HIV, AIDS and THE PUBLIC HEALTH SECTOR IN MOROCCO (1)
Prof. Dr. Abdessamad Dialmy
University of Rabat, Morocco
This paper deals with the AIDS epidemic in Morocco, the institutional response to that epidemic and its limits. It divides in three sections.
The first section tries to describe the AIDS epidemic in Morocco (evolution and distribution) and to expose the responses to this epidemic while presenting institutions and NGOs that manage it, their plans and programs, their financing and their performances. The official data indicate a low prevalence (less than 1%) but the impact of HIV on the development of the health sector, both institutional and associative, is remarkable. A good cooperation exists between institutions and thematic NGOs in the management of the epidemic. This cooperation was a critical factor in its acceptance by the Global Fund of the Morocco’s proposition for supporting the implementation of the National Strategic Plan. The approval of the 2nd slice confirms the recognition by the Global Fund of the expanded efforts for the implementation of the program. These efforts continue to make Morocco a model for MENA region.
The second section deals with the question of the prevention through three indicators, the IEC campaigns, HIV testing and the use of condoms. It presents some aspects of the IEC national campaigns and especially analyzes the popular reticence and resistance toward HIV test and the use of condom. It concludes by a brief overview on the structural vulnerability in Morocco. The question that arises in this section is how can we measure the impact of the social communication campaigns on the social representations of HIV/AIDS, on the attitude toward HIV test and toward the use of condom. The condom is still an object of multidimensional resistance. It is not only condemned by popular opinion and traditional jurist, but also to some extent by the official health system itself.
The third section treats the question of the management of Sexually Transmitted Infections’ patients and people living with HIV. This question has a double dimension, the first is the access to care and medicines; the second is the psychosocial accompaniment of patients. STIs are not completely taken in charge. This situation is due to three factors: the cultural resistance of population to seek care for STIs, the insufficiency of the sanitary structure and the unacceptability of care in the public sector, the insufficiency of the medical insurance and the financial inaccessibility of the private sector. Regarding AIDS patients requiring trio-therapy, they have access to it since February 2003 thanks to the grant of the Global Fund. 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. As for the psychosocial management of persons living with HIV, it is mainly assured by NGOs. The zones of the NGOs constitute the only place where HIV+ and AIDS patients express themselves freely without fear of dismissal.
The paper concludes by some recommendations. The main one is that 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. This struggle is necessary because of the sexual disempowerment of individuals effects the spread of HIV/AIDS. Finally, one could fear that the transition to curative measures, thanks to the Global Fund, risks bringing the social representation of HIV/AIDS in the paradigm of chronicity. The result could be a neglect of the prevention and its definition mainly as the socioeconomic invulnerability of the individual, as his/her responsibility and as his/her liberty of choice.
Keywords : cares, communication, HIV-AIDS, institution, management, medicines, NGOs, prevention, program, vulnerability.
In Morocco, HIV and AIDS constitute a national curse that impact the health sector, which begins to develop and organize itself within institutions and programs that aim to promote sexual health, especially understood as prevention and treatment of HIV/AIDS. But as Information, Education and Communication (IEC) with HIV risky groups like prostitutes and homosexuals cannot be an official and public objective of the public policy in a Moslem country, the involvement of civil society became necessary and unavoidable. Indeed, from the beginning of the epidemic, some national NGOs were created to help in managing the HIV/AIDS epidemic and especially in dealing with the non recognized risky groups. The impact of HIV-AIDS is clear: at least, it led to the creation of new policies and programs within the current health institutions but it also showed the limits of those institutions, the necessity to involve other arms of government, and to create new thematic NGOs.
The definition of a public sexual health policy in Morocco, a young democracy with an old Islamic tradition that opens up progressively on human rights, is not a comfortable task. This health policy, necessarily multi-sectorial, resembles the Moroccan politics and oscillates between modernity and tradition, freedom and repression, God’s rights and human rights. Indeed, the set up of the policy tries to combine between persuasion through IEC and the defense of individual liberties on one hand, with the repression of non marital sexuality, prostitution, homosexuality, forced HIV test of at-risk groups on the other hand.
In the political unconscious, a correlation is established between AIDS epidemic and the so-called risky or vulnerable groups and between these groups and the poor milieu. Even epidemiological data do not systematically support this correlation. Without the intervention of NGOs, the correlation AIDS/poor milieu, besides the fragility of the young democratic experience, would lead to a repressive and coercive management of the epidemic. The collective action of NGOs is the main channel through which the paradigm of citizenship and human rights of the sick is heard. Further, those NGOs at least participate in the elaboration of the public sexual health policy. It is thanks to their pressure that AIDS became, in spite of its weak prevalence, one of the priorities of the Ministry of Health. Some public tasks are reserved for them: preventive advertisement, HIV testing, counseling through the national listening telephonic line, research funding, distribution of medicines and condoms. Thus, “the public powers consecrated the status occupied by the movement for struggle against AIDS in the implementation of a struggle policy against the epidemic” (Thiaudière 2002: 39).
This paper divides in three sections. The first tries to describe the AIDS epidemic in Morocco (evolution and distribution) and to expose the responses to this epidemic while presenting institutions and NGOs that manage it, their plans and programs, their financings and their performances. The second section deals with the question of the prevention through three indicators, the IEC campaigns, HIV testing, the use of condoms to conclude on the necessity to fight the structural vulnerability. The third section treats the question of the management of Sexually Transmitted Infections’ (STI) patients and people living with HIV. This question has a double dimension, the first is the access to care and medicines; the second is the psychosocial accompaniment.
I-AIDS Epidemic, Institutions, NGOs, and Programs
What is the AIDS prevalence in Morocco? How did the epidemic evolve? Which groups are most affected? How was AIDS institutionally managed from the beginning of the epidemic? What is the identity of the thematic NGOs and what role have they played in the management of AIDS epidemic? These are the questions that will be addressed in this section.
I-1 A Low Prevalence
What is the epidemiological situation of AIDS in Morocco? The answer to this question cannot be completely exact because the quantification of the epidemic is difficult for two reasons: the first is the insufficiency of the anonymous and free HIV test centers and the second is the immoral (illegal), and therefore difficult to quantify, character of some modes of transmission. For instance, the homosexual mode leads to a differential and more serious social condemnation. These two reasons mean that HIV and AIDS cases are not all diagnosed. However, the ministry of health (Ministry of Health 2001a) states that from 1986 (when the diagnosis of the first case of AIDS in Morocco was made) until 30 June 2001, 879 accumulated cases of AIDS were counted. These cases are mainly correlated with males (65%), 20-39 aged (44%), bachelors (39%), urban (88.5%) and heterosexuals (68%).
A year and half later, 234 cases were recorded bringing the number to 1113 by December 31, 2002. Six months later, there were 1237 AIDS cases, making it an increase of 16.7%, a striking development when compared with the rate of the spread in 2002. The transmission mode predominating stays the sexual transmission in 82% of cases (73% heterosexual and 9% homosexual). In 2003, the prevalence is 0.09% for STD patients, 0.12% for pregnant women, 0.5% for patients with tuberculosis, and 0.02% for blood donors.
In June 2004, the number of cases reached 1442, out of which 62% were males. 84% of these cases were concentrated in the cities. The age distribution was as the follows: 2% for those under 15 years, 25% for those between 15 and 29 years, 44% for those 30 to 39, and 12% for those 40 to 49 years. 75% of the patients were heterosexuals, 5% were homosexuals, 4% were bisexuals, 1% was contaminated through blood transfusion, 2% from intravenous drug injection, and 3% were perinatal cases (mother-child transmission). Six months later, being December 2004, 1587 of accumulated cases were recorded.
In 2004, the system of surveillance was extended to embrace sexual workers and prisoners. The prevalence is 2.27% among sexual workers and 0.83% among prisoners. 0.13% were pregnant women and 0.23% were STD patients.
The first years of testing (1986-1990) found most positive results among foreigners, returning citizens, or those infected through blood or blood products. Now the patterns are shifting and a rising proportion of cases are resulting from sexual transmission, especially through heterosexual contacts. The rate of infection among women exploded veritably, increasing from 8% in 1988 to 38% in 2001. Transmission among Intra-venous Drug Users (UDIs) is more common at Tangier while homosexuality remains the transmission mode dominating at Marrakech.
At the level of HIV+, the last official data suggests that their number oscillates between 15 000 and 30 000 people.
These data indicate a low prevalence. Indeed, “the AIDS epidemic has yet to impact Morocco in the same manner that AIDS has devastated neighboring sub-Saharan countries” (Schuette 2003). Does this low prevalence of AIDS explain itself by supposedly Moroccan immunological and constitutional specificity? Does it refer to the hypothesis that male circumcision is a factor of reduction of the HIV infection? Does it refer only to a under-declaration, especially in the private sector? Indeed, most the declared cases are by physicians of the public sector and very few physicians of the liberal sector declare their patients. What is paradoxical in a country where more of the half of the population seek medical cares in the liberal sector. In addition to these hypotheses, the difficulty of access to taking a HIV test because of its non-availability in all regions explains certainly the under-diagnosis. Besides, only the AIDS cases are obliged to be declared. The declaration of seropositivity is not obligatory.
The weakness of AIDS prevalence in Morocco is definitely amazing because factors of HIV propagation are very present and varied enough. These factors are mainly reflected in: the wide prevalence of STIs, the growing sex work industry, drug use, sexual exploitation, the paucity of the use of prophylactics, multi-partnership, homosexuality, precarious economic conditions, periodical return of Moroccan workers (in Europe), wild urbanization, international exchange and tourism (largely sexual), subordinate feminine condition.
Furthermore, the low prevalence can be ascribed to either the lack of official recognition of the real numbers for national considerations (the national honour) or to religious considerations (the denial of the existence of AIDS in Moslem Morocco) or to economic considerations (not to scare off the tourist). But, some Moroccan medical authorities affirm that the official low prevalence is true. They relate the low spread of the pandemic to the distinction between two types of HIV: one that spreads essentially through sexual relations and another that spreads through blood, especially among IDUs. These medical authorities hold that the type of virus that has spread in Morocco is the type that passes through blood, the fact that explains the low prevalence of infection because the consumption of drugs by syringes is a phenomenon that has not yet reached a level of spread that allows it to become the major mode of transmission.
Despite the low prevalence, Morocco belongs to the second level which “consists of those countries with a gradually growing accumulation of infections and at least some high-risk groups identified” (Jenkins and Robalino 2003: 19). Thus, despite the low prevalence (less than 1%), the impact of HIV on the development of the health sector, institutional and associative, is remarkable.
I-2 Institutions and NGOS
Between 1987 and 1988 the Ministry of Health created an AIDS program under the Direction of Epidemiology and the Struggle against Diseases (DELM). In 1986, a setting up of a management cell and constitution of a technical committee of struggle against STIs-AIDS was established.
In 1991 a working group was created, including Ministry of Health, USAID, WHO and ACLS (the sole Moroccan thematic NGO at this period). The group operates under the name: Programme National de Lutte contre le SIDA (PNLS). In this context, some important measures were taken such as: the agreement to sponsor medical costs, the exploitation of blood grants to exercise the serological testing, the setting up of a system of STIs-AIDS notification, the financial support to infected people, the production of information media, and the organization of information campaigns. Another objective of the PNLS was to take free charge of patients and to provide information (on IEC policy), with a focus on more vulnerable populations such as soldiers, migrated workers, prisoners, hotel employees, and drug addicts.
Between 1991 and 1994, integrated programs of STIs and AIDS were promoted. These programs aimed at the institutionalization of a system of epidemiological STIs-AIDS surveillance. Inaugurating these integrated programs would seem to suggest that surveillance in Morocco has evolved into second-generation surveillance, which precisely includes STIs surveillance and behavioral surveillance. Earlier surveillance recommendations were for serology only. Behavioral surveillance of at-risk groups, constituting the second aspect of the second generation surveillance, seems to be more difficult to launch officially. So this aspect of surveillance will be delegated to national NGOs like ALCS and OPALS-Maroc.
Moroccan Association of Struggle Against AIDS (ALCS) is the first thematic NGO founded in 1988 when only 30 AIDS cases were recorded. It was recognized as a public utility in 1993. It has initiated some laudable efforts aimed at bringing the attention of Moroccan populations to the problem of AIDS through radio, the press, and through conferences. It undertook a sensitization campaign that targeted secondary school students and produced audio and visual cassettes with messages on AIDS to female prostitutes (UNFPA 1997: 32). The ALCS aims, in particular, targets not recognized by the public authorities such as prostitutes and homosexuals. In 1990, it had enlightenment projects addressed to homosexuals in Casablanca and Rabat (Imane 1994 : 1). But, the absence of a gay community that assumes itself and that is self coordinating made the task more difficult. Consequently, ALCS dealt mainly with male prostitutes because those are the most visible exhibition of homosexuality in Morocco. For that reason, Morocco appears to be the first country in the region to have developed HIV prevention programs for male sex workers. Also, in the 1990s, ALCS created centers for anonymous free testing in Agadir, Casablanca, Meknes, Rabat and Tangier. By mid June 2005, ALCS had established 16 stations in the national territory.
OPALS-Maroc is another important thematic NGO. It was created in 1994 with the mission of contributing to the improvement of the access to care for vulnerable persons. It has 14 stations (Tetouan, Tangier, Fez, Marrakech, Casablanca, Settat, El Kalaa, Taza, Beni Mellal, Azrou, Essaouira, Khenifra, Agadir, Laayoune). Its national bureau is based at Rabat. In partnership with the ministry of health, Opal-Morocco created 14 Centers of Ambulatory Treatment (CTA) in 14 cities. The CTA has a light structure that offers a whole range of services like consultation, counseling, HIV testing and prevention, treatment of STIs, management of people living with HIV, psychosocial support, treatment of opportunistic diseases, and the accompaniment of patients to hospitals.
The involvement of the civil society is crucial. Indeed, it is thanks to the work of various associations that the struggle against AIDS is one of the priorities of the Ministry of Health. However, those associations do not constitute a philanthropic movement because of the fact that being infected with HIV, stigmatized as a deviant, do not predispose infection with HIV to be an object of charity. Therefore, it is necessary to define these associations first as mediators between the institution (Ministry of HealthDELM/PNLS) and patients, then as of under-administrators of the HIV epidemic, thanks to their implication in the prevention and cares. Their main stake is to be recognized by the institution as the spokesperson of victims of HIV. Thus, there is no confrontation between NGOs and sanitary and political authorities in the measure where associations respect the red lines drawn by these authorities: the defense of people living with HIV does not lead the NGOs to the defense of premarital sexuality, prostitution and homosexuality.
These NGOs are solely thematic in the sense that they are concerned with the AIDS theme in general. No NGO constitutes itself by addressing the needs of infected people of a precise type, example, the transfused, or drug users, or homosexuals, or prostitutes. No NGO is specialized in the management of a precise group of HIV+ or AIDS patients. So they do not defend or represent a particular stigmatized group concerned with HIV-AIDS; for instance, sex workers, MSM (Men having Sex with Men), or UDIs. Each of the NGOs tends to represent the maximum number of seropositive and sick persons. The Moroccan NGOs in the struggle against AIDS differ between them only by the degree of their dynamism. Consequently, the strength of the NGOs comes from the fact that they have not been founded by people living with HIV. These people are absent from the social scene and from the political field: they are invisible.
The strength of these thematic NGOs is also determined by their proximity to the political power. Indeed, the Moroccan NGOs are generally “tools of integration, through the elitization of new strengths of change, in the circuits of the state" (Al Ouazzani 1987). In other words, the association provides another way of doing politics; that is, another way of gaining a pseudo-political status and influence thanks to the struggle against AIDS. The advantage of this strategy is that “normal” and healthy people can be involved in the struggle against AIDS. Further, a part of the elite can be involved and is effectively involved. This fact also explains why there is a remarkable cooperation between DELM/PNLS and civil society.
I-3 PSN, Global Fund, Moroccan Committee of Coordination
In 2001, a Strategic National Plan of Struggle Against AIDS (PSN) was adopted (Ministry of Health 2001b). This plan is based on two major axes which are the prevention of HIV and the treatment of STIs patients and Persons living with HIV (at all the phases).
The set up of this plan necessitated a co-ordination between the health department, other governmental departments, UN agencies, and NGOs. Initially, all these institutions worked together in setting up the thematic group ONUSIDA. Later, in February 2002, the Moroccan Coordination Committee (CCM) was created from the thematic group ONUSIDA for the purpose of fulfilling the requirements of the Global Fund. Morocco’s proposition for supporting the implementation of the National Strategic Plan (PSN) was the only one approved in the MENA region in June 2002. The acceptance of the Moroccan proposition is the result of a good dialogue between the PNLS, NGOs and other ministries in the struggle against AIDS. The acceptance of the national proposal means also the institutional strengthening of CCM.
The initial composition of the CCM was constituted from a hard core represented by the thematic group ONUSIDA that has been functioning actively since 1999. This thematic group includes representatives of the PNLS, thematic NGOs, the UN system and other international partners. Since the signing of the proposition of the support program for the struggle against AIDS, the CCM has been widened in order to incorporate new partners from the private sector and some governmental departments like education, youth, and Islamic affairs.
The CCM is composed of 7 beneficiary members of the Global Fund. The Ministry of Health (DELM/PNLS) is the main beneficiary. ALCS AMJCS, AMSED, LM-LMST, OPALS-Maroc and the Secretariat of state for Youth are the under-beneficiaries. Among the other ministerial departments represented in the CCM was the Ministry of National Education. This led to the creation of several health clubs in schools that give also some notions of sexual education. The incorporation of the Ministry of the Islamic Affairs is fundamental in islamically legitimizing all PSN actions, especially the promotion of the condom. Let's recall here the critics of some fundamentalist who are against the promotion of the condom by the Ministry of Health and who accuse ALCS to be a Zionist organization.
A unit to manage the program of support of the World Fund was created to serve as the secretariat of the CCM. This unit guarantees the diffusion of information among members of the CCM for follow-ups and for the implementation of the program. It also prepares the quarterly meetings of the CCM, elaborates on minutes and ascertains their diffusion by different means of communication (email, fax, and postal mail).
In order to deepen some domains, under-committees emanated from the CCM during quarterly meetings. These under-committees meet according to needs and periods for several times per month. They present a synthesis of their reflections for validation at the time of the CCM’s meetings.
- “Under-committee on information, education and communication”: This under-committee deals with the validation of the educational support, which is produced during the setting up of the support program. Its main task for 2004 was the follow-up of the implementation of the national campaign on social communication.
- “Under-committee of follow-up and evaluation”: Its main task is the implementation of the plan and the follow-up of different associated activities. This committee works at present on the production of an adequate system of information. The goal is to produce reliable and qualitative data for the appreciation of indicators of the program while adopting the information on the Countries Ripostes for Information System (CRIS) of the ONUSIDA. The setting up of a system of supervision of the field activities was also among the terms of reference of this work group for 2004.
- “Under-committee of taking charge”: This under-committee deals with the planning of needs in medicines, the setting up of strategies for distribution and management of stocks, and the coordination of the different services under its control.
The support of the Global Fund to the setting up of PSN aims to contribute to the control of the HIV/AIDS infection in its two main components: the prevention of the HIV infection and the reduction of the impact of the HIV/AIDS on infected people and their family. The general objectives of the program are:
1) the reduction of the vulnerability of groups more exposed to HIV/AIDS in the important intervention regions.
2) the implementation of a social communication program to the profit of youngsters and women.
3) the diagnosis and the control of people living with the HIV.
The first two objectives are concerned with the setting up of the first component of the support program, while the third objective works on reducing the impact on people living with HIV.
The first component has three subdivisions: supporting projects for the reduction of vulnerability to HIV, supporting the implementation of a social communication program, supporting the reinforcement of counseling and voluntary HIV test.
Support for projects on reduction of vulnerability is confided exclusively to the ALCS. These projects touch risky and vulnerable groups, that is to say sex workers, men having sex with men, and female workers of the agro-food sector. Support for the implementation of a social communication program is entrusted to multiple actors. The ministry of health is charged with the national campaign of social communication and the access to condoms. The LM-LMST is charged with producing a theater piece on AIDS. The sensitization campaign in youth clubs in rural areas is entrusted to the Secretariat of State for Youth. Women and illiterate girls are the concern of the AMSED. The AMJCS keeps its specialty, that is to say the mobile kiosks of information. Finally, the reduction of vulnerability in women and girls as well as HIV/AIDS’ education through the computer are confided to OPALS Maroc.
The support for the reinforcement of the counseling and of the voluntary HIV test is also sub-divided into three tasks :
1) the equipment of counseling centers and HIV test, confided to the ALCS, OPALS and the LM-LMST
2) the mobile unit of prevention and diagnosis of HIV, confided to ALCS
3) the equipment of the provincial laboratories of the Health Ministry for the realization of diagnosis tests, confided to the National Institute of Hygiene (INH).
The second component, the reduction of the impact on people living with the HIV, is subdivided in two major actions: access to the Anti-Retro-Viral medicines (ARV) and biological follow-up of patients.
 Thus, there exists a discriminative distinction between good and bad sicknesses. The first are represented by the accidentally contaminated people as hemophiliacs, transfused and newborns. These are considered as innocent victims and are treated with less contempt. The second, that owe their status to their deviant conducts (homosexuality, drug use, prostitution) are strongly condemned and rejected. In the same way, HIV+ women are stigmatized more violently than men because they are accused of having illegal sex, something not permitted to women in under patriarchal logic, which is still extensively dominant.
 « How to explain the reduction of the HIV transmission bound to the circumcision? For the momznt, the different hypotheses notably imply a thickening (keratinization ") of the acorn’s skin at the circumcised man, that would give back it less permeable to the HIV, and the fact that the foreskin, deleted by the circumcision, rich in cells called " Langerhans ", that possesses many receptors for the HIV. But, nothing is yet sure », Le Monde, September 5, 2005.
 ALCS : Association Marocaine de Lutte contre le Sida.
 OPALS-Maroc : Organisation Panafricaine de Lutte contre le Sida.
 AMJCS : Association Marocaine des Jeunes contre le Sida.
 AMSED : Association Marocaine de Solidarité et de Développement.
 LM-LMST : Ligue Marocaine de Lutte contre les Maladies Sexuellement Transmissibles.
 Other members are : 1) Other associations: Association Marocaine de la Planification Familiale, Croissant Rouge Marocain, 2) Organisms of Private Sector : Conseil National de l’Ordre des Médecins , Confédération Générale des Entreprises Marocaines, Association Marocaine des Industries Pharmaceutiques, 3) UN Agencies : WHO, UNPD, UNFPA, UNICEF, ONUSIDA, UNFEM, FAO, 4) Bilateral and Multilateral : Belgium, Deuschland , European Union.