Lessons from HIV to Guide COVID-19 Responses in the Central African Republic

Pierre Somse and Patrick M. Eba

Almost 40 years ago, the Central African Republic, like other countries in Africa and around the world, was confronted with the HIV pandemic that would shake the human, social, and economic foundations of entire societies. Since the beginning of that epidemic, more than 32 million people have died of HIV-related illnesses globally.[1]

The HIV epidemic was first presented as a disease of homosexuals, then of people who use drugs, sex workers, and foreigners.[2] The associated stigma to those categorizations remains one of the greatest challenges to the response to HIV.[3] In the Central African Republic, a 2018 study found that 45% of people living with HIV had experienced stigma and more than 85% had faced discrimination, including in health care settings.[4]

Like HIV, the spread of the 2019 coronavirus disease (COVID-19)—which as of March 31, 2020, had infected more than 750,000 people globally and caused 36,405 deaths—is accompanied by rampant stigma.[5] Around the world, stigmatizing behaviour is reported against those diagnosed with COVID-19 and people perceived as potentially infected with the coronavirus, often because of their national origin.[6] In the Central African Republic, the announcement of the first COVID-19 positive person—a Catholic missionary who had lived in the country for many years and had just returned from a trip to Italy—led to verbal and written attacks against the patient, and Catholics and foreigners generally considered to be vectors of the disease.[7] Although several COVID-19 positive people diagnosed in the country were nationals who had returned from abroad, widespread stigma from the first case fuelled through social media, and the sensationalist press has ingrained in the collective imagination that foreigners are the vectors of the disease. Addressing the harms of stigma and misinformation must thus be a priority with COVID-19 and indeed effective responses to the pandemic would greatly benefit from all the lessons of the multi-sectoral and rights-based approaches to the HIV epidemic.

Five lessons from the HIV response

COVID-19 is very different from HIV in its modes of transmission and the rapid global spread of this pandemic—which has led to the quarantine of one fifth of the world’s population—is unprecedented.[8] However, the four decades of response to the HIV epidemic offer lessons that are vital for the fight against COVID-19 and the stigma that it creates.[9] Five of these lessons are particularly relevant.[10]

  1. Scientific evidence and correct information on the pandemic

Effective public health responses must be grounded in sound scientific evidence on the modes of transmission of the epidemic, its prevention, and (potential) treatments. Scientific evidence must guide the actions of political leaders and decision-makers. Health experts and health institutions—supported by the World Health Organization (WHO)—play an essential role in the development and dissemination of scientific data on the epidemic and response. Evidence on the prevention and management of COVID-19 must be well communicated to the media and communities, with special efforts made to address ‘fake news’ and debunk myths.

Positive experiences from countries facing the epidemic should guide responses elsewhere. In the fight against HIV, experiences from Senegal, Thailand, Switzerland, and Uganda were systematically described and used as good practice. In the context of COVID-19, experiences from China and South Korea are already being used and insights from early successes should be made readily available.[11]

  1. Community involvement

However, scientific evidence by itself is not sufficient to end fear, combat stigma, and ensure community involvement in responses to epidemics. Specific additional efforts are needed to educate and mobilize communities. AIDS activists remind us that “whatever is done without communities is done against them”.[12] Thus, community actors, youth and women’s organizations, patients’ associations, artists, opinion leaders, and traditional leaders, amongst others, must be involved meaningfully from the beginning in national responses.

Community engagement is necessary to ensure understanding and acceptance of isolation and other restrictions, and it also has an essential role in monitoring and accountability. Global and national processes must be set up so the community can effectively hold the government and its agencies leading and implementing responses to account.

  1. Challenging stigma and protecting human rights

The fight against stigma and discrimination is paramount to the response to any epidemic. It requires a combination of behavioural and structural interventions at individual, community, and national levels.[13] It is a crucial component of rights-based public health responses which involve respect of dignity, the prohibition of torture and degrading treatment, the right to health, and the right to food. Some human rights may be limited or subject to derogation when required for the protection of public health. However, the exceptional measures adopted must be in accordance with the law, limited in time, and necessary to combat the epidemic.[14] Further, although criminal law is already being deployed in some contexts in the response to COVID-19, its use should be minimalised.[15]

Upholding human rights in times of epidemics is not only an obligation for states. It is also a public health imperative because it enables adherence to public health messages and it helps build the trust of populations affected and those most at risk.[16] In the Central African Republic, a National charter on the quality of care and the rights of patients, launched on 1 March 2020—Zero Discrimination Day—is a tool to advance the protection of human rights in the context of COVID-19.[17]

A rights-based approach to health helps ensure that no one is left behind and that particular attention is paid to the most vulnerable. In COVID-19 this includes the elderly, those with pre-existing diseases, prisoners, refugees, and displaced persons.[18]

  1. Global and national leadership at the highest level

Like HIV, the COVID-19 pandemic is not only a health concern, but is also a social, economic, and human security issue. The United Nations Security Council recognised HIV as a peace and security issue on 10 January 2000 when it met to discuss the impact of the epidemic in Africa. This was the first time the Security Council had addressed a health issue as a threat to peace and security, paving the way for the adoption of Resolution 1308 on HIV/AIDS and international peacekeeping operations.[19]

Responding to pandemics such as HIV and COVID-19 calls for a multi-sectoral approach that mobilizes leadership at the highest level. From Malaysia to Uruguay, to Italy and the Central African Republic, heads of state and government are personally engaged in the response to COVID-19 and are overseeing the implementation of measures to curb its spread. The involvement of heads of state is needed to bring all departments and institutions into the response, to activate crisis mechanisms and resources, and to convey the urgency of the situation.

  1. Partnership and global solidarity

The HIV epidemic is a formidable example of multilateralism and global cooperation. Thanks to community activism, international solidarity, and cooperation in the fields of science and medicine, 24.5 million people are on antiretroviral treatment today, mostly in low- and middle-income countries.[20]

The United Nations Secretary-General and the Director General of WHO at the G20 Leaders’ Extraordinary Summit on COVID-19 on 26 March 2020, stressed the urgent need to accelerate global partnership and solidarity in the response the pandemic.[21] This solidarity must be anchored in a multilateral framework to support and finance the global response and recovery with specific attention to countries most affected and those most fragile. These principles are further articulated in the Secretary General’s report, Shared responsibility, global solidarity: Responding to the socio-economic impacts of COVID-19.[22]

With a health system severely weakened by decades of political instability and conflict, one of the lowest ratios of qualified health workers per capita in the world, and more than half its population in need of humanitarian assistance, the Central African Republic is one of the most fragile countries facing COVID-19.[23] Early measures adopted by the government with the support of WHO, MINUSCA, the World Bank, UNICEF, and other UN agencies and partners, appear to have been effective with only six primarily imported cases of COVID-19 recorded at the end of March and limited evidence of local transmission. But the window is narrowing for effective action and for full deployment of international solidarity to beat the pandemic in the Central African Republic and elsewhere.

Time for courageous and multilateral action against COVID-19

Now is the time for bold approaches against COVID-19 grounded in scientific evidence, community involvement, human rights protection, and leadership. Courage in the face of this pandemic means having the strength to recognize that the solutions do not lie within national borders but require a coordinated, transparent, and truly global response. We must mobilise all the technological, medical, and financial resources available globally to act decisively against this pandemic in a multi-sectoral, human rights framework. These are the lessons from our joint response to HIV. We ignore them at our own peril.

Dr. Pierre Somse is Minister of Health and Population of the Central African Republic. He was the first head of CAR’s HIV programme in the early 1990s.

Dr. Patrick M. Eba is UNAIDS Country Director in the Central African Republic. Email: EBAP@unaids.org

References

[1] Joint United Nations Programme on HIV and AIDS (UNAIDS). Global HIV & AIDS statistics 2019 fact sheet. Available at https://www.unaids.org/en/resources/fact-sheet accessed March 30, 2020.

[2] G. M. Herek. Thinking about AIDS and stigma: A psychologist’s perspective. Journal of Law, Medicine & Ethics. 2003; 30(4):594-607.

[3] L. Cabal and P. Eba. “Editorial: Learning from the past: Confronting legal, social, and structural barriers to the HIV response.” Health and Human Rights Journal. December 6, 2017;19(2). Available at https://www.hhrjournal.org/2017/12/editorial-learning-from-the-past-confronting-legal-social-and-structural-barriers-to-the-hiv-response/ accessed March 30, 2020.

[4] Réseau Centrafricain des personnes vivant avec le VIH, Index de stigmatisation et de discrimination des personnes vivant avec le VIH en République Centrafricaine, 2018.

[5] World Health Organization. Coronavirus disease 2019 (COVID-19) Situation report – 71. March 31, 2020. Available at https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200331-sitrep-71-covid-19.pdf?sfvrsn=4360e92b_4 accessed April 1, 2020.

[6] Al Jazeera. Foreign tourists face hostility in India amid coronavirus panic. March 24, 2020. Available at https://www.aljazeera.com/news/2020/03/foreign-tourists-face-hostility-india-coronavirus-panic-200324083648362.html accessed March 30, 2020.

[7] Radio Ndeke Luka. RCA : Le gouvernement et le système des Nations Unies se mobilisent contre la propagation du COVID-19. March 19, 2020. Available at https://www.radiondekeluka.org/actualites/sante/35295-rca-le-gouvernement-et-le-systeme-des-nations-unies-se-mobilisent-contre-la-propagation-du-covid-19.html accessed April 1, 2020.

[8] The Telegraph. Which countries are under lockdown – and is it working? March 29, 2020 https://www.telegraph.co.uk/news/2020/03/29/lockdown-countries/ accessed March 30, 2020.

[9] Some of these lessons from HIV were also highlighted for the response to the 2014 Ebola epidemic. See P. Eba “Ebola and human rights in West Africa” Lancet 384/9960 (2014), p.2091.

[10] For more lessons from the HIV response for addressing the COVID-19 pandemic, see T. Avafia, B. Konstantinov, K. Esom, J. R. Sanjuan, R. Schleifer. A Rights-based response to COVID-19: Lessons learned from HIV and TB epidemics. Available at https://www.hhrjournal.org/2020/03/a-rights-based-response-to-covid-19-lessons-learned-from-hiv-and-tb-epidemics/ accessed on March 30, 2020.

[11] Human rights concerns were raised on the COVID-19 response in China, see M. Heywood. Coronavirus: Why protecting human rights matters in epidemics. February 24, 2020. https://www.dailymaverick.co.za/article/2020-02-24-covid-19-why-protecting-human-rights-matters-in-epidemics/ accessed March 30, 2020.

[12] UNAIDS. Nothing for us, without us,’ hammer young people at AIDS Conference. July 31, 2018. Available at https://www.unaids.org/en/resources/presscentre/featurestories/2018/july/nothing-for-us-without-us accessed 30 March, 2020.

[13] UNAIDS. Key programmes to reduce stigma and discrimination and increase access to justice in national HIV responses. 2012. Available online at https://www.unaids.org/en/resources/documents/2012/Key_Human_Rights_Programmes accessed March 30, 2020.

[14] UN Commission on Human Rights, The Siracusa Principles on the Limitation and Derogation Provisions in the International Covenant on Civil and Political Rights, 28 September 1984, E/CN.4/1985/4, available at: https://www.refworld.org/docid/4672bc122.html accessed March 30, 2020.

[15] See HIV Justice Network. HIV Justice Worldwide Steering Committee Statement on COVID-19 criminalisation. March 25, 2020. http://www.hivjustice.net/news/hiv-justice-worldwide-steering-committee-statement-on-covid-19-criminalisation/ accessed March 30, 2020.

[16] UNAIDS. Rights in the time of COVID-19: Lessons from HIV for an effective, community-led response. Available at https://www.unaids.org/sites/default/files/media_asset/human-rights-and-covid-19_en.pdf accessed March 30, 2020.

[17] Réseau des Journalistes pour les Droits de l’Homme (RJDH). Centrafrique : Une charte nationale pour améliorer la qualité de soins validée par le gouvernement. February 12, 2020. Available at https://rjdh.org/index.php/actu/item/664-centrafrique-une-charte-nationale-pour-ameliorer-la-qualite-de-soins-validee-par-le-gouvernement accessed March 30, 2020.

[18] J. Amon “COVID-19 and detention: Respecting human rights” March 23, 2020. Available at https://www.hhrjournal.org/2020/03/covid-19-and-detention-respecting-human-rights/ accessed 30 March, 2020.

[19] UN Security Council, Resolution 1308 (2000). The responsibility of the Security Council in the maintenance of international peace and security: HIV/AIDS and international peacekeeping operations. Adopted by the Security Council at its 4172nd meeting, on 17 July 2000. Available at http://data.unaids.org/pub/basedocument/2000/20000717_un_scresolution_1308_en.pdf accessed 30 March, 2020.

[20] UNAIDS. Global HIV & AIDS statistics – 2019 fact sheet. Available at https://www.unaids.org/en/resources/fact-sheet accessed March 30, 2020.

[21] United Nations. Secretary-General urges G20 countries to suppress COVID-19 transmission, keep households afloat, amid pandemic’s “human crisis”. March 26, 2020. Available at https://www.un.org/press/en/2020/sgsm20024.doc.htm accessed March 30, 2020.

[22] United Nations. UN launches COVID-19 plan that could ‘defeat the virus and build a better world’. March 31, 2020. Available at https://news.un.org/en/story/2020/03/1060702 accessed April 1, 2020.

[23] United Nations Office for the Coordination of Humanitarian Affairs (UN OCHA). Plan de réponse humanitaire 2020 : République Centrafricaine. Available at https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/ocha_car_hrp_2020_fr_vf.pdf accessed March 30, 2020.