NY Times Article: Contraceptives and HIV in Africa

Last week, the New York Times published a front-page article with the results of a study on the effect of contraceptives on HIV tranmission in Africa (sorry, I know I am now a week late on this post, but that’s how things work in Burkina Faso – slow). A recent study suggests that injectable contraceptives, which are widely used in Africa, may increase the risk of HIV transmission and infection. The hormones in the shot seem to have some physiological effect on women, although it is unclear what exactly that effect is and why it doubles the risk of transmission and infection. The study followed couples where one partner was already infected with HIV. In couples where the hormone shot was used, the uninfected partner was almost twice as likely to become infected with HIV during the two years of the study compared to those that did not use the shot. (The study also recorded condom use. Couples using another method of family planning are less likely to use a condom. However, researchers controlled for that and were able to eliminate that as a cause for the increased risk in HIV transmission and infection.) Although the study focuses on eastern and southern Africa, it still applies here in Burkina Faso. While the HIV prevalence rate in Burkina Faso (and West Africa) is much lower than it is in eastern and southern Africa, it is still present and people need to learn how they can protect themselves.

Family Planning in Burkina Faso
Family planning is a huge priority health initiative in Burkina Faso. Education and awareness are really important. During pre-natal consultations, I commonly see women coming in on their 9th pregnancy (although usually not all 8 children are still living). However, especially in a place where maternal and post-natal health care are sub-standard and women generally have to do a lot of physical work often very soon after giving birth, multiple pregnancies without appropriate spacing exhaust a woman’s body and increase the risk for complications. In addition, there are economic and social consequences if you do not have the resources to support all your children. The availability of family planning methods greatly increases the health of women as well as the economic and social dynamics of a community. At the end of the day, there are some people in Burkina Faso that understand the importance of family planning. But there are also some that don’t or don’t accept it and don’t want to talk about it. And even among those who understand the importance, it is hard to translate that attitude into practice for many reasons. There are always exceptions (positive deviants as we like to call them in Peace Corps). I have many conversations in the market about family planning. One man called me over, knowing I work with the CSPS (health center), to show me his wife’s health card and confirm her next rendez-vous at the CSPS for the next dose of the hormone shot. He was involved and supportive of his wife. I have others ask me about the different methods available and where they can go to get them. While I haven’t done much work on family planning in my first year, I definitely want to in my second year and these instances of openness are encouraging, especially knowing there will be just as many instances of restraint and resistance.

According to documents in my health center (CSPS), about 13% of women of procreating age use some method of family planning through the CSPS (hormone shots or pills). This number does not include those who use only condoms, which are available at the CSPS as well as the boutique/store and one of the bars in my village. This may seem low, but considering the cultural norms, access, and education, this is actually pretty good, although there is still much room for improvement. The injectable (hormone shot, what the article is talking about) is by far the most common family planning method used. It is a much more realistic form of family planning here. First – it’s once every three months instead of remembering to take a pill every day. Second, for women whose husbands are not supportive, they can do it quietly at the health center, without their husbands knowing. If she has to take the pill, it is much more likely her husband would find out. (Just to be clear, this is obviously not ideal. It is much more ideal for the men to be supportive and implicated in family planning, not just leave it as a burden for the women or even worse, prohibit it. However, we do not live in an ideal world.) It is always important to emphasize that neither of these methods protect against HIV – condoms do. So even if another method of family planning is being used, condoms should still be used as well. But again, in the case of a husband who refuses to use a family planning method, the shot at least does something. There are other methods of family planning, like implants and intrauterine devices, however those are not available at my health center, but in our district hospital.

HIV in Burkina Faso
The HIV prevalence rate in Burkina Faso, like most West African countries, is much lower than other African countries. Here are some HIV prevalence rates from UNAIDS.

Burkina Faso: 1.2%
Ghana: 1.8%
Côte d’Ivoire: 3.4%
Benin: 1.2%
Togo: 3.2%
Niger: 0.8%
Botswana: 24.8%
Kenya: 6.3%
Uganda: 6.5%
South Africa: 17.8%
United States: 0.6%

Education and awareness are really important in Burkina Faso, both to prevent future transmission of HIV and lower the present rate. There are many misconceptions and just total lacking of information about what HIV is and how it is transmitted. In addition, knowledge on prevention is low and there is still a stigma against those living with HIV. While I do not have a rate for just my health region, I would guess (and it seems to be confirmed through my observations at the CSPS), that it might be slightly higher than the national average because we are by a border and the mines in the region attract many young men from my village to live and work there. These factors and the social effects of them make the population more vulnerable to HIV.

Impact of the study
It seems like officials are trying to be cautious – rightfully so. Sending out alarm signals too soon on the number one family planning method could unnecessarily place women in increased risk. While it is certainly irresponsible to knowingly do something that makes a patient more vulnerable to HIV, the dangers of discrediting or warning against injectable contraceptives in Burkina Faso (I can only speak from my experience here, but it can probably apply elsewhere) are also quite serious. It may mean some women no longer use any family planning method, increasing unwanted and improperly-spaced pregnancies, which would in turn increase injury, illness, and death from complications in childbirth. However, it is just as serious if it is proven true; the public health sector here would have to immediately educate people about other safe forms of family planning and make them available in addition to continuing education on HIV prevention.

Bikes, Bats, and Burgers

So I’ve had quite an exciting past two weeks. After finishing the malnutrition training in my district capital, I biked back to site to leave the next morning to join the Burkina Faso Bike Tour. It was so much fun! The Bike Tour is a fundraiser put on by volunteers in Burkina Faso to raise money for gender and development projects. The tour went around the entire country, although I only did four and a half days of it. They passed by one of my satellite villages, so I joined en route to Beka. I finished the tour from there into Ouaga (the capital) to celebrate the 50^th Anniversary of Peace Corps. Definitely hard and exhausting, but like every other part of our service, we got through it together and had some fun on the way! We were greeted by a huge welcome ceremony when we arrived in Beka. Literally, the entire village must have come out for it. There were drummers and dancers and of course tons of people just staring at us (we were about 20 people in total). As well as people taking pictures of us with their cell phones (yes, there is no electricity or running water, but don’t worry, you can still take pictures with your cell phone). After our two host volunteers thanked everyone, we presented the chief, mayor, and prefet with certificates to thank them for hosting us. Then we split the men and women and did a health talk – malaria with the men, nutrition with the women. It was really cool how excited everyone was to have us there and a great chance to educate lots of people.

The next morning, we packed up at 4:30 am to leave at 5 am for Pô. I had a rough day because my gears broke and it wasn’t possible to repair them – so I biked most of the day on a gear setting that was way too low. But we did stop in Tiebélé, which although you probably haven’t heard of it, is actually a tourist site.   There are traditional Gourounsi houses and after discussing for 20 minutes a good price, we went to tour. They were really cool. One of the things I liked was the pictures and symbols painted on the outside of every house that represented different parts of their traditions. They also use the pictures to teach the children things like not to mess with snakes. The doors are really unique too – you have to crouch to get into the house because they’re really low. And then you have to hop down into the house. It used to serve as a protection against warriors from enemy tribes. Because you duck under and then have to go over another ledge to get in, you could see the head of the person before they fully entered. So if it was an enemy, you could chop off their head. I did not however like the bats in the houses. Apparently in their culture, bats are a good luck symbol. They teach kids not to tease the bats. We were inside a house and going into the back room. I was next to enter when someone said, “Hey wow, look at all those bats!” To which I said, “Yep, no way I’m going in there. I’m leaving.” But then I decided, what the heck, I’m in the Peace Corps to challenge myself. I’ve already overcome my fear of chickens, why not bats too. S o just as I crouched down to enter the really small doorway, a bat decided to fly out at the exact same moment. It flew by just centimeters from my face, to which I naturally screamed. But I made it in the room and stayed despite seeing at least five other bats hanging out there too. Although later I felt bad for screaming at the good luck symbol, I’m so glad that’s not a thing in the Bissa culture.

The next day was the longest bike I did – Pô to Léo, which wound up being 124 km (77 miles). But we kicked butt that bike ride! Luckily, I was able to trade bikes with someone leaving the tour, which made the rest of the tour much easier. We of course left ridiculously early (4:30 am), so it was still dark. My headlamp broke my first week at site (which I don’t mind because it makes my forehead too hot anyways), but it made biking in the dark challenging. The first stretch was through an elephant park that was beautiful. We had a gendarme (police) escort through the park and we were required to bike close together for a good 15 km, I guess the danger zone. I’m still not exactly sure how they could have protected us from elephants, but we sadly did not see any. I arrived in Léo around 12:20 and was greeted with a cold Coke. The highlight of Léo was the tofu brochettes.  So they usually sell meat on a stick here, called brochettes. But this entrepreneur in Léo, on his own, researched soya beans and what you can do with it. He found the recipe for tofu and tested it out in his market. It has become really successful. He has done this project with young women for them to have a source of income. Many of the young women use the money to pay school fees. So not only delicious, but also for a good cause.

The next day, we biked to Gallo, a small village, so definitely a change of pace from Pô and Léo, which are bigger towns. The bike was only 80 km, much easier than the day before, although still far. And all paved. In Gallo, we had a quick welcome ceremony at the school and then had time to just hang out and relax. Some of the neighbors decided to come over and dance, so we had a small dance circle and they were of course entertained by us attempting to join in. Gallo is in the Mossi region of the country (Mossi is the dominant ethnicity in BF). They have a traditional dance where they bump hips. It looks quite painful actually because they do it with such force. The Bissa (my region) are more into stomping, so I don’t know how to do this hip bump thing, but it was fun watching others try.

The last day, we biked into Ouaga, the capital city, as the start of the 50^th Anniversary Fair. That morning, the newest group of volunteers was sworn-in. We biked most of the morning in rain. We meet at the edge of Ouaga and had a police escort to the Maison de Peuple. They had sirens and everything and we were running all the red lights – super legit and official. We arrived however, and there was only one person waiting for us – the swear-in ceremony was still going on, so everyone was inside. We did get to shake hands with the Prime Minister. As he left the ceremony, we were all lined up waiting outside.

As a celebration to the end of the bike tour, we made burgers. So to you at home, this may not seem so special. But if you only understood the food here, you would understand why we took this task so seriously. We were divided into teams (strike forces) to buy ingredients. Then we made burgers. I was responsible for dishes (fun, right). There was quite a lot of planning involved in this. We don’t joke about a good burger here (because the ones you actually do find in Ouaga do not suffice). So we had our grill masters make the cheese burgers plus an assortment of toppings, including BBQ sauce, bacon, avocado, tomato, lettuce, onion, etc. I can confidently say it was the best burger on the continent of Africa. 

There is an official Bike Tour Blog. Check it out for more pictures, stories, and info. You can also still support us with a donation! All the money funds projects done by volunteers here in Burkina Faso.

The next two days, I was at the 50^th Anniversary Fair. It was really cool. The Fair Committee did a fantastic job with all of it. The Fair was a chance for volunteers to showcase their work and bring their association/community group to sell stuff, network, or sensibilize. Committees also had tables (that’s what I was doing, helping out with the Community Health and AIDS Task Force table. I’m on that committee). There’s a ton of great videos up on YouTube. I unfortunately can’t get the internet to download them that easily so will probably watch them in 10 months when I’m back. But you should check them out!

After the Fair, I went back to site for a week and am back in Ouaga now for a training of trainers. We are welcoming a new group of health volunteers to Burkina Faso on October 11 and I will be working at some point during their training.

I’m excited to get back to site. Between the nutrition training, Bike Tour, Fair, and training of trainers, I’ve been out of site the past 4 out of 5 weeks. And now that rainy season is almost over, as is harvesting, I can start picking up speed on projects. I am doing another FARN (rehabilitation program for moderately malnourished babies, the same thing I did back in May). The cool thing is I am working with the same counterpart from before plus two new ones who attended my nutrition training, so it gives me the chance to be more hands off and really empower them to have the confidence to do the program on their own (and ideally after I leave too…). We are doing it in one of my satellite villages. I also received some grant money to build 16 latrines, so will start that process again (although it should be easier the second time around). And as soon as school has started next week, I will be doing more health classes plus a pen pal program with the English class. Then in December, CHAT (Community Health and AIDS Task Force, which I am part of) is planning an activity for World AIDS Day, so I am involved in that. We are trying to get tons of volunteers to paint murals. We’ve done all the work to get the funding and will buy the materials, to make it as easy as possible for volunteers. So I will be doing a mural in my village and helping other volunteers do murals. Sounds like I’ll be busy, but a welcome change of pace. That’s just how Peace Corps goes – your first year is slow, the second is packed.

Wow, I know, super long update. I’ll be here until Saturday and then back the next weekend for meeting, so I’d love to hear from you (e-mail, facebook, gchat if it loads with my super slow internet, whatever works). Miss you and hope you’re doing well!

Erika