Yaoundé, with a population of more than 3.3 million people, is the capital of Cameroon and home to approximately 86 000 people living with HIV, or 16.7% of the national HIV burden1.
The city has a generalized HIV epidemic with an overall prevalence of around 3,9% (15+ years). There are concentrated epidemics among key populations, with prevalence reaching 23,3% among female sex workers and 43,1% among gay men and other men who have sex with men1.
The city is divided into seven administrative districts or subdivisional councils with elected municipal councils, each with its own mayor who has oversight over district health, including HIV activities, and a responsible focal person trained in HIV.
This complex structure presents both challenges and opportunities for coordinating the city’s HIV response. All seven mayors have signed the Paris Declaration and have committed to integrating HIV interventions into local development plans. The city’s seven mayors also support community mobilization at special events, such as World AIDS Day and national celebrations. They have recently begun using official wedding celebrations to share HIV prevention messages.
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1 Source: Spectrum 2020
Yaoundé was enrolled in the Joint UNAIDS–IAPAC Fast-Track Cities project in 2018 and immediately set to work strengthening the evidence base for the city’s HIV response. Baseline data were collected for all seven districts, which enabled the development of district epidemiological profiles. The exercise showed that HIV prevalence varies widely across the seven districts, ranging from approximately 3% to 6%. District profiles are further disaggregated by age and gender.
In addition, data on HIV testing, the prevention of mother-to-child HIV transmission and treatment services were compiled, and mapping of services for people living with HIV across the seven districts was completed. Key population hotspots across Yaoundé were also mapped to identify areas with greater needs for prevention services.
A city action plan
The type of disaggregated data collected by Yaoundé is fundamental to the identification of high-burden locations and populations, and it helps pinpoint priorities for strengthening prevention, testing and treatment. It is also essential for a decentralized response, where individual town halls are responsible for mobilizing action and resources to meet Fast-Track Targets. The maps and data have been compiled into fact sheets for use by the authorities. The information was presented at technical meetings, and it directly informed the development of the Yaoundé City Action Plan for 2018– 2020, which was launched and validated at an event chaired by the Minister of Public Health in December 2018 and attended by all seven district mayors and other district stakeholders.
Yaoundé is driving change in its HIV response by engaging mayors, municipal authorities, partners and communities. Its success provides insights and strategies used by other municipalities and at the national level through the National Strategic Plan and Global Fund resources.
Advocacy: Engaging Yaoundé’s mayors
Yaoundé has eight mayors: one for each of seven municipalities, and a Metropolitan Mayor. Each of the seven mayors has responsibility for their own budgets, programming and planning – which means that the sustained engagement of all is needed to improve the city’s HIV response.
The Fast-Track Cities project provides the vehicle for ensuring that these mayors are aware of Yaoundé’s HIV epidemic and response (including service delivery and uptake), challenges, and their role in the response. Briefings are therefore held for newly appointed HIV focal points and other members of municipal councils, and their engagement and commitment are maintained through coordination meetings and involvement in planned activities. Factsheets for Yaoundé Metropolitan Area and each of the seven municipalities (see “Data” tab) provide HIV estimates and data, which help to generate mayoral support, and are being used by partners to assist in planning activities and to mobilize additional funding.
Fast-Track City advocacy has also strengthened coordination and collaboration between municipalities and community-based organizations, to the benefit of the HIV response.
The mayors and their offices have increased ownership of the HIV response in their municipalities, and have been including HIV in municipal plans and budgets. As a result, the mayors support community mobilization for the HIV response. They might display the municipal HIV factsheets in townhalls and public places to sensitize the public – or share HIV prevention messages at official wedding celebrations. They use events, such as World AIDS Day, to increase HIV awareness and education, including among young people at secondary schools and youth centres, the police, and traditional and religious leaders. They also undertake mobile HIV testing campaigns in public places, such as markets.
All seven mayors actively participated in the development and launch of a City HIV Strategic Plan, and the municipalities are already working to operationalize it. The Municipality of Yaoundé VI established a technical working group to develop and implement its own HIV action plan. The Municipality of Yaoundé V has included HIV activities in its communal plan and budget, and has a consultation platform with public and private sector actors. Other municipalities are partnering with individual stakeholders to implement one-off or regular activities, including health care facilities, civil society organizations and the National Security Insurance Fund. For example, ReCAP+, the national network of associations of people living with HIV, received funding from the Municipality of Yaoundé II to carry out a candlelight memorial.
Addressing barriers at the city level
Yaoundé aims to ensure that health services are delivered to all people in need, free from stigma and discrimination. The seven municipalities, key implementers and other strategic partners involved in the HIV and tuberculosis responses work together to identify and address gaps and barriers in the response, with a specific focus on marginalized and key populations.
As part of this collaboration, partners from the Association des Communes et Villes Unies du Cameroun (CVUC, the coordinating body for Cameroonian mayors), government bodies, the private sector and civil society organizations (including key population-led organizations and networks) participate in ongoing capacity building and training activities. This has included a national UNAIDS/UNDP workshop in September 2021 on human rights-related barriers to HIV service access, uptake and retention, and how to overcome such challenges. Yaoundé partners came together with national institutions involved in the multisectoral HIV response to better understand the universality of human rights, and how stigma and discrimination based on HIV status, sexual orientation, gender, gender identity and substance use negatively affect individuals and communities and increase their vulnerability to HIV. They identified priority actions that are now being used to define national objectives, and produced recommendations to integrate related interventions into HIV sectoral plans. At the city level, partners now work to ensure that the terms of reference for HIV focal points include responsibility for addressing these barriers.
Addressing barriers in communities
Equally important is ensuring that service providers and communities learn about, and counter, human rights-related barriers. IAPAC-led training for health care facilities to eliminate stigma and discrimination has led to facility codes of conduct and action plans for stigma reduction. Participants involved in the training created a network to facilitate collaboration and communication and to share experiences and best practices between health facilities. The network is particularly valuable for supporting high-volume hospitals to improve the quality of services for members of key populations. It has also been invaluable in bringing health facilities together with community leaders and community-based organizations of key populations involved in the community dispensing of antiretroviral medicines and other HIV-related activities. The new relationships and collaboration that have been created as a result have helped to improve the quality of services provided at the community level.
Meanwhile, peer educators in Yaoundé are currently field-testing a community education group-counseling tool focused on “Staying in Care for U=U”. U=U (Undetectable=Untransmittable) is a global campaign to educate people living with HIV (and others) about the benefits of staying in treatment. Stable and consistent adherence to treatment lowers HIV viral load, leading to viral suppression – which means the virus cannot be transmitted to sexual partners. The tool – a Conversation Map – was developed by IAPAC and Healthy Interactions and supports peer educator-facilitated dialogue with people living with HIV. Thirty-six peer educators have been trained to use the tool.
Other community initiatives include the 2020 MOTO Action poster contest. The competition, run by a local non-governmental organization, used an ‘urban’ theme and challenged community-based organizations to produce the best HIV and COVID-19 prevention messages. The entries were disseminated through social media platforms, reaching over 45,000 people.