PREVENTING HIV/AIDS IN MOROCCO

by Issam Moussaoui

It is hard to describe or to analyze the situation of the HIV/AIDS epidemic in Morocco. Certainly experience helps us to provide a better description, but the more one becomes involved in this epidemic, the more one realizes how complex it is. We shall endeavour to provide a chronological description in order to illustrate what the response has been in Morocco, before reaching some conclusions and observations on key issues regarding the epidemic’s evolution in the country.


The HIV/AIDS Situation in Morocco

According to the classification established by UNAIDS, prevalence of the disease in Morocco is low, but the risk is unfortunately high. A total of 834 AIDS cases were declared by 30 September 2000. There are not yet any official figures for seroprevalence, although the introduction of sentinel surveillance has made it possible to extrapolate information from target populations. HIV prevalence is 0.16% among carriers of sexually transmitted infections (STI), 0.15% among pregnant women, 0.14% among tuberculosis patients, and 0.02% among blood donors.

Why is Morocco considered to be a high-risk country? Factors include the high level of STIs among the general population. While the official declared figure is 214,000 new cases of STIs each year, the actual figure may be closer to 600,000 cases. This discrepancy is attributable to, among other things, under-reporting and use of traditional treatments and self-medication. Other factors include trends in prostitution and migration, both rural-urban within Morocco and to other countries such as France, Spain and Italy.

The first case of AIDS in Morocco was registered in 1985. One year later, the National AIDS Control Programme (PNLS) was established. Initial actions were limited to providing information by organizing lectures on World AIDS Day and distributing leaflets and posters.

Civil society at large in Morocco was not long in reacting, and an association specialized in AIDS control—the Moroccan AIDS Control Association (ALCS)—was founded in 1988. This was the first initiative of its kind in North Africa and indeed in the Arab world. ALCS now has some ten sections throughout Morocco. In the wake of this initiative other associations came into being, particularly after the International Conference on AIDS in Africa held in Marrakech in 1993. These groups focus on specific interventions, with priority given to populations such as prisoners and commercial sex workers. 

Given the close links between STIs and AIDS, in 1995 the National AIDS Control Programme launched an anthropological study into sexually transmitted infections. The study led to the adoption and implementation of syndromic case management of STIs. This approach, adapted to suit the situation in Morocco, was implemented throughout the country by the end of 2000. In late 2001, an in-depth analysis of both the situation and the response will culminate with the elaboration of a national strategy on STI and AIDS.


Findings

Epidemiological Data
Analysis of figures shows that 90% of HIV cases in the country are found in urban areas and major towns and targetted interventions are possible. This information, while important, must be put into context. Screening is not systematic in Morocco and not everyone has access to it, especially in rural areas where inhabitants must travel to towns for facilities when they can afford to.

In view of the Moroccan context as an Arab and Muslim country, many issues connected with the epidemic and sexuality in general are taboo. As a result these subjects cannot be openly discussed in schools or within the family. This limits the use of media, especially audiovisual resources, in raising public awareness about HIV/AIDS. Teaching aids are restricted to posters, leaflets and brochures; their impact is confined to those who can read, but the literacy rate in Morocco is only 40%. In addition, regional differences such as language have not been taken into account in the production of support materials.

Characteristics of the Epidemic in Morocco
About 70% of HIV cases are spread through heterosexual transmission, a high percentage when compared to the 600,000 new STI cases believed to occur in Morocco each year. Clearly, this figure requires a close look at the cultural and social environment surrounding AIDS if issues relating to sexuality and STIs are to be discussed.
The epidemic in Morocco increasingly tends to affect women; the proportion of women with HIV/AIDS compared to men rose from 16% in 1990 to 38% in 2000. This will worsen the situation of many women, given their already limited decision-making ability and lack of access to services and care.

In 1990, foreigners—tourists and immigrants—accounted for a significant number of HIV and AIDS cases in Morocco. By 2000, all declared cases were indigenous.

Social Factors and Phenomena
Because a thorough analysis of the impact of AIDS is difficult, we shall limit ourselves to examining a number of key indicators. Migration has played both a positive and a negative role in the spread of HIV. The economic impact of AIDS has fuelled external migration, and has contributed to changing lifestyles and social norms.

Prostitution in the country has become more widespread; in many cases this has been due to economic factors, although in others it may be attributable to changes in lifestyle. A change in lifestyle is particularly evident in major cities such as Casablanca, Agadir and Marrakech, where most female prostitutes are compelled to take up prostitution because of poverty. According to one sex worker interviewed in a bar in Meknès, “If I had an alternative, I would give this up because there’s no respect for me.” 

Sexual relations between men have always existed in Moroccan society, but are never discussed openly because they are banned by Islam and the national Constitution. Such practices are now becoming more open, especially in major cities. 


The Role of NGOs

As mentioned earlier, civil society mobilized rapidly to join the fight against AIDS. In addition to their many activities on the ground, associations have played a significant role in both advocacy and in behavioural change. Two examples of this are triple therapy drugs and the preventive approach.

Morocco is considered a low-prevalence country and is hence not a priority for donors. As a result, most AIDS activity until 1997 was limited to prevention. In 1998, ALCS successfully advocated for the introduction of antiretroviral drug therapy in Morocco. As a result, costs were reduced by 40%. Mobilization of the private sector also led to contributions by health insurance companies to lower drug costs.

In terms of prevention, the early AIDS response focused on providing information and considered AIDS strictly a health issue. To move the fight against AIDS forward, the Association Marocaine de Solidarité et de Développement (AMSED) shifted the battle from raising awareness to promoting behavioural change, while positioning the response into a wider socio-economic context. AMSED’s approach has now been adopted by others and is reflected in projects elaborated by the Ministry of National Education to integrate sexual education into the national school curriculum and into literacy courses. Peer education has now been adopted in Morocco.

As NGOs develop their know-how, they will take on an increasingly important role in developing effective interventions. Non-governmental organizations are active in Morocco’s United Nations Theme Group on HIV/AIDS, and with the PNLS in the committee directing situation analysis and response. However, it should be stressed that greater efforts are required to coordinate the work of different associations, which should become possible as they develop and reach maturity.


The AMSED Approach

The Association Marocaine de Solidarité et de Développement is a non-profit group whose aim is to assist poor people through support and self-development projects in the fields of literacy and basic education, health and environment, and microcredit. 

A major programme was developed to assist the associative sector with STI/AIDS control, in partnership with the London-based International Alliance against HIV/AIDS. The programme is designed to control AIDS by providing support for groups active in the field of HIV/AIDS control. It has two objectives:
--to provide Moroccan associations with technical assistance that will help them strengthen their organizational capacity and with financial support to identify needs and implement AIDS projects that have a development dimension; and
--to promote communications and the exchange of experiences among the programme’s member associations regarding the various approaches for AIDS control.
To address the social and economic dimensions of the disease, the Programme d’Appui du Secteur Associatif (PASA) pour la Lutte contre les IST/SIDA plans to integrate prevention into development projects for vulnerable populations. Initially, groups involved in AIDS control have been invited to establish contacts with the target population in order to identify their main needs and potential.

Mobilizing and involving the population facilitates the work of associations that focus on changing attitudes and behaviour. Since 1996 when the programme began, AMSED has supported some 30 associations and funded some 60 six-month projects throughout Morocco. PASA has also developed training modules to promote interventions by associations on such topics as techniques for data collection, and data analysis, participative prevention, building partnerships in the area of AIDS, peer education, and participative evaluation.

Clearly NGOs working on the issue of AIDS in Morocco are still in their infancy, but they are quickly gaining strength and influence. In all spheres of HIV/AIDS work in the country, their presence is visible and their impact is felt. Working hand in hand with the government, these groups can help broaden the response to the disease and make sure that prevention measures help keep HIV/AIDS figures low in the country.

Voices from Africa no. 10