HIV, AIDS and THE PUBLIC HEALTH SECTOR IN MOROCCO (3)
Prof. Dr. Abdessamad Dialmy
University of Rabat, Morocco
III- Management of STIs and AIDS patients
This third section will deal with the syndromic approach in the management of STIs before moving to the access to care and psychosocial support for AIDS patients.
III-1 Management of STIs
First, one should state that the statistics on STIs were absent before 1991. This year, 50 567 STIs cases were registered. This number reached 307 040 in 2000 and 600 000 in 2004. Thus, the statistics of STIs are a result of the impact of HIV-AIDS epidemic on the policies of the ministry of health. Because STIs are the bed of AIDS, the knowledge of their prevalence in order to prevent and treat them belongs to the adoption of the second-generation surveillance.
All types of STIs exist with a majority of leucorrhees and uretrites. Women infected by STIs other than AIDS are more numerous than men and their proportion is increasing: 63% in 1991 and 79.5% in 1994.
How are STIs combated by DELM/PNLS? These institutions launched the syndromic approach since 1997 to avoid an expensive etiological diagnosis as well as any risk of a wrong clinical diagnosis. This approach avoids laboratory analyses, which are expensive, and avoids the risk of the sick not coming back after a first clinical diagnosis or after been asked to do some biological analyses. This approach means that the patient has to be immediately and freely treated of all-important causes of the syndrome. The treatment is supported by education (counseling, condom, and information for the partner…). Syndrome approach could be summarized in four stages: clinical history, clinical exam, administration of a treatment and education (condom…). In principle, this approach permits primary health care services to take STIs in charge.
According to a declaration of the ministry of health (ONUSIDA 2001), the implementation of syndromic approach since 2000 embraced all regions of the country, especially in terms of supplying specific medicines. This statement is not realistic in the sense that medicines are still unavailable in public structures according to several testimonies sourced through informal interviews. But it also means that before 2000, STIs were not completely taken in charge. This situation is due to three factors:
1) the cultural resistance of population to seek care for STIs.
2) the insufficiency of the sanitary structure and the unacceptability of care in the public sector.
3) the insufficiency of the medical insurance and the financial inaccessibility of the private sector
As an indicator of fornication for an extensively illiterate population, STIs constitute an extreme taboo issue to the point that the sick rarely bothers to even try to take care of himself/herself. Because of shame, there is sometimes auto-medication either by the use of plants or by the consumption of medicines that drags in the house or at a friend's. About 50% of STI carriers use auto-medication (Jrondi 1998: 298) encouraged by sellers in the pharmacies (Ministry of Health 1887: 11). In a lot of cases, sellers in pharmacies deliver medicines to the sick without medical prescription. In this way, the sick make savings and avoid the embarrassment of being examined by a physician. In spite of several and varied resistance toward consulting a physician, the general belief claims that modern medicine alone can treat STIs efficiently. But according to a nurse, seeking medical care starts only when the illness has worsened (Dialmy and Manhart 1997: 86).
In the case of minors, its more difficult. Indeed, according to the Moroccan legislation, minors cannot benefit from care or medical treatment without the downstream of their parents or legal tutors. Health professionals are obliged, except in a case of emergency, to procure parental consent. No medial act on a minor is therefore legally foreseeable without the knowledge and consent of the parents. In the case of minors, the medical power and the medical secret fade away when facing the parental authority. In practice, and in the interest of minors, several nurses accept to take them in charge and to respect of their privacy, but they risk being pursued if a problem results. Evidently, the downstream of the parents poses more problems in the case of the STIs. One could not imagine easily a teenager telling his/her parents that he/she has a STI. The communication on sexuality between parents and their progeny is traditionally unconceivable, especially between the father and his progeny. It would be necessary to think, therefore, how to review the law in order to allow nurses to take minors in charge without the consent of parents in the case where a health problem concerns their sexuality.
On the other hand, insufficient services are a major obstacle for treating STIs. Sanitary condition in the remote rural areas and the expensive medicine are often evoked by the population (Dialmy and Manhart 1997: 118-119). In spite of efforts undertaken to improve sanitation in rural areas, 31% of the rural population live further than 10 km from the nearest health care centers and 47% spend in the minimum about one hour to reach them (CERED 1999). The physical inaccessibility of the different health structures contributes to their weak utilization by the population. Thus, in 1999, the rate of medical consultation in public health centers didn't go beyond 0.4 contacts per capita and per year, while the rate of bed occupation did not exceed 56%. The weak recourse to public health services (CERED 1998), notably in rural areas (49% against 68.4% in urban), can also be explained by the cultural resistance to dispensed cares. It starts with a poor welcome (a long wait and neglect) and continues with the speed of the exam, the absence of discretion and privacy, the absence of communication and the prevalence of corruption (Dialmy and Manhart 1997: 126-130). In certain cases, women refuse to be examined by a male physician and men by a female physician. The nurses themselves recognize that conditions of welcome and care are depressing (Dialmy 1997: 14). Consequently, according to a study on the quality of managing STIs in the public sector, only 2% of the patients received correct information about their disease whereas 84.5% affirmed that the physician didn't give them any explanation on the cause. Only 13.9% of male patients and 2% of female patients were adequately treated (Ministry of Health 1997).
The absence of medical insurance has, of course, a negative impact on access to medical care. Indeed, access to medicine is still quite difficult for different social strata even though the cost of medical care in Morocco is about 30% cheaper than in the European countries. The average rate of medicine consumption doesn't exceed 18 $US per capita and per year (against 36 $US in Algeria, 280 $US in France and 400 $US in Japan). Results of a survey (UNICEF 1997) show that the provisions of medicines in health centers did not provide more than 15% of what the population needs. The availability of medicines is only $0.40 per capita and per year whereas the registered credits to the title of the budgetary exercise 1997-98 foresees an equivalent endowment per capita to $1,30 DHS. The average varies between $0.23 and $0.85.
of the weakness of the patients’ spending power, the population bought 65% of prescribed medicines. This indicates the interest of the population in medical care on the one hand, and on the other hand, its strong disposition to contribute to its financing. In fact, medical care expenses supported by households constitute 55% of the covered medical expenses. Moreover, medicines occupy the first position (65%) in the global medical consumption of households.
III-2 Access to care for HIV-AIDS patients
In 2001, only 100 infected people benefited form the trio-therapy. 70 benefited from the budget allocated to this effect by the ministry of health (400 000 $US) and the support of the International Therapeutic Solidarity Fund (270 000 $US). 30 others benefited from the social security of the trio-therapy. The cost of trio-therapy was at this period 650 $USS per person per month and 7 800 $USS per year. 140 people requiring a trio-therapy were excluded from it.
Since February 2003, patients requiring ARV have access to it thanks to the grant of the Global Fund. The initial prescription and the ulterior modifications of the treatment with ARV are made at the level of the poles of excellence. As for to the centers of reference, they assure medical follow-up (visits, numeration of the CD4 and measure of the viral load, opportunist infection treatment) and regular provision of patients with ARV. For instance, the center of reference of Marrakech began to play a more important role in managing people living with HIV in the region. The number of people who are followed up there continues to grow, from 11 patients in 2003 to 71 in 2004. In this way, the rate of patient displacements, often expensive and laborious, to the pole of excellence of Casablanca has been appreciably decreased.
Before 2003, the trio-therapy cost more than $600 per patient per month. Thanks to negotiations led by laboratories, it only costs $100 per patient per month. However, after the signing by Morocco of the free exchange agreement with the United States, perspectives changed. This agreement forbids the importation and manufacture of the generic drug, implying more payment for the ARV. The consequence is the impossibility to perpetuate the generalization of the ARV. On January 13, 2005, Moroccan Parliament endorsed the legal project n° 28-04 approving the principle of adoption of the free trade agreement between Morocco and the United States. The text collected 55 voices for and a voice against, emanating from the GSU (Unified Socialist Left) as well as 23 abstentions of the PJD (the fundamentalist political party). President Bush described the free exchange agreement between Morocco and the United States in March 2, 2005 in a message addressed to the American Congress: “This agreement contains the protective degree of high intellectual property, ever gotten in a free exchange agreement with a developing country”. The American Congress adopted the agreement on July 21, 2005.
The American government is anxious to sign this kind of agreement in order to be able to set up its own policy in the international management of AIDS. For the year 2004, the American Congress granted President Bush only $2,4 billions to be dedicated to the Presidential emergency plan against AIDS. This money won't be given to the Global Fund. It will be employed in the bilateral programs of USA in order to help countries that accept programs of struggle against AIDS conceived and elaborated by the American government. These programs impose to use medicines which are produced by American laboratories. Therefore, the free exchange agreement with Morocco is a defense of the American pharmaceutical industry. Besides, the American policy insists on a prevention based on abstinence and fidelity and not on the promotion of condoms. In the same way, it doesn't foresee programs of intended risk reduction among sexual workers and IDUs. In one word, it seems to be a very conservative policy. Also, the American government doubted the efficiency and security of the ARV, notably combinations of stationary doses (3 ARV in 1) having been yet pre-qualified by the WHO and MSF. However these combinations are less coercive for patients and therefore perfectly adapted to patients in poor countries, thanks to the simplicity of their utilization.
III-3 Psychosocial management of persons living with HIV
The psychosocial management of persons living with HIV is mainly assured by NGOs. For instance, ALCS especially provides help to people living with HIV. It grants emergency financial support to poor patients by taking over transportation and feeding expenses. Its volunteers assure daily services for infectious diseases in Ibn Rochd hospital in Casablanca. These volunteers listen and respond to the needs of hospitalized people. The reception of non-hospitalized persons is assured while a legal and administrative aid is granted to Moroccan migrants in Europe. At the level of medical treatment, ALCS provides 80% of other medicines, besides the anti-retroviral, that are necessary for the treatment of opportunist infections that complicate AIDS. Among other activities of ALCS are: sponsorship of medicines, documentation, animation of conferences, free distribution of condoms, bus Info, the telephonic permanence, and informative seminars. ALCS also provides a therapeutic accompaniment at the hospital Ibn Rochd of Casablanca where a team of volunteers are available three times per week to help and to counsel patients involved benefiting a trio-therapy, to take their medicines correctly, despite daily constraints, and to manage the secondary effects of it.
All these activities show that “the only NGO working on all aspects of the AIDS epidemic in Morocco is ACLS” (Schuette 2003). This positive image of ALCS came out in an exploratory investigation with people living with HIV (Cakir 2003). The investigation, which we directed, took place at the Ibn Rochd hospital in Casablanca; in the zone of the ALCS in Tangier, and in the zone of OPALS-Maroc at Rabat.
Indeed, patients discern from services in Casablanca and Rabat a preservation of anonymity and confidentiality. “The only place where I can communicate is in the service at Casablanca” affirms a sick. Another patient testifies in favor of OPALS at Rabat: “OPALS is always there and I can go there when I want to tell them of the small details of my life. I always find someone to whom I can talk”.
People living with HIV and more especially women accord a primordial importance to the existence of these associations. The zones of the associations constitute the only place where they can express themselves freely without fear of dismissal. Finally, the associations’ personnel, by their advice, their capacity to listen, and their psychological support represents for these isolated people an inestimable source of comfort.
HIV and AIDS are not faces of a visible social identity. The stigmatization, the discrimination and the exclusion of HIV victims result in their invisibility. No movement or group claims public expression for HIV+ or AIDS patients. Even though there is a popular distinction between “good sick” (victims of blood transfusion for example) and back sick”, HIV and AIDS remain correlated to prostitutes, IDUs and homosexuals (bad sick) in the Moroccan daily thought. Even though “the interpretations of the AIDS proceed from an opposition between “endogenous risks” and “exogenous risks” (Paicheler and Quemin 1994), AIDS is still perceived as God's punishment on the personal mistake and the unhealthy life style (endogenous risks), that is to say sexual perversions. Certainly, HIV is invested in the explanation of the pathology but it is coated in a global understanding of the disease as cruelty and as God’s intervention toward social regulation.
This social representation of AIDS is implicitly adopted by health policy makers and Moroccan associations when they continue to use the epidemiological category of “at-risk groups”. This notion is founded on moral and religious presuppositions. Indeed, it assumes the social perceptions that make AIDS a divine punishment, the punishment that God inflicts on the deviant and risky groups. One of the first tasks that imposes itself on policymakers in Morocco is how to replace this moralizing notion of “at-risk groups” with the notion of “risky practices”. This one avoids the paradigm of deviance and makes people aware that HIV risk concerns the day-to-day life of everybody. This notion refers to the individual with the aim of making him/her responsible without stigmatizing any particular group.
Otherwise, the Moroccan conception for prevention never tries to fight for the legalization of non-marital sexuality, homosexuality and the use of the drug on the grounds of human rights and individual freedoms. It works in the setting of the established religious values. However it is demonstrated that the criminalization of these practices is a serious obstacle to the success of preventive measures. In one word, sexual disempowerment (Herdt 1997) of individuals effects the spread of HIV/AIDS. So, one can wonder if the Moroccan management of HIV favors the transformation of social norms.
In what measures can associations precede institutions in this direction to modify representations and the relative attitudes toward non-marital sexuality, homosexuality and use of drug? In what measure can the associative action lead to the legal recognition of these practices in order to better protect those at risk of HIV? Because one can objectively suppose that the promotion of the condom alone is insufficient to modify the traditional representations of sexuality. But first are the NGOS conscious of this strategic stake; the secularization of sexuality as the best way for its protection? Currently, one must note that the dependence of NGOs on the state and political parties explains that the secular option is muzzled as public opinion. In other terms, the existence of associations in Morocco is not a veritable proof of the existence of a civil society. A real civil society is necessarily secular. It is the society in which the man is freed of religious tutelage. It is the society of the adult citizen that chooses his/her religion freely (or his no-religion) without that the state intervenes in this choice.
It is necessary to conclude therefore that the Moroccan institutional and associative fight against AIDS is currently at the technical stage. At the level of prevention, it is about simple IEC action that does not attack the ideological foundations of the state and the society. For this reason, one can wonder on the real impact of this IEC action on behavioral change of the population. But the transition to curative measures, thanks to the Global Fund, risks bringing the social representation of HIV/AIDS in the paradigm of chronicity and to make (people or government?) forget that the best prevention resides in the socioeconomic invulnerability of the individual, in his/her responsibility and in his/her liberty of choice. The new notion of chronicity can reduce AIDS to a question of access to care. Consequently, the risk is to forget that the real stake is to build a health system that fairly allows access to care for all the sick, but which also act in the direction of the modernization of the Moroccan daily thought and its development.
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 This level of consumption didn't change since 1995 according to acts of Journée de l'Association Marocaine de l'Industrie Pharmaceutique, Casablanca, 29 juin 2000.
 The North excellence pole is constituted by the service of Medicine A in the Ibn Sina hospital at Rabat. It covers the North zone of the country. The South excellence pole is constituted by the service of the Infectious Diseases of the hospital Ibn Rochd at Casablanca. It covers the South zone of the country. These two poles of excellence work in cooperation with regional reference centers.
 The Centers of reference are situated in the Regional Hospitable Centers and in the military teaching hospital Mohammed V at Rabat. They have referent physicians for the management of HIV/AIDS. In the South region, these centers are represented by the regional hospitals of Agadir, Safi, Marrakech, El Jadida, Beni-Mellal et Laâyoune. In the North region, they are represented by the regional hospitals of Tangier, Tetuan, Fez, Meknes, Oujda et Kenitra.
 MSF : Médecins Sans Frontières.