The PRSP too has its limitations. The way the Sierra Leonean PRSP is being implemented, some independent experts say, has political implications. The PRSP is based on a National Recovery Strategy but this focused only on the northern and eastern regions. The official reason given for this focus was that these two regions were the last to be liberated from rebel control and, therefore, are worse affected than other parts of Sierra Leone.
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But these experts claim that one reason for continuing to pour money into these two regions through the PRSP is that they are government strongholds - and potential vote-banks. Officials and health experts appear to recognise the enormity of the task at hand. "Our challenge now is to move from rhetoric to reality in controlling the disease through strategies and ideas," says Professor Sidi T O Alghali, national director of SHARP.
But so far there is little indication that the government is listening to people with HIV/AIDS - a significant constituency - to learn about their concerns and needs in the fight against AIDS.
In September, a woman turned up at the building of the Ministry of Social Welfare, Gender and Women's Affairs in Freetown and declared herself to be HIV positive. She was taken to the Connaught hospital, where she died a few days later in the outpatients ward.
Before she died, she had this to say: "I lost all my properties in 1999 and my boyfriend also left for Guinea. I started having affairs with different men just to survive. Now, I know I am dying slowly but God will forgive me."
She had been abandoned without any medical attention. After death, it was the government that arranged for her burial. No one made any attempt to identify any of her several sex partners.
