Morocco's open campaign against a secret epidemic starts with diagnosis
Objectively, Morocco's HIV indicators paint a relatively reassuring picture of a country only grazed lightly by an epidemic that has had ruinous consequences elsewhere in Africa.
Prevalence rates have never risen above 0.2% and, for the most part, only a small sub-section of the population is really at risk of infection: members of those globally identified vulnerable groups, including sex workers, men who have sex with men and people who inject drugs.
But delve a little deeper and the picture is not as rosy -- because among those vulnerable groups, there is serious danger in the unknown. Three in four of Morocco's most at-risk do not know their status, according to Dr Abdelaziz Ouassadan, coordinator of the diagnostics department at the Association for the Fight Against AIDS (ALCS). And while Morocco's human rights record is improving, stigma and discrimination continue -- so finding them is like searching for a needle in a haystack.
"It's really challenging, in the context of a 0.1% prevalence rate, to find 30,000 people," he told Aidspan during a recent visit. "Think about just how many tests you would have to do to find 100% of the infections."
Since 1992, ALCS has been responsible for most of the diagnostic testing in Morocco. But of course it cannot be responsible for testing all 30 million people in Morocco alone and, despite all of the awareness campaigns of the last decade, many of which received Global Fund support, voluntary testing remains rare. A goal of reaching 80% of both men who have sex with men and sex workers seems far off.
Rather than abandoning the effort, however, the Moroccan government is putting more resources into achieving the diagnostic goals. A 'know your status' campaign is at the heart of the national strategic plan (NSP) for 2012-2016, and includes an arsenal of activities, education and community mobilization led by grassroots organizations that know their clientele: the clandestine and vulnerable key populations. Taking diagnostics out of the hands of medical professionals and putting them into the hands of community health workers is another innovative component of a program currently in development.
Overcoming fear and ignorance
Since 2013, ALCS has joined other sub-recipients of Global Fund support such as OPALS and the Southern Association Against AIDS in pivoting towards working exclusively on the issues affecting key populations. In Morocco's large cities and priority regions, teams of educators work directly in the communities of vulnerable populations, developing trust and affinity as they encourage people to get tested.
In Agadir, it is teams of women who are sent by ASCS into the red light zones where sex workers ply their trade. Equally, ALCS is doing its part to reach the truck drivers who form the largest part of the sex trade client base and those who are most likely to pass infections into the general population.
Work in this population has shown some modest result, said Dr Fatima Zahara, who heads the truck driver outreach program. The number of sex workers visited on average by a truck driver has declined from nine to six since 2007, and higher condom usage has been recorded. Truck drivers are also more inclined to get tested than they were before, she said, and they are taking fewer risks.
"I got tested, like almost half of the others in the [Association of Truck Drivers] because ALCS encouraged us to and brought the mobile clinic to make it easier," said Taoufik Choukri as he relaxed next to his rig at a truck stop in Petromin, Agadir's industrial zone.
NGOs have had to be more innovative in their efforts to reach the Moroccan gay community, which remains in the shadows for fear of stigma and persecution.
"There are a lot of people we have not been able to reach, who use chat sites," said Abdoullah Tif, who manages the web presence for ALCS. It was at Tif's initiative, therefore, that ALCS has created a profile on PlanetRomeo, the most popular site for gay men in Morocco. "If you're gay and can read and write, you're on PlanetRomeo," Tif said. ALCS now has an profile it uses to reach out to the more than 13,000 Moroccan users, to chat anonymously and share health information on topics such as HIV education, invitations for people to come to the ALCS office, and subtle encouragement for people to get tested and know their status.
But for all the innovations and efforts to overcome HIV-related stigma, it remains a complicated proposition to reach the people most vulnerable to infection, said Mouna Balil, who runs ALCS programs in Marrakesh, the country's third-largest city.
"We've had a tough time finding doctors. Some of them have said very clearly that they will help us carry out diagnostic testing -- but not with men who have sex with men," she said. So how to bridge the gap between a medical community that is still stigmatizing homosexuality and a gay community staying firmly underground poses a critical challenge.
For ALCS, it means removing doctors from the equation. A new program about to get under way will provide training to community volunteers in diagnostics and counseling, so that people can work directly with their peers.
"In light of the need, the Health Ministry has approved the program," said Younes Yatine, who leads the prevention campaigns for ALCS within the gay community. "Now it's up to us to find the right volunteers, to provide the right kind of training, and to have the right start to the campaign."
These community-led diagnostic programs should only be one among a number of different activities, cautioned Boutaina El Omari, who is the Global Fund focal point for the Ministry of Health "It's not the one and only solution," she said. "Studies have clearly shown that even with the tremendous effort being made by the NGOs, they will never reach everyone."
So for now the ministry will continue with other strategies that have worked in the past: annual diagnostic campaigns that target the entire population with ads on social media, television and radio. While expensive, this campaign has seen the number of HIV tests administered skyrocket, from 70,000 to more than 500,000 per year. And while just 300 new infections were identified in 2011, another 1,100 people were diagnosed in 2012, and 1,200 in 2013. These campaigns have also helped bring down the numbers of people who are unaware of their HIV status, from 80 to 75%.
"We've been an interesting case study for the World Health Organization," said El Omari. "They have hypothesized that where there is a low infection rate, generalized campaigns don't work; we are evidence to the contrary."