By Kemo Cham
Along Levuma Beach in the west end of Sierra Leone's capital, Freetown, a group of volunteers carefully scavenge a long stretch of piles of rubbish, looking for syringes and hypodermic needles randomly dumped by drug users.
The volunteers scratch through the debris, collect and carefully drop the syringes into boxes, one at a time.
"The beaches along this coast are littered with used syringes and they pose danger to beachgoers," says Habib Kamara, Executive Director of Social Linkages for Youth Development and Child Link (SLYDCL), the organization behind the clean-up exercise.
The activity is part of a routine exercise, with the objective of engaging communities vulnerable to sexually transmitted diseases (STDs), such as HIV/AIDS. During such engagement, SLYDCL field officers provide free testing for various STDs and volunteers are provided with lifesaving supplies like syringes, needles, condoms and psychosocial counselling as incentives.
This initiative is part of the Harm Reduction approach by SLYDCL, which says the criminalization of drug use is fuelling a culture of stigma and discrimination and driving people who use drugs into risky behaviors.
“Because of stigma and discrimination, they are forced into hiding and they share the same needles and syringes, which exposes them to HIV and STDs,” says Kamara.
People who inject drugs are among those highly prone to infectious diseases – known as the key populations – whom the Sierra Leone government has identified as the central focus in its strategy in the fight against the viral pandemic. The other categories are people having same-sex relationships, especially men who have sex with other men, and commercial sex workers.
Risky behaviour
Like many beaches along Freetown’s coastline, Levuma is lined with numerous slum communities, like Crab Tong, which are home to many jobless youths, most of whom make a living through casual work, as fishermen, commercial motor bike riders or apprentices. Some female sex workers have based themselves here, many of them living with partners who may be dealing in drugs to earn a living.
Many of these people feel ostracised in their former communities because of the lives they lead now – where policies that prevent legal access to support services can lead to risky behaviour, such as sharing of needles and unprotected sex, spreading infectious diseases.
Latest data from the National AIDS Secretariat (NAS), the government agency coordinating Sierra Leone’s HIV response, indicates that the prevalence of the disease in the country has increased from 1.5 percent in 2015 to 1.7 percent in 2020, with the number of people living with the virus increasing from 54, 000 in 2015 to an estimated 78, 667.
But NAS Director General Abdurahman Sesay says Sierra Leone made progress despite the rise in those numbers, citing the treatment rate, which increased from 73 percent in 2017 to 86 percent in 2020. Many of those receiving treatment have supressed viral loads, he adds.
But Sesay recognises that the global goal of AIDS no longer being a public health threat by 2030 is well beyond reach. The rate of testing, for example, is lower than acceptable, he points out.
Only 51 percent of people living with HIV in Sierra Leone know their status, according to the NAS data, and Sesay says one factor to blame here is fear of stigma and discrimination.
Lack of awareness
The Network of HIV Positives (NETHIPS), the umbrella organization representing people living with HIV in Sierra Leone, in December published its latest Stigma Index, showing that people in the key populations are among those facing prejudice.
“Stigma, and discrimination, is a very critical issue and we believe that it is something we need to address in this country,” Sesay tells Politico. He blames misconceptions and a widespread lack of awareness about the realities of HIV, adding that the agency aims to address this.
According to UNAIDS’ 2019 estimates, about 8.5 percent of an estimated 1, 500 people who inject drugs in Sierra Leone are living with HIV. Prevalence is higher among the estimated 220, 000 men who have sex with men, at about 14 percent, and only about a third of them use condoms. Among an estimated 240, 000 sex workers there is an HIV prevalence of 6.7 percent, with lower use of condoms – at only about 14.9 percent.
But the numbers are estimates and may be substantially higher.
SLYDCL's focus is on people who use drugs, and its Freetown office is one of a few places serving as a drop-in centre, where people in these key populations can get help without being stigmatized.
Among them are sex workers and people in same-sex relationships.
Last year the organization assisted 1, 825 people, of whom 1, 725 were tested for various STDs. Over 90 percent of those tested positive for at least one STD, 42 of which were HIV, SLYDCL’s data shows,
In 2019, 1, 810 people were attended to. The organization says the increase in those who were helped was a result of the COVID-19 pandemic, as people who were in isolation were easier to contact.
Change agents
Thaimu Bangura, Needle and Syringe Exchange Field Officer for SLYDCL, is a “Change Agent” – a former drug user who uses his experience to motivate others to take a safer path in life.
Bangura recounts stories of people who go into hiding because of stigma, and losing their lives after their illnesses worsen due to lack of treatment. He says the complaints show that discrimination happens at home, in the streets and even at the hospital.
One of his clients, a sex worker called Sarah, abandoned treatment for HIV after a bad encounter with an unfriendly nurse. She found a safe haven in the drop-in centre.
But when SLYDCL peer educators visited her at home to make sure she was OK, her neighbours suspected she was under treatment for a sexually transmitted disease. In the face of harassment, she changed her address and even her telephone number to avoid the field officers.
"She could be in the community transmitting the disease to unsuspecting people," observes Bangura.
Other cases have had fatal consequences. A youth called Abdulie, who was in denial about his condition, defaulted on his treatment and died.
Campaigners say many of those who live with HIV are in denial because they fear stigma and discrimination. And by the time they come to terms with reality it may be too late.
But Allieu is one of those who seek help and do their best to survive. He was diagnosed with HIV in November 2020 and enrolled in SLYDCL’s programme.
Fear of stigma
Only his counsellor and nurses at the centre where he collects his antiretroviral drugs each month know his HIV status. Allieu lives with his father and is concerned how he would react if he found out.
But a bigger concern for the unemployed young man is how his neighbours would react if word spread about his status – which he is sure would happen if he told any relatives.
“I have not experienced it (stigma) yet, but I have seen my friend go through it,” Allieu says, explaining that his friend died of suspected HIV/AIDS though he was never tested, despite health problems. The friend’s wife also later died in similar circumstances.
“People in the community were calling him names and telling him that he had HIV,” Allieu recalls.
“Someday my family will know, but I want to take my time to get them aware of the disease and to know that it is not what many people in society think about it, which is why they treat people living with HIV so badly,” he adds.
According to the 2020 Stigma Index, nearly 60 percent of people surveyed were worried about family, friends or partners finding out about their status and so kept it secret.
The National HIV and AIDS Commission Act 2011 prohibits stigmatization and discrimination against people living with HIV, yet they continue to face prejudice and rejection.
Legal review
There have been suggestions for a review of the law, which some campaigners say does not help those who have the virus, and may even discriminate against them. For example, female sex workers complain that police arrest and charge them for crimes their male counterparts do not face.
“While in other countries people now live openly with their status, in Sierra Leone it is still an offence to disclose someone’s status,” says Joseph Dumbuya, Programmes Manager at the Legal Aid Board (LAB), a government-funded agency providing legal advice to disadvantaged people.
Dumbuya says the law needs to address stigma and discrimination.
With support from the Global Fund, the LAB offers free legal services to people in key populations who face any form of prejudice.
In the last six months of 2020 it investigated 115 cases reported through partner organizations representing key population groups – many of them sex workers or people who inject drugs.
But Dumbuya says people with complaints may be put off from taking matters further because they worry their health status will be revealed during a police investigation.
The LAB has been lobbying parliament for three years with the goal of doing away with the secrecy provision in the law. Another key change it seeks is a provision that allows for compulsory testing of pregnant women, leaving that for their male partners voluntary.
Campaigners say barring issues of HIV drug stockouts, which are common occurrence, the rate of people on treatment could have been higher than it is, if it were not for the secrecy issue.
Stop the spread
Sesay, the NAS boss, acknowledges the scale of stigma and discrimination, and says the agency and its partners are working to review the laws.
But campaigners like SLYDCL’s Kamara believe it will take much more than just revising legislation to solve the problem.
He also wants drug laws to be reviewed and aligned with the HIV/AIDS laws, to focus on harm reduction, rather than punishment. He says that offering clean needles to people who would otherwise share dirty needles, and offering judgment-free services to people with HIV, can help to prevent the further spread of the virus.
“The global approach now is harm reduction. Punishment through incarceration is not going to help, it only worsens the situation. It goes against the spirit of the universal health coverage, which ECOWAS (Economic Community of West African States) has adopted and which Sierra Leone is a signatory to,” Kamara says.
“If you cannot stop them, help them to do it in a safe way, for them not to engage in risky behaviours that help spread the HIV virus further,” he adds.
This story was produced as part of the ‘Breaking Down Barriers to Heath Services’ journalism programme, run by the Thomson Reuters Foundation and the Global Fund. The names of some of the individuals mentioned in the report were changed for their protection.
Copyright © 2021 Politico Online
