- In the deeply conservative Muslim society of the Red Sea state of Djibouti, HIV-positive people wear their status as a cloak of shame.
"Being HIV positive is like having death glued to your skin - it's difficult to forget," said Kadidja Mohamed, 28, whose husband divorced her when he discovered she was HIV-positive, leaving her and her three-year-old child to fend for themselves.
Since learning of her status, she has been cared for by the country's Centre for Social Protection, a group of 25 doctors providing treatment to HIV-positive people.
Djibouti has a population of some 700,000 people and a prevalence rate of around three percent, but only 480 of the estimated 10,000 people living with HIV are accessing life-prolonging antiretroviral therapy, according to the government.
Ebass Moussa, a psychological counsellor at the Yonis Toussaint Centre, a mobile HIV/AIDS referral facility, noted the serious problems of stigma and discrimination. "The family finds it difficult to live with this situation of having a close relative infected with HIV; the first instinct is to reject the patient, who suffers a lot from this."
Another advisor at the Toussaint centre, commented, "At the discovery of their HIV status there are many diverse reactions: some patients do not acknowledge the results and disappear, others are depressed, the most emotional are not easy to handle."
The centre teaches HIV-positive people how to live positively with the virus, and that it is not necessarily a death sentence. The family is also given counselling to help them accept the diagnosis and provide moral support to their infected loved one. Part of his job, Moussa explained, was to break down the shame of discovering one's relative was HIV-positive. "We reconcile the two through dialogue sessions during our house visits."
French and American military bases in Djibouti have contributed to the growth of a large commercial sex industry, heightening the risk of a rapid growth in infections. The strategic location of the tiny country's port also means that trucks from neighbouring Ethiopia frequently pass through, further fuelling the commercial sex industry.
Another trend hastening the spread of HIV/AIDS is that most Djiboutian men chew 'khat', a popular stimulant that often leads to risky sexual behaviour, while cultural traditions, such as female genital mutilation, which is widespread in Djibouti, put young girls at risk of contracting the virus.
The government, the United States Agency for International Development and the French Development Agency have started multisectoral programmes targeting the military, the youth, women and other vulnerable groups in an attempt to lower the spread of HIV.
In December 2005 President Ismail Omar Guelleh recognised that continued denial of the seriousness of the pandemic was fruitless, saying, "I would like to ensure the support of the whole national community to break this silence and construct a favourable environment."
Omar Ali Ismail, executive secretary of Djibouti's Programme to Fight AIDS, Malaria and Tuberculosis, noted that "The awareness campaign was strongly developed through countrywide fixed and mobile media campaigns in order to promote behavioural change.
"The result today is that the ignorance on modes of transmission is over. The condom, which encountered some resistance from religious institutions, who continue to criticise it as an agent of promiscuity, has been welcomed by the youth," he added.
Moussa said the country's HIV-positive people needed a "complete package", incorporating psychological, nutritional and medical support. There are now 11 treatment centres, all located in the capital, Djiboutiville, and 25 testing centres, of which 19 are also in the capital.
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