The epidemic of HIV infection in French Guyana : a political problem

Members of the French Departments of America Commission
 François Bourdillon,
 Jean-Pierrre Dozon,
 Chantal Lebatard,
 Pierre Mathiot,
 Jean-Luc Romero,
 Willy Rozenbaum, President.

Report produced by : Michel Celse, Marc Dixneuf.

 The epidemic of HIV infection in French Guyana : a political problem

For several years, the epidemic of HIV infection in French Guyana has been a significant concern and has attracted the attention of the Conseil national du sida (CNS). The first report on the subject was published in 1996 and focused on all the French overseas departments (DOM). It particularly highlighted the serious shortcomings in terms of resources and insisted on the essential equality of rights between people living in the overseas departments and those living in mainland France. The second report, published in March 2003, was written in the context of a completely different environment following the implementation of effective treatments. Without underestimating the numerous problems that professionals face in the fight against AIDS, the report from 2003 noted that the epidemic was still not under control, especially in the French Departments of America (FDA). As in 1996, the deficiencies in terms of access to rights, the shortfalls in healthcare, the inadequacy of prevention policies and the potentially positive effects of regional cooperation were again highlighted. Following on from this publication, ten recommendations were submitted to the government. The latter of these specifically related to French Guyana and urged the implementation of a general public health and social care plan [1].

Given the persistence of certain problems originally set forth in 1996 and 2003, the Conseil felt it necessary to re-examine these departments. The context has evolved. For instance, the framework of healthcare policies has been changed by the public health legislation and the organisation of HIV treatment and care is undergoing a transformation with the establishment of regional steering committee to fight HIV infection (Corevih). French Guyana has also witnessed changes in terms of action against the epidemic of HIV infection with the reinforcement of the network of associations and the publication of various public action programmes in the healthcare sector. It is also benefiting from the completion of the first action plan against HIV which ran from 2003 to 2006. 2007 therefore seemed an auspicious year for the CNS to cast a retrospective glance over the actions carried out since 2003 in order to review how things have changed in recent years and to see how things stand now. The objective of this exercise is to make plans for the future.

Unlike the two previous reports, the CNS has this time felt it more appropriate to produce separate documents for French Guyana and the West Indies. In fact, despite characteristics that the departments appear to have in common, specific reports would seem to allow a closer examination of the problems currently being faced and the progress made. They would also allow recommendations to be made that are particular to each of the departments. The need for this has become more acute following the mission carried out by a delegation of the CNS in French Guyana and Guadeloupe at the end of October 2007 [2].

For reasons relating to the level of prevalence in the department and the significant problems that have to be overcome by local professionals (elected representatives, institutions, associations), the CNS’s first target is thus French Guyana, a department that is unique by virtue of its vastness and its sparse population : Officially, some 200,000 people live on an area of 91,000 square kilometres, around 16% of the country’s total land mass.

French Guyana has the highest rates of prevalence in France. In 2006, the number of diagnoses of HIV infection per million inhabitants was 308, compared to 150 in the Ile de France region [3]. The prevalence rate among women who have just given birth in Saint-Laurent-du-Maroni is 1.3 %, which constitutes a widespread epidemic [4]. The infection is primarily transmitted through heterosexual sex, and women represent the majority of people receiving treatment and care. The reported number of cases of AIDS has fallen, however it is still higher than in mainland France, with a figure of 141 per million compared to 43 in the Ile de France region, the area of mainland France with the highest rates of infection. The delay in screening is significant, at 42.9% for the first semester of 2006 compared to 33% in mainland France [5]. Nevertheless, the number of people receiving treatment and care is low, that is fewer than 2,000 (i.e. 1 - 2% of the total of people receiving treatment and follow-up in France).

Moreover, French Guyana is facing problems of many kinds, from the significant epidemics of dengue fever to more specific issues such as sickle-cell anaemia or diabetes. The more general issues of environmental health also require sustained attention. The population’s economic and social situation in French Guyana is more unfavourable than in other overseas departments and more unfavourable still than in mainland France. More than 30% of the population receives income support (RMI) [6], unemployment rates are higher and the number of single-parent families, who are in the most serious economic situation, is greater [7]. That said, French Guyana represents a haven of wealth compared to other islands or states in the region. Its appeal causes significant immigration, which brings with it recurrent problems to Guyanese society. The problem of immigration, coupled with economic and social issues in a context of high prevalence rates of infection, creates links in people’s minds as regards the cause of the department’s epidemic.

The epidemic of HIV infection in French Guyana therefore represents a public health problem as much from an epidemiological point of view as from a social point of view. An understanding of how this works requires approaches based on ethnography and sociology research. However, the fight against this epidemic first poses a political problem. What is at stake here remains the paradigm that shapes the main conceptions and which defines the definition of choice, the governance of the response to the epidemic by professionals and its control, as well as the allocation of financial and human resources. In this sense, the problem is a wholesale one that cannot be resolved by singular public health and medical approaches.

Given the local and regional context, the epidemic of HIV infection remains a preoccupying issue as much by virtue of its dynamic nature as by the persistent problems associated with producing responses through healthcare policies. This report will not revisit the ethnographic issues of the epidemic, since these considerations are largely well-known [8]. Sometimes, these considerations even attempt to analyse the political processes that also explain the inadequacies of the results [9]. Similarly, the epidemiological parameters and the economic and social problems are sufficiently documented for there to be no need to revisit these issues in depth here.

The report is the result of the work by the French Departments of America Commission of the Conseil national du sida. Several series of interviews were carried out in Paris and French Guyana in order to gather an analysis of the situation using the largest number of people involved in the response to the epidemic. The data available on the active file populations and epidemiology was gathered from the Inserm, the Invs and Guyana’s hospital services. The literature used cites official reports by various state bodies and services as well as social science texts. In order to document the issues surrounding the epidemic more coherently, the commission has endeavoured to understand the nature of the relationships between the various players involved, the relevance of the tools they have available and the networking of the various levels of the public decision-making process and its implementation.

One approach, where the epidemic of HIV infection is restricted to the public health and social sector, is possible in a mainland France environment, but French Guyana must be considered with the analytical frameworks and responses adopted for countries with widespread epidemics : The involvement of the entire social and political body and the adoption of public policy frameworks designed to respond to the epidemic - not just their adaptation to a challenge that would be considered as temporary. Care providers, public health and social services professionals, members of associations and state services have largely contributed towards changing the environment of the fight against HIV over the course of the past five years. Today, these actions must be built upon with the clear involvement of local political leaders.

The report will therefore first of all outline the obstacles that healthcare professionals are facing and also highlight their successes. These obstacles relate as much to public policy frameworks in general as they do to more specific healthcare policies. Secondly, the report will focus on the shortcomings of the political management of the epidemic, both from the steering point of view within the department and from the perspective of relationships with neighbouring countries.

Sommaire

• The epidemic of HIV infection in French Guyana : a political problem [page 1]
• Part I The limits of the constant battle by healthcare professionals [page 2]
• Part II The inadequacies of the political management of the epidemic [page 6]
• Acknowledgements [page 10]
• Appendices [page 11]
• Recommendations by the Conseil national du sida in 2003 [page 11]
• Bibliography [page 11]