Data Diplomacy: Conducting an AIDS Indicator Survey in a Country in Crisis

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Côte d’Ivoire’s HIV prevalence rate continues to be reported as the highest in the West African region, at an estimated 7% among adults. Since September 2002, Cote d’Ivoire has experienced a profound political-military and economic crisis with an uncertain but anticipated deleterious impact on HIV transmission.  To date, information on the epidemic has been largely limited to data collected on pregnant women and high-risk groups. In order to better understand the current epidemiology of HIV/AIDS in this crisis environment and to improve program planning and policy development, the Ivorian national authorities prioritized the implementation of a nationwide population-based AIDS Indicator Survey (AIS).

Implementation of the survey required overcoming serious obstacles presented by the political-military crisis, which has divided the country into three zones, only a part of which is controlled by government forces. Successful completion of the data-collection phase of the nationwide AIS necessitated diplomatic and logistical finesse, along with extraordinary survey and other technical expertise.

Sporadic military hostilities gave way to a tense, unpredictable standoff when the AIS was launched in September 2004. The country remained divided into three zones: the South under government control, the North controlled by the rebel Forces Nouvelles (New Forces), and a buffer zone controlled by U.N. and French forces. The North (60% of the country), where government services had collapsed, was administratively subdivided into zones and sectors controlled by rebel leaders.

The challenge of coordinating the implementation of a nationally representative high quality survey in such an environment was assigned to an AIS Steering Committee, representing government ministries, technical agencies (National Institute of Statistics (INS), ORC-Macro, CDC/Projet RETRO-CI, National Laboratory of Public Health (LNSP)), development partners (PEPFAR, UNAIDS, UNFPA, UNICEF, WHO, Global Fund), and NGO and PLWH/A representatives. To prevent or resolve problems in the northern and buffer zones, a coordinating committee was formed by the INS, the Forces Nouvelles, French and U.N. forces, and the U.N. Agencies.

Mapping for sampling began in October 2004 in Abidjan and, after interruptions because of large-scale political demonstrations and violence in November, was completed throughout the government zone. In the North, four teams were trained and deployed, each consisting of a team leader, mapping agents from both government and northern zones, and a Forces Nouvelles-provided security agent charged with ensuring the team’s safe passage and abstention from subversive activities.

Training in data and blood-sample collection was provided and supervised by the INS, LNSP and CDC/RETRO-CI in the two zones. ORC Macro, an Emergency Plan-funded international NGO, provided assistance in all technical aspects of the survey, including preparation of questionnaires and manuals, training, data processing, and tabulation and analysis plans.

In April 2005, a delegation comprised of UNAIDS, the ministries of AIDS and of Territorial Administration, and the INS traveled to Bouake (capital city of the rebel-controlled zone) to negotiate procedures for implementation of the AIS. After explaining the project’s precise activities and organizational/logistical requirements, and after much discussion, the team obtained Forces Nouvelles’ cooperation, under two conditions: that the survey personnel, except for INS supervisors, be recruited from the northern zone, and that mapping documents remain in the zone at the end of the survey. U.N. peacekeeping forces played a major role by helping to transport survey personnel in the buffer and northern zones and by serving as facilitators for field teams. When necessary, U.N.-C.I. escorted field teams and intervened with rebel leaders.

Data and dry blood spot collection were successfully carried out nationwide between Aug. 4 and Oct. 20, 2005, with assistance from U.N.-C.I. for the supervision of field activities in the North. Analysis of data from the field implementation of the survey is continuing.  However, the response rate of the population, in all three zones (government-controlled, rebel-controlled and buffer) was very high.  This response rate was all the more extraordinary, given the conditions under which this survey activity ensued.

All data were compiled and entered in the database in Abidjan, completing part of the AIS, for which crisis conditions increased both the price tag and payback in experience and knowledge gained.  Little is known about the dynamics of HIV/AIDS in crisis conditions, and yet such conditions are fairly common among those countries and populations most affected.  Information from the CdI AIS will prove invaluable in informing USG HIV/AIDS programming and ensuring cost-effective use of Emergency Plan funding to best mitigate the impact of the disease on these most vulnerable populations.