HIV, reproductive health and disability in West Africa

Although HIV infection remains a public health problem, it has shifted in most sub-Saharan African countries from a generalized epidemic to an epidemic concentrated in at-risk or vulnerable populations (Djomand et al., 2014; Tanser et al., 2014). Among these so-called risk groups, studies have focused on sex workers, men who have sex with men, injecting drug users, prisoners, etc., and actions have been taken to reduce the transmission of the infection (Abdul-Quader et al., 2015; Barr et al., 2021; Brown & Peerapatanapokin, 2019; Lancaster et al., 2018) However, the general observation is that people with disabilities (PWDs) are not included as a specific group which should benefit from specific measures in sexual health plans, programs and national strategic frameworks to fight against HIV/AIDS. As a result, people with disabilities may develop a greater vulnerability to HIV/AIDS.

Indeed, the United Nations defines persons with disabilities as persons with long-term physical, mental, intellectual or sensory disabilities who, in interaction with various barriers, may hinder their full and effective participation in society on an equal basis with others (United Nations, 2014). According to the World report on the disability situation in 2011, 15% of the world’s population has at least one disability and 80% reside in resource-limited countries (World Health Organization and World Bank, 2011). It is recognized that people with disabilities are more socioeconomically disadvantaged and poorer than non-disabled people. The United Nations Convention on the Rights of Persons with Disabilities (CRPD) adopted by the Member States in 2006 stipulates that persons with disabilities have the right to the highest attainable standard of health without discrimination on the basis of disability (Hendriks, 2007).

Several national bio-behavioral studies on HIV and disability have been commissioned by Humanity & Inclusion as part of its regional project “HIV and Disability” implemented in six West African countries (Senegal, Guinea Bissau, Cape Verde, Mali, Burkina Faso and Niger). In each of these countries, a cross-sectional study on level 3 and/or 4 disabled people. Identification of PWDs aged 15–69 years was done in households using the Washington Group (WG) Short questionnaire, followed by HIV behavioral survey and HIV testing.

The surveys were conducted on a stratified sampling basis, with the stratum represented by the administrative region and the residential environment (urban/rural). In each stratum, a two-stage cluster survey was conducted: (1) the selection of primary units (enumeration areas) was done proportionally to their size and (2) the census of secondary units (households). All household members aged 15–69 years were interviewed using WG short questionnaire to look for a level 3 and/or 2 disability. Qualitative studies were also conducted in each country. It consisted of in-depth interviews and focus groups among persons with various disabilities.

A large sample of people were screened for these studies. In Burkina Faso, 28 667 people were interviewed with WG in 8540 Households and 973 PWDs were included in the study. In Mali, 45,812 people were covered by the survey in 5,284 households, and 20,704 people between the ages of 15 and 69 were surveyed. Of these people, 15,480 responded to the Washington group (WG) questionnaire, including 1,056 cases of functional limitation level 3 or 4 (6.82%) of them 1,051 agreed to participate. A total of 21,979 persons aged 15–69 years were screened; of them, 949 participants have a severe disability (level 3 or 4) in Niger.

In this supplement, we present HIV infection’s prevalence and its associated risk factors in different contexts. In Burkina Faso, Ouedraogo et al. (2022) found that the HIV prevalence was 4.6% (95%CI: 3.3%–6.1%) and the factors associated with HIV infection were age, type of disability, the income and the sexual partners. The prevalence of HIV infection among people with disabilities was 2.38% (95%CI: 1.58%–3.44%) in Mali. Multivariate analysis shows that age, sex, type of disability and sexual violence are the risk factors for HIV infection among people with disabilities in Mali (Cisse et al., 2022). The HIV prevalence among persons with disabilities was 0.66% (95% CI:0.33–1.30) in Niger (Ouedraogo et al., 2022). In Cabo Verde, the HIV prevalence rate was 2.3% (3.5% in men; 1.7% in women) (Celina et al., 2022). Globally, the HIV prevalence is higher in people with disability compared to the HIV prevalence in the general population in these countries. Cissé et al. (2022) showed that the proportion of people with disabilities involved in high-risk behaviors was 9.5%, and the factors associated were age, education level, sex, income, and marital status.

Stigmatization, discrimination and violence are also addressed in this supplement since it makes people with disability more vulnerable to HIV infection. Indeed, the prevalence of stigma was 18% in Niger. People with intellectual (OR = 1.89; 95% CI = [1.58–5.03]) and cognitive (OR = 2.82; 95% CI = [1.14–3.13]) disabilities were more likely to experience stigma than other types of disabilities. People with disabilities over the age of 20 years were 57%–71% less likely to be stigmatized than people with disabilities aged 15–19. Living in the same accommodation with other people with disabilities was also a protective factor against the stigma experience (Sory et al., 2022).

Violence including sexual violence is an important contributor to the vulnerability of PWDs. In Burkina Faso, the prevalence of violence was 13.9%. Type of disability, age and marital status, education, type of residence are the main risk factors (Kouanda et al., 2022). In Cabo Verde, a total of 307 (45%) PwDs had suffered from some kind of violence, 14.4% were verbal violence, 10.4% from physical and 4.7% from economic violence (Celina et al., 2022). Fomba et al. (2022) showed that the prevalence of sexual violence in people with disabilities was 7.3% (95%: CI 5.7–9.1) in Burkina Faso. Females with disabilities were more likely than males with disabilities to report lifetime sexual violence (8.1% vs 6.1%). Gender, having multiple sexual partners over a lifetime, and the place where the person lives were all significantly associated with the occurrence of sexual violence. Sexual violence is frequent among PWDs in Burkina Faso (Fomba et al., 2022). Wayack-Pambè & Kouanda (2022) in a qualitative study in Burkina Faso showed that the combination of stereotypes and prejudices linked to disability and unequal gender relations make these women predominantly vulnerable to gender-based violence, especially sexual violence.

People with disabilities often face barriers that prevent them from accessing the health and rehabilitation services they need (physical or communication barriers, barriers related to the high cost of care, barriers related to the behaviors of health care workers, etc.). The ability to easily obtain a condom when needed was reported by only 29.4% of respondents in Burkina Faso and 5.7% of respondents in Niger. The proportion of participants who had been tested for HIV was 32.2% in Burkina Faso and 13.6% in Niger. We observed that 5.7% and 3.5% of the participants, respectively, in Burkina Faso and Niger were in contact with an HIV-related service. Only educational status was associated with access to HIV prevention services in both countries (Samadoulougou et al., 2022).

These studies highlight that people with disabilities are at a greater risk of HIV and are more vulnerable than the general population because they are poor, marginalized, discriminated against and subject to violence and have no access to HIV-related services. Being a woman with a disability is an additional vulnerability factor. In addition, these studies show a number of unmet needs in the field of HIV/AIDS, including access to knowledge and information which remains insufficient, availability of condoms which remains too limited, HIV testing that is very rare in the disabled population and limited access to HIV care services. There is an urgent need to target PWDs in HIV programs in order to protect them against HIV.

To overcome the difficulties faced by people with disabilities, particularly in the case of HIV/AIDS care, interventions to address these barriers are necessary. It is time to act, by implementing vigorous actions to:

1. Promote voluntary HIV testing of persons with disability: Each person with a disability must know his or her HIV status “Promote social mobilization and active testing in PH cluster sites”

2. Include disability issues in the national HIV plan

3. Training of health-care professionals to provide HIV care adapted to people with disabilities and including sign language

4. Ease access for persons with disability to the HIV services package: Prevention, testing, care and support services must be accessible to all people with disabilities.

5. Include persons with disability in community activities (awareness and care) to fight HIV/AIDS.

Acknowledgements

We would like to thank the NGO Humanity and Inclusion and all of the reviewers of this supplement and Dr Rebecca Compaoré who coordinated this supplement. Dr Rebecca Compaoré coordinated of this supplement.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This supplement was funded by WHO/HRP.