[NAME] [FIRM] [ADDRESS] [PHONE NUMBER] [FAX NUMBER]
UNITED STATES DEPARTMENT OF JUSTICE EXECUTIVE OFFICE FOR IMMIGRATION REVIEW IMMIGRATION COURT [CITY, STATE]
______) In the Matter of: ) ) File No.: A ______) ) In removal proceedings ) ______)
INDEX TO DOCUMENTATION OF COUNTRY CONDITIONS REGARDING PERSECUTION OF HIV-POSITIVE INDIVIDUALS IN BURKINA FASO
TAB SUMMARY BURKINA FASO STATUTORY SOURCES 1. Loi No. 030-2008/AN Portant Lutte Contre Le VIH/SIDA et Protection Des Droits Des Personnes Vivant Avec Le VIH/SIDA, Burkina Faso Government (May 20, 2008) (with excerpted translation), available at https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/--- ilo_aids/documents/legaldocument/wcms_126288.pdf • “Article 20: Any person who knows they are infected with HIV and who has unprotected sexual intercourse with a partner who is not informed of his/her HIV infection status, even if the partner is him/herself HIV positive, is guilty of the crime of willful transmission of HIV and shall be punished in accordance with the penal code.” (page 2 of translation) • “Article 22: o Any person who willfully transmits HIV-infected substances by any means whatsoever is guilty of willful transmission of HIV. o Any person who has granted or procured the means to commit the offense indicated in paragraph 1 is an accomplice in an act of willful transmission. TAB SUMMARY o The guilty persons or accomplices in the act of willful transmission of HIV shall be punished in accordance with the provisions in the penal code.” (page 2 of translation) • “Article 26: o Any individual who is aware of his/her HIV infection status and does not take the necessary and sufficient precautions for the protection of his/her partner(s) shall incur criminal sanctions. o Any person who knows that he/she has HIV and does not take the necessary and sufficient precautions for the protection of his/her partner(s) shall be punished by a fine of one hundred thousand (100,000) CFA francs to one million (1,000,000) CFA francs. o If this results in contamination, he/she shall incur the penalty for attempted willful homicide in accordance with the penal code.” (page 3 of translation) GOVERNMENTAL SOURCES 2. Bureau of Democracy, Human Rights and Labor, U.S. Dep’t of State, 2019 Country Reports on Human Rights Practices: Burkina Faso (Mar. 2020), available at https://www.state.gov/reports/2019-country-reports-on-human-rights-practices/burkina- faso/ • “Societal discrimination against persons with HIV/AIDS continued to be a problem and prohibited some individuals from receiving medical services due to fear of harassment. Families sometimes shunned persons who tested positive and sometimes evicted HIV-positive wives from their homes…. Some property owners refused to rent lodgings to persons with HIV/AIDS.” (p. 24) • “Discrimination occurred based on . . . HIV-positive status or having other communicable diseases . . . with respect to employment and occupation. The government took few actions during the year to prevent or eliminate employment discrimination.” (p. 28) 3. Bureau of Democracy, Human Rights and Labor, U.S. Dep’t of State, 2018 Country Reports on Human Rights Practices: Burkina Faso (Mar. 2019), available at https://www.state.gov/reports/2018-country-reports-on-human-rights-practices/burkina- faso/ • “Societal discrimination against persons with HIV/AIDS was a problem, and families sometimes shunned persons who tested positive. Families sometimes evicted HIV-positive wives from their homes.... Some property owners refused to rent lodgings to persons with HIV/AIDS.” (p. 21) • “Discrimination occurred based on . . . HIV-positive status or other communicable diseases, or social status with respect to employment and occupation. The government took few actions during the year to prevent or eliminate employment discrimination.” (p. 25) 4. Bureau of Democracy, Human Rights and Labor, U.S. Dep’t of State, 2017 Country Reports on Human Rights Practices: Burkina Faso (Apr. 2018), available at https://www.state.gov/reports/2017-country-reports-on-human-rights-practices/burkina- faso/ TAB SUMMARY • “Societal discrimination against persons with HIV/AIDS was a problem, and persons who tested positive were sometimes shunned by their families. Families sometimes evicted HIV-positive wives from their homes…. Some property owners refused to rent lodgings to persons with HIV/AIDS.” (p. 22) • “Discrimination occurred based on . . . HIV-positive status . . . with respect to employment and occupation. The government took few actions during the year to prevent or eliminate it.” (p. 26) INTER-GOVERNMENTAL SOURCES 5. The Joint United Nations Programme on HIV/AIDS (UNAIDS), Burkina Faso piloting PrEP (Apr. 8, 2019), available at https://www.unaids.org/en/resources/presscentre/featurestories/2019/april/20190408_bur kina-faso-piloting-prep • “Burkina Faso does not penalize homosexuality, but stigma against it is high. As a result, gay men and other men who have sex with men often hide their sexuality and tend to avoid health services. HIV prevalence in Burkina Faso among gay men and other men who have sex with men stands at 1.9%, more than double the rate among the general population.” (p. 2) 6. UNAIDS, Health and safety: sex workers reaching out to sex workers (Feb. 26, 2019) available at https://www.unaids.org/en/resources/presscentre/featurestories/2019/february/20190226_ burkina-sex-workers • “‘Because of stigma and discrimination, many sex workers hide and move around so they miss out on health services and are much more likely to be infected with HIV,’ [a REVS PLUS/Coalition PLUS advocacy manager] said. HIV prevalence among sex workers is 5.4% in Burkina Faso, while it’s 0.8% among all adults in the country.” (p. 6) NON-GOVERNMENTAL SOURCES 7. HIV Justice Network, Burkina Faso (Sept. 2020), available at https://www.hivjustice.net/country/bf/ • “Burkina Faso has two HIV-specific laws outlining the obligation of all persons living with HIV to disclose their HIV status to their sexual partners and to abstain from having ‘unprotected sex.’” (p. 1) • “[N]on-disclosure of HIV-status prior to ‘unprotected sex’, even if their partner is also HIV-positive, is classified as deliberate transmission and can be punished in accordance with the provisions of the criminal code, even if transmission (i.e. alleged superinfection) did not occur.” (p. 1) • “In cases of alleged transmission, non-disclosure of HIV-status prior to ‘unprotected sex’ leads to the charge of attempted intentional homicide.” (p. 1) 8. Freedom House, Freedom In The World 2020: Burkina Faso (Mar. 4, 2020), available at https://freedomhouse.org/country/burkina-faso/freedom-world/2020 • “LGBT+ people, as well as those living with HIV, routinely experience discrimination.” (p. 15) TAB SUMMARY 9. Canadian HIV Legal Network and HIV Justice Worldwide, Regional HIV Criminalization Report Francophone Africa (Nov. 2017), available at https://www.hivjusticeworldwide.org/wp-content/uploads/2018/11/HJWW-Francophone- Africa-Regional-HIV-Criminalization-Report-1.pdf • “HIV can also be directly or indirectly penalized by other legislation in a country. For example, some laws . . . focus specifically on HIV [and] are provided for in laws on sexual violence, child protection, reproductive health or in the Criminal Code (. . . Burkina Faso [an example among others]. . .).” (p. 63) • “We have been informed of prosecutions for sexual exposure or transmission of HIV (including cases that have been discontinued or settled outside of the courts) in . . . Burkina Faso . . . .” (p. 64)
ACADEMIC SOURCES 10. Ramatou Ouedraogo et al. Aging in the Context of HIV/AIDS: Spaces for Renegotiation and Recomposition of Mutual Solidarity in Burkina Faso, J. Int. Assoc. Provid. AIDS Care Jan-Dec 2019 (Sept. 17, 2019), available at https://journals.sagepub.com/doi/full/10.1177/2325958219881402 • “[M]en who. . . sometimes ascertain their HIV-positive status avoid health facilities for fear of shame and stigmatization.” (p. 5) 11. Ashley L. Grosso, Sosthenes C. Ketende, Shauna Stahlman et al., Development and reliability of metrics to characterize types and sources of stigma among men who have sex with men and female sex workers in Togo and Burkina Faso, BMC Infectious Diseases (Mar. 5, 2019), available at https://bmcinfectdis.biomedcentral.com/track/pdf/10.1186/s12879-019-3693-0.pdf • “In Burkina Faso, same-sex practices are not mentioned in the law. Selling sex is tolerated and not prohibited; soliciting and facilitating sex works are criminalized. However, stigma related to HIV, sex work and same-sex practices is common.” (p. 3) • “Socially and in the media there are strong expressions against same-sex sexual practices and relationships. For example, 95% of participants from Burkina Faso in the Afrobarometer said they would dislike living next to gay or lesbian neighbors.” (p. 3) 12. Fati Kirakoya-Samadoulougou, Kévin Jean, and Mathieu Maheu-Giroux, Uptake of HIV testing in Burkina Faso: an assessment of individual and community-level determinants, BMC Public Health (May 22, 2017), available at https://spiral.imperial.ac.uk/bitstream/10044/1/43824/9/art%253A10.1186%252Fs12889- 017-4417-2.pdf • “This is especially relevant for Burkina Faso where levels of stigma were found to be high: only 7% of women and 5% of men expressed no stigmatizing attitudes about [people living with HIV].” (p. 5-9) • “We observed that uptake of [voluntary counseling and testing] was generally higher among individuals with less stigmatizing views. Decision-making about HIV testing are often linked to an individual’s social network influences and addressing HIV-related stigma could improve community norms about testing.” (p. 5) TAB SUMMARY 13. Ziemlé Clément Méda, Télesphore Somé, et al., Patients infected by tuberculosis and human immunodeficiency virus facing their disease, their reactions to disease diagnosis and its implication about their families and communities, in Burkina Faso: a mixed focus group and cross sectional study, BMC Research Notes (Jul. 29, 2016), available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4965888/pdf/13104_2016_Article_2183 .pdf • “For reactions facing to disease diagnosis, perception of the disease and experiences lived with the relatives of the patient and his community about the disease, patients from both quantitative and qualitative study perceived as grave diseases and faced stigma, perceived bad attitude towards TB/HIV and were discriminated against or isolated.” (p. 4) • “All patients were shocked hearing about having . . . HIV, locally called ‘white cough’ and ‘spider’, are still perceived as grave diseases. At the announcement of their status, all patients felt bad and associated the diagnosis to a death sentence. Moreover, they expressed fear because they thought about the interpretation of the disease in the community . . . .” (p. 5) • “The gravity of the HIV infection is greater expressed by PLWHA [people living with HIV/AIDS] patients who seek care with healers, as confirmed by 21.3% of PLWHA patients; because they think that medical facilities do not have solution for them.” (p. 6) • “Across all focus groups, TB patients and PLWHA felt that their friends and relatives distanced themselves after learning their status. They still perceived stigmatization and some (more related to PLWHA) lost their home and job because of their status.” (p. 6) • “[A]bout 93 (10.8%) patients had to change their housing after contracting their illness. Indeed, up to 12.7% of PLWHA patients pointed out this fact . . . 131 (14.7%) patients revealed that they had lost their job following their disease diagnosis. . . .” (p. 6) • “From the quantitative data, TB patients and PLWHA perceived isolation by their community (45.5%) and from their family (53.2%). . . .” (p. 7) 14. Fidèle Bakiono et al., Quality of life in persons living with HIV in Burkina Faso: a follow-up over 12 months, BMC Public Health (Nov. 13, 2015), available at https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/s12889-015-2444-4.pdf • “Because HIV is still considered as a family shame, living with HIV puts people on the margins of society or their family. In a previous study in Burkina Faso, Ouedraogo et al. showed that 57.5% of [people living with HIV/AIDS] were living without any financial support from families.” (p. 7)
MEDIA SOURCES 15. Rachel’s HIV Revolution, Al Jazeera (Nov. 27, 2016), available at https://www.aljazeera.com/program/witness/2016/11/27/rachels-hiv-revolution/ • “She made this clear to us every day, as she accompanied us deeper and deeper into the world of HIV-positive women, who – in Burkina Faso and in a number of TAB SUMMARY countries in West Africa – end up being the first to fall victim to discrimination, and risk being thrown out, excluded and repudiated by their own families.” (p. 4) • “Others showed us their loneliness and their fear of stigma. We were not always able to collect their stories, because their husbands often prevented them from talking about themselves.” (p. 4) 16. Boniface Dulani, Gift Sambo, and Kim Yi Dionne, Good neighbours? Africans express high levels of tolerance for many, but not for all, Afrobarometer (Mar. 1, 2016), available at https://media.africaportal.org/documents/ab_r6_dispatchno74_tolerance_in_africa_eng1. pdf • “[Data from fieldwork in Burkina Faso from April-May 2015 showed that 40% of respondents in Burkina Faso] would object to having HIV-positive neighbours . . . .” (p. 10) • “[When asked whether they would like, dislike or not care about having people who have HIV/AIDS as neighbors], 26% of respondents in Burkina Faso said that they would ‘strongly dislike’ it and 14% responded that they would ‘somewhat dislike’ it.” (p. 24)
Dated: [DATE] Respectfully submitted, [CITY, STATE]
[FIRM] Pro Bono Counsel for Respondent______
By: ______[NAME] [FIRM] [ADDRESS] [PHONE NUMBER] [FAX NUMBER]
TAB 1
Translation of Excerpt from pages 1, 10, and 11 of Governmental Source Entitled: Loi No. 030-2008/ AN BURKINA FASO IVTH REPUBLIC ------UNITY-PROGRESS-JUSTICE FOURTH LEGISLATURE ------NATIONAL ASSEMBLY
LAW No. 030-2008/ AN
FIGHTING AGAINST HIV/AIDS AND PROTECTION OF THE RIGHTS OF PEOPLE LIVING WITH HIV/AIDS.
1. Translation of Excerpt from pages 1, 10, and 11 of Governmental Source Entitled: Loi No. 030-2008/ AN 10
- when the determination of HIV status is necessary to resolve a marital dispute
CHAPTER 5: PENAL PROVISIONS
Article 20:
Any person who knows they are infected with HIV and who has unprotected sexual intercourse with a partner who is not informed of his/her HIV infection status, even if the partner is him/herself is HIV positive, is guilty of the crime of willful transmission of HIV and shall be punished in accordance with the penal code.
Article 21:
Any physical or legal person guilty of discriminatory acts against PLHIV shall be punished by a prison sentence of one to five years and a fine of three hundred thousand (300,000) CFA francs to one million, five hundred thousand (1,500,000) CFA francs or only one of these two penalties.
Article 22:
Any person who willfully transmits HIV-infected substances by any means whatsoever is guilty of willful transmission of HIV.
Any person who has granted or procured the means to commit the offense indicated in paragraph 1 is an accomplice in an act of willful transmission.
The guilty persons or accomplices in the act of willful transmission of HIV shall be punished in accordance with the provisions in the penal code.
Article 23:
Any person, whether based on his/her occupation or based on a function or a mission, who is the custodian of confidential information on the health status of a person living with HIV/AIDS and who reveals this to a person who is not qualified to find out the secret, shall be punished by a prison sentence of three months to one year and/or a fine of four hundred thousand (400,000) CFA francs to one million (1,000,000) CFA France.
The maximum amount of the fine shall be raised to ten million (10,000,000) CFA France if the offense is committed by means of media or multimedia or other mass communication methods;
2. Translation of Excerpt from pages 1, 10, and 11 of Governmental Source Entitled: Loi No. 030-2008/ AN 11
Article 24:
Any physical or legal person who is guilty of the crimes indicated below shall be punished by a prison sentence of three months to three years and a fine of four hundred thousand (400,000) CFA francs to one million (1,000,000) CFA francs or only one of these penalties:
- dissemination of information relating to the control and prevention of HIV/AIDS through false or erroneous advertising;
- commercial promotion of medications, carriers, agents or procedures, without advance authorization from the ministry responsible for health and the national coordination structure in the fight against HIV/AIDS and STDs, and which has no medical and scientific basis;
- the listing and indication on medications that these are intended to treat HIV/AIDS or to protect against the disease, which has no medical and scientific basis.
Article 25:
The fraudulent exploitation of the state of ignorance or situation of weakness of a person infected by HIV or affected by HIV/AIDS, whether to offer him/her a fraudulent treatment involving extorsion of funds, or to force that person to consent to an act this is clearly prejudicial to him/her, shall be punished by the penalties applicable to scams.
Article 26:
Any individual who is aware of his/her HIV infection status and does not take the necessary and sufficient precautions for the protection of his/her partner(s) shall incur criminal sanctions.
Any person who knows that he/she has HIV and does not take the necessary and sufficient precautions for the protection of his/her partner(s) shall be punished by a fine of one hundred thousand (100,000) CFA francs to one million (1,000,000) CFA francs.
If this results in contamination, he/she shall incur the penalty for attempted willful homicide in accordance with the penal code.
3. December 23, 2020
This is to certify that the attached translation is, to the best of my knowledge and belief, a true and accurate translation from French into English of the attached documents:
•LOI N° 030-2008/AN • RÉALITÉS JURIDIQUES ET SOCIALES DES MINORITÉS SEXUELLES DANS LES PRINCIPAUX PAYS D’ORIGINE DES PERSONNES NOUVELLEMENT ARRIVÉES AU QUÉBEC • Reportage "On est loin d'envisager une gay pride au Burkina Faso"
Linguistic Systems, Inc. adheres to an ISO-certified quality management system that ensures best practices are always followed in the selection of linguists skilled in both the languages and subject matters necessary for every translation.
Patrick Evanson Production Manager Linguistic Systems
TAB 2
BURKINA FASO 2019 HUMAN RIGHTS REPORT
EXECUTIVE SUMMARY
Burkina Faso is a constitutional republic led by an elected president. In 2015 the country held peaceful and orderly presidential and legislative elections, marking a major milestone in a transition to democracy. President Roch Mark Christian Kabore won with 53 percent of the popular vote, and his party--the People’s Movement for Progress--won 55 seats in the 127-seat National Assembly. National and international observers characterized the elections as free and fair.
The Ministry of Internal Security and the Ministry of Defense are responsible for internal security. The Ministry of Internal Security includes the National Police and the gendarmerie. The Army and the Air Force, which operate within the Ministry of Defense, are responsible for external security but sometimes assist with missions related to domestic security. Civilian authorities generally maintained effective control over security forces.
Significant human rights issues included unlawful or arbitrary killings by the government, including extrajudicial killings; forced disappearance by the government; torture by the government; arbitrary detention by the government; harsh and life-threatening prison conditions; widespread corruption; and crimes involving violence or threats of violence targeting members of national, racial, and ethnic minorities.
The government investigated and punished some cases of abuse, but impunity for human rights abuses remained a problem.
Armed groups connected to violent extremist organizations, including Jama’at Nasr al-Islam wal Muslim, Group for the Support of Islam and Muslims (JNIM), the Islamic State in the Greater Sahara (ISGS), and homegrown Ansaroul Islam perpetrated more than 300 attacks that resulted in hundreds of civilian deaths as well as the death of government security forces. In the protracted conflict with terrorist groups, members of the security forces engaged in numerous extrajudicial killings. The Koglweogo, a vigilante justice/self-defense group, carried out numerous retaliatory attacks, resulting in at least 100 civilian casualties. In August the government arrested nine members of the Koglweogo suspected of planning the January 1 attack on the village of Yirgou that killed at least 49 and displaced thousands more.
BURKINA FASO 2
Section 1. Respect for the Integrity of the Person, Including Freedom from: a. Arbitrary Deprivation of Life and Other Unlawful or Politically Motivated Killings
There were numerous reports the government or its agents committed arbitrary and unlawful killings. Multiple independent domestic and international human rights groups accused the security forces (FDS) of committing hundreds of extrajudicial killings of civilians as part of its counterterrorism strategy (section 1.g.). On July 14, 11 detainees died under the custody of the antidrug police unit in Ouagadougou.
On May 31, Fahadou Cisse and Hama Balima, two human rights defenders with the Organization for Democratic Youth in Burkina Faso, were abducted in Sebba in Yagha Province while researching a case of alleged government corruption. Prominent local human rights organizations alleged gendarmes were responsible for their deaths. As of August 20, the government had not released the results of their autopsies or opened an investigation into their deaths.
Terrorists carried out approximately 300 attacks, targeting members of government security forces and civilians. For example, on October 11, terrorists killed 16 worshippers in a mosque in the town of Salmossi in the northern Oudalon Province. On August 19, approximately 50 members of terrorist groups ISGS, JNIM, or Ansaroul Islam on motorcycles and trucks with mounted machine guns attacked the Koutougou military outpost, killing 24 soldiers and wounding dozens more (section 1.g.).
There were several accounts of criminal groups working in concert with terrorist organizations and drug traffickers killing gendarme, police, and park rangers, especially in the East Region of the country. For example, on September 6, unidentified armed individuals attacked a forest ranger position located in the Boucle du Mouhoun Region, killing the commander.
On January 2, members of Koglweogo attacked a string of ethnic Fulani herding communities outside the town of Barsalogho, killing 46 civilians, according to the government, or 216 civilians, according to civil society groups, resulting in mass displacement of local communities. The attack occurred in retribution against Fulani herding communities the Koglweogo suspected of having provided shelter to purported terrorists allegedly responsible for the January 1 killings of a local village chief and two of his children.
Country Reports on Human Rights Practices for 2019 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 3
According to the nongovernmental organization (NGO) Collective Torture and Impunity and Community Stigmatization (CISC), on May 22, members of the Batie Gendarmerie arrested and severely beat Diakite Saliou. Family members recovered his corpse on May 24 at University Hospital Center Souro Sanon. b. Disappearance
There were numerous reports of disappearances of civilians who were suspected of committing acts of terrorism, during counterterrorism military operations by security forces. According to CISC, on April 25, Ousseni Diallo and Souleymane Diallo disappeared after being interdicted by security forces. The Directorate of Military Justice continued its investigation of extrajudicial killings and disappearances of civilians in the village of Damba in 2017 and 2018 but, as of September 5, had not made any arrests. During a March military operation to dismantle terrorist networks in the eastern region, the military appointed human rights provosts to some deployed units, who sought to ensure that detainees captured during the operation received their due process rights.
Terrorists and criminal groups kidnapped dozens of civilians, including humanitarian aid workers (see section 1.g.). In December 2018 a Canadian citizen and an Italian citizen disappeared while travelling through the southwestern region of the country toward the border with Togo. c. Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment
The constitution and law prohibit such practices. Local rights groups alleged numerous accounts of torture committed by gendarmerie, police, and members of the Koglweogo. The majority of allegations of torture involved victims suspected of being linked with terrorists or of being of Fulani/Peuhl ethnicity.
According to local independent human rights groups, on April 4, Koglweogo abducted and tortured 11 persons in Tchambalawal before releasing them to the gendarmerie. Fatoumata Dicko, a 42-year old man, died from his wounds.
Prison and Detention Center Conditions
Country Reports on Human Rights Practices for 2019 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 4
Conditions in prisons and detention facilities were harsh and at times life threatening due to overcrowding and inadequate sanitary conditions and medical care.
Physical Conditions: Authorities held pretrial detainees with convicted prisoners. Female prisoners had better conditions than those of men, in large part due to less crowding. Some infants and children younger than age five accompanied their inmate mothers. Prisoners received two meals a day, but diets were inadequate, and inmates often relied on supplemental food from relatives. In some prisons overcrowding or severe overcrowding exacerbated inadequate ventilation, although some cells had electricity and some inmates had fans. Sanitation was rudimentary.
According to local NGOs and international human rights and protection organizations, at least five deaths of inmates occurred during the year at the Central Prison in Ouagadougou (MACO) and the High Security Prison in Ouagadougou resulting from a combination of poor health, illness, and other undisclosed causes.
There were no appropriate facilities or installations for prisoners or detainees with disabilities, who relied on other inmates for assistance.
A human rights NGO reported that prison guards at the MACO occasionally used excessive physical force, inflicting injuries on prisoners.
Food, potable water, sanitation, heating, ventilation, lighting, and medical care were inadequate in the majority of detention facilities across the country. Tuberculosis, HIV, AIDS, and malaria were the most common health problems among prisoners. For example, at the High Security Prison, there were three nurses employed to treat more than 800 detainees and prisoners, with no doctor present on site but available on an on-call basis. Detention conditions were better for wealthy or influential citizens, or detainees considered nonviolent.
Local media regularly reported on cases of detainees who had spent more than one year without trial.
Administration: President Kabore ordered an administrative and a judicial investigation of the 11 detainee deaths at the police antidrug unit that occurred on July 14 and a temporary dismissal of prison guards under the antidrug unit who were on duty when the deaths occurred. The government immediately suspended the members of the unit on shift during the incident pending the conclusion of the
Country Reports on Human Rights Practices for 2019 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 5 investigation. A new policy caps the number of detainees held at the National Police’s Anti-Drug Unit detention facility at 10, with any additional detainees transferred to a different police station in Ouagadougou.
Independent Monitoring: The government permitted monitoring by independent nongovernmental observers. Due to strikes by prison guards, prison authorities sometimes denied access to representatives of local and international human rights groups, media, foreign embassies, and the International Committee of the Red Cross to visit prisons, even with advance notice of the visit. d. Arbitrary Arrest or Detention
The constitution and law prohibit arbitrary arrest and detention and provide for the right of persons to challenge the lawfulness of their arrest or detention in court. Arbitrary arrests occurred, and judicial corruption and inadequate staffing of the judiciary, largely due to protracted strikes by civil servants, deterred detainees from challenging the lawfulness of their arrest in court.
Arrest Procedures and Treatment of Detainees
By law police and gendarmes must possess a court-issued warrant based on sufficient evidence before apprehending a person suspected of committing a crime, but authorities did not always follow these procedures. Authorities did not consistently inform detainees of charges against them. By law detainees have the right to expeditious arraignment, bail, access to legal counsel, and, if indigent, access to a lawyer provided by the government after being charged. A judge may order temporary release without bail pending trial. Authorities seldom respected these rights. The law does not provide detainees access to family members, although authorities generally allowed detainees such access through court-issued authorizations.
The law limits detention without charge for investigative purposes to a maximum of 72 hours, renewable for a single 48-hour period. In terrorism investigations, the law allows detention for a 10-day period. In cases not related to terrorism, police rarely observed the law, and the average time of detention without charge (preventive detention) was one week. Once authorities charge a suspect, the law permits judges to impose an unlimited number of consecutive six-month preventive detention periods while the prosecutor investigates charges. Authorities often detained defendants without access to legal counsel for weeks, months, or
Country Reports on Human Rights Practices for 2019 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 6 even years before the defendant appeared before a magistrate. There were instances in which authorities detained suspects incommunicado.
Arbitrary Arrest: Local independent rights groups alleged that security forces regularly arbitrarily arrested individuals for suspected involvement in terrorism. An official with the Ministry of Justice reported that hundreds of individuals detained at the High Security Prison remained in detention without being charged.
Pretrial Detention: Authorities estimated 52 percent of prisoners nationwide were in pretrial status, but local independent rights groups estimated it to be as high as 70 percent. A lack of counsel specialized in criminal law, particularly defense lawyers willing to represent detainees arrested on terrorism charges, greatly contributed to delays in bringing cases to trial. In some cases authorities held detainees without charge or trial for longer periods than the maximum sentence for conviction of the alleged offense. A pretrial release (release on bail) system exists, although the extent of its use was unknown.
Detainee’s Ability to Challenge Lawfulness of Detention before a Court: The law provides persons arrested or detained the right to challenge in court the legal basis or arbitrary nature of their detention. Prisoners who did so, however, reportedly faced difficulties due to either judicial corruption or inadequate staffing of the judiciary. e. Denial of Fair Public Trial
The constitution and law provide for an independent judiciary, but the judiciary was corrupt, inefficient, and subject to executive influence, according to NGOs. There were no instances in which the trial outcomes appeared predetermined, and authorities respected court orders. Legal codes remained outdated, there were not enough courts, and legal costs were excessive. Citizens’ poor knowledge of their rights further weakened their ability to obtain justice.
Military courts try cases involving military personnel charged with violating the military code of conduct. Rights provided in military courts are equivalent to those in civil criminal courts. Military courts are headed by a civilian judge, hold public trials, and publish verdicts in the local press.
Trial Procedures
Country Reports on Human Rights Practices for 2019 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 7
The law presumes defendants are innocent. Defendants have the right to be informed promptly and in detail of the charges, with free assistance of an interpreter. Trials are public but may be delayed. Judicial authorities use juries only in criminal cases. Defendants have the right to be present at their trials and to legal representation, consultation, and adequate time and facilities to prepare a defense. Defendants have the right to provide evidence. Defendants have the right not to be compelled to testify or confess guilt, but a refusal to testify often resulted in harsher decisions. Defendants may challenge and present witnesses, and they have the right of appeal. In civil cases where the defendant is destitute and files an appeal, the state provides a court-appointed lawyer. In criminal cases court- appointed lawyers are mandatory for those who cannot afford one. The government did not always respect these rights, due in part to popular ignorance of the law and a continuing shortage of magistrates and court-appointed lawyers.
The Ministry of Justice, Human Rights, and Civic Promotion claimed courts usually tried cases within three months, although human rights organizations reported major case backlogs. The 2011 “processing of criminal penalties in real time” reform to shorten pretrial detention allows the prosecutor and investigators (police and gendarmerie) to process a case prior to the criminal hearing. This countrywide approach allows authorities to inform defendants of the charges and trial date before authorities release them pending trial.
Political Prisoners and Detainees
There were no reports of political prisoners or detainees during the year, although some arrests and detentions may have been politically motivated.
Civil Judicial Procedures and Remedies
There is an independent judiciary in civil matters, but it was often inefficient, corrupt, and subject to executive influence. As a result citizens sometimes preferred to rely on the Office of the Ombudsman to settle disputes with the government.
The law provides for access to a court to file lawsuits seeking damages for, or cessation of, a human rights violation, and both administrative and judicial remedies were available for alleged wrongs. Victims of human rights violations may appeal directly to the Economic Community of West African States (ECOWAS) Court of Justice, even before going through national courts. For civil and commercial disputes, authorities may refer cases to the ECOWAS Common
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Court of Justice and Arbitration in Abidjan, Cote d’Ivoire. The courts issued several such orders during the year.
There were problems enforcing court orders in sensitive cases involving national security, wealthy or influential persons, and government officials. f. Arbitrary or Unlawful Interference with Privacy, Family, Home, or Correspondence
The constitution and law prohibit such actions, and the government generally respected these prohibitions. In cases of national security, however, the law permits surveillance, searches, and monitoring of telephones and private correspondence without a warrant. In June the National Assembly passed revisions to the penal code that permit wiretapping in terrorism cases, to be authorized by the president of a tribunal for a limited term. Investigative judges have the authority to authorize audio recording in private places. These investigations techniques are new in the legal framework. The national intelligence service is authorized to use technology for surveillance, national security, and counterterrorism purposes.
In December 2018 President Kabore declared a state of emergency in 14 provinces within seven of the country’s 13 administrative regions that granted additional powers to the security forces to carry out searches of homes and restrict freedom of movement and assembly. The state of emergency was extended on July 11 for an additional six months.
According to international and local independent rights groups, the military employed informant systems to generate lists of suspected terrorists based on anecdotal evidence. g. Abuses in Internal Conflict
Killings: There were at least 500 security force members and civilians that died as a result of actions by armed groups and terrorist groups, including ISGS, JNIM, and Ansaroul Islam, as well as more than 200 deaths of civilians allegedly resulting from the security forces’ counterinsurgency efforts.
According to Human Rights Watch, from August 2018 through March, security forces executed at least 116 civilians within a 30-mile radius of the town of Arbinda, whom they suspected of supporting or harboring terrorists. The
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Burkinabe Movement for Human Rights (MBDHP), a credible local human rights organization, documented 60 civilian deaths in Kahn and Bahn after a February 4 counterterrorist military operation executed by the security forces.
On March 18, during a counterterrorism military operation in the east, five civilians, four of whom were minors, were unintentionally killed by security force gunfire near the Boungou and Lopadi villages.
An investigation opened by the government in 2017 regarding allegations by Human Rights Watch of extrajudicial killings by soldiers in Damba remained open, with no arrests or charges made.
On June 9, dozens of armed unidentified gunmen, presumed to be terrorists by the government, killed at least 19 and injured 13 others in Arbinda in the north. On April 26, terrorists attacked a school in the village of Maitaougou, killing six civilians, including five teachers.
On May 12, terrorists attacked a Catholic church in the town of Dablo, killing six and wounding dozens more. On August 19, terrorist groups attacked the Koutougou military base located in the northwest, killing 24 soldiers and wounding dozens more.
On November 3, terrorists killed the mayor of Djibo and member of the National Parliament, Oumarou Dicko, along with three other passengers travelling by vehicle southward from Djibo towards Ouagadougou.
On November 6, terrorists killed 39 employees of the SEMAFO mining company in the East Region in a roadside ambush using an improvised explosive device and gunfire, injuring 60 others.
During the year terrorists killed seven municipal councilors.
On January 1, members of Koglweogo attacked a herding encampment outside the town of Yirgou, killing 49 ethnic Fulani civilians, according to the government, or more than 200 Fulani civilians, according to international aid organizations and local NGOs. The attack resulted in mass internal displacement of an estimated 25,000 civilians in the Center-North Region.
Abductions: Terrorists kidnapped dozens of civilians throughout the year, including international humanitarian aid and medical workers. For example, on
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February 2, terrorists kidnapped four Red Cross workers deployed on a humanitarian mission from their marked vehicle. In April terrorists belonging to ISIS kidnapped four international travelers, including a U.S. citizen, holding them hostage between one to four weeks before they were liberated by French special forces on May 9. In addition, terrorists kidnapped one mayor and two other municipal counselors.
Physical Abuse, Punishment, and Torture: According to Human Rights Watch and MBDHP, on several occasions, security force members tortured and beat civilians they suspected of having ties to terrorist groups, sometimes destroying their property. According to witnesses, in early August terrorists raped four women in the village of Naafo.
Other Conflict-related Abuse: Throughout the year armed groups and terrorists attacked medical facilities and hijacked ambulances and official vehicles of humanitarian and medical aid workers. Local authorities in the Sahel, North, and East Regions reported terrorists displaced thousands of civilians and limited movement in rural areas. On February 14, a bomb hidden in a corpse dressed in military uniform killed an army doctor and wounded two police officers. In July armed assailants, most likely belonging to violent extremist organizations Ansaroul Islam or JNIM, attempted to blow up a bridge connecting Djibo, the capital of Soum Province, to the rest of the country. On September 8, terrorists attacked a United Nations World Food Program convoy transporting food and materials for internally displaced persons (IDPs), killed two contracted civilian drivers, and seized and destroyed all materials.
Section 2. Respect for Civil Liberties, Including: a. Freedom of Expression, Including for the Press
The constitution and law provide for freedom of expression, including for the press, but the government did not always respect this right. In June the National Assembly voted to amend the penal code banning journalists from reporting any security-related news in an effort to preserve national security and prevent the demoralization of the military. Attempts to “demoralize” members of the military was previously a crime, but the code was amended to state “by any means,” presumably to criminalize any press or other media intended to demoralize security forces. A 2015 law decriminalizes press offenses and replaces prison sentences with penalties ranging from one million to five million CFA francs ($1,700 to
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$8.500). Some editors complained that few newspapers or media outlets could afford such fines.
Despite the advent of the 2015 law, journalists occasionally faced criminal prosecution for libel and other forms of harassment and intimidation.
Freedom of Expression: The June revision of the penal code criminalizes communicating the position or movements of defense forces, or sites of national interest or of a strategic nature, and the publication of any terrorist crime scene without authorization. The law also permits a judge, at the request of a “public minister” (prosecutor), to block internet websites or email addresses being used to spread “false information” to the public. Local and international associations of journalists called for the rejection of the amendments as an unacceptable attempt to stifle freedom of speech. The law significantly increases penalties for the existing crime of publicly insulting another person if electronic communications are used to publish the insult, and it prohibits persons from insulting the head of state or using derogatory language with respect to the office.
Press and Media, Including Online Media: Independent media were active and expressed a wide variety of views, albeit with some restrictions. Foreign radio stations broadcast without government interference.
All media are under the administrative and technical supervision of the Ministry of Communications, which is responsible for developing and implementing government policy on information and communication. The Superior Council of Communication (CSC) monitored the content of radio and television programs, newspapers, and internet websites to enforce compliance with standards of professional ethics and government policy. The CSC may summon journalists and issue warnings for subsequent violations. Hearings may concern alleged libel, disturbing the peace, inciting violence, or violations of state security.
Censorship or Content Restrictions: In addition to prohibitions on publishing security-related information and insulting the head of state, the law also prohibits the publication of shocking images or material that demonstrates lack of respect for the deceased. Journalists practiced self-censorship, fearing that publishing blatant criticism of the government could result in arrest or closure of their newspaper.
Libel/Slander Laws: On September 23, the Djibo police filed a defamation suit for the “demoralization of police force” against the mayor of Djibo after he publicly denounced their behavior and accused them of rape and killing of civilians.
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Nongovernmental Impact: Terrorist groups sought to inhibit freedom of expression by forcing women, predominantly in the North and Sahel Regions, to cover their heads, forcing men to wear religious garb, preventing children from going to non-Quranic school, and prohibiting civilians from drinking alcohol, smoking, frequenting bars, and listening to music at the risk of beatings or death.
Internet Freedom
The government did not restrict or disrupt access to the internet, although the CSC monitored internet websites and discussion forums to enforce compliance with regulations.
Academic Freedom and Cultural Events
There were no government restrictions on academic freedom or cultural events. b. Freedoms of Peaceful Assembly and Association
The law provides for the freedoms of peaceful assembly and association, but the government at times restricted these rights.
Freedom of Peaceful Assembly
On multiple occasions throughout the year, the government denied requests for permits to NGOs and civil society organizations who sought to organize demonstrations and rallies. The government stopped a planned rally by a coalition of civil society organizations and labor unions on September 16, using tear gas to disperse demonstrators. The government had previously denied a permit to the demonstrators to hold the march, but the group proceeded to hold the event anyway.
Political parties and labor unions may hold meetings and rallies without government permission, although advance notification and approval are required for public demonstrations that may affect traffic or threaten public order. If a demonstration or rally results in violence, injury, or significant property damage, penalties for the organizers include six months’ to five years’ imprisonment and fines of between 100,000 and two million CFA francs ($170 and $3,400). These penalties may be doubled for conviction of organizing an unauthorized rally or
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Freedom of Association
On November 13, the minister of territorial administration, decentralization, and social cohesion suspended the political party Renewal Patriotic Front for three months on the grounds the group had violated the charter of political parties when its leader publicly demanded the resignation of President Kabore on November 3 and again on November 11. c. Freedom of Religion
See the Department of State’s International Religious Freedom Report at https://www.state.gov/religiousfreedomreport/. d. Freedom of Movement
The constitution provides for freedom of internal movement, foreign travel, emigration, and repatriation, and the government generally respected these rights.
In-country Movement: The government required citizens to carry a national identity document, and it authorized officials to request the document at any time. Without a national identity card, citizens could not pass between certain regions of the country and were subject to arrest and fines.
Armed terrorists restricted movement of thousands of rural inhabitants throughout the country by planting improvised explosive devices on major highways, hijacking vehicles, and setting up checkpoints. In response to dozens of attacks by unknown armed groups presumed to be terrorists, local authorities instituted a ban on motorcycle traffic from 7 p.m. to 5 a.m. in the East and North Regions. e. Internally Displaced Persons
Recurrent armed attacks and interethnic clashes throughout the northern and eastern regions caused a steep increase in the number of IDPs from 39,731 registered in October 2018 to more than 560,000 by the end of October, according to the UN Office of Humanitarian Affairs. Since January an average of 30,000 persons every month fled from their homes. The government worked effectively with international and local aid organizations to improve food, water, health
Country Reports on Human Rights Practices for 2019 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 14 services, and protection of affected civilians against abuse and violations. The government promoted local integration of IDPs by offering limited assistance to host families. Nevertheless, during the year the National Commission for Human Rights criticized the government for failing to provide sufficient resources and medical services to IDPs resulting from the January 1 attack on Yirgou. f. Protection of Refugees
Abuse of Migrants, Refugees, and Stateless Persons: The government cooperated with the Office of the UN High Commissioner for Refugees (UNHCR) and other humanitarian organizations in providing protection and assistance to internally displaced persons, refugees, returning refugees, asylum seekers, stateless persons, and other persons of concern.
Recurrent terrorist attacks hampered access by humanitarian workers to deliver lifesaving supplies and assistance to refugees and IDPs. On March 19, suspected terrorists killed two persons teaching refugee students at a secondary school in Djibo. UNHCR relocated 18 refugee students from Mentao refugee camp to Goudoubo refugee camp, allowing them to participate in their final exams. On May 24, suspected terrorists kidnapped three Burkinabe staff members of UNHCR’s international health partner, the Centre de Support en Sante International, resulting in the closure of a medical center for refugees. In July and August, hundreds of refugees living outside of camps in the North and Sahel Regions returned to camps seeking protection from attacks. On August 15, armed groups linked to violent extremist organizations attacked a security post on a main road near the Mentao refugee camp, killing three soldiers and wounding a refugee woman. In December 2018 a primary school in Mentao camp closed due to threats from terrorists.
Access to Asylum: The law provides for granting asylum or refugee status, and the government has established a system for providing protection to refugees. The Ministry of Women, National Solidarity, Family, and Humanitarian Affairs, aided by the National Committee for Refugees, is the focal point for coordination of national and international efforts.
Freedom of Movement: According to UNHCR, police arbitrarily arrested Fulani refugees travelling from the Sahel Region to Ouagadougou on multiple occasions, sometimes holding them in detention overnight before releasing them.
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Access to Basic Services: According to UNHCR, public institutions such as banks, schools, and hospitals occasionally refused service to refugees on a discriminatory basis.
Temporary Protection: The government agreed to offer temporary protection to individuals who did not qualify as refugees, but there were no such applicants during the year. g. Stateless Persons
According to UNHCR, more than 700,000 habitual residents were legally or de facto stateless, mostly due to a lack of documentation. The Ministry of Justice, Human Rights, and Civic Promotion worked with UNHCR to deploy mobile courts to remote villages to issue birth certificates and national identity documents to residents who qualified for citizenship.
Section 3. Freedom to Participate in the Political Process
The constitution provides citizens the ability to choose their government in free and fair periodic elections held by secret ballot and based on universal and equal suffrage.
Elections and Political Participation
Recent Elections: In the 2015 national elections, Roch Mark Christian Kabore won the presidency with 53 percent of the popular vote. His party, the People’s Movement for Progress, won 55 of the 127 seats in the National Assembly. The Union for Progress and Change won 33 seats, and the former ruling party, the Congress for Democracy and Progress, won 18 seats. National and international observers characterized the elections as free and fair.
The 2015 electoral code approved by the National Transitional Council stipulated the exclusion of certain members of the former political majority. The code stated that persons who “supported a constitutional change that led to a popular uprising” are ineligible to be candidates in future elections. In July 2018 the National Assembly passed a new electoral law that allows all political candidates to run for election and opened the vote to members of the Burkinabe diaspora in possession of a national identity card or passport.
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Participation of Women and Minorities: No laws limit participation of women and members of minorities in the political process, and they did participate. Although the gender quota law requires political parties to name women to fill at least 30 percent of the positions on their candidate lists in legislative and municipal elections, no political party met this requirement during the 2016 and the May 2017 make-up municipal elections. In March a new law establishing “zebra lists” mandates that electoral lists alternate names of men and women in order to better achieve a 30 percent quota. The law also establishes positive incentives for political parties respecting the quota, but no penalties for those who did not abide by the law. Parties and government officials stated women were less engaged in politics, due to cultural and traditional factors. Women held seven of 32 ministerial seats and 14 of 127 seats in the National Assembly.
Section 4. Corruption and Lack of Transparency in Government
The law provides criminal penalties for corruption by officials, but the government did not implement the law effectively. Throughout the year the press reported cases of misappropriation, fraud, or other offenses. The NGO National Network for Anti-Corruption cited the customs, police and General Directorate of Land and Maritime Transport as the most corrupt entities in the government.
Corruption: In August the government announced it would prosecute 12 employees of Iamgold Essakane SA for smuggling and fraud in the marketing of gold and other precious substances as hazardous waste for illegal export. Authorities opened an investigation of former minister of defense Jean-Claude Bouda and Minister of Infrastructure Eric Bougouma for using government funds to build personal wealth.
Financial Disclosure: A 2015 anticorruption law requires government officials-- including the president, lawmakers, ministers, ambassadors, members of the military leadership, judges, and anyone charged with managing state funds--to declare their assets and any gifts or donations received while in office. The Constitutional Council is mandated to monitor and verify compliance with such laws and may order investigations if noncompliance is suspected. Disclosures are not made public, however, and there were no reports of criminal or administrative sanctions for noncompliance. As of September National Assembly members elected in 2015 had not complied with this law yet faced no sanctions.
In 2016 the Higher Authority for State Control and the Fight against Corruption extended the requirement to declare assets to include government officials’ spouses
Country Reports on Human Rights Practices for 2019 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 17 and minor children. Infractions are punishable by a maximum prison term of 20 years and fines of up to 25 million CFA francs ($42,400). The law also punishes persons who do not reasonably explain an increase in lifestyle expenditures beyond the 5 percent threshold set by regulation in connection with lawful income. Convicted offenders risk imprisonment for two to five years and a fine of five million to 25 million CFA francs ($8,500 to $42,400). A 2016 law limits the value of a gift a government official may receive to 35,000 CFA francs ($60).
Section 5. Governmental Attitude Regarding International and Nongovernmental Investigation of Alleged Abuses of Human Rights
A variety of domestic and international human rights groups operated without government restriction, investigating and publishing their findings on human rights cases. Government officials were cooperative and somewhat responsive to their views.
Government Human Rights Bodies: As a result of a January 24 government reshuffle, President Kabore established the Ministry of Human Rights and Civic Promotion, separating it from the Ministry of Justice, which previously was charged with overseeing human rights. During the year the ministry organized several training sessions for security forces on the law of armed conflict, provided assistance to victims of terrorist- and gender-based violence, and organized antistigmatization and social cohesion campaigns. The government also assigned a human rights provost to accompany deployed troops during military operations in order to assure detainees were afforded proper treatment and due rights. On October 22, the minister of security administered human rights training to law enforcement members in Dori, the capital of the Sahel Region. This was the first of a series of three training sessions to be expanded to include security forces in other regions in the east and west.
The Office of the Ombudsman addresses citizen complaints regarding government entities and other bodies entrusted with a public service mission. The ombudsman, whom the president appoints for a nonrenewable five-year term and who may not be removed during the term, was generally viewed as effective and impartial.
The government-funded National Commission on Human Rights provides a permanent framework for dialogue on human rights concerns. Its members include 15 representatives of human rights NGOs, unions, professional associations, and the government. Although inadequately funded, the commission produced a well
Country Reports on Human Rights Practices for 2019 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 18 documented report on intercommunal violence and made recommendations to the government on responding to IDP population needs.
Section 6. Discrimination, Societal Abuses, and Trafficking in Persons
Women
Rape and Domestic Violence: Violence against women was prevalent, including rape and domestic violence. According to the penal code, rape is punishable by a prison sentence of 11 to 20 years and a fine of one million to three million CFA francs ($1,700 to $5,000) when committed against a minor between ages 13 and 15. The penalty is punishable by 11 to 30 years in prison and a fine of three to 10 million CFA francs ($5,000 to $17,000) when the victim is younger than age 13. Rape was widely underreported in part due to societal taboos and the drawn-out judicial process owing to the overburdened justice system. Media, however, reported on the prevalence of rape cases and subsequent convictions. For example, an investigation was underway into the rape of a 12-year-old girl in December 2018 who became pregnant.
Victims seldom pursued legal action due to shame, fear, or reluctance to take their spouses to court. For the few cases that went to court, the Ministry of Justice could provide no statistics on prosecutions, convictions, or punishment. A government- run shelter for women and girls who were victims of gender-based violence welcomed victims regardless of nationality. In Ouagadougou the Ministry of Women, National Solidarity, Family, and Humanitarian Affairs assisted victims of domestic violence at four centers. The ministry sometimes provided counseling and housing for abused women.
The ministry has a legal affairs section to educate women on their rights, and several NGOs cooperated to protect women’s rights. To raise awareness of gender discrimination and reduce gender inequalities, the ministry organized numerous workshops and several awareness campaigns mainly in the North, Sahel, East, and Center-West Regions.
The law makes conviction of “abduction to impose marriage or union without consent” punishable by six months to five years in prison. Conviction of sexual abuse or torture or conviction of sexual slavery is punishable by two to five years in prison. Conviction of the foregoing abuses may also carry fines of 500,000 to one million CFA francs ($850 to $1,700).
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The law requires police to provide for protection of the victim and her minor children and mandates the establishment of chambers in the High Court with exclusive jurisdiction over cases of violence against women and girls. The law requires all police and gendarmerie units to designate officers to assist female victims of violence--or those threatened by violence--and to respond to emergencies; however, some units had not complied by year’s end. It also mandates the creation of care and protection centers in each commune for female victims of violence and a government support fund for their care. The centers receive victims on an emergency basis, offer them security, provide support services (including medical and psychosocial support), and, when possible, refer the victims to court.
Female Genital Mutilation/Cutting (FGM/C): FGM/C is a practice prohibited by law, and those found guilty are liable to a prison sentence of one to 10 years with a fine of 500,000 to three million CFA francs ($850 to $5,000). If a victim of FGM/C dies following the excision, the sentence increases to a term of 11 to 20 years’ imprisonment and a fine of one to five million CFA francs ($1,700 to $8,500). Accomplices are also punishable with penalties. The government continued to fund and operate a toll-free number to receive anonymous reports of the practice.
The government continued to fund the Permanent Secretariat of the National Council for the Fight Against the Practice of Excision. During the year it reported that 1,089 practitioners of FGM/C agreed to cease practicing excision. The government provided training to 6,272 health workers to strengthen their skills in caring for FGM/C-related medical complications, enabling medical care to reach 520 victims of excision.
In December 2018 the Ministry of Women, National Solidarity, Family, and Humanitarian Affairs convened 55 judicial actors and members of the ministry’s gender task force. The purpose was to discuss guidelines for the care of survivors and the application of the law on FGM/C and child marriage.
Other Harmful Traditional Practices: In the Center-East Region, self-proclaimed traditional healers performed rituals in which participants denounced relatives as witches they held responsible for their misfortune, and subsequently punished them. The latter were tied up, humiliated, beaten, and brutalized. Neighbors accused elderly women, and less frequently men, without support, living primarily in rural areas, and often widowed in the case of women, of witchcraft and subsequently banned them from their villages, beat them, or killed them. On
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August 8, a man accused of witchcraft was beaten to death by the population in Samba commune in Yako. Widows were disproportionately accused of witchcraft by male relatives, who then claimed their land and other inheritance. The law, which was seldom enforced, makes the conviction of physical or moral abuse of women or girls accused of witchcraft punishable by one to five years in prison, a fine of 300,000 to 1.5 million CFA francs ($500 to $2,500), or both.
Sexual Harassment: The law provides for sentences of three months to one year in prison and a fine of 300,000 to 500,000 CFA francs ($500 to $850) for conviction of sexual harassment; the maximum penalty applies if the perpetrator is a relative or in a position of authority, or if the victim is “vulnerable.” The government was ineffective in enforcing the law. Owing to social taboos, victims rarely reported sexual harassment.
Coercion in Population Control: There were no reports of coerced abortion or involuntary sterilization.
Discrimination: Although the law generally provides the same legal status and rights for women as for men--including under family, labor, property, and inheritance laws--discrimination frequently occurred. Labor laws provide that all workers--men and women alike--should receive equal pay for equal working conditions, qualifications, and performance. Women nevertheless generally received lower pay for equal work, had less education, and owned less property.
Although the law provides equal property and inheritance rights for women and men, land tenure practices emphasized family and communal land requirements more than individual ownership rights. As a result, authorities often denied women the right to own property, particularly real estate. Many citizens, particularly in rural areas, held to traditional beliefs that did not recognize inheritance rights for women and regarded a woman as property that could be inherited upon her husband’s death.
The government conducted media campaigns to change attitudes toward women. It sponsored a number of community outreach efforts and awareness campaigns to promote women’s rights.
Children
Birth Registration: Citizenship derives either from birth within the country’s territory or through a parent. Parents generally did not register births immediately;
Country Reports on Human Rights Practices for 2019 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 21 lack of registration sometimes resulted in denial of public services, including access to school. To address the problem, the government periodically organized registration drives and issued belated birth certificates.
Child Abuse: The penal code provides for a prison sentence of one to three years with a fine of 300,000 to 900,000 CFA francs ($500 to $1,500) for those found guilty of inhuman treatment or mistreatment of children. On August 6, the government launched a National Child Protection Strategy to create a strengthened institutional, community, and family environment in order to ensure effective protection for children by 2023.
Early and Forced Marriage: The law prohibits forced marriage and provides for sentences ranging from six months to two years in prison for offenders, as well as a three-year prison sentence if the victim is younger than age 13.
According to the family code, “marriage can only be contracted between a man older than age 20 and a woman older than 17, unless age exemption is granted for serious cause by the civil court.” According to UNICEF, 10 percent of girls were married before the age of 15 and 52 percent before the age of 18. In March the government, in collaboration with UNICEF, launched a national campaign called “Do not call me Madam” to combat child marriage, as part of their National Strategy against Child Marriage, with the goal of eliminating child marriage by 2025. Despite government efforts at combatting early marriage, civil society organizations reported that minors, especially girls, were kidnapped on their way to school or to market and forced into early marriage. In May the government organized a travelling campaign called “zero child marriage,” targeting specific communes for education against the practice.
According to media reports, the traditional practice persisted of kidnapping, raping, and impregnating a girl and then forcing her family to consent to her marriage to her violator.
Sexual Exploitation of Children: The law provides penalties for conviction of “child prostitution” or child pornography of five to 10 years’ imprisonment, a fine of 1.5 to three million CFA francs ($2,500 to $5,000), or both. The minimum age of consensual sex is 15. A 2014 law criminalizes the sale of children, child commercial sexual exploitation, and child pornography. Children from poor families were particularly vulnerable to sex trafficking. The government did not report any convictions for violations of the law during the year. The penal code prescribes penalties of 11 to 20 years’ imprisonment and a fine of two million to 10
Country Reports on Human Rights Practices for 2019 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 22 million CFA ($3,400 to $17,000) francs for sex trafficking involving a victim 15 years or younger. It also prescribes five to 10 years’ imprisonment and fines of one million and five million CFA francs ($1,700 and $8,500) for sex trafficking involving a victim older than age 15.
Infanticide or Infanticide of Children with Disabilities: The law provides for a sentence of 10 years’ to life imprisonment for infanticide. Newspapers reported several cases of abandonment of newborn babies.
Displaced Children: Recurrent armed attacks displaced thousands of children. According to a UN humanitarian organization, women and children accounted for 85 percent of the IDPs (see section 2.e.). The government, in collaboration with humanitarian actors, provided 12,372 children with formal and informal education.
International Child Abductions: The country is a party to the 1980 Hague Convention on the Civil Aspects of International Child Abduction. See the Department of State’s Annual Report on International Parental Child Abduction at https://travel.state.gov/content/travel/en/International-Parental-Child- Abduction/for-providers/legal-reports-and-data/reported-cases.html.
Anti-Semitism
There was no known Jewish community. There were no reports of anti-Semitic acts.
Trafficking in Persons
See the Department of State’s Trafficking in Persons Report at https://www.state.gov/trafficking-in-persons-report/.
Persons with Disabilities
The law prohibits discrimination against persons with physical, sensory, intellectual, and mental disabilities in employment, education, transportation, access to health care, the judicial system, or the provision of other state services. There is legislation to provide persons with disabilities less costly or free health care and access to education and employment. The law also includes building codes to provide for access to government buildings. The government did not effectively enforce these provisions.
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Persons with disabilities encountered discrimination and reported difficulty finding employment, including in government service.
The government had limited programs to aid persons with disabilities, but NGOs and the National Committee for the Reintegration of Persons with Disabilities conducted awareness campaigns and implemented integration programs.
During the year President Kabore presided over a national forum on developing more socioeconomic inclusion for persons with disabilities. The government continued to arrange for candidates with vision disabilities to take the public administration recruitment exams by providing the tests in Braille. Additionally, authorities opened specific counters at enrollment sites to allow persons with disabilities to register more easily for public service admission tests. According to the Ministry of Education, children with disabilities attended school at lower rates than others, although the government provided for limited special education programs in Ouagadougou.
National/Racial/Ethnic Minorities
Longstanding conflicts between Fulani (Peuhl) herders and sedentary farmers of other ethnic groups sometimes resulted in violence. Herders commonly triggered incidents by allowing their cattle to graze on farmlands or farmers attempting to cultivate land set aside by local authorities for grazing. Government efforts at dialogue and mediation contributed to a decrease in such incidents. In the aftermath of the January attack on Yirgou, President Kabore and the minister of foreign affairs and cooperation convened ethnic and religious leaders in private audience in an attempt to de-escalate violence and promote community cohesion.
Between March 31 and April 1, terrorists reportedly shot and killed Cheickh Werem Issouf, a revered religious leader, along with six members of his family, in the village of Arbinda, and raped the women of his family. On April 1, dozens of ethnic Fulse killed at least 62 Fulani villagers in a reprisal attack, whom they suspected to be complicit with the terrorists that carried out the assassination of their leader.
Indigenous People
Indigenous persons and their institutions sometimes participated in decisions affecting their land. Exploitation of natural resources near indigenous land endangered the welfare and livelihoods of indigenous communities. A Chinese
Country Reports on Human Rights Practices for 2019 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 24 construction project to build a hospital in a classified forest in Bobo-Dioulasso sparked a controversial debate and was strongly rejected by the local population. Indigenous communities criticized the government’s decision to downgrade 16 hectares (approximately 38 acres) of this forest and suggested that the hospital be built on another site. Following the controversy, the government suspended the project and commissioned an environmental impact study of the site. The results of the study were pending at year’s end.
Acts of Violence, Discrimination, and Other Abuses Based on Sexual Orientation and Gender Identity
The country has no hate crime laws or other criminal justice mechanisms to aid in the investigation, prosecution, or sentencing of bias-motivated crimes against the lesbian, gay, bisexual, transgender, and intersex (LGBTI) community. NGOs reported police occasionally arrested gay men and transgender individuals and humiliated them in detention before releasing them.
Societal discrimination against LGBTI persons was a problem, and it was exacerbated by religious and traditional beliefs. Medical facilities often refused to provide care to members of the transgender community, and LGBTI individuals were occasionally victims of verbal and physical abuse, according to LGBTI support groups. There were no reports the government responded to societal violence and discrimination against LGBTI persons.
LGBTI organizations had no legal status in the country but existed unofficially with no reported harassment. There were no reports of government or societal violence against such organizations, although incidents were not always reported due to stigma or intimidation.
HIV and AIDS Social Stigma
Societal discrimination against persons with HIV/AIDS continued to be a problem and prohibited some individuals from receiving medical services due to fear of harassment. Families sometimes shunned persons who tested positive and sometimes evicted HIV-positive wives from their homes, although families did not evict their HIV-positive husbands. Some property owners refused to rent lodgings to persons with HIV/AIDS. The government distributed free antiretroviral medication to some HIV-positive persons who qualified according to national guidelines.
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Other Societal Violence or Discrimination
Vigilante groups apprehended and sometimes arbitrarily detained individuals usually involved in petty crime, employing severe beatings to solicit a confession. On August 7, a security guard working for the Youga Gold Mine shot and killed a local artisanal miner. The following day an estimated 100 artisanal miners in the area launched an attack against the Youga Gold Mine, injuring several employees. According to journalists in the community, this attack was related to preexisting labor disputes at the mine and locals’ discontent over the hiring of foreign workers.
NGOs reported that police frequently discriminated against the Fulani, stigmatizing them as terrorists. According to NGOs, police often arrested them because of their physical appearance, interrogated them on terrorism charges, and finally released them without charging them.
Section 7. Worker Rights a. Freedom of Association and the Right to Collective Bargaining
The law allows workers to form and join independent unions, except for essential workers, such as magistrates, police, military, and other security personnel, who may not join unions. The law provides unions the right to conduct their activities without interference.
The law provides for the right to strike, although it significantly limits that right. For strikes that call on workers to stay home and that do not entail participation in a rally, the union is required to provide eight to 15 days’ advance notice to the employer. If unions call for a march, they must provide three days’ advance notice to the city mayor. Authorities hold march organizers accountable for any property damage or destruction that occurs during a demonstration. The law also gives the government extensive requisitioning powers, authorizing it to requisition private- and public-sector workers to secure minimum service in essential services.
The law prohibits antiunion discrimination and allows a labor inspector to reinstate immediately workers fired because of their union activities. Relevant legal protections cover all workers, including migrants, workers in the informal sector, and domestic workers. There were no reports of antiunion discrimination during the year.
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The law provides for freedom of association and collective bargaining. The government effectively enforced the law. The law lists sanctions for violations, including warnings, penalties, suspension, or dissolution and were generally sufficient to deter violations. Penalties consist of imprisonment and fines and vary depending on the gravity of the violation. Amendments to the law award a legal existence to labor unions of NGOs, create a commission of mediation, and require that associations abide by the law concerning funding terrorism and money laundering. The law also states that no one may serve as the head of a political party and the head of an association at the same time.
The government generally respected freedom of association and the right to collective bargaining. The government generally respected the right of unions to conduct activities without interference. Unions have the right to bargain directly with employers and industry associations for wages and other benefits. Worker organizations were independent of the government and political parties. There were no reports of strikebreaking during the year. Government resources to enforce labor laws were not sufficient to protect workers’ rights.
There were no reports of government restrictions on collective bargaining during the year. There was extensive collective bargaining in the formal wage sector, which was where many worker rights violations occurred. b. Prohibition of Forced or Compulsory Labor
The law prohibits all forms of forced or compulsory labor. The law considers forced or compulsory any labor or service provided by an individual under the threat of any type of sanction and not freely offered. The government did not effectively enforce applicable laws. The government did not have a significant, effective program in place to address or eliminate forced labor. The government continued to conduct antitrafficking advocacy campaigns and operated a toll-free number for individuals to report cases of violence and trafficking. Penalties were not sufficiently stringent to deter violations.
Forced child labor occurred in the agricultural (particularly cotton), domestic labor, and animal husbandry sectors, as well as at gold panning sites and stone quarries. Educators forced some children sent to Quranic schools by their parents to engage in begging (see section 6, Children). Women from other West African countries were fraudulently recruited for employment and subsequently subjected to forced prostitution, forced labor in restaurants, or domestic servitude in private homes.
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See the Department of State’s Trafficking in Persons Report at https://www.state.gov/trafficking-in-persons-report/. c. Prohibition of Child Labor and Minimum Age for Employment
The law prohibits the worst forms of child labor, including the commercial sexual exploitation of children, child pornography, mining, and jobs that harm the health of a child. The law sets the minimum age for employment at 16 and prohibits children younger than age 18 from working at night, except in times of emergency. The minimum age for employment was consistent with the age for completing educational requirements, which is 16. In the domestic labor and agricultural sectors, the law permits children who are 13 and above to perform limited activities for up to four and one-half hours per day. Penalties were sufficient to deter violations.
The government was implementing the National Action Plan to combat the worst forms of child labor and to reduce significantly exploitative child labor.
The plan coordinated the efforts of several ministries and NGOs. Its goals included greater dissemination of information in local languages, increased access to services such as rehabilitation for victims, revision of the penal code to address the worst forms of child labor, and improved data collection and analysis. The government organized workshops and conferences to inform children, parents, and employers of the dangers of exploitative child labor.
The government did not consistently enforce the law. Largely due to the insecurity imposed by violent extremist groups, the Ministry of Civil Service, Labor, and Social Security, which oversees labor standards, lacked transportation and access and other resources to enforce worker safety and the minimum age law. No data were available on number of prosecutions and convictions during the year.
Child labor took place in the agricultural sector, or in family-owned small businesses in villages and cities. There were no reports of children younger than age 15 employed by either government-owned or large private companies. Children also worked in the mining, trade, construction, and domestic labor sectors. Some children, particularly those working as cattle herders and street hawkers, did not attend school. Many children younger than age 15 worked long hours. A study by the International Labor Organization reported that children working in artisanal mining sometimes worked six or seven days a week and up to 14 hours per day. Street beggars often worked 12 to 18 hours daily. Such children
Country Reports on Human Rights Practices for 2019 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 28 suffered from occupational illnesses, and employers sometimes physically or sexually abused them. Child domestic servants worked up to 18 hours per day. Employers often exploited and abused them. Criminals transported Burkinabe children to Cote d’Ivoire, Mali, and Niger for forced labor or sex trafficking.
Also see the Department of Labor’s Findings on the Worst Forms of Child Labor at https://www.dol.gov/agencies/ilab/resources/reports/child-labor/findings. d. Discrimination with Respect to Employment and Occupation
The law prohibits discrimination with respect to employment and occupation. The government did not effectively enforce the laws and regulations.
Discrimination occurred based on race, color, sex, religion, political opinion, social origin, gender, disability, language, sexual orientation or gender identity, HIV- positive status or having other communicable diseases, or social status with respect to employment and occupation. The government took few actions during the year to prevent or eliminate employment discrimination. e. Acceptable Conditions of Work
The law mandates a minimum monthly wage in the formal sector, which does not apply to subsistence agriculture or other informal occupations. The minimum wage was less than the poverty income level.
The law mandates a standard workweek of 40 hours for nondomestic workers and a 60-hour workweek for household employees. The law provides for overtime pay, and there are regulations pertaining to rest periods, limits on hours worked, and prohibitions on excessive compulsory overtime.
The government sets occupational health and safety standards. There are explicit restrictions regarding occupational health and safety in the labor law. Employers must take measures to provide for safety and protect the physical and mental health of all their workers and verify that the workplace, machinery, materials, substances, and work processes under their control do not present health or safety risks to the workers.
The law requires every company with 30 or more employees to have a work safety committee. If an employee working for a company with fewer than 30 employees
Country Reports on Human Rights Practices for 2019 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 29 decides to remove himself due to safety concerns, a court rules on whether the employee’s decision was justified.
The Ministry of Civil Service, Labor, and Social Security is responsible for enforcing the minimum wage and hours of work standards. The government employed 255 labor inspectors, an increase of more than 50 percent compared with the previous year, surpassing the International Labor Office’s technical advice of the appropriate level of labor inspectors for the country. Ministry inspectors and labor tribunals are responsible for overseeing occupational health and safety standards in the small industrial and commercial sectors, but these standards do not apply in subsistence agriculture and other informal sectors.
These standards were not effectively enforced. Penalties for violations were insufficient to deter violations. There were no reports of effective enforcement of inspection findings during the year.
Employers often paid less than the minimum wage. Employees usually supplemented their income through reliance on extended family, subsistence agriculture, or trading in the informal sector. Employers subjected workers in the informal sector, who made up approximately 50 percent of the economy, to violations of wage, overtime, and occupational safety and health standards.
Between April and June, approximately 500 workers lost their jobs at Youga gold mine, and foreign workers were hired instead. Some Burkinabe workers were critical of the dismissals, stating that management violated the 2015 mining code by hiring unqualified foreign workers instead of giving preference to local employees as stipulated in the code. Mining operations at Youga were suspended on June 7, as employees and management could not reach an agreement regarding work schedules and wages. In particular, the company proposed a 14-day work period with a single day of rest and an hourly wage as opposed to a monthly salary; workers rejected the proposals. Labor laws call for a 24-hour rest period every week, unless an exception has been granted with the consent of a labor inspector.
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TAB 3
BURKINA FASO 2018 HUMAN RIGHTS REPORT
EXECUTIVE SUMMARY
Burkina Faso is a constitutional republic led by an elected president. In 2015 the country held peaceful and orderly presidential and legislative elections, marking a major milestone in a transition to democracy. President Roch Mark Christian Kabore won with 53 percent of the popular vote, and his party--the People’s Movement for Progress--won 55 seats in the 127-seat National Assembly. National and international observers characterized the elections as free and fair.
Civilian authorities generally maintained effective control over security forces.
Human rights issues included arbitrary deprivation of life by violent extremist organizations; torture and degrading treatment by security forces and vigilante groups; arbitrary detention by security personnel; life-threatening detention conditions; official corruption; violence against women; and forced labor and sex trafficking, including of children.
The government investigated and punished some cases of abuse, but impunity for human rights abuses remained a problem. The government investigated alleged violations by vigilante groups and security forces but in most cases did not prosecute them.
More than 50 terrorist attacks throughout the country resulted in dozens of deaths, particularly of security personnel and local government officials, kidnappings, and the displacement of civilians, especially in the Sahel Region, located in the northernmost part of the country. As of May forced closures of more than 473 schools affected more than 64,659 students.
Section 1. Respect for the Integrity of the Person, Including Freedom from: a. Arbitrary Deprivation of Life and Other Unlawful or Politically Motivated Killings
Unknown assailants, but assumed to belong in some capacity to violent extremist organizations, waged attacks on security forces throughout the year. These included attacks on law enforcement, military, customs, and park ranger outposts, patrols, and the use of improvised explosive devices (IEDs) detonated under security vehicles. On March 2, in downtown Ouagadougou, terrorist organization
BURKINA FASO 2
Jama’at Nasr al-Islam wal Muslimin (JNIM) attacked National Army Headquarters and the French embassy, killing eight security personnel. Between August and October, dozens of Burkinabe, including three civilians, died in attacks conducted in the Est Region. b. Disappearance
There were no reports of disappearances by or on behalf of government authorities. c. Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment
The constitution and law prohibit such practices; in 2014 the National Assembly adopted a law to define and prohibit torture and all related practices.
On February 19, a provincial director of the national police, Alexandres Kawasse, assaulted an 11-year-old girl at his residence. His subordinates reported him, resulting in his arrest on February 23. Authorities relieved him of his duties and charged him with assault on a minor; a judicial police investigation was ongoing at year’s end.
Prison and Detention Center Conditions
Conditions in prisons and detention facilities were harsh and at times life threatening due to overcrowding and inadequate sanitary conditions and medical care.
Physical Conditions: Authorities held pretrial detainees with convicted prisoners. Female prisoners had better conditions than those of men, in large part due to less crowding. Prisoners received two meals a day, but diets were inadequate, and inmates often relied on supplemental food from relatives. In some prisons overcrowding or severe overcrowding exacerbated inadequate ventilation, although some cells had electricity and some inmates had fans. Sanitation was rudimentary.
According to prison administration officials and medical staff, no prisoner deaths occurred during the year at the Central Prison in Ouagadougou (MACO) or the High Security Prison in Ouagadougou.
There were no appropriate facilities or installations for prisoners or detainees with disabilities, who relied on other inmates for assistance.
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A human rights nongovernmental organization (NGO) reported that prison guards at the MACO occasionally used excessive physical force, inflicting injuries on prisoners.
Food, potable water, sanitation, heating, ventilation, lighting, and medical care were inadequate in the majority of detention facilities across the country. Tuberculosis, HIV, AIDS, and malaria were the most common health problems among prisoners. For example, at the High Security Prison, there were three nurses employed to treat 673 detainees and prisoners, with no doctor present on site but available on an on-call basis. Detention conditions were better for wealthy or influential citizens, or detainees considered nonviolent.
Local media regularly reported on cases of detainees who had spent more than one year without trial.
Administration: There were no reports that authorities failed to investigate credible allegations of inhuman prison conditions.
Independent Monitoring: The government permitted monitoring by independent nongovernmental observers. Prison authorities regularly granted permission to representatives of local and international human rights groups, media, foreign embassies, and the International Committee of the Red Cross to visit prisons without advance notice.
Improvements: In November 2017 the Ministry of Justice, Human Rights, and Civic Promotion sent a team to assess prison conditions and interview detainees, convicted prisoners, and prison guards in 95 percent of the country’s prisons and detention centers. Throughout the year the government funded an awareness and training campaign for prison administration staff. To address overcrowding, the government funded a building expansion at the prison in Bobo-Dioulasso. As of October, however, there was no evidence that these measures effectively reduced overcrowding. During the year the ministry also appointed a special advisor for gender and vulnerable populations in prisons.
To improve detention conditions, improve prisoner health, and facilitate social reintegration of prisoners, the Ministry of Justice, Human Rights, and Civic Promotion launched a three-year prison reform project with EU support. Prison administration officials allowed NGOs and religious organizations regular access to prisoners to provide supplementary psychological and medical care.
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d. Arbitrary Arrest or Detention
The constitution and law prohibit arbitrary arrest and detention and provide for the right of persons to challenge the lawfulness of their arrest or detention in court. Arbitrary arrests occurred, and judicial corruption and inadequate staffing of the judiciary deterred detainees from challenging the lawfulness of their arrest in court.
Role of the Police and Security Apparatus
The Ministry of Internal Security and the Ministry of Defense are responsible for internal security. The Ministry of Internal Security includes the National Police and the gendarmerie. The army, which operates within the Ministry of Defense, is responsible for external security but sometimes assists with missions related to domestic security. Use of excessive force, corruption, widespread impunity, and lack of training contributed to police ineffectiveness. The government announced some investigations were in progress, and others had resulted in prosecutions. Inadequate resources also impeded police effectiveness.
The Military Justice Administration examines all cases involving killings by military personnel or gendarmes to determine whether they occurred in the line of duty or were otherwise justifiable. The administration refers cases deemed outside the line of duty or unjustifiable to civilian courts. Civilian courts automatically handle killings involving police. The gendarmerie is responsible for investigating abuse by police and gendarmes, but it rarely made public the results of its investigations.
NGOs and the Ministry of Justice, Human Rights, and Civic Promotion conducted numerous training activities on human rights for security forces throughout the year.
Arrest Procedures and Treatment of Detainees
By law police and gendarmes must possess a court-issued warrant based on sufficient evidence before apprehending a person suspected of committing a crime, but authorities did not always follow these procedures. Authorities did not consistently inform detainees of charges against them. By law detainees have the right to expeditious arraignment, bail, access to legal counsel, and, if indigent, access to a lawyer provided by the government after being charged. A judge may order temporary release without bail pending trial. Authorities seldom respected
Country Reports on Human Rights Practices for 2018 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 5 these rights. The law does not provide detainees access to family members, although authorities generally allowed detainees such access through court-issued authorizations.
The law limits detention without charge for investigative purposes to a maximum of 72 hours, renewable for a single 48-hour period. In terrorism investigations, the law allows detention for a 10-day period. In cases not related to terrorism, police rarely observed the law, and the average time of detention without charge (preventive detention) was one week. Once authorities charge a suspect, the law permits judges to impose an unlimited number of consecutive six-month preventive detention periods while the prosecutor investigates charges. Authorities often detained defendants without access to legal counsel for weeks, months, or even years before the defendant appeared before a magistrate. There were instances in which authorities detained suspects incommunicado.
Arbitrary Arrest: On August 29, elite security forces arrested political and web activist Safiatou Lopez, an outspoken critic of the government, without a warrant, encircling her house at nightfall and flying an intelligence drone overhead. Without presenting any evidence, authorities charged her with an attempt to “destabilize the state.” At year’s end she remained in detention.
Pretrial Detention: Authorities estimated 46 percent of prisoners nationwide were in pretrial status. In some cases authorities held detainees without charge or trial for longer periods than the maximum sentence for conviction of the alleged offense. A pretrial release (release on bail) system exists, although the extent of its use was unknown.
Detainee’s Ability to Challenge Lawfulness of Detention before a Court: The law provides persons arrested or detained the right to challenge in court the legal basis or arbitrary nature of their detention. Prisoners who did so, however, reportedly faced difficulties due to either judicial corruption or inadequate staffing of the judiciary. e. Denial of Fair Public Trial
The constitution and law provide for an independent judiciary, but the judiciary was corrupt, inefficient, and subject to executive influence, according to NGOs. There were no instances in which the trial outcomes appeared predetermined, and authorities respected court orders. Legal codes remained outdated, there were not
Country Reports on Human Rights Practices for 2018 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 6 enough courts, and legal costs were excessive. Citizens’ poor knowledge of their rights further weakened their ability to obtain justice.
Military courts try cases involving military personnel charged with violating the military code of conduct. Rights provided in military courts are equivalent to those in civil criminal courts. Military courts are headed by a civilian judge, hold public trials, and publish verdicts in the local press.
Trial Procedures
The law presumes defendants are innocent. Defendants have the right to be promptly informed and in detail of the charges, with free assistance of an interpreter. Trials are public but may be delayed. Judicial authorities use juries only in criminal cases. Defendants have the right to be present at their trials and to legal representation, consultation, and adequate time and facilities to prepare a defense. Defendants have the right to provide evidence. Defendants have the right not to be compelled to testify or confess guilt, but a refusal to testify often resulted in harsher decisions. Defendants may challenge and present witnesses, and they have the right of appeal. In civil cases where the defendant is destitute and files an appeal, the state provides a court-appointed lawyer. In criminal cases court- appointed lawyers are mandatory for those who cannot afford one. The law extends these rights to all defendants, but the government did not always respect these rights, due in part to popular ignorance of the law and a continuing shortage of magistrates and court-appointed lawyers.
The Ministry of Justice, Human Rights, and Civic Promotion claimed courts usually tried cases within three months, although human rights organizations reported major case backlogs. The 2011 “processing of criminal penalties in real time” reform to shorten pretrial detention allows the prosecutor and investigators (police and gendarmerie) to process a case prior to the criminal hearing. This countrywide approach allows authorities to inform defendants of the charges and trial date before authorities release them pending trial.
Political Prisoners and Detainees
There were no reports of political prisoners or detainees during the year, although some arrests and detentions may have been politically motivated.
In December 2017 security forces arrested and detained Colonel Auguste Denise Barry on charges of “conspiracy to destabilize the state,” although the government
Country Reports on Human Rights Practices for 2018 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 7 did not provide any evidence to justify his arrest. On August 29, authorities provisionally released him without a trial.
Civil Judicial Procedures and Remedies
There is an independent judiciary in civil matters, but it was often inefficient, corrupt, and subject to executive influence. As a result, citizens sometimes preferred to rely on the Office of the Ombudsman (see section 5, Government Human Rights Bodies) to settle disputes with the government.
The law provides for access to a court to file lawsuits seeking damages for, or cessation of, a human rights violation, and both administrative and judicial remedies were available for alleged wrongs. Victims of human rights violations may appeal directly to the Economic Community of West African States (ECOWAS) Court of Justice, even before going through national courts. For civil and commercial disputes, authorities may refer cases to the ECOWAS Common Court of Justice and Arbitration in Abidjan, Cote d’Ivoire. The courts issued several such orders during the year.
There were problems enforcing court orders in sensitive cases involving national security, wealthy or influential persons, and government officials. f. Arbitrary or Unlawful Interference with Privacy, Family, Home, or Correspondence
The constitution and law prohibit such actions, and the government generally respected these prohibitions. In cases of national security, however, the law permits surveillance, searches, and monitoring of telephones and private correspondence without a warrant. g. Abuses in Internal Conflict
Killings: As of October 18, alleged terrorists belonging to Ansaroul Islam, JNIM and Islamic State Greater Sahara (ISGS) carried out more than 35 attacks throughout the country, killing at least 34 security force members and 13 civilians. For example, on September 15, unidentified armed individuals shot and killed eight citizens, including an imam and his family members, in the villages of Diapiga and Kompienbiga in the Est Region. Between August and October, terrorist groups carried out seven attacks using IEDs in the Est Region. On April
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1, terrorists claiming to be from ISGS shot and killed Hamidou Koundaba, mayor of Koutougou in the Sahel Region.
Authorities continued to investigate Human Rights Watch’s (HRW) allegations that state security forces executed 14 individuals suspected of engaging in terrorist activities in December 2017. As of September 16, the minister of justice had appointed a military prosecutor, who created an investigative commission composed of judicial police officers to interview witnesses.
Abductions: As of November 16, terrorist groups associated with JNIM and ISGS abducted at least 12 individuals throughout the country. For example, on April 12, terrorists kidnapped primary school teacher Issouf Souabo in the northern town of Bourou, allegedly because he was teaching in French. A stray bullet fired during the abduction killed Sana Sakinatou, a primary school student. Terrorists released Souabo on June 11.
Physical Abuse, Punishment, and Torture: According to HRW, on February 26, the bodies of Harouna Hassan Dicko and Housseni Ousmanne Dicko were found in the northern town of Djibo with deep gashes in their throats. Neighbors reported that jihadists had abducted and tortured the men because they had provided information to the government.
Other Conflict-related Abuse: NGOs reported that terrorist groups recruited boys under age 15 to fight. Local authorities in the Sahel, Nord, and Est Regions reported that terrorists displaced thousands of civilians and limited movement in rural areas.
Section 2. Respect for Civil Liberties, Including: a. Freedom of Expression, Including for the Press
The constitution and law provide for freedom of expression, including for the press, but the government did not always respect this right. A 2015 law decriminalizes press offenses and replaces prison sentences with penalties ranging from one million to five million CFA francs ($1,800 to $9,200). Some editors complained that few newspapers or media outlets could afford such fines.
Despite the advent of the 2015 law, journalists occasionally faced criminal prosecution for libel and other forms of harassment and intimidation.
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Freedom of Expression: The law prohibits persons from insulting the head of state or using derogatory language with respect to the office. On June 14, authorities arrested web activist Naim Toure after he criticized the government in a Facebook post for failing to deliver adequate medical care to soldiers recently wounded in the line of duty. On July 3, a judge sentenced Toure to two months in jail.
Press and Media Freedom: There were numerous independent newspapers, satirical weeklies, and radio and television stations, some of which strongly criticized the government. Foreign radio stations broadcast without government interference. Government media outlets--including newspapers, television, and radio--sometimes displayed a progovernment bias but allowed significant opposition participation in their newspaper and television programming.
All media are under the administrative and technical supervision of the Ministry of Communications, which is responsible for developing and implementing government policy on information and communication. The Superior Council of Communication (CSC) monitored the content of radio and television programs, newspapers, and internet websites to enforce compliance with standards of professional ethics and government policy. The CSC may summon journalists and issue warnings for subsequent violations. Hearings may concern alleged libel, disturbing the peace, inciting violence, or violations of state security.
Censorship or Content Restrictions: In addition to prohibitions on insulting the head of state, the law also prohibits the publication of shocking images or material that demonstrates lack of respect for the deceased. Journalists practiced self- censorship, fearing that publishing blatant criticism of the government could result in arrest or closure their newspaper.
Internet Freedom
The government did not restrict or disrupt access to the internet, although the CSC monitored internet websites and discussion forums to enforce compliance with regulations. According to the International Telecommunication Union, 16 percent of the population used the internet in 2017.
Academic Freedom and Cultural Events
There were no government restrictions on academic freedom or cultural events. b. Freedoms of Peaceful Assembly and Association
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Freedom of Peaceful Assembly
The constitution and law provide for freedom of peaceful assembly, and the government generally respected this right.
In October 2017 national police arrested Pascal Zaida, a civil society leader and open government critic, for holding a demonstration to protest against the administration without a permit. National police issued a statement that they had denied his three prior requests to protest because the protest presented “a risk of disturbing public order.” Authorities released Zaida in November 2017 after 37 days in pretrial detention.
Political parties and labor unions may hold meetings and rallies without government permission, although advance notification and approval are required for public demonstrations that may affect traffic or threaten public order. If a demonstration or rally results in violence, injury, or significant property damage, penalties for the organizers include six months to five years’ imprisonment and fines of between 100,000 and two million CFA francs ($180 and $3,600). These penalties may be doubled for conviction of organizing an unauthorized rally or demonstration. Demonstrators may appeal denials or imposed modifications of a proposed march route or schedule before the courts. c. Freedom of Religion
See the Department of State’s International Religious Freedom Report at www.state.gov/religiousfreedomreport/. d. Freedom of Movement
The constitution provides for freedom of internal movement, foreign travel, emigration, and repatriation, and the government generally respected these rights. The government cooperated with the UN High Commissioner for Refugees (UNHCR) and other humanitarian organizations in providing protection and assistance to internally displaced persons, refugees, returning refugees, asylum seekers, stateless persons, and other persons of concern.
In-country Movement: The government required citizens to carry a national identity document (ID), and it authorized officials to request the ID at any time. Without a national ID card, citizens could not pass between certain regions of the
Country Reports on Human Rights Practices for 2018 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 11 country and were subject to arrest and fines. On September 2, in Bobo Dioulasso, local police fired warning shots to stop vehicles in a wedding procession, resulting in the injury and hospitalization of two women.
Armed terrorists restricted movement of thousands of rural people in the north. In response to dozens of attacks by unknown armed assailants presumed to be terrorists, local authorities instituted a ban on motorcycle traffic from 7 p.m. until 5 a.m. in the Est and Nord Regions.
Internally Displaced Persons (IDPs)
Attacks in the Nord and Est Regions caused a steep increase in the number of IDPs from 3,600 in October 2017 to 39,731 registered in October 2018, according to the UN Office of Humanitarian Affairs. In response, the Ministry of Justice, Human Rights, and Civic Promotion organized a training session August 29-31 in the northern town of Dori to educate development partners on the international human rights standards afforded to IDPs. The majority of IDPs were located in the Sahel, Nord, and Centre-Nord Regions.
Protection of Refugees
Access to Asylum: The law provides for granting asylum or refugee status, and the government has established a system for providing protection to refugees. The Ministry of Women, National Solidarity, and Family, aided by the National Committee for Refugees (CONAREF), is the focal point for coordination of national and international efforts.
In 2012 fighting resumed in northern Mali between government forces and Tuareg rebels, resulting in the flight of more than 250,000 Malians to neighboring countries, including Burkina Faso. According to UNHCR, approximately 50,000 Malians--most of them Tuaregs and Arabs--fled across the border to Burkina Faso and registered with local authorities as displaced persons. Authorities granted all displaced persons from Mali prima facie refugee status, pending the examination of all applications individually. Authorities settled most of the refugees in Soum and Oudalan Provinces in the Sahel Region. The ministry, aided by CONAREF, was the government’s focal point to help coordinate all national and international efforts. During the year, refugees received an undetermined amount of government assistance.
Stateless Persons
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According to UNHCR, more than 700,000 habitual residents were legally or de facto stateless, mostly due to a lack of documentation. During the year the Ministry of Justice, Human Rights, and Civic Promotion worked with UNHCR to deploy mobile courts to remote villages in order to issue birth certificates and national identity documents to residents who qualified for citizenship. The goal was to register 32,000 during the year, but no final statistics were available.
Section 3. Freedom to Participate in the Political Process
The constitution provides citizens the ability to choose their government in free and fair periodic elections held by secret ballot and based on universal and equal suffrage.
Elections and Political Participation
Recent Elections: In the 2015 national elections, Roch Mark Christian Kabore won the presidency with 53 percent of the popular vote. His party, the People’s Movement for Progress, won 55 of the 127 seats in the National Assembly. The Union for Progress and Change won 33 seats, and the former ruling party, the Congress for Democracy and Progress, won 18 seats. National and international observers characterized the elections as free and fair.
In the 2016 municipal and regional council elections, the postelection selection process of mayors by municipal councils was marred by clashes among political party activists, resulting in at least three deaths and dozens of injuries in Karangasso and Kantchari. As of September 20, authorities had taken no legal action against anyone involved in the violence.
The 2015 electoral code approved by the National Transitional Council (CNT) stipulated the exclusion of certain members of the former political majority. The code stated that persons who “supported a constitutional change that led to a popular uprising” are ineligible to be candidates in future elections. On July 30, the National Assembly passed a new electoral law that allows all political candidates to run for election and opened the vote to members of the Burkinabe diaspora in possession of a national identity card or passport.
Participation of Women and Minorities: There are no laws limiting the participation of women and members of minorities in the political process, and they did participate. Although the gender quota law requires political parties to
Country Reports on Human Rights Practices for 2018 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 13 name women to fill at least 30 percent of the positions on their candidate lists in legislative and municipal elections, no political party met this requirement during the May 2016 and the May 2017 make-up municipal elections. Parties and government officials said women were less engaged in politics, due to cultural and traditional factors. Women held five of 35 ministerial seats and 14 of 127 seats in the parliament.
Section 4. Corruption and Lack of Transparency in Government
The law provides criminal penalties for corruption by officials, but the government did not implement the law effectively, and officials often engaged in corrupt practices with impunity. Local NGOs criticized what they called the overwhelming corruption of senior civil servants. They reported pervasive corruption in the customs service, gendarmerie, tax agencies, national police, municipal police, public health service, municipal governments, education sector, government procurement, and the Ministry of Justice, Human Rights, and Civic Promotion. The local NGO Anticorruption National Network categorized the municipal police as the most corrupt government sector in its 2017 annual report. They reported a lack of political will to fight corruption, and stated the government rarely imposed sanctions against prominent government figures.
Corruption: News media and NGOs reported that government officials practiced nepotism on a widespread basis. For example, in January the National Agency for the Promotion of Employment hired 85 administrative agents to work for the National Social Security Fund (CNSS). In June auditors working within the CNSS office found that one third of the hires had family connections with officials working within the institution, including the wife, niece, and nephew of the director of human resources at CNSS.
Financial Disclosure: A 2015 anticorruption law requires government officials-- including the president, lawmakers, ministers, ambassadors, members of the military leadership, judges, and anyone charged with managing state funds--to declare their assets and any gifts or donations received while in office. The Constitutional Council is mandated to monitor and verify compliance with such laws and may order investigations if noncompliance is suspected. Disclosures are not made public, however, and there were no reports of criminal or administrative sanctions for noncompliance. As of September national assembly members elected in 2015 had not complied with this law yet faced no sanctions.
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In June 2016 the Higher Authority for State Control and the Fight against Corruption extended the requirement to declare assets to include government officials’ spouses and minor children. Infractions are punishable by a maximum prison term of 20 years and fines of up to 25 million CFA francs ($45,000). The law also punishes persons who do not reasonably explain an increase in lifestyle expenditures beyond the 5 percent threshold set by regulation in connection with lawful income. Convicted offenders risk imprisonment for two to five years and a fine of five million to 25 million CFA francs ($9,200 to $45,000). In April 2016 a law was passed limiting the value of a gift a government official could receive to 35,000 CFA francs ($63).
Section 5. Governmental Attitude Regarding International and Nongovernmental Investigation of Alleged Abuses of Human Rights
A variety of domestic and international human rights groups operated without government restriction, investigating and publishing their findings on human rights cases. Government officials were generally cooperative and responsive to their views.
The United Nations or Other International Bodies: The government did not comply with a December 2017 recommendation from the UN Working Group on Arbitrary Detention for the release of Djibrill Bassole, a former foreign minister arrested in 2015 on charges of treason. At year’s end he remained under house arrest.
Government Human Rights Bodies: The Office of the Ombudsman addresses citizen complaints regarding government entities and other bodies entrusted with a public service mission. The ombudsman, whom the president appoints for a nonrenewable five-year term and who may not be removed during the term, was generally viewed as effective and impartial. For example, in May Ombudsman Saran Sereme Sere presided over a two-day community dialogue in the Boucle du Mouhoun Region to resolve a conflict between the Mossi and Banwana ethnic groups in the village of Solenzo. During 2017, the most recent year for which statistics were available, the office registered 560 complaints, approximately 59 percent of which it resolved.
The Ministry of Justice, Human Rights, and Civic Promotion is responsible for the protection and promotion of human and civil rights, and during the it year conducted education campaigns for the general public as well as administered human rights training for security force and judicial sector members to raise their
Country Reports on Human Rights Practices for 2018 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 15 awareness of human rights. In its most recent annual report, for 2017, the ministry reported it received 356 human rights related cases, of which 270 went to trial, and the remaining 86 were settled out of court.
The government-funded National Commission on Human Rights provides a permanent framework for dialogue on human rights concerns. Its members include representatives of human rights NGOs, unions, professional associations, and the government. The Burkinabe Movement for Human and People’s Rights, which did not participate on the commission, charged that the commission was subject to government influence. Although inadequately funded, the commission continued to be more effective and visible in promoting human rights than in previous years.
Section 6. Discrimination, Societal Abuses, and Trafficking in Persons
Women
Rape and Domestic Violence: Under the law conviction for rape, including spousal rape, is punishable by five to 10 years’ imprisonment and may include fines of 100,000 to 500,000 CFA francs ($180 to $900). According to human rights NGOs, rape occurred frequently. Although authorities prosecuted rape cases during the year, no statistics were available on the number of cases reported or prosecuted. For example, in April local media reported that a man raped his eight- year-old niece repeatedly before her parents took her to receive medical and psychological care. His arrest was delayed because the crime was perpetrated in a different county from where the victim reported the crime and received treatment. As of October 22, the case was with an investigative judge.
The law does not specifically mention domestic violence, but it enumerates all forms of violence that in substance covers domestic violence. Domestic violence against women occurred habitually; Catholic, Protestant, and Muslim religious leaders in Kaya stated on July 19 that their followers frequently abused their wives. They noted the husbands’ anger was often triggered by their wives’ requests for money for food, clothing, or school fees for their children.
Victims seldom pursued legal action due to shame, fear, or reluctance to take their spouses to court. For the few cases that went to court, the Ministry of Justice, Human Rights, and Civic Promotion could provide no statistics on prosecutions, convictions, or punishment. A government-run shelter for women and girls who were victims of gender-based violence welcomed victims regardless of nationality. In Ouagadougou the Ministry of Women, National Solidarity, and Family assisted
Country Reports on Human Rights Practices for 2018 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 16 victims of domestic violence at four centers. The ministry sometimes provided counseling and housing for abused women.
The ministry has a legal affairs section to educate women on their rights, and several NGOs cooperated to protect women’s rights. To raise awareness of gender discrimination and reduce gender inequalities, the ministry organized numerous workshops and several awareness campaigns mainly in the Nord, Sahel, Est, and Center-West Regions.
The law makes conviction of “abduction to impose marriage or union without consent” punishable by six months to five years in prison. Conviction of sexual abuse or torture or conviction of sexual slavery is punishable by two to five years in prison. Conviction of the foregoing abuses may also carry fines of 500,000 to one million CFA francs ($920 to $1,800).
The law requires police to provide for protection of the victim and her minor children and mandates the establishment of chambers in the High Court with exclusive jurisdiction over cases of violence against women and girls. The law requires all police and gendarmerie units to designate officers to assist female victims of violence--or those threatened by violence--and to respond to emergencies; however, some units had not complied by year’s end. It also mandates the creation of care and protection centers in each commune for female victims of violence and a government support fund for their care. The centers receive victims on an emergency basis, offer them security, provide support services (including medical and psychosocial support), and, when possible, refer the victims to court.
Female Genital Mutilation/Cutting (FGM/C): The law prohibits FGM/C for women 18 and above and girls below 18, but it was practiced discreetly in both urban and rural areas on victims ranging between 10 months and 24 years of age. Perpetrators, if convicted, are subject to a fine of 150,000 to 900,000 CFA francs ($270 to $1,620) and imprisonment of six months to three years, or up to 10 years if the victim dies.
On September 18, authorities arrested and charged 30 perpetrators of FGM/C. Throughout the year the National Secretariat against Circumcision worked with local populations to combat the practice. The first lady participated in training and awareness campaigns in cooperation with NGOs and the Ministry of Women, National Solidarity, and Family. NGOs reported an overall decrease in the practice from 10 years ago.
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For additional information, see Appendix C.
Other Harmful Traditional Practices: The law makes the conviction of physical or moral abuse of women or girls accused of witchcraft punishable by one to five years in prison, a fine of 300,000 to 1.5 million CFA francs ($540 to $2,700), or both. Neighbors accused elderly women, and less frequently men, without support, living primarily in rural areas, and often widowed in the case of women, of witchcraft and subsequently banned them from their villages, beat them, or killed them. In April the Ministry of Justice, Human Rights, and Civic Promotion announced an action plan for assistance to and social reintegration of girls and women marginalized by their communities.
Sexual Harassment: The law provides for sentences of three months to one year in prison and a fine of 300,000 to 500,000 CFA francs ($540 to $900) for conviction of sexual harassment; the maximum penalty applies if the perpetrator is a relative, in a position of authority, or if the victim is “vulnerable.” The government was ineffective in enforcing the law.
Coercion in Population Control: There were no reports of coerced abortion or involuntary sterilization.
Discrimination: Although the law generally provides the same legal status and rights for women as for men--including under family, labor, property, and inheritance laws--discrimination frequently occurred. Labor laws provide that all workers--men and women alike--should receive equal pay for equal working conditions, qualifications, and performance. Women nevertheless generally received lower pay for equal work, had less education, and owned less property.
Although the law provides equal property and inheritance rights for women and men, land tenure practices emphasized family and communal land requirements more than individual ownership rights. As a result, authorities often denied women the right to own property, particularly real estate. Many citizens, particularly in rural areas, held to traditional beliefs that did not recognize inheritance rights for women and regarded a woman as property that could be inherited upon her husband’s death.
NGOs reported that authorities arrested women working in the sex industry on charges of prostitution, while ignoring men who sought to hire prostitutes alone.
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The government conducted media campaigns to change attitudes toward women. It sponsored a number of community outreach efforts and awareness campaigns to promote women’s rights.
Children
Birth Registration: Citizenship derives either from birth within the country’s territory or through a parent. Parents generally did not register births immediately; lack of registration sometimes resulted in denial of public services, including access to school. To address the problem, the government periodically organized registration drives and issued belated birth certificates.
For additional information, see Appendix C.
Education: According to multiple government sources and NGOs, more than 473 schools closed due to fear of attacks, leaving more than 64,000 children without an option for education.
Child Abuse: Authorities tolerated light corporal punishment, and parents widely practiced it. The government conducted seminars and education campaigns against child abuse. The penal code mandates a one- to three-year prison sentence and fines ranging from 300,000 to 900,000 CFA francs ($540 to $1,620) for conviction of inhuman treatment or mistreatment of children.
The government did not effectively enforce the law. None of the calls to report violence against children, which led to intervention by security force members, resulted in an arrest or prosecution.
Early and Forced Marriage: The legal age for marriage is 17 for girls and 20 for boys, but early and forced marriage was a problem. The law prohibits forced marriage and prescribes penalties of six months to two years in prison for violators, and a three-year prison term if the victim is under age 13. There were no reports of prosecutions during the year. A government toll-free number allowed citizens to report forced marriages.
The Ministry of Women, National Solidarity, and Family conducted information and awareness campaigns. On April 21, local authorities from the ministry in Sanmatenga, a rural region with a historically high rate of child marriage, organized a march and publicly denounced the practice.
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According to media reports, the traditional practice persisted of kidnapping, raping, and impregnating a virgin girl and then forcing her family to consent to her marriage to her violator.
Sexual Exploitation of Children: The law provides penalties for conviction of “child prostitution” or child pornography of five to 10 years’ imprisonment, a fine of 1.5 to three million CFA francs ($2,700 to $5,400), or both. The minimum age of consensual sex is 15. A 2014 law criminalizes the sale of children, child commercial sexual exploitation, and child pornography. Children from poor families were particularly vulnerable to sex trafficking. The government did not report any convictions for violations of the law during the year.
Infanticide or Infanticide of Children with Disabilities: The law provides for a sentence of 10 years’ to life imprisonment for infanticide. Newspapers reported several cases of abandonment of newborn babies.
Displaced Children: Repeated armed attacks in the Sahel, Nord, and Est Regions caused the displacement of thousands of children throughout the year. Between January and July, UNHCR registered 27,347 IDPs, of whom 57 percent were children. There were numerous street children, primarily in Ouagadougou and Bobo-Dioulasso. Many children ended up on the streets after their parents sent them to the city to study with an unregistered Quranic teacher or to live with relatives and go to school. In August in the capital, the government launched an initiative to recruit children living on the streets and place them in government-run youth centers where the youth had access to food, shelter, and limited vocational training.
International Child Abductions: The country is a party to the 1980 Hague Convention on the Civil Aspects of International Child Abduction. See the Department of State’s Annual Report on International Parental Child Abduction at https://travel.state.gov/content/travel/en/International-Parental-Child- Abduction/for-providers/legal-reports-and-data.html.
Anti-Semitism
There was no known Jewish community. There were no reports of anti-Semitic acts.
Trafficking in Persons
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See the Department of State’s Trafficking in Persons Report at www.state.gov/j/tip/rls/tiprpt/.
Persons with Disabilities
The law prohibits discrimination against persons with physical, sensory, intellectual, and mental disabilities in employment, education, transportation, access to health care, the judicial system, or the provision of other state services, but the government did not effectively enforce these provisions. There is legislation to provide persons with disabilities less costly or free health care and access to education and employment. The law also includes building codes to provide for access to government buildings. Authorities did not implement all of these measures effectively.
Persons with disabilities encountered discrimination and reported difficulty finding employment, including in government service.
The government had limited programs to aid persons with disabilities, but NGOs and the National Committee for the Reintegration of Persons with Disabilities conducted awareness campaigns and implemented integration programs.
The government continued to arrange for candidates with vision disabilities to take the public administration recruitment exams by providing the tests in Braille. Additionally, authorities opened specific counters at enrollment sites to allow persons with disabilities to register more easily for public service admission tests. According to the Ministry of Education, children with disabilities attended school at lower rates than others, although the government did provide for limited special education programs in Ouagadougou.
National/Racial/Ethnic Minorities
Longstanding conflicts between Fulani (Peuhl) herders and sedentary farmers of other ethnic groups sometimes resulted in violence. Herders commonly triggered incidents by allowing their cattle to graze on farmlands or farmers attempting to cultivate land set aside by local authorities for grazing. Government efforts at dialogue and mediation contributed to a decrease in such incidents.
On April 15, conflict broke out between members of the Peuhl and Gourmantche ethnic groups living in the Est Region over the alleged murder of a Gourmantche man. Local newspapers reported that in retaliation, members of the Gourmantche
Country Reports on Human Rights Practices for 2018 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 21 community allegedly burned several buildings in a Peuhl village, displacing approximately 100 persons.
Acts of Violence, Discrimination, and Other Abuses Based on Sexual Orientation and Gender Identity
The country has no hate crime laws or other criminal justice mechanisms to aid in the investigation, prosecution, or sentencing of bias-motivated crimes against the lesbian, gay, bisexual, transgender, and intersex (LGBTI) community. NGOs reported police occasionally arrested gay men and humiliated them in detention before releasing them.
Societal discrimination against LGBTI persons was a problem, and it was exacerbated by religious and traditional beliefs. LGBTI individuals were occasionally victims of verbal and physical abuse, according to LGBTI support groups. There were no reports the government responded to societal violence and discrimination against LGBTI persons.
LGBTI organizations had no legal status in the country but existed unofficially with no reported harassment. There were no reports of government or societal violence against such organizations, although incidents were not always reported due to stigma or intimidation.
HIV and AIDS Social Stigma
Societal discrimination against persons with HIV/AIDS was a problem, and families sometimes shunned persons who tested positive. Families sometimes evicted HIV-positive wives from their homes, although families did not evict their HIV-positive husbands. Some property owners refused to rent lodgings to persons with HIV/AIDS. The government distributed free antiretroviral medication to some HIV-positive persons who qualified according to national guidelines.
Other Societal Violence or Discrimination
Vigilante groups apprehended and sometimes arbitrarily detained individuals, usually involved in petty crime, employing severe beatings to solicit a confession. On May 2, assailants attacked a school in Kaya and set on fire the headquarters of vigilante group Kogleweogo. NGOs reported that the dominant Mossi ethnic group often discriminated against the Fulani ethnic group, stigmatized them as terrorists, and in some cases refused to lease housing to or hire Fulanis. NGOs
Country Reports on Human Rights Practices for 2018 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 22 reported that police often arrested a Fulani person based on their physical appearance, questioning them on charges of terrorism before eventually releasing them without charge.
Section 7. Worker Rights a. Freedom of Association and the Right to Collective Bargaining
The law allows workers to form and join independent unions of their choice without prior authorization or excessive requirements, but essential workers, such as magistrates, police, military, and other security personnel, may not join unions. The law provides unions the right to conduct their activities without interference.
The law provides for the right to strike, although it stipulates a narrow definition of this right. For strikes that call on workers to stay home and that do not entail participation in a rally, the union is required to provide eight to 15 days’ advance notice to the employer. If unions call for a march, they must provide three days’ advance notice to the city mayor. Authorities hold march organizers accountable for any property damage or destruction that occurs during a demonstration. The law also gives the government extensive requisitioning powers, authorizing it to requisition private- and public-sector workers to secure minimum service in essential services.
The law prohibits antiunion discrimination and allows a labor inspector to reinstate immediately workers fired because of their union activities, although in private companies such reinstatement was considered on a case-by-case basis. Relevant legal protections cover all workers, including migrants, workers in the informal sector, and domestic workers. There were no reports of antiunion discrimination during the year.
The law provides for freedom of association and collective bargaining. The government effectively enforced the law. The law lists sanctions for violations, including warnings, penalties, suspension, or dissolution, and were generally sufficient to deter violations. Penalties consist of imprisonment and fines and vary depending on the gravity of the violation. Amendments to the law award a legal existence to labor unions of NGOs, create a commission of mediation, and require that associations abide by the law concerning funding terrorism and money laundering. The law also states that no one may serve as the head of a political party and the head of an association at the same time.
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The government generally respected freedom of association and the right to collective bargaining.
The government generally respected the right of unions to conduct activities without interference. Government resources to enforce labor laws were not sufficient to protect workers’ rights.
Unions have the right to bargain directly with employers and industry associations for wages and other benefits. Worker organizations were independent of the government and political parties. There were no reports of strikebreaking during the year.
There were no reports of government restrictions on collective bargaining during the year. There was extensive collective bargaining in the formal wage sector, as the subcontracting sector was where many worker rights violations occurred. b. Prohibition of Forced or Compulsory Labor
The law prohibits all forms of forced or compulsory labor. The law considers forced or compulsory any labor or service provided by an individual under the threat of any type of sanction and not freely offered. The government did not effectively enforce applicable laws. Forced child labor occurred in the agricultural (particularly cotton), informal trade, domestic labor, restaurant, and animal husbandry sectors, as well as at gold panning sites and stone quarries. Educators forced some children sent to Quranic schools by their parents to engage in begging (see section 6, Children). The government did not have a significant, effective program in place to address or eliminate forced labor. Women from other West African countries were fraudulently recruited for employment and subsequently subjected to forced prostitution, forced labor in restaurants, or domestic servitude in private homes. The government continued to conduct antitrafficking advocacy campaigns and operated a toll-free number for individuals to report cases of violence and trafficking.
See the Department of State’s Trafficking in Persons Report at www.state.gov/j/tip/rls/tiprpt/. c. Prohibition of Child Labor and Minimum Age for Employment
The law sets the minimum age for employment at 16 and prohibits children under age 18 from working at night, except in times of emergency. The minimum age
Country Reports on Human Rights Practices for 2018 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 24 for employment was consistent with the age for completing educational requirements, which is 16. In the domestic labor and agricultural sectors, the law permits children who are 13 and above to perform limited activities for up to four and one-half hours per day.
The law prohibits the worst forms of child labor, including the commercial sexual exploitation of children, child pornography, and jobs that harm the health of a child. The government was implementing the National Action Plan to combat the worst forms of child labor and to reduce significantly exploitative child labor. In 2015 the CNT adopted a revised mining code that includes new provisions prohibiting child labor in mines. The amendment establishes a penalty of two to five years in prison and a fine of five million CFA francs ($9,200) to 24 million CFA francs ($43,300) for violators. Antitrafficking legislation provides penalties of up to 10 years for violators and increases maximum prison terms from five to 10 years. The law also provides terms as long as 20 years’ to life imprisonment under certain conditions.
The National Action Plan against the worst forms of child labor coordinated the efforts of several ministries and NGOs. Its goals included greater dissemination of information in local languages, increased access to services such as rehabilitation for victims, revision of the penal code to address the worst forms of child labor, and improved data collection and analysis. A 2014 law criminalizes the sale of children, child prostitution, and child pornography.
Punishment for violating child labor laws includes prison terms of up to five years and fines of up to 600,000 CFA francs ($1,080). The government did not consistently enforce the law. The Ministry of Civil Service, Labor, and Social Security, which oversees labor standards, lacked sufficient inspectors, transportation, and other resources to enforce worker safety and the minimum age law. No data were available on number of prosecutions and convictions during the year.
The government organized workshops and conferences to inform children, parents, and employers of the dangers of exploitative child labor. Despite efforts by the government and several NGOs, violence against children, child labor, and child trafficking occurred. According to 2011 statistics compiled by the National Institute of Statistics, 76 percent of children between the ages of five and 17 engaged in some form of economic activity, 81 percent of whom worked in the agricultural sector. Children commonly worked with their parents in rural areas or in family-owned small businesses in villages and cities. There were no reports of
Country Reports on Human Rights Practices for 2018 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 25 children under the age of 15 employed by either government-owned or large private companies.
Children also worked in the mining, trade, construction, and domestic labor sectors. According to a 2012 UNICEF study, 20,000 children worked as servants, gold washers, or diggers in the gold mining sector. Some children, particularly those working as cattle herders and street hawkers, did not attend school. Many children under age 15 worked long hours. A study by the International Labor Organization reported that children working in artisanal mining sometimes worked six or seven days a week and up to 14 hours per day. Street beggars often worked 12 to 18 hours daily. Such children suffered from occupational illnesses, and employers sometimes physically or sexually abused them. Child domestic servants earned from 3,000 to 6,000 CFA francs ($5.40 to $10.80) per month and worked up to 18 hours per day. Employers often exploited and abused them. Criminals transported Burkinabe children to Cote d’Ivoire, Mali, and Niger for forced labor or sex trafficking.
Also see the Department of Labor’s Findings on the Worst Forms of Child Labor at www.dol.gov/ilab/reports/child-labor/findings/. d. Discrimination with Respect to Employment and Occupation
The law prohibits discrimination with respect to employment and occupation. The government did not effectively enforce the laws and regulations. Discrimination occurred based on race, color, sex, religion, political opinion, social origin, gender, disability, language, sexual orientation or gender identity, HIV-positive status or other communicable diseases, or social status with respect to employment and occupation. The government took few actions during the year to prevent or eliminate employment discrimination. e. Acceptable Conditions of Work
The law mandates a minimum monthly wage in the formal sector, which does not apply to subsistence agriculture or other informal occupations. The minimum wage was less than the poverty income level. Approximately 46 percent of the population lived below the poverty line. Poverty remained higher in rural areas.
The law mandates a standard workweek of 40 hours for nondomestic workers and a 60-hour workweek for household employees. The law provides for overtime
Country Reports on Human Rights Practices for 2018 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 26 pay, and there are regulations pertaining to rest periods, limits on hours worked, and prohibitions on excessive compulsory overtime.
The government sets occupational health and safety standards. There are explicit restrictions regarding occupational health and safety in the labor law. Employers must take measures to provide for safety and protect the physical and mental health of all their workers and assure that the workplace, machinery, materials, substances, and work processes under their control do not present health or safety risks to the workers.
The law requires every company with 30 or more employees to have a work safety committee. If an employee decides to remove himself due to safety concerns, a court rules on whether the employee’s decision was justified.
The Ministry of Civil Service, Labor, and Social Security is responsible for enforcing the minimum wage and hours of work standards. Ministry inspectors and labor tribunals are responsible for overseeing occupational health and safety standards in the small industrial and commercial sectors, but these standards do not apply in subsistence agriculture and other informal sectors.
These standards were not effectively enforced. Penalties for violations were insufficient to deter violations. There were no reports of effective enforcement of inspection findings during the year.
Employers often paid less than the minimum wage. Employees usually supplemented their income through reliance on extended family, subsistence agriculture, or trading in the informal sector. Mining sector companies generally respected hours of work, overtime, and occupational safety and health standards. Employers subjected workers in the informal sector, which made up approximately 50 percent of the economy, to violations of wage, overtime, and occupational safety and health standards.
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TAB 4
BURKINA FASO 2017 HUMAN RIGHTS REPORT
EXECUTIVE SUMMARY
Burkina Faso is a constitutional republic led by an elected president. In 2015 the country held peaceful and orderly presidential and legislative elections, marking a major milestone in the country’s transition to democracy. President Roch Mark Christian Kabore won with 53 percent of the popular vote, and his party--the People’s Movement for Progress--won 55 seats in the 127-seat National Assembly. The Union for Progress and Change won 33 seats, and the former ruling party, the Congress for Democracy and Progress (CDP), won 18 seats. National and international observers characterized the elections as free and fair.
Civilian authorities generally maintained effective control over security forces.
The most significant human rights issues included arbitrary deprivation of life; torture and degrading treatment by security forces and vigilante groups; arbitrary detention; life-threatening detention conditions; judicial inefficiency and lack of independence; official corruption; limited government action to hold accountable those responsible for violence against women and children, including female genital mutilation/cutting (FGM/C) and early marriage; and forced labor and sex trafficking, including of children.
The government lacked effective mechanisms to investigate and punish abuse, and impunity for human rights abuses remained a problem. The government investigated alleged violations of former officials but in most cases did not prosecute them.
Section 1. Respect for the Integrity of the Person, Including Freedom from: a. Arbitrary Deprivation of Life and Other Unlawful or Politically Motivated Killings
There were reports that the government or its agents committed arbitrary or unlawful killings. According to the international nongovernmental organization (NGO) Human Rights Watch (HRW), on June 9, Burkinabe soldiers detained approximately 74 men and severely beat many of them during a cross-border operation near the border with Mali. The soldiers accused the detainees of supporting the Burkinabe Islamist armed group Ansaroul Islam. According to
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HRW, the soldiers transported 44 of the men into Burkina Faso for questioning, and two of the detainees died from mistreatment shortly after arriving in Djibo.
In June 2016 an investigative commission submitted its report on the 28 persons killed and 625 injured in 2014 during protests against former president Blaise Compaore’s efforts to force a National Assembly vote to change presidential term limits. The report recommended the prosecution of 31 persons, including former president Compaore and former transition prime minister Yacouba Isaac Zida. Most of the others recommended for prosecution were former members of the Presidential Security Regiment (RSP). The report was transmitted to judicial authorities, but none of those listed in the report was prosecuted. Compaore and Yacouba Isaac Zida reportedly remained abroad, and no arrest warrants had been issued against them in this case. b. Disappearance
There were no reports of disappearances by or on behalf of government authorities. c. Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment
The constitution and law prohibit such practices, and in 2014 the National Assembly adopted a law to define and prohibit torture and all related practices. Nevertheless, HRW documented severe beatings by security forces during cross- border operations near the border with Mali that resulted in two deaths (see section 1.a.).
In addition, according to videos shared on social media and reports in the local press, on August 1, gendarmes assaulted several protesting truck drivers, injuring at least one of them. According to press reports, the minister of security publicly told the gendarmes that no legal action would be taken against them. As of September authorities had not prosecuted any of the gendarmes involved in the incident.
Local press reported that on May 12, a gendarme assaulted and injured Guezouma Sanogo, a journalist at the Radio Burkina state radio--who was also president of the Association of Burkina Faso Journalists--during the country’s National Peasant’s Day, allegedly because he did not obey established security measures. President Kabore addressed the incident, stating that he “sincerely regrets the
Country Reports on Human Rights Practices for 2017 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 3 incident which should not occur in our time.” As of September 20, Sanogo had not pressed charges, and authorities had not opened an investigation into the case.
Some former RSP members accused of attempting to attack an armory in 2015 claimed during their trial that gendarmes tortured them during their detention in Ouagadougou and Leo. Additionally, one of the witnesses, Ali Ouedraogo, a son of one of the accused RSP members, stated gendarmes physically assaulted him during the search of their house as part of the investigation. As of October 15, no legal action had been taken against the gendarmes, nor had the government undertaken an investigation.
Prison and Detention Center Conditions
Conditions in prisons and detention facilities were harsh and at times life threatening due to overcrowding and inadequate sanitary conditions and medical care.
Physical Conditions: Authorities held pretrial detainees with convicted prisoners. Female prisoners had better conditions than those of men, in large part due to less crowding. Although regulations require the presence of a doctor and five nurses at the Ouagadougou Detention and Correction Center’s (MACO) health unit, only three nurses were on duty to treat detainees, and a doctor was present once a week. Prisoners’ diets were inadequate, and inmates often relied on supplemental food from relatives. Prison infrastructure throughout the country was decrepit. In MACO and other prisons, severe overcrowding exacerbated inadequate ventilation, although some cells had electricity and some inmates had fans. Sanitation was rudimentary.
On August 10, diplomatic representatives visited MACO to verify compliance with standards of detention and human rights. Their report cited overcrowding, malnutrition, sanitation, health problems, and slowness in judicial processes.
According to human rights organizations, deaths occurred in prisons and jails due to harsh conditions and neglect. Human rights activists estimated one or two inmates died monthly because of harsh prison conditions.
There were no appropriate facilities or installations for prisoners or detainees with disabilities, who relied on other inmates for assistance.
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Physical abuse was a problem in many detention centers across the country. For example, the NGO Burkinabe Movement of Human Rights and People (MBDHP) alleged that in 2016 gendarmes tortured and killed two suspects. In April 2016 Bokoum Salif, a driver in Dedougou, died after being arrested and detained by the local gendarmerie. Bokoum was accused of stealing a computer at the house of the head of the local gendarmerie. Relatives who visited him before his death stated that he presented signs of torture. According to the MBDHP, in May 2016 Sidibe Yero, a herder from Dedougou accused of rape, died under similar circumstances. The gendarmerie reportedly asked his relatives to bury his remains without conducting an autopsy. As of October 15, authorities had not taken legal action in either case.
Food, potable water, sanitation, heating, ventilation, lighting, and medical care were inadequate in the majority of detention facilities across the country, including MACO. Conditions of detention were better for wealthy or influential citizens.
Local media regularly reported on cases of detainees who spend more than one year without trial. For example, one detainee, who had been detained at MACO since 2015, reportedly met the investigative judge for only 15 minutes after more than 13 months in detention. In January when the case was reported in the local press, the same detainee had spent 18 months in prison without seeing the judge again and without a scheduled trial date.
Administration: There were no reports that authorities failed to investigate credible allegations of inhuman prison conditions.
Independent Monitoring: The government permitted monitoring by independent nongovernmental observers. Prison authorities regularly granted permission to representatives of local and international human rights groups, media, foreign embassies, and the International Committee of the Red Cross to visit prisons without advance notice.
Improvements: To address overcrowding, the government opened a new prison in Koupela, in the Kouritenga Province, and transferred prisoners from overcrowded prisons to those with lower occupancy rates. Other measures also taken during the year to reduce prison overcrowding included enforcing fines and community service rather than prison time, and allowing for the provisional release of certain prisoners. As of October, however, there was no evidence that these measures effectively reduced overcrowding.
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To improve detention conditions, improve prisoner health, and facilitate social reintegration of prisoners, the Ministry of Justice launched a three-year prison reform project with EU support. The Ministry of Justice also partnered with the NGO SOS Doctor Burkina Faso to provide free health consultations to approximately 1,500 to 2,000 detainees. d. Arbitrary Arrest or Detention
The constitution and law prohibit arbitrary arrest and detention and provide for the right of persons to challenge the lawfulness of their arrest or detention in court, but security forces did not always respect these provisions. For example, security forces arrested and detained web activist Naim Toure in December 2016 for posting on his Facebook page information on the health condition of a former RSP member detained at the military prison. On February 27, he was sentenced to pay a fine of 300,000 CFA francs ($550).
HRW reported that during the June 9 cross-border operation near the border with Mali (see section 1.a.), soldiers detained approximately 74 men, ages 20 to 70. The soldiers accused the men of supporting the Burkinabe Islamist armed group Ansaroul Islam, which also had bases in Mali. According to HRW, 44 men were taken to Burkina Faso for questioning, and seven remained in detention. Minister of Justice Rene Bagoro opened an investigation and was working with the Ministry of Defense and Ministry of Security to investigate the allegations. Minister Bagoro also announced that the permanent secretary of the interministerial committee on human rights and international humanitarian law began to conduct predeployment training on human rights for soldiers.
Role of the Police and Security Apparatus
The Ministry of Internal Security and the Ministry of Defense are responsible for internal security. The Ministry of Internal Security includes the National Police and the gendarmerie. The army, which operates within the Ministry of Defense, is responsible for external security but sometimes assists with missions related to domestic security. Use of excessive force, corruption, a climate of impunity, and lack of training contributed to police ineffectiveness. The government announced investigations in progress, but as of September 20, none had led to prosecution. Inadequate resources also impeded police effectiveness.
Following an attempt to seize power in September 2015, the government dismantled the RSP and integrated former RSP members into the regular army,
Country Reports on Human Rights Practices for 2017 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 6 except those at large or previously arrested for involvement in the putsch attempt. The unit subsequently responsible for presidential security included police officers, gendarmes, and soldiers.
The Military Justice Administration examines all cases involving killings by military personnel or gendarmes to determine whether they occurred in the line of duty or were otherwise justifiable. The administration refers cases deemed outside the line of duty or unjustifiable to civilian courts. Civilian courts automatically handle killings involving police. The gendarmerie is responsible for investigating abuse by police and gendarmes, but the results of their investigations were not always made public.
NGOs and the Ministry of Justice, Human Rights, and Civic Promotion conducted training activities on human rights for security forces. The previous united Ministry of Territorial Administration, Decentralization, and Internal Security organized a meeting for defense and security forces, journalists, and human rights organizations on February 3, during which participants from the eastern region discussed human rights protection in the region and overcame their disagreements.
Arrest Procedures and Treatment of Detainees
By law police and gendarmes must possess a court-issued warrant based on sufficient evidence before apprehending a person suspected of committing a crime, but authorities did not always follow these procedures. Authorities did not consistently inform detainees of charges against them. By law detainees have the right to expeditious arraignment, bail, access to legal counsel, and, if indigent, access to a lawyer provided by the government after being charged. A judge may order temporary release pending trial without bail. Authorities seldom respected these rights. The law does not provide detainees access to family members, although authorities generally allowed detainees such access through court-issued authorizations.
The law limits detention without charge for investigative purposes to a maximum of 72 hours, renewable for a single 48-hour period. Police rarely observed the law, and the average time of detention without charge (preventive detention) was one week. Once authorities charge a suspect, the law permits judges to impose an unlimited number of consecutive six-month preventive detention periods while the prosecutor investigates charges. Authorities often detained defendants without access to legal counsel for weeks, months, or even years before the defendant
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Pretrial Detention: Authorities estimated 48 percent of prisoners nationwide were in pretrial status. In some cases authorities held detainees without charge or trial for longer periods than the maximum sentence for conviction of the alleged offense. A pretrial release (release on bail) system exists, although the extent of its use was unknown.
Detainee’s Ability to Challenge Lawfulness of Detention before a Court: The law provides persons arrested or detained the right to challenge in court the legal basis or arbitrary nature of their detention. Prisoners who did so, however, reportedly faced difficulties due to either judicial corruption or inadequate staffing of the judiciary. e. Denial of Fair Public Trial
The constitution and law provide for an independent judiciary, but the judiciary was corrupt, inefficient, and subject to executive influence, according to NGOs. There were no instances in which the outcomes of trials appeared predetermined, and authorities respected court orders. Legal codes remained outdated, there were not enough courts, and legal costs were excessive. Citizens’ poor knowledge of their rights further weakened their ability to obtain justice.
Military courts try cases involving military personnel charged with violating the military code of conduct. Rights provided in military courts are equivalent to those in civil criminal courts. Military courts are headed by a civilian judge, hold public trials, and publish verdicts in the local press.
Trial Procedures
The law presumes defendants are innocent. Defendants have the right to be informed promptly and in detail of the charges, with free assistance of an interpreter. Trials are public but may be delayed. Judicial authorities use juries only in criminal cases. Defendants have the right to be present at their trials and to legal representation, consultation, and adequate time and facilities to prepare a defense. Defendants have the right to provide evidence. Defendants have the right not to be compelled to testify or confess guilt, but a refusal to testify often resulted in harsher decisions. Defendants may challenge and present witnesses, and they have the right of appeal. In civil cases where the defendant is destitute and files an
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The Ministry of Justice, Human Rights, and Civic Promotion claimed courts usually tried cases within three months, although human rights organizations reported major case backlogs. The 2011 “processing of criminal penalties in real time” reform to shorten pretrial detention allows the prosecutor and investigators (police and gendarmerie) to process a case prior to the criminal hearing. This countrywide approach allows authorities to inform defendants of the charges and trial date before authorities release them pending trial.
Political Prisoners and Detainees
There were no reports of political prisoners or detainees during the year, although some arrests and detentions may have been politically motivated.
In 2015 gendarmes arrested Leonce Kone, interim CDP president, and Hermann Yameogo, president of the National Union for Democracy and Development, for refusing to condemn the RSP attempt to seize power. Authorities granted provisional release to Kone in July 2016 and released Yameogo in October 2016. As of September 20, the government had not provided any update on this pending case.
In January 2016 authorities arrested CDP president Eddie Komboigo and charged him with involvement in the preparation of the 2015 attempted putsch. Komboigo was granted provisional release in June 2016 for “medical reasons.” On July 24, the presiding judge reportedly informed Komboigo that the investigation concluded he was not guilty of the charges against him.
Authorities of the transition government arrested former minister of foreign affairs and founder of opposition party New Alliance of the Faso, Djibril Bassole, in 2015 for allegedly providing support to the failed 2015 military coup. In July a UN working group released its investigative report calling for his immediate release and demanding that he stand trial by a civilian court instead of a military court. In response to the working group’s request, the government announced on July 8 that it would request a review of the case through the revision procedure of the UN
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Human Rights Council’s work. On October 10, Bassole was granted provisional release for medical reasons and placed under house arrest.
Civil Judicial Procedures and Remedies
There is an independent judiciary in civil matters, but it was often inefficient, corrupt, and subject to executive influence. As a result, citizens sometimes preferred to rely on the Office of the Ombudsman (see section 5, Government Human Rights Bodies) to settle disputes with the government.
The law provides for access to a court to file lawsuits seeking damages for, or cessation of, a human rights violation, and both administrative and judicial remedies were available for alleged wrongs. Victims of human rights violations may appeal directly to the Economic Community of West African States Court of Justice, even before going through national courts. For civil and commercial disputes, authorities may refer cases to the Abidjan Common Court of Justice and Arbitration. The courts issued several such orders during the year.
There were problems enforcing court orders in sensitive cases involving national security, wealthy or influential persons, and government officials. f. Arbitrary or Unlawful Interference with Privacy, Family, Home, or Correspondence
The constitution and law prohibit such actions, and the government generally respected these prohibitions. In cases of national security, however, the law permits surveillance, searches, and monitoring of telephones and private correspondence without a warrant.
Section 2. Respect for Civil Liberties, Including: a. Freedom of Expression, Including for the Press
The constitution and law provide for freedom of expression, including for the press, and the government generally respected this right. In 2015 the government adopted a law decriminalizing press offenses. The law replaces prison sentences with penalties ranging from one million to five million CFA francs ($1,838 to $9,191). Some editors complained that few newspapers or media outlets could afford such fines.
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Despite the advent of the 2015 law, journalists occasionally faced criminal prosecution for libel and other forms of harassment and intimidation.
Freedom of Expression: The law prohibits persons from insulting the head of state or using derogatory language with respect to the office. Individuals generally criticized the government without reprisal, but opposition leaders accused the government of tailing and wiretapping opposition figures in the government.
Press and Media Freedom: There were numerous independent newspapers, satirical weeklies, and radio and television stations, some of which strongly criticized the government. Foreign radio stations broadcast without government interference. Government media outlets--including newspapers, television, and radio--sometimes displayed a progovernment bias but allowed significant opposition participation in their newspaper and television programming. On June 17, the minister of communications stated that government-owned national television news broadcasts should begin with the activities of government officials and that journalists employed by government media should either support the government or resign. On July 21, the journalists’ union denounced the minister for his statement, and in September the journalists’ union launched strikes and demanded that the government end “intimidation and pressure.”
All media are under the administrative and technical supervision of the Ministry of Communications, which is responsible for developing and implementing government policy on information and communication. The Superior Council of Communication (CSC) monitored the content of radio and television programs, newspapers, and internet websites to enforce compliance with standards of professional ethics and government policy. The CSC may summon journalists and issue warnings for subsequent violations. Hearings may concern alleged libel, disturbing the peace, inciting violence, or violations of state security. On July 14, the CSC suspended the programming of private radio Optima for one month, due to alleged abusive remarks uttered by the radio show host.
Violence and Harassment: According to local press, journalist Mamadou Ali Compaore, known to be critical of the regime on television programs, claimed he received threats from two individuals on January 6. Journalist Lookman Sawadogo, owner of local newspaper Le Soir, was prosecuted on defamation charges following statements on social media on April 5 denouncing acts of corruption by magistrates who were in charge of investigating the magistracy. Sawadogo was released at trial, and all charges against him were dismissed due to lack of evidence.
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Censorship or Content Restrictions: In addition to prohibitions on insulting the head of state, the law also prohibits the publication of shocking images or material that demonstrates lack of respect for the deceased. Journalists practiced self- censorship. On February 26, police ordered the Burkina Information Agency to remove an article--Fara: Bandits Shut Down Police Station before Robbing It-- from the agency’s website, claiming that the report was offensive and false. Police later forced the agency to issue a denial of the accuracy of the story.
Internet Freedom
The government did not restrict or disrupt access to the internet, although the CSC monitored internet websites and discussion forums to enforce compliance with regulations. According to the International Telecommunication Union, 14 percent of the population used the internet in 2016.
Academic Freedom and Cultural Events
There were no government restrictions on academic freedom or cultural events. b. Freedom of Peaceful Assembly and Association
Freedom of Peaceful Assembly
The constitution and law provide for freedom of peaceful assembly, and the government generally respected this right.
Political parties and labor unions may hold meetings and rallies without government permission, although advance notification and approval are required for public demonstrations that may affect traffic or threaten public order. If a demonstration or rally results in violence, injury, or significant property damage, penalties for the organizers include six months to five years’ imprisonment and fines of between 100,000 and two million CFA francs ($183 and $3,676). These penalties may be doubled for conviction of organizing an unauthorized rally or demonstration. Demonstrators may appeal denials or imposed modifications of a proposed march route or schedule before the courts. c. Freedom of Religion
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See the Department of State’s International Religious Freedom Report at www.state.gov/religiousfreedomreport/. d. Freedom of Movement
The constitution provides for freedom of internal movement, foreign travel, emigration, and repatriation and the government generally respected these rights. The government cooperated with UNHCR and other humanitarian organizations in providing protection and assistance to internally displaced persons, refugees, returning refugees, asylum seekers, stateless persons, and other persons of concern.
Protection of Refugees
Access to Asylum: The law provides for granting asylum or refugee status, and the government has established a system for providing protection to refugees. The Ministry of Women, National Solidarity, and Family, aided by the National Committee for Refugees (CONAREF), is the focal point for coordination of national and international efforts. According to UNHCR, as of May 31, there were 34,207 refugees in the country, including 33,501 Malian refugees. Of this number, 23,318 Malian refugees lived in Burkina Faso’s two refugee camps, Goudebou and Mentao, 8,800 resided in villages in Ouadalan and Soum Provinces, and 1,383 lived in the cities of Ouagadougou and Bobo Dioulasso. Government assistance to Malian refugees totaled 240 million CFA francs ($441,176) in 2016.
In 2012 fighting resumed in northern Mali between government forces and Tuareg rebels, resulting in the flight of more than 250,000 Malians to neighboring countries, including Burkina Faso. According to UNHCR, approximately 50,000 Malians--most of them Tuaregs and Arabs--fled across the border to Burkina Faso and registered with local authorities as displaced persons. Authorities granted all displaced persons from Mali prima facie refugee status, pending the examination of all applications individually. Authorities settled most of the refugees in Soum and Oudalan Provinces in the Sahel Region. The ministry, aided by CONAREF, was the government focal point to help coordinate all national and international efforts to assist more than 33,500 Malian refugees remaining in the country at year’s end. During the year the refugees received an undetermined amount of government assistance.
Section 3. Freedom to Participate in the Political Process
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The constitution provides citizens the ability to choose their government in free and fair periodic elections held by secret ballot and based on universal and equal suffrage.
Elections and Political Participation
Recent Elections: In May 2016 the country held elections to replace municipal and regional councils dissolved by the transitional government in 2014. Voter turnout was lower than usual. Voting did not occur in three of the 368 communes. In several areas of the country, the postelection selection process of mayors by municipal councils was marred by clashes among political party activists, resulting in at least three deaths and dozens of injuries in Karangasso and Kantchari. The government condemned the violence and promised swift judicial action. As of September 20, no legal action was taken against anyone involved in the violence. In the districts that were unable to hold contests in 2016 due to pre-election violence and those that did not complete the installation process for their municipal councils and mayors, makeup elections were organized and concluded quietly on May 28. The ruling party, the People’s Movement for Progress, won most districts.
The 2015 electoral code approved by the National Transitional Council (CNT) stipulates the exclusion of certain members of the former political majority. The code states that persons who “supported a constitutional change that led to a popular uprising” are ineligible to be candidates in future elections. In addition to exclusion from the 2015 legislative and presidential elections, a number of candidates were also excluded from the municipal elections in May. In 2015 administrative courts rejected appeals filed by political opponents of the former ruling party against a number of its candidates. Unlike in previous municipal elections during which some candidates were excluded, all parties were allowed to take part to the complementary municipal elections.
Participation of Women and Minorities: There are no laws limiting the participation of women and members of minorities in the political process, and they did participate. Although the gender quota law requires political parties to name women to fill at least 30 percent of the positions on their candidate lists in legislative and municipal elections, no political party met this requirement during the May 2016 and the May 28, 2017, make-up municipal elections. Parties and government officials said women were less engaged in politics. Women held seven of 34 ministerial seats and 13 of 127 seats in the parliament.
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Section 4. Corruption and Lack of Transparency in Government
The law provides criminal penalties for corruption by officials, but the government did not implement the law effectively, and officials often engaged in corrupt practices with impunity. Local NGOs criticized what they called the overwhelming corruption of senior civil servants. They reported pervasive corruption in the customs service, gendarmerie, tax agencies, national police, municipal police, public health service, municipal governments, education sector, government procurement, and the Ministry of Justice, Human Rights, and Civic Promotion. The local NGO Anticorruption National Network (REN-LAC) categorized the municipal police as the most corrupt government sector. They reported a lack of political will to fight corruption, stating the government rarely imposed sanctions against prominent government figures.
Corruption: On September 6, the Ministry of Justice issued a warrant against the head of the CSC, Nathalie Some, for embezzling 650 million CFA francs ($1.2 million). Some, who was in detention at the MACO since September awaiting trial, held numerous prominent positions in the previous three administrations.
Additionally, in July, two staff members from the Ouagadougou International Craft Fair, accountant Siriki Coulibaly and cashier Claude Guebre, were accused of misappropriating at least 251 million CFA francs ($461,000) from public funds. Coulibaly confessed to misappropriating 131 million CFA francs ($240,000), while Guebre denied any involvement. They were sentenced each to 60 months in detention and a fine of 20 million CFA francs ($367,000). The verdict did not require them to reimburse the misappropriated amount.
Financial Disclosure: In 2015 the CNT adopted an anticorruption law that requires government officials--including the president, lawmakers, ministers, ambassadors, members of the military leadership, judges, and anyone charged with managing state funds--to declare their assets and any gifts or donations received while in office. The Constitutional Council is mandated to monitor and verify compliance with such laws and may order investigations if noncompliance is suspected. Disclosures are not made public, however, and there were no reports of criminal or administrative sanctions for noncompliance. As of September national assembly members who were elected in the 2015 legislative elections had not complied with this law, yet they did not face any sanctions.
In June 2016 the Higher Authority for State Control and the Fight against Corruption extended the requirement to declare assets to include government
Country Reports on Human Rights Practices for 2017 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 15 officials’ spouses and minor children. Infractions are punishable by a maximum jail term of 20 years and fines of up to 25 million CFA francs ($45,955). The law also punishes persons who do not reasonably explain an increase in lifestyle expenditures beyond the 5 percent threshold set by regulation in connection to lawful income. Convicted offenders risk imprisonment for two to five years and a fine of five million to 25 million CFA francs ($9,191 to $45,955). In April 2016 a law was passed limiting the value of a gift a government official could receive to 35,000 CFA francs ($64). In direct violation of the law, members of the National Assembly accepted computer tablets from Huawei International, a company that had been awarded a national optical fiber construction contract in November 2016. Following public outcry led by civil society and the local press, the members of the national assembly were forced to return the gifts.
Section 5. Governmental Attitude Regarding International and Nongovernmental Investigation of Alleged Abuses of Human Rights
A variety of domestic and international human rights groups generally operated without government restriction, investigating and publishing their findings on human rights cases. Government officials were generally cooperative and responsive to their views.
Government Human Rights Bodies: The Office of the Ombudsman addresses citizen complaints regarding government entities, public institutions, and other bodies entrusted with a public service mission. The ombudsman, whom the president appoints for a nonrenewable five-year term and who may not be removed during the term, was generally viewed as effective and impartial. During 2014, the most recent year for which statistics were available, the office registered 560 complaints, approximately 59 percent of which it resolved.
The Ministry of Justice, Human Rights, and Civic Promotion is responsible for the protection and promotion of human and civil rights and conducts education campaigns for security force members to raise their awareness of human rights.
The government-funded National Commission on Human Rights provides a permanent framework for dialogue on human rights concerns. Its members include representatives of human rights NGOs, unions, professional associations, and the government. The Burkinabe Movement for Human and People’s Rights, which did not participate on the commission, charged that it was subject to government influence. Although inadequately funded, the commission continued to be more effective and visible in promoting human rights than in previous years. During the
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Section 6. Discrimination, Societal Abuses, and Trafficking in Persons
Women
Rape and Domestic Violence: In 2015 the government passed the Law on the Prevention and Repression of Violence Against Women and Girls and Support for Victims. Conviction of rape is punishable by five to 10 years’ imprisonment, but the 2015 law includes fines of 100,000 to 500,000 CFA francs ($183 to $919). According to human rights NGOs, rape occurred frequently. Although authorities prosecuted rape cases during the year, no statistics were available on the number of cases reported or prosecuted.
Domestic violence against women occurred frequently, primarily in rural areas. For example, a man raped a 14-year-old girl on July 31 in Bittou, Center-East Region. Local media reported the girl was taken to a health center for medical examination and the perpetrator was released after his arrest by the local police.
Victims seldom pursued legal action due to shame, fear, or reluctance to take their spouses to court. For the few cases that went to court, the Ministry of Justice, Human Rights, and Civic Promotion could provide no statistics on prosecutions, convictions, or punishment. A government-run shelter for women and girls who were victims of gender-based violence was set up in 2015 and welcomed victims regardless of nationality. In Ouagadougou the Ministry of Women, National Solidarity, and Family assisted victims of domestic violence at four centers. The ministry sometimes provided counseling and housing for abused women.
The ministry has a legal affairs section to educate women on their rights, and several NGOs cooperated to protect women’s rights. To raise awareness of gender discrimination and reduce gender inequalities, the ministry organized numerous workshops and several awareness campaigns mainly in the North, Sahel, East, and Center-West Regions.
The law makes conviction of “abduction to impose marriage or union without consent” punishable by six months to five years in jail. Conviction of sexual abuse or torture or conviction of sexual slavery is punishable by two to five years in
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The law requires police to provide for protection of the victim and her minor children and mandates the establishment of chambers in the High Court with exclusive jurisdiction over cases of violence against women and girls. The law requires all police and gendarmerie units to designate officers to assist female victims of violence--or those threatened by violence--and to respond to emergencies; however, some units had not complied by year’s end. It also mandates the creation of care and protection centers in each commune for female victims of violence and a government support fund for their care. The centers receive victims on an emergency basis, offer them security, provide support services (including medical and psychosocial support), and, when possible, refer the victims to court.
Female Genital Mutilation/Cutting (FGM/C): The law prohibits FGM/C, but it was practiced widely in rural areas, and at an early age. Perpetrators, if convicted, are subject to a fine of 150,000 to 900,000 CFA francs ($278 to $1,654) and imprisonment of six months to three years, or up to 10 years if the victim dies.
Security force members and social workers from the Ministry of Women, National Solidarity, and Family arrested four perpetrators in Orodara, Bobo Dioulasso, Tenkodogo, and Leo between January 4 and February 16. Two of them were tried and convicted, one was awaiting trial as of September 5, and one was at large. Twenty-nine accomplices were also sentenced to pay fines or given suspended fines. Of the 49 cases of FGM/C recorded during the year, there was only one case in which the victim was more than 30 years old. For the remaining cases, the victims’ age range from 30 months to 15 years.
For example, in April, an 89-year-old woman age from Sissili Province, described as a professional practitioner of FGM/C, was sentenced by an open court to 12 months in prison and a fine of 500,000 CFA francs ($920). She was accused of performing FGM/C on her six-year-old granddaughter on February 21.
The government also integrated FGM/C prevention in prenatal, neonatal, and immunization services at 35 percent of public health facilities. Government measures taken during the year to combat FGM/C included: the establishment of mobile courts in Tuy Province to try persons accused of FGM/C; creation of a public education Facebook page; distribution to public and private health centers of 322 treatment kits; training 164 Ministry of Education and Literacy officials on
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The ministry also trained 60 police officers and 60 gendarmes in efforts to prevent FGM/C.
For more information, see data.unicef.org/resources/female-genital-mutilation- cutting-country-profiles/.
Other Harmful Traditional Practices: The law makes the conviction of physical or moral abuse of women or girls accused of witchcraft punishable by one to five years in prison and/or a fine of 300,000 to 1.5 million CFA francs ($551 to $2,757). Elderly women, and less frequently men, without support, living primarily in rural areas, and often widowed in the case of women, were sometimes accused of witchcraft by their neighbors and subsequently banned from their villages, beaten, or killed. Actions taken by the government to protect elderly persons accused of witchcraft included financial support and the organization of an International Women’s Day advocacy event on March 8, The Moral Value of the Human Being: Responsibility of the Communities in Combatting the Social Exclusion of Women.
Sexual Harassment: The law provides for sentences of three months to one year in prison and a fine of 300,000 to 500,000 CFA francs ($551 to $919) for conviction of sexual harassment; the maximum penalty applies if the perpetrator is a relative, in a position of authority, or if the victim is “vulnerable.” The government was ineffective in enforcing the law.
Coercion in Population Control: There were no reports of coerced abortion, involuntary sterilization, or other coercive population control methods. Estimates on maternal mortality and contraceptive prevalence are available at: www.who.int/reproductivehealth/publications/monitoring/maternal-mortality- 2015/en/.
Discrimination: Although the law generally provides the same legal status and rights for women as for men--including under family, labor, property, and
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Although the law provides equal property and inheritance rights for women and men, land tenure practices emphasized family and communal land requirements more than individual ownership rights. As a result, authorities often denied women the right to own property, particularly real estate. Many citizens, particularly in rural areas, held to traditional beliefs that did not recognize inheritance rights for women and regarded a woman as property that could be inherited upon her husband’s death.
The government conducted media campaigns to change attitudes toward women. It sponsored a number of community outreach efforts and awareness campaigns to promote women’s rights.
Children
Birth Registration: Citizenship derives either by birth within the country’s territory or through a parent. Parents generally did not register many births immediately; lack of registration sometimes resulted in denial of public services, including access to school. To address the problem, the government periodically organized registration drives and issued belated birth certificates. (For data, see UNICEF Multiple Indicator Cluster Survey.)
Child Abuse: Authorities tolerated light corporal punishment, and parents widely practiced it. The government conducted seminars and education campaigns against child abuse. The penal code mandates a one- to three-year prison sentence and fines ranging from 300,000 to 900,000 CFA francs ($551 to $1,654) for conviction of inhuman treatment or mistreatment of children.
The government did not effectively enforce the law. None of the calls to report violence against children, which led to intervention of security force members, resulted in an arrest or prosecution.
Early and Forced Marriage: The legal age for marriage is 17 for girls and 20 for boys, but early and forced marriage was a problem. The law prohibits forced marriage and prescribes penalties of six months to two years in prison for violators, and a three-year prison term if the victim is under age 13. There were no reports of
Country Reports on Human Rights Practices for 2017 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 20 prosecutions during the year. A government toll-free number allowed citizens to report forced marriages.
The Ministry of Women, National Solidarity, and Family conducted information sessions for 120 teenagers from the provinces with the highest child marriage rates, including Comoe, Leraba, Kossi, and Souro, as well as advocacy sessions on child marriage by bringing together approximately 300 community leaders. The ministry also paid the school fees for 600 girls and supported the socio- professional training of 500 young persons at risk of early and forced marriage.
According to media reports, the traditional practice persisted of kidnapping, raping, and impregnating a virgin minor girl and then forcing her family to consent to her marriage to her violator. (For data, see the UNICEF website.)
Sexual Exploitation of Children: The law provides penalties for conviction of child prostitution or child pornography of five to 10 years’ imprisonment, a fine of 1.5 to three million CFA francs ($2,750 to $5,500), or both. The minimum age of consensual sex is 15. In 2014 the National Assembly enacted a law criminalizing the sale of children, child prostitution, and child pornography. Children from poor families were particularly vulnerable to sex trafficking.
Infanticide or Infanticide of Children with Disabilities: The law provides for a sentence of 10 years’ to life imprisonment for infanticide. Newspapers reported several cases of abandonment of newborn babies.
Displaced Children: There were numerous street children, primarily in Ouagadougou and Bobo-Dioulasso. Many children ended up on the streets after their parents sent them to the city to study with an unregistered Quranic teacher or to live with relatives and go to school. Government action to contain the increase in children living on the streets and to achieve their social reintegration included education campaigns for Quranic teachers in Nouna, Tougan, Dori, and Po.
International Child Abductions: The country is a party to the 1980 Hague Convention on the Civil Aspects of International Child Abduction. See the Department of State’s Annual Report on International Parental Child Abduction at travel.state.gov/content/childabduction/en/legal/compliance.html.
Anti-Semitism
Country Reports on Human Rights Practices for 2017 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 21
There was no known Jewish community. There were no reports of anti-Semitic acts.
Trafficking in Persons
See the Department of State’s Trafficking in Persons Report at www.state.gov/j/tip/rls/tiprpt/.
Persons with Disabilities
The law prohibits discrimination against persons with disabilities, but the government did not effectively enforce these provisions. There is legislation to provide persons with disabilities less costly or free health care and access to education and employment. The law also includes building codes to provide for access to government buildings. Authorities did not implement all of these measures effectively.
Persons with disabilities encountered discrimination and reported difficulty finding employment, including in government service.
The government had limited programs to aid persons with disabilities, but NGOs and the National Committee for the Reintegration of Persons with Disabilities conducted awareness campaigns and implemented integration programs.
The government continued to arrange for candidates with vision disabilities to take the public administration recruitment exams by providing the tests in Braille. Additionally, authorities opened specific counters at enrollment sites to allow persons with disabilities to register more easily for public service admission tests.
In an attempt to better provide for youths with disabilities and advance women’s economic empowerment, the government provided loans at zero percent interest to help women and youth carry out economic activities. The Ministry of Women, National Solidarity, and Family also provided agricultural assistance to 500 women with disabilities living in rural areas to help them strengthen their agricultural production activities. Finally, the government organized a special session to recruit 41 persons with disabilities into the public service after providing them with vocational training.
National/Racial/Ethnic Minorities
Country Reports on Human Rights Practices for 2017 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 22
Longstanding conflicts between Fulani herders and sedentary farmers of other ethnic groups sometimes resulted in violence. Herders commonly triggered incidents by allowing their cattle to graze on farmlands or farmers attempting to cultivate land set aside by local authorities for grazing. Government efforts at dialogue and mediation contributed to a decrease in such incidents.
Acts of Violence, Discrimination, and Other Abuses Based on Sexual Orientation and Gender Identity
Societal discrimination against lesbian, gay, bisexual, transgender, and intersex (LGBTI) persons was a problem and was exacerbated by religious and traditional beliefs. LGBTI individuals were occasionally victims of verbal and physical abuse, according to LGBTI support groups. There were no reports the government responded to societal violence and discrimination against LGBTI persons.
The country has no hate crime laws or other criminal justice mechanisms to aid in the investigation, prosecution, or sentencing of bias-motivated crimes against the LGBTI community.
LGBTI organizations had no legal status in the country but existed unofficially. The Ministry of Territorial Administration, Decentralization, and Internal Security did not approve repeated requests by LGBTI organizations to register, and it provided no explanation for the refusals. There were no reports of government or societal violence against such organizations, although incidents were not always reported due to stigma or intimidation.
HIV and AIDS Social Stigma
Societal discrimination against persons with HIV/AIDS was a problem, and persons who tested positive were sometimes shunned by their families. Families sometimes evicted HIV-positive wives from their homes, although families did not evict their HIV-positive husbands. Some property owners refused to rent lodgings to persons with HIV/AIDS. The government distributed free antiretroviral medication to some HIV-positive persons who qualified according to national guidelines.
Other Societal Violence or Discrimination
Vigilante groups across the country operated detention facilities. Media reported cases of torture and killing that took place in these facilities. For example, on
Country Reports on Human Rights Practices for 2017 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 23
January 6, a suspected thief named Bindi Kouldiaty died in Diapaga (East Region) after being tortured by local vigilante members in December 2016. Also, on March 28, a suspected thief was found dead in Pama (Kompienga Province) after being tortured by local vigilantes for 48 hours. Authorities did not arrest or charge the perpetrators in the majority of cases involving vigilante groups.
Section 7. Worker Rights a. Freedom of Association and the Right to Collective Bargaining
The law allows workers to form and join independent unions of their choice without prior authorization or excessive requirements, but essential workers, such as magistrates, police, military, and other security personnel, may not join unions. The law provides unions the right to conduct their activities without interference.
The law provides for the right to strike, although it stipulates a narrow definition of this right. For strikes that call on workers to stay home and that do not entail participation in a rally, the union is required to provide eight to 15 days’ advance notice to the employer. If unions call for a march, three days’ advance notice must be provided to the city mayor. Authorities hold march organizers accountable for any property damage or destruction that occurs during a demonstration. The law also gives the government extensive requisitioning powers, authorizing it to requisition private- and public-sector workers to secure minimum service in essential services.
The law prohibits antiunion discrimination and allows a labor inspector to reinstate immediately workers fired because of their union activities, although in private companies such reinstatement was considered on a case-by-case basis. Relevant legal protections cover all workers, including migrants, workers in the informal sector, and domestic workers. There were no reports of antiunion discrimination during the year.
The law provides for freedom of association and collective bargaining. The government effectively enforced the law. The law listed sanctions for violations, including warnings, penalties, suspension, or dissolution and were generally sufficient to deter violations. Penalties consist of imprisonment and fines and vary depending on the gravity of the violation. In 2015 the CNT adopted amendments to the law. The amendments award a legal existence to labor unions of NGOs, create a commission of mediation, and require that associations abide by the law concerning funding terrorism and money laundering. The law also states that no
Country Reports on Human Rights Practices for 2017 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 24 one may serve as the head of a political party and the head of an association at the same time.
Despite limitations on the right to strike, the government generally respected freedom of association and the right to collective bargaining. Private-sector employers did not always respect freedom of association, especially in the gold mining sector.
The government generally respected the right of unions to conduct activities without interference. Government resources to enforce labor laws were not sufficient to protect workers’ rights.
Unions have the right to bargain directly with employers and industry associations for wages and other benefits. Worker organizations were independent of the government and political parties. There were no reports of strikebreaking during the year.
There were no reports of government restrictions on collective bargaining during the year. There was extensive collective bargaining in the formal wage sector, but this sector included only a small percentage of workers. Employers sometimes refused to bargain with unions. In the private sector, particularly in mining and other industries, employers’ use of subcontracting made it difficult to enforce worker rights systematically. b. Prohibition of Forced or Compulsory Labor
The law prohibits all forms of forced or compulsory labor. The law considers forced or compulsory any labor or service provided by an individual under the threat of any type of sanction and not freely offered. The government did not effectively enforce applicable laws. Forced child labor occurred in the agricultural (particularly cotton), informal trade, domestic labor, restaurant, and animal husbandry sectors, as well as at gold panning sites and stone quarries. Educators forced some children sent to Quranic schools by their parents to engage in begging (see section 6, Children). The government did not have a significant, effective program in place to address or eliminate forced labor. Women from other West African countries were fraudulently recruited for employment in the country and subsequently subjected to forced prostitution, forced labor in restaurants, or domestic servitude in private homes. The government continued to conduct antitrafficking advocacy campaigns and operated a toll-free number for individuals to report cases of violence and trafficking.
Country Reports on Human Rights Practices for 2017 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 25
See the Department of State’s Trafficking in Persons Report at www.state.gov/j/tip/rls/tiprpt/. c. Prohibition of Child Labor and Minimum Age for Employment
The law sets the minimum age for employment at 16 and prohibits children under age 18 from working at night, except in times of emergency. The minimum age for employment was consistent with the age for completing educational requirements, which was 16. In the domestic labor and agricultural sectors, the law permits children who are 13 and above to perform limited activities for up to four and one-half hours per day.
The law prohibits the worst forms of child labor, including the commercial sexual exploitation of children, child pornography, and jobs that harm the health of a child. The government was implementing the National Action Plan to combat the worst forms of child labor and to reduce significantly exploitative child labor. In 2015, the CNT adopted a revised mining code that includes new provisions prohibiting child labor in mines. The amendment establishes a penalty of two to five years in prison and a fine of five million CFA francs ($9,191) to 24 million CFA francs ($44,117) for violators. Antitrafficking legislation provides penalties of up to 10 years for violators and increases maximum prison terms from five to 10 years. The law also provides terms as long as 20 years’ to life imprisonment under certain conditions.
The National Action Plan against the worst forms of child labor coordinated the efforts of several ministries and NGOs. Its goals included greater dissemination of information in local languages, increased access to services such as rehabilitation for victims, revision of the penal code to address the worst forms of child labor, and improved data collection and analysis. A 2014 law criminalizes the sale of children, child prostitution, and child pornography.
Punishment for violating child labor laws includes prison terms of up to five years and fines of up to 600,000 CFA francs ($1,103). The government did not consistently enforce the law. The Ministry of Civil Service, Labor, and Social Security, which oversees labor standards, lacked sufficient inspectors, transportation, and other resources to enforce worker safety and minimum age laws. No data were available on number of prosecutions and convictions during the year.
Country Reports on Human Rights Practices for 2017 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 26
The government organized workshops and conferences to inform children, parents, and employers of the dangers of exploitative child labor. Despite efforts by the government and several NGOs, violence against children, child labor, and child trafficking occurred. According to 2011 statistics compiled by the National Institute of Statistics, 76 percent of children between the ages of five and 17 engaged in some form of economic activity, 81 percent of whom worked in the agricultural sector. Children commonly worked with their parents in rural areas or in family-owned small businesses in villages and cities. There were no reports of children under the age of 15 employed by either government-owned or large private companies.
Children also worked in the mining, trade, construction, and domestic labor sectors. According to a 2012 UNICEF study, 20,000 children worked as servants, gold washers, or diggers in the gold mining sector. Some children, particularly those working as cattle herders and street hawkers, did not attend school. Many children under age 15 worked long hours. A study by the International Labor Organization reported that children working in artisanal mining sometimes worked six or seven days a week and up to 14 hours per day. Street beggars often worked 12 to 18 hours daily. Such children suffered from occupational illnesses, and employers sometimes physically or sexually abused them. Child domestic servants earned from 3,000 to 6,000 CFA francs ($5.50 to $11) per month and worked up to 18 hours per day. Employers often exploited and abused them. Criminals transported Burkinabe children to Cote d’Ivoire, Mali, and Niger for forced labor or sex trafficking.
Also see the Department of Labor’s Findings on the Worst Forms of Child Labor at www.dol.gov/ilab/reports/child-labor/findings/. d. Discrimination with Respect to Employment and Occupation
The law prohibits discrimination with respect to employment and occupation. The government did not effectively enforce the laws and regulations. Discrimination occurred based on race, color, sex, religion, political opinion, social origin, gender, disability, language, sexual orientation or gender identity, HIV-positive status or other communicable diseases, or social status with respect to employment and occupation. The government took few actions during the year to prevent or eliminate it. e. Acceptable Conditions of Work
Country Reports on Human Rights Practices for 2017 United States Department of State • Bureau of Democracy, Human Rights and Labor BURKINA FASO 27
The law mandates a minimum monthly wage in the formal sector, which does not apply to subsistence agriculture or other informal occupations. Approximately 46 percent of the population lived below the poverty line. Poverty remained higher in rural areas. The minimum wage was less than the poverty income level.
The law mandates a standard workweek of 40 hours for nondomestic workers and a 60-hour workweek for household employees. The law provides for overtime pay, and there are regulations pertaining to rest periods, limits on hours worked, and prohibitions on excessive compulsory overtime.
The government sets occupational health and safety standards. There are explicit restrictions regarding occupational health and safety in the labor law. Employers must take measures to provide for safety and protect the physical and mental health of all their workers and assure that the workplace, machinery, materials, substances, and work processes under their control do not present health or safety risks to the workers.
The law requires every company with 30 or more employees to have a work safety committee. If an employee decides to remove himself due to safety concerns, a court rules on the relevancy of the decision.
The Ministry of Civil Service, Labor, and Social Security is responsible for enforcing the minimum wage and hours of work standards. Ministry inspectors and labor tribunals are responsible for overseeing occupational health and safety standards in the small industrial and commercial sectors, but these standards do not apply in subsistence agriculture and other informal sectors.
These standards were not effectively enforced. The Labor Inspector Corps lacked sufficient resources, including staff, offices, and transport. Penalties for violations were insufficient to deter violations. There were no reports of effective enforcement of inspection findings during the year.
Employers often paid less than the minimum wage. Employees usually supplemented their income through reliance on extended family, subsistence agriculture, or trading in the informal sector. Mining sector companies generally respected hours of work, overtime, and occupational safety and health standards. Employers subjected workers in the informal sector, which made up approximately 50 percent of the economy, to violations of wage, overtime, and occupational safety and health standards.
Country Reports on Human Rights Practices for 2017 United States Department of State • Bureau of Democracy, Human Rights and Labor
TAB 5 Burkina Faso piloting PrEP
unaids.org/en/resources/presscentre/featurestories/2019/april/20190408_burkina-faso-piloting-prep
Feature story
08 April 2019
08 April 201908 April 2019 For the past four months, Benjamin Sana has been regularly attending the Oasis Clinic in Ouagadou
For the past four months, Benjamin Sana has been regularly attending the Oasis Clinic in Ouagadougou, Burkina Faso, where he sees a doctor who gives him a full check-up.
The doctor and peer educators also check whether Mr Sana has any questions regarding his pre-exposure prophylaxis (PrEP) regimen. PrEP is taken by people who are HIV-negative but at higher risk of infection, and has proved to be very effective at keeping people free from HIV.
“Two plus one plus one,” answers Mr Sana, referring to when he needs to take the pills—two pills two hours before sex, then one the day after and one again the following day or one a day until his last sexual encounter. After his check-up, the 34-year-old gay man said, “PrEP protects me and I feel reassured.” He still uses condoms and lubricant, but when he doesn’t he said he feels safer.
1/3 Watch Video At:
https://youtu.be/FGXgsz61SvI
Mr Sana is one of 100 men taking part in the PrEP pilot project at the Oasis Clinic, run by the Association African Solidarité (AAS). Health clinics in Côte d’Ivoire, Mali and Togo are also taking part in the pilot project, which has been running since 2017.
Camille Rajaonarivelo, a doctor at AAS, said that PrEP is part of a combination prevention approach that also involves trained peers from his community. The project will gauge adherence to treatment and whether participants take PrEP correctly, she explained.
“The final aim of this pilot project is to scale up and roll out PrEP nationally once the authorities give the green light,” she said.
The study aims to evaluate whether the preventive option gains traction and how feasible it would be to roll it out nationally and regionally. Financed by the French National Agency for Research on AIDS and Expertise France in partnership with Coalition PLUS and three European health institutes, the pilot project will provide data and ascertain if the treatment lowers the number of new HIV infections among gay men and other men who have sex with men.
Burkina Faso does not penalize homosexuality, but stigma against it is high. As a result, gay men and other men who have sex with men often hide their sexuality and tend to avoid health services. HIV prevalence in Burkina Faso among gay men and other men who have sex with men stands at 1.9%, more than double the rate among the general population.
2/3 The first definitive results of the PrEP pilot project in Ouagadougou should be available in 2020. Mr Sana said that many of his friends had shown interest in taking PrEP. “Because the pilot project has limited participants, a lot of people have been turned away,” he said.
He believes that PrEP will save lives, especially those of young men. “Nowadays, young men take a lot more risks and they don’t protect themselves,” Mr Sana said. Ms Rajaonarivelo agreed and added that this applies to young men and young women. “I am stunned to see new cases of HIV every week,” she said. “We have to beef up HIV prevention and awareness again.”
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TAB 6 Health and safety: sex workers reaching out to sex workers
unaids.org/en/resources/presscentre/featurestories/2019/february/20190226_burkina-sex-workers
Prostitution in Burkina Faso is not illegal, but the penal code forbids soliciting.
By recruiting peer educators who know the realities of the job and can relate to other women, HIV awareness has increased in the community.
1/7 All sex workers now need to carry a health card showing that they have had regular health check-ups.
2/7 Donning plastic gloves, the trained peer educators sat with women, who had their finger pricked and within five minutes were given their HIV test result.
3/7 HIV prevalence among sex workers is 5.4% in Burkina Faso, while it’s 0.8% among all adults in the country.
4/7 After documenting police abuse for a year with the help of bar owners and feedback from sex workers, REVS Plus met with government officials and then the police.
Feature story
26 February 2019
26 February 201926 February 2019 Leaving the meeting of the REVS PLUS nongovernmental organization, the women bid each other farew
5/7 Leaving the meeting of the REVS PLUS nongovernmental organization, the women bid each other farewell, saying, “A demain soir (See you tomorrow night).” They had gathered at a health drop-in centre that also acts as a network hub for various HIV networks in Bobo- Dioulasso, Burkina Faso, to discuss the following evening’s plan: HIV testing among their peers at selected sites.
“We share our experiences and act as confidantes,” said Camille Traoré (not her real name), a sex worker and peer educator. Her colleague, Julienne Diabré (not her real name), wearing a long flowing dress, chimed in, “In our line of work, it’s hard to confide in someone, so confidentiality is key.”
REVS PLUS/Coalition PLUS advocacy manager, Charles Somé, described the group of women as an essential link in the chain to reach out to sex workers.
“Because of stigma and discrimination, many sex workers hide and move around so they miss out on health services and are much more likely to be infected with HIV,” he said. HIV prevalence among sex workers is 5.4% in Burkina Faso, while it’s 0.8% among all adults in the country.
By recruiting peer educators who know the realities of the job and can relate to other women, Mr Somé said that HIV awareness has increased in the community.
“We also innovated and started HIV testing in the evenings in places where sex workers gather,” he said. Prostitution in Burkina Faso is not illegal, but the penal code forbids soliciting.
Watch Video At: https://youtu.be/6ixEaON5b4Q
6/7 The following evening, along a darkened street, REVS PLUS set up foldable tables with two stools at each table. A solar lamp allowed the peer educators to see in the pitch dark and jot down information. Donning plastic gloves, the trained peer educators sat with women, who had their finger pricked and within five minutes were given their HIV test result. No doctors, no nurses were needed. The testing was done by peers because sex workers are afraid to be identified as sex workers.
Mr Somé explained that over the years REVS PLUS outreach has gained the trust of sex workers.
Peer educators, he said, regularly called him to complain about police violence. “It went from arbitrary arrests, to stealing their money, to rape,” Mr Somé said.
Ms Diabré described her dealings with the police. “During the day they point a finger at you and discriminate, while at night they become all nice to get favours and if we don’t deliver then it gets ugly,” she said.
After documenting police abuse for a year with the help of bar owners and feedback from sex workers, REVS PLUS met with government officials and then the police.
“Our approach got their attention and we started awareness training with police officers based on law basics and sex work,” Mr Somé said.
Slowly, REVS PLUS identified allies in each police station, facilitating dialogue whenever an issue occurred. In addition, all sex workers now need to carry a health card showing that they have had regular health check-ups.
A Nigerian woman wearing purple lipstick, Charlotte Francis (not her real name), said, “We still have issues and stay out of their way, but it’s gotten better.” She waved her blue health card, which she says bar owners regularly demand.
Showing off his bar and a series of individual rooms around an outdoor courtyard, Lamine Diallo said that the police no longer raid his establishment. “Before, police would haul away all the women and even my customers,” he said.
UNAIDS, with funds from Luxembourg, is currently partnering with REVS PLUS to scale up the police awareness training across the country. Trainings have taken place in the capital city, Ouagadougou, and in Bobo-Dioulasso.
UNAIDS Burkina Faso Community Mobilization Officer Aboubakar Barbari sees the programme as two-fold. “We supported the awareness sessions for police and security forces because it not only reduces stigma, it also puts a spotlight on basic human rights.”
7/7
TAB 7 Burkina Faso
hivjustice.net/country/bf/
Number of reported cases 0 How do we calculate the number of cases
Overview
Burkina Faso has two HIV-specific laws outlining the obligation of all persons living with HIV to disclose their HIV status to their sexual partners and to abstain from having “unprotected sex”. There is no definition of unprotected sex, which suggests that the prevention benefit of treatment might be used as a defence, as well as condom use.
However, non-disclosure of HIV-status prior to “unprotected sex”, even if their partner is also HIV-positive, is classified as deliberate transmission and can be punished in accordance with the provisions of the criminal code, even if transmission (i.e. alleged superinfection) did not occur.
In cases of alleged transmission, non-disclosure of HIV-status prior to “unprotected sex” leads to the charge of attempted intentional homicide.
Our partners in Burkina Faso are aware of several cases but none are thought to have resulted in convictions. The only reported prosecution giving rise to a conviction related to an injection case, which qualified as aggravated assault.
Laws
Act No. 030-2008/AN on combating HIV/AIDS and protecting the rights of people living with HIV/AIDS
HIV-specific criminal law (active) Year enacted 2008 Relevant text of the law Article 1: […]
– HIV transmission: contamination of a healthy person by another person already infected with HIV, most often through sexual intercourse, blood transfusion, use of needles or other objects already contaminated or from mother to child;
– Voluntary HIV transmission: the conscious inoculation of HIV-infected substances into a person in any way whatsoever that these substances have been used or administered.
1/4 Article 7: Every person living with HIV is required to disclose his or her HIV status to his or her spouse or sexual partner without delay.
Article 10: Any person knowing that he or she is infected with HIV must refrain from unprotected sexual intercourse with another person.
Article 20: Any person who knows he or she is infected with HIV and who knowingly has unprotected sexual intercourse with a partner who is not informed of his or her HIV status, even if he or she is HIV-positive, is guilty of the crime of wilful transmission of HIV and is punished in accordance with the Criminal Code.
Article 22: Anyone who has voluntarily transmitted HIV-infected substances by any means whatsoever is guilty of the deliberate transmission of HIV.
Any person who has granted or provided the means to commit the offence referred to in paragraph 1 shall be an accomplice to the act of voluntary transmission.
Persons guilty of or complicit in the act of wilful transmission of HIV are punished in accordance with the provisions of the Criminal Code.
Article 26: Anyone who is aware of his or her HIV status and fails to take the necessary and sufficient precautions to protect his or her partner(s) shall be subject to criminal sanctions.
Anyone who knows that he or she is infected with HIV and does not take the necessary and sufficient precautions to protect his or her partner(s) is liable to a fine of one hundred thousand (100,000) CFA francs to one million (1,000,000) CFA francs. If contamination has resulted, the penalty is attempted murder in accordance with the provisions of the Criminal Code.
View the full law online
Law n°045 -2005 / AN of 21 December 2005 on Reproductive Health in Burkina Faso
Other law (active) Year enacted 2005 Relevant text of the law Law n°045 -2005 / AN of 21 December 2005 on Reproductive Health in Burkina Faso
2/4 Article 17: Any individual who is aware of his or her status as a patient with sexually transmitted infections (STIs) or human immunodeficiency virus (HIV) infection has a duty to inform his or her partner (s).
Article 18: Any individual who is aware of his or her state of infection with the Human Immunodeficiency Virus (HIV) and who does not take sufficient precautions to protect his or her partner(s) is subject to criminal sanctions.
Anyone who suffers from a serious sexually transmitted infection or HIV who fails to take sufficient precautions to protect his or her partner(s) shall be punished by a fine of one hundred thousand (100.00) to one million (1,000,000) CFA francs.
If contamination has resulted, the penalty is attempted murder in accordance with the provisions of the Criminal Code.
If death results, the penalty is voluntary homicide, in accordance with the provisions of the Criminal Code.
Article 22: The following shall be prohibited and punished in accordance with the laws and regulations in force:
– All forms of sexual violence;
– Female genital mutilation;
– Castration;
– Voluntary transmission of HIV/AIDS;
– Sexual exploitation in all its forms;
– Misleading advertising on contraceptive methods;
– The dissemination of images and messages that may affect reproductive health.
View the full law online
Further resources
Revue du Cadre Juridique Burkinabe de la Riposte au VIH et SIDA This document is an analysis, conducted in collaboration with UNDP, of the Burkinabe legal framework addressing issues of criminalization of key populations and including a section on the criminalization of HIV transmission in Burkina Faso (page 77).
Acknowledgements
3/4 La pénalisation du VIH en Afrique francophone : état des lieux Report presenting the results of a survey on HIV criminalization in African countries where French is spoken (hereinafter "Francophone Africa"), conducted from May to September 2017. Authors: Stéphanie Claivaz-Loranger & Cécile Kazatchkine for the Canadian HIV Legal Network and HIV JUSTICE WORLDWIDE
This information was last reviewed in September 2020
4/4
TAB 8 12/10/2020 Burkina Faso | Freedom House
FREEDOM IN THE WORLD 2020 Burkina Faso 56 PARTLY FREE /100
Political Rights 23 /40
Civil Liberties 33 /60
LAST YEAR'S SCORE & STATUS 60 /100 Partly Free Global freedom statuses are calculated on a weighted scale. See the methodology.
https://freedomhouse.org/country/burkina-faso/freedom-world/2020 1/18 12/10/2020 Burkina Faso | Freedom House Overview
Multiparty presidential and legislative elections held in late 2015 ushered in a new government and laid a foundation for the continued development of democratic institutions. Despite extreme poverty, terrorism, and government attempts to curtail press freedoms, civil society and organized labor remain strong forces for democracy and for the respect of civil liberties. Key Developments in 2019
Islamist militants launched violent attacks in northern and eastern Burkina Faso throughout the year, targeting Christian churches and individuals wearing Christian paraphernalia. Clashes with militants and reprisals by government forces forced 560,000 Burkinabè to flee their homes by year’s end. In September, generals Gilbert Diendéré and Djibrill Bassolé, who were accused of plotting a 2015 coup attempt, were convicted by a military tribunal, receiving 20– and 10-year prison terms respectively. In June, the parliament adopted a revised penal code that criminalizes the dissemination of information related to terrorist attacks; the revised code also criminalizes speech that can “demoralize” the defense and security services. Political Rights A. Electoral Process
A1 0-4 pts
https://freedomhouse.org/country/burkina-faso/freedom-world/2020 2/18 12/10/2020 Burkina Faso | Freedom House
Was the current head of government or other chief national authority elected through free and fair elections? 2 / 4
The president is head of state and is directly elected to no more than two five- year terms. Roch Marc Christian Kaboré of the People’s Movement for Progress (MPP) won the 2015 presidential election with approximately 53 percent of the vote. Observers described the election as the most competitive ever to be held in the country. However, a number of politicians who supported former president Blaise Compaoré’s unsuccessful attempt to amend the constitution to allow himself a third presidential term were barred from contesting the election.
The prime minister is head of government and is appointed by the president with the approval of the National Assembly. The prime minister is then responsible for recommending a cabinet that is formally appointed by the president. In January 2019, President Kaboré appointed Christophe Dabiré to serve as prime minister following Paul Kaba Thieba’s resignation earlier that month.
A2 0-4 pts
Were the current national legislative representatives elected through 2 free and fair elections? / 4
The 127 members of the National Assembly are directly elected to five-year terms under a proportional representation system. The 2015 legislative elections were held concurrently with the presidential election and were viewed as generally credible, despite the exclusion of a number of candidates who had supported Compaoré’s term-limit changes. The MPP won a plurality in the National Assembly, with 55 of the 127 seats.
https://freedomhouse.org/country/burkina-faso/freedom-world/2020 3/18 12/10/2020 Burkina Faso | Freedom House
Municipal elections held in 2016 reflected continuing erosion of support for the Congress for Democracy and Progress (CDP), the former ruling party, and increasing support for the MPP. Election observers from local civil society groups and international missions noted only minor irregularities in the polls. However, election-related violence prevented polling in a number of districts, which, according to some observers, contributed to relatively low turnout. Makeup elections for several constituencies were held peacefully in 2017, though once again some candidates were reportedly excluded.
A3 0-4 pts
Are the electoral laws and framework fair, and are they implemented 3 impartially by the relevant election management bodies? / 4
The Independent National Electoral Commission (CENI) is responsible for organizing elections, and the 2015 and 2016 polls were generally well administered.
The electoral code, adopted in 2018, was criticized by opposition parties for imposing new restrictions on voters living abroad. This code requires either the national identity card or a Burkinabè passport for those living abroad to register to vote, whereas a consular card was previously accepted. Opposition critics claimed that many Burkinabè abroad, particularly those in Côte d’Ivoire, would not possess these documents and therefore be disenfranchised. B. Political Pluralism and Participation
B1 0-4 pts
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Do the people have the right to organize in different political parties or other competitive political groupings of their choice, and is the system 2 free of undue obstacles to the rise and fall of these competing parties or / 4 groupings?
The constitution guarantees the right to form political parties, but their ability to participate in political life is sometimes restricted by the government. In August 2019, Ablassé Ouédraogo, leader of opposition party Le Faso Autrement (Faso Otherwise) claimed that the government prohibited his party from participating in a political dialogue. In November, the Patriotic Front for Renewal (FPR), another opposition party, was suspended for three months after calling for the government’s resignation.
Major political parties, such as the MPP, CDP, and Union for Progress and Change (UPC), have extensive patronage networks and disproportionate access to media coverage, making it difficult for other political parties to build their support bases.
B2 0-4 pts
Is there a realistic opportunity for the opposition to increase its support 3 or gain power through elections? / 4
The end of former president Compaoré’s 27-year regime in 2014 has given way to a freer environment, in which opposition parties were able to consolidate popular support and gain power through recent elections. However, a history of rotation of power between parties has yet to be firmly established.
B3 0-4 pts
Are the people’s political choices free from domination by forces that are external to the political sphere, or by political forces that employ 2
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extrapolitical means? / 4
Burkina Faso’s military maintains a significant presence in the political sphere, and the history of military intervention poses a persistent threat to democratic stability. In 2015, the presidential guard, which was loyal to former president Compaoré, attempted to stage a coup d’état. The maneuver sparked widespread protests, and failed after the army’s chief of staff moved to support the transitional government.
B4 0-4 pts
Do various segments of the population (including ethnic, religious, gender, LGBT, and other relevant groups) have full political rights and 3 electoral opportunities? / 4
The constitution enshrines full political rights and electoral opportunities for all segments of the population. However, a small educated elite, the military, and labor unions have historically dominated political life.
Women are underrepresented in political leadership positions and hold 13.4 percent of seats in the parliament. Within parties, women are frequently relegated to women’s secretariats that have little influence. Burkina Faso has a gender quota law mandating that women must represent 30 percent of candidate lists, but its application is limited. A revised gender quota law was drafted by civil society groups in March 2019, but has failed to gain any traction. C. Functioning of Government
C1 0-4 pts
Do the freely elected head of government and national legislative representatives determine the policies of the government? 2
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/ 4
Laws are promulgated and debated by the National Assembly. While democratic institutions continue to develop, they are not yet strong enough to withstand the influence of the military and other elite groups. Attacks by Islamic militants, which have increased in frequency in recent years, severely impede the government’s ability to implement its policies in the insecure north and east.
C2 0-4 pts
Are safeguards against official corruption strong and effective? 2 / 4
Corruption is widespread, particularly among customs officials and municipal police. Anticorruption laws and bodies are generally ineffective, though local nongovernmental organizations (NGOs) provide some accountability by publicizing official corruption and its effects.
C3 0-4 pts
Does the government operate with openness and transparency? 2 / 4
The successful 2015 elections and installation of a civilian government signified a marked improvement in government accountability and transparency. However, government procurement processes are opaque, and procedures meant to increase transparency are often not followed. Government officials are required to make financial disclosures, but the information is rarely made public, and penalties for noncompliance do not appear to be enforced.
https://freedomhouse.org/country/burkina-faso/freedom-world/2020 7/18 12/10/2020 Burkina Faso | Freedom House Civil Liberties D. Freedom of Expression and Belief
D1 0-4 pts
Are there free and independent media? 2 / 4
The environment for media has improved since the end of Compaoré’s rule. Since then, defamation has been decriminalized, reporters at the public broadcaster have experienced less political interference, and private media operates with relative freedom.
However, a revision of the penal code, adopted by the parliament in June 2019, made disseminating information about terrorist attacks and security force activity, along with the “demoralization” of defense and security forces, criminal offenses punishable by prison terms of up to 10 years. These revisions were subsequently declared constitutional by the Constitutional Council in July. Media outlets have since become more reluctant to report on terrorist incidents, with journalists either delaying their reporting or deferring to official government releases.
Score Change: The score declined from 3 to 2 because the National Assembly passed a revised penal code that imposed penalties on journalists who report information that "demoralizes the defense and security forces," which has caused media outlets to delay their reporting and limit the scope of their coverage.
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D2 0-4 pts
Are individuals free to practice and express their religious faith or 3 nonbelief in public and private? / 4
Burkina Faso is a secular state, and freedom of religion is generally respected. The population is predominately Muslim with a large Christian minority. Followers of both religions often engage in syncretic practices.
Recent actions by Islamic militant groups, which have attacked and intimidated civilians in the north and east, contributed to increased tensions between Muslims and Christians. Christian churches were targeted in several deadly attacks during 2019; at least four attacks were recorded in April and May, resulting in the deaths of 20 people. In August, another three people died in attacks on Protestant and Catholic churches in the east.
Christians who wore paraphernalia were also targeted in 2019. Assailants who attacked a church in April targeted individuals wearing crosses. A May procession of Christians the north was attacked, leaving four people dead. In June, gunmen killed 4 people in the village of Béni for wearing crucifixes.
Muslims have also been attacked while expressing their faith in public; in October, assailants entered a mosque in the northern village of Salmossi, killing least 15 worshippers.
Score Change: The score declined from 4 to 3 because Islamist militants operating in the north and east carried out direct attacks on religious leaders, worshippers, and ceremonies as well as on individuals wearing Christian paraphernalia.
D3 0-4 pts
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Is there academic freedom, and is the educational system free from extensive political indoctrination? 3 / 4
Academic freedom is unrestricted, though due to the former regime’s repressive tactics against student-led protests, a legacy of tension between the government and academic organizations persists. Islamic militant groups in the north have threatened teachers in an effort to force them to adopt Islamic teachings, resulting in the closure of schools.
D4 0-4 pts
Are individuals free to express their personal views on political or other 3 sensitive topics without fear of surveillance or retribution? / 4
Private discussion is unrestricted in much of the country. However, attacks and intimidation by militant Islamic groups in the north and east, an increased security presence in response to their activities, and the June 2019 penal code revisions have dissuaded people from speaking about local news, politics, and other sensitive topics. E. Associational and Organizational Rights
E1 0-4 pts
Is there freedom of assembly? 3 / 4
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The constitution guarantees freedom of assembly, which is sometimes upheld in practice. Under the new government, space for demonstrations and protests has opened. However, some demonstrations were banned by government authorities who cited security concerns or were forcibly dispersed in 2019. In late August, trade unions organized nationwide rallies to criticize the country’s economic and security troubles; however, their mid-September rally in Ouagadougou was interrupted by police, which used tear gas to disperse 2,000 protesters. In October, the Ouagadougou City Council banned a march planned by the Burkinabé Movement for Human and Peoples’ Rights (MBDHP), a local NGO.
In July 2019, the parliament extended a state of emergency that was originally declared in 14 provinces in 2018. The state of emergency, which will expire in 2020, allows the government to restrict the freedom of assembly.
E2 0-4 pts
Is there freedom for nongovernmental organizations, particularly those 2 that are engaged in human rights– and governance-related work? / 4
While many NGOs operate openly and freely, human rights groups have reported abuses by security forces in the past. NGOs still face harassment in carrying out their work, and NGO leaders argue that some legal provisions, including vaguely worded terrorism laws, are vulnerable to being misused to silence human rights defenders. In December 2019, police detained Kémi Séba, president of NGO Pan-African Emergencies, after he criticized President Kaboré and other African heads of state. Séba was convicted of “contempt of the head of state” and given a suspended prison sentence.
NGO members and activists also risk punishment under the June 2019 penal code revisions. In November 2019, activist Naïm Touré was arrested for
https://freedomhouse.org/country/burkina-faso/freedom-world/2020 11/18 12/10/2020 Burkina Faso | Freedom House
“attempted demoralization” of the defense and security forces, but was ultimately released without charge.
Burkina Faso’s insecurity has impacted the ability of NGOs to work freely, with aid workers losing access to large parts of the country due to pervasive violence. NGO workers themselves are at risk of violence; in May 2019, two Democratic Youth Organization (ODJ) activists were killed while traveling to meet a government official in the northern province of Yagha. The ODJ claimed that the government refused to autopsy the victims in November.
Score Change: The score declined from 3 to 2 because increasing insecurity has prevented NGOs from operating in conflict-affected areas.
E3 0-4 pts
Is there freedom for trade unions and similar professional or labor 3 organizations? / 4
The constitution guarantees the right to strike. Unions frequently and freely engage in strikes and collective bargaining, and coordinate with civil society to organize demonstrations on social issues. However, the government has used legal means to suppress union activity, including the denial of permits for planned demonstrations.
In June 2019, the National Police Alliance (APN) denounced the government’s refusal to extend legal recognition in spite of a court order. F. Rule of Law
F1 0-4 pts
Is there an independent judiciary?
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2 / 4
The judiciary is formally independent but has historically been subject to executive influence and corruption. In 2018, a highly anticipated military trial of 84 people accused of involvement in the 2015 coup commenced. Some analysts have questioned whether the accused could receive a fair trial, since the members of the military tribunal ruling on the case are appointed by the Defense Ministry and the president.
Despite these concerns, at least 10 people were convicted by the tribunal in Septembner 2019. Generals Gilbert Diendéré and Djibrill Bassolé, the coup plotters, received 20-year and 10-year prison terms respectively. Fatoumata Diendéré, Gilbert Diendéré’s wife, received a 30-year sentence in absentia for her involvement in the plot. A group of soldiers who participated by arresting government officials during the coup were also convicted, receiving 15– to 19- year sentences.
F2 0-4 pts
Does due process prevail in civil and criminal matters? 2 / 4
Constitutional guarantees of due process are undermined by corruption and inefficacy of the judiciary and police force. In April and May 2019, lawyers organized protests against judicial inefficiency and the denial of legal rights for detainees.
The military has been accused of arbitrarily detaining large groups of men in the vicinity of attacks by Islamic militants. While most detainees are released in a matter of days, some are held for months or are summarily executed. In
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March 2019, the MBDHP reported that at least 60 people were executed by soldiers carrying out a counterterrorism operation in February.
F3 0-4 pts
Is there protection from the illegitimate use of physical force and 0 freedom from war and insurgencies? / 4
The security environment has declined in recent years due to activity by Islamic militant groups, bandits, and militias. Traditional leaders, government officials, lawmakers, and civilians are regularly targeted for assassination by Islamic militants. In November 2019, militants attacked a mining convoy, killing at least 37 people and wounding another 60; the attack prompted President Kaboré to announce plans to recruit volunteers to collaborate with security services. In some areas, armed operate with sufficient strength to attack military outposts. In late December, two armed groups attacked a military detachment and civilians living in the northern town of Arbinda; while the military repelled the attack, at least 7 soldiers and 35 civilians were killed.
Islamist militants have made multiple incursions into rural towns during 2019, often issuing ultimatums for their residents to leave; this prompted large movements of civilians to urban centers in the north. More than 560,000 Burkinabè were internally displaced at year’s end.
The January 2019 killing of the village chief of Yirgou sparked communal clashes between members of the Fulani and Mossi ethnic communities. A series of reprisal attacks, partly organized by the Koglwéogo militia group, against Fulani left approximately 50 people dead by April according to the government; local civil society groups reported that as many as 200 were killed. In August, two Koglwéogo chiefs and five other individuals were arrested for their role in the violence.
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In some cases, security forces have engaged in extrajudicial killings and torture, particularly against Fulani. In August 2019, the defense and security services reportedly executed 17 Fulani civilians, collaborating with the Koglwéogo to identify targets. Victims and civil society complain that authorities have failed to investigate human rights abuses perpetrated by security forces.
Allegations of torture and abuse of suspects in custody by the police are common, and prison conditions are poor.
Score Change: The score declined from 1 to 0 due to acute and widespread violence perpetrated by Islamist militants, as well as continued extrajudicial responses by the government.
F4 0-4 pts
Do laws, policies, and practices guarantee equal treatment of various 2 segments of the population? / 4
Discrimination against ethnic minorities occurs, but is not widespread. LGBT+ people, as well as those living with HIV, routinely experience discrimination. While illegal, gender discrimination remains common in employment and education. G. Personal Autonomy and Individual Rights
G1 0-4 pts
Do individuals enjoy freedom of movement, including the ability to change their place of residence, employment, or education? 2 / 4
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Due to insecurity, the government has established a number of heavily guarded checkpoints on roads, and has instituted curfews and states of emergency in some provinces. Schools are a common target of armed groups, with Islamist militants targeting schools that operate in French instead of Arabic.
G2 0-4 pts
Are individuals able to exercise the right to own property and establish private businesses without undue interference from state or nonstate 2 actors? / 4
In recent years, the government has implemented reforms to reduce the amount of capital necessary to start a business, facilitating the ability to obtain credit information, and improving the insolvency resolution process. However, the business environment is hampered by corruption.
G3 0-4 pts
Do individuals enjoy personal social freedoms, including choice of marriage partner and size of family, protection from domestic violence, 2 and control over appearance? / 4
Women face discrimination in cases involving family rights and inheritance. Early marriage remains an issue, especially in the north. The practice of female genital mutilation is less common than in the past, but still occurs. Domestic violence remains a problem despite government efforts to combat it.
G4 0-4 pts
Do individuals enjoy equality of opportunity and freedom from 2 economic exploitation? / 4
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Burkina Faso is a source, transit, and destination country for human trafficking. Child labor is present in the agricultural and mining sectors. Women from neighboring countries are recruited by traffickers and transported to Burkina Faso, where they are forced into prostitution.
According to the US Department of State’s 2019 Trafficking in Persons Report, Burkina Faso has worked to combat human trafficking through expanded efforts to convict perpetrators and protect victims of trafficking. However, the country fell short in key areas, including comprehensive data reporting and the identification and referral of adult victims.
On Burkina Faso See all data, scores & information on this country or territory. See More
Country Facts
Global Freedom Score 56 /100 Partly Free
Other Years
2019
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https://freedomhouse.org/country/burkina-faso/freedom-world/2020 18/18
TAB 9 RAPPORT RÉGIONAL SUR LA PÉNALISATION DU VIH AFRIQUE FRANCOPHONE
REGIONAL HIV CRIMINALISATION REPORT FRANCOPHONE AFRICA
Produit par / produced by
Soutien financier du / Pour / on behalf of supported by a grant from La pénalisation du VIH en Afrique francophone : état des lieux
HIV criminalisation in Francophone Africa : state of play (English summary only)
Stéphanie Claivaz-Loranger et Cécile Kazatchkine pour le Réseau juridique canadien VIH/sida et HIV JUSTICE WORLDWIDE
Novembre 2017
1 La pénalisation du VIH en Afrique francophone : état des lieux, 2017 Table des matières Introduction ...... 3 Sommaire des résultats ...... 7 Algérie...... 9 Bénin...... 10 Burkina Faso………………………………………………………………………………………………………………………………………….12 Burundi………………………………………………………………………………………………………………………………………………….16 Cameroun………………………………………………………………………………………………………………………………………………18 Comores……………………………………………………………………………………………………………………………………..…………20 Congo...... 21 Cote d'Ivoire……………………………………………………………………………………………………………………………………….…23 Djibouti…………………………………………………………………………………………………………………………………………….……25
Gabon ...... 26 Guinée (Conakry)...... 27 Guinée équatoriale...... 29 La Réunion ...... 30 Madagascar ...... 31 Mali…………………………………………………………………………………………………………………………………………………….…33 Maroc ...... 35 Maurice...... 37 Mauritanie...... 38 Mayotte…………………………………………………………………………………………………………………………………………………40 Niger ...... 41 République centrafricaine ...... 44 République démocratique du Congo……………………………………………………………………………………………………..46 Rwanda...... 50 Seychelles ...... 51 Sénégal ...... 52 Tchad ...... 55 Togo………………………………………………………………………………………………………………………………………………………57 Tunisie ...... 59 Liste de ressources sur la pénalisation du VIH et ses conséquences……………………………………….………… …61
Erratum Novembre 2018…………………………………………………………………………………………………………… …..62
English summary………………… ……………………………………………………………………………………………… ……….63
2 La pénalisation du VIH en Afrique francophone : état des lieux, 2017 English summary
The Law
HIV-Specific Laws 18 African countries where French is spoken have HIV-specific laws. 16 HIV-specific laws criminalize HIV transmission or exposure (only the HIV-specific laws of Comoros and Mauritius contain no criminal provisions in this respect).
In many cases, criminal provisions set out in national laws have been modeled on the N'Djamena Model Law. The N'Djamena Model Law was developed as part of a workshop organized in 2004 by Action for West Africa Region- HIV/AIDS (AWARE-HIV/AIDS). The model and the resulting national laws have been heavily criticized for their provisions penalizing HIV. These provisions ran counter to international recommendations that urge states to limit criminal law to cases of intentional HIV transmission. They are often extremely vague and potentially very wide in scope. In some countries, these criticisms have made it possible to amend the laws (Togo, Guinea, Niger). In others, they have led to the adoption of more restrictive HIV laws (Senegal, Côte d'Ivoire, Congo) or the abandonment of specific legislative bill penalizing HIV (Cameroon, Gabon).
The most common offense is that of voluntary, deliberate or intentional transmission (8 of the 16 specific laws penalizing HIV transmission and exposure provide for such an offense). However, the term “voluntary” is not always clearly defined and sometimes there is not much evidence that there must indeed be a deliberate intention to transmit HIV for the offense to be grounded. Lastly, the notion of “transmission” of the term “voluntary transmission” is also sometimes confusing, because it may, depending on the way in which it is defined in the legal texts, also include the only exposure to HIV (e.g. order amending the HIV law in Guinea). Other offenses include having unprotected sex, not informing a sexual partner of his or her HIV status, or transmitting HIV by negligence.
Some laws explicitly provide for grounds that exclude criminal responsibility in certain circumstances (5 out of 16). Congolese law is the one that excludes criminal responsibility in the greatest number of circumstances, in the following cases: mother-to-child transmission, no significant risk of transmission, HIV-positive partner is unaware of his or her HIV status, safe sex, disclosure of HIV status, HIV-negative sexual partner knows the status of the HIV-positive partner and non-disclosure for fear of reprisals. Other countries whose laws explicitly exclude criminal responsibility in certain circumstances are Côte d'Ivoire, Niger, Senegal and Togo.
Other applicable laws
HIV can also be directly or indirectly penalized by other legislation in a country. For example, some laws have provisions penalizing the transmission of “contagious diseases” that may be applicable to HIV (Democratic Republic of the Congo, Tunisia). Others focus specifically on HIV but are provided for in laws on sexual violence, child protection, reproductive health or in the Criminal Code (Democratic Republic of the Congo, Burkina Faso, Niger, Central African Republic). In some countries, the general provisions of the Criminal Code have been used against people living with HIV (Morocco, Congo).
63 La pénalisation du VIH en Afrique francophone : état des lieux, 2017 Prosecution We have been informed of prosecutions for sexual exposure or transmission of HIV (including cases that have been discontinued or settled outside of the courts) in 11 countries – Benin, Burkina Faso, Cameroon, Congo, Morocco, Mauritania, Niger, Central African Republic, Democratic Republic of the Congo, Togo and Tunisia.
We have filed proceedings that have resulted in a court decision in at least 5 countries: Cameroon, Congo, Morocco, Niger and the Democratic Republic of the Congo.
The number of proceedings remains thus limited. However, it is important to treat this information with care. It is very difficult to access case law and to know how many people have been charged or prosecuted for HIV exposure or transmission. Furthermore, we found that the criminalization of HIV is of concern to all respondents who are worried that specific HIV laws can be used against people living with HIV. Some cases of prosecution threats have been identified.
Prosecution took place under HIV-specific laws but also under general provisions of the Criminal Code or other applicable laws.
In at least four cases that resulted in a court decision, the accused was a woman (Cameroon, Morocco, Niger, Democratic Republic of the Congo). In one of those cases, the accused was a sex worker who turned out to be seronegative (Cameroon).
Mobilization The level of civil society mobilization against the criminalization of HIV varies from country to country, even though we noted a great interest from all respondents for this issue. In some countries, civil society actors are actively and collectively mobilizing (advocacy calling for legislative reforms, monitoring of prosecutions, training of judicial or police actors, etc.); in others, the mobilization is rather ad hoc or less structured. Legislative reform efforts are currently underway in Niger, the Democratic Republic of the Congo and the Central African Republic.
64 La pénalisation du VIH en Afrique francophone : état des lieux, 2017 Cette publication contient des renseignements d’ordre général. Elle ne constitue pas un avis juridique et ne devrait pas être considérée comme telle.
This publication contains general information. It does not constitute legal advice and should not be considered as such.
2017
65 La pénalisation du VIH en Afrique francophone : état des lieux, 2017
TAB 10 Original Article
Journal of the International Association of Providers of AIDS Care Volume 18: 1-8 Aging in the Context of HIV/AIDS: Spaces ª The Author(s) 2019 Article reuse guidelines: for Renegotiation and Recomposition sagepub.com/journals-permissions DOI: 10.1177/2325958219881402 of Mutual Solidarity in Burkina Faso journals.sagepub.com/home/jia
Ramatou Ouedraogo, PhD1, Anne Attane´, PhD2, and Razak M Gyasi, PhD1
Abstract Purpose: The HIV-infected older people in sub-Saharan Africa are inevitably vulnerable to chronic health-related conditions, yet the needed social support for these people is mostly inadequate. Drawing on the anthropology of disease and health paradigms, this study explores the recomposition of multidimensional and multidirectional nature of mutual familial support for older people living with or affected by HIV/AIDS in Burkina Faso. Methods: We conducted multiple in-depth interviews among 147 individuals recruited from nonprofit organizations in Ouagadougou, Bobo-Dioulasso, Ouahigouya, and Yako through 2 projects funded by the National Agency for AIDS Research. Thematic and narrative analytical frameworks were used to analyze the data. Results: We found that older people suffered serious socioeconomic and psychological challenges associated with HIV/AIDS. Older people were particularly vulnerable to the double burden of HIV/AIDS and caregiving responsibility for family members infected with the disease. However, the infected older people who received adequate treatment and familial support regained sociocultural positions as agents for cultural transition and material/emotional resources. Conclusions: Although HIV/AIDS potentially renegotiated the nature, intensity, and direction of familial support for vulnerable older people, the extrafamily solidarity seems an integral part of the great cycle of reciprocity and intrafamily mutual support. Health and policy interventions targeted at strengthening the interpersonal relationships and support for HIV/AIDS-infected and HIV/AIDS- affected older people are needed to improve their independence and well-being.
Keywords aging, HIV/AIDS, familial social support, older people, Burkina Faso
Date received: 20 May 2019; revised: 16 September 2019; accepted: 17 September 2019.
Introduction belonging, but it also shows a relationship, social networks, and discontinuous segments which may illustrate an elective link Recalling the social revealing nature of HIV/AIDS pandemic between kin, leading to an “ego-centered kinship.”8 This is remains a commonplace in low- and middle-income countries particularly true in the context of demographic aging and its (LMICs). Over the past 30 years, research on HIV, both the concomitant multiple health challenges, including HIV/ infected and affected individuals, has shown serious effects, AIDS.1,9 Therefore, the analysis of the recomposition of intra- such as widespread socioeconomic challenges including pov- family solidarity among PLHIV in Burkina Faso may highlight erty, stigma, and social isolation.1 From anthropology of dis- the elective nature of intrafamily solidarity. However, limited ease, health, and policy (note 1) to the analysis of interpersonal relationships, the understanding of the social situations associ- 2-6 ated with HIV/AIDS has yielded stimulating insights. Fur- 1 African Population and Health Research Center (APHRC), Nairobi, Kenya ther, the HIV/AIDS pandemic reveals patterns of practical 2 Institut de Recherche pour le Developpement (IRD)/LPED, Marseille, France kinship.7,8 The effective family ties existing between persons living Corresponding Author: with HIV (PLHIV) may shed light on mechanisms that are Razak M Gyasi, Aging and Development Unit, African Population and Health Research Center (APHRC), Manga Close, Off-Kirawa Road, PO Box 10787- likely to strengthen or weaken a bond between close relatives. 00100, Nairobi, Kenya. 7 Weber noted that kinship is not only a recognized or claimed Emails: [email protected], [email protected]
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 Journal of the International Association of Providers of AIDS Care
women in terms of social and medical management of the What Do We Already Know about This Topic? disease. It is, therefore, important to understand gender dimen- sions in HIV/AIDS. The specifics of our methods contextua- Clinical and social science research has shown that the lized the modalities of data collection and allow a discussion on prevalence and disparaging effect of HIV/AIDS among the the evolution of the epidemiological context and the changes in general and older populations are high in sub-Saharan case management that we have witnessed during fieldwork, and Africa. to date. The situations described provide elucidation in changes in mutual support, which are closely linked to the status granted How Does Your Research Contribute to the to older people. Differences in harm based on the gender and Field? socioeconomic situations may shed light on what it means to grow older in the context of PLHIV or offering care for an Although HIV/AIDS potentially changed the direction and infected relative. intensity of familial support for older adults, the extrafam- ily solidarity seems to be an integral part of the great cycle of reciprocity and intrafamily mutual support. Methods What Are Your Research’s Implications toward A Collective Research: An Interpersonal Approach Theory, Practice, or Policy? Multiple qualitative interviews were conducted between 2006 We argue for policies and practices to strengthen interper- and 2010 as part of two National Agency for AIDS Research sonal relations and social support for HIV/AIDS-infected (ANRS) projects (note 2). The study involved 147 people in and affected older adults to ensure their independence and Ouagadougou, Bobo-Dioulasso, Ouahigouya, and Yako. The quality of life. participants included 111 women and 36 men living with HIV/AIDS in seven support and health-care nonprofit organi- zation (note 3). Seven of them were close relatives of people with HIV and eight couples. Indeed, the inclusion of different research has evaluated the nature and direction of familial sup- categories of participants in our analysis provided the opportu- port for older people living with or affected by HIV/AIDS in nity to capture a comprehensive and nuanced picture of the LMICs and how this may affect their health outcomes. lived experiences and the support trajectories for people living In this article, we propose a continuous reflection on the with HIV/AIDS. We did not predetermine the number of recomposition of family mutual support in an LMIC context, women; the respondents were interviewed until reaching focusing on vulnerable older adults to whom social support 10 saturation. For the men, given that those living with HIV/AIDs networks are critical. Studies have analyzed the elective in most cases feel reluctant and fail to attend health facilities for nature of intrafamily relationships and mutual support from the 11-14 support and care compared with their female counter- perspective of generations and population cohorts. This parts,9,20,21 we were able to interview only those present in the has lopsided toward refining scholarly and popular insights 15,16 facilities who consented to participate during the study period. about the sense of mutual aid within African families. Our This justifies the highly biased gender distribution against men. main objective is to continue the debate on the ability of con- The relatives of PLHIV who consented that we meet their temporary West African societies to generate care for vulner- parents, brother, sister, aunt, and so on were also interviewed. able older people through mandatory mutual aid mechanisms. The Bobo-Dioulasso site became one of our survey sites Considering the perspective of older people requires us to only in 2008 as part of the second ANRS program, while we determine when it is possible to qualify and categorize a person continued to visit Ouahigouya and Yako regularly for 4 years as “older” in contemporary West African societies. We define and also carried out surveys on Ouagadougou in parallel. Both older person in this study as those aged to be in an effective or men (aged 25-59) and women (aged 16-68) were interviewed in symbolic position as a grandfather or grandmother but also the nonprofit organizations. Among the participants recruited persons aged 50 years and older who have become inactive at the nonprofit organizations of Ouahigouya, Yako and in a and/or dependent for various reasons, such as retirement and district hospital in Bobo-Dioulasso, hail from villages that are 17 difficulties in performing activities of daily living. It is crit- often several kilometers away. Trusted relationships were ical to highlight the increased vulnerability of older people who established, with a dozen of interviewees and the meetings took live with HIV/AIDS18 and those dwelling in a skipped gener- place multiple times at their homes. By sharing interesting ation households caring for orphans of HIV-related deaths.19 daily moments, we were able to capture their family environ- However, it cannot be assumed that older people are more ment. The data were, therefore, mainly from recorded inter- vulnerable and require support from others.19 views but also from multiple observations and informal Further, it is also important to ascertain gendered dimen- discussions. Two-thirds of the interviews were conducted in sions in growing older, particularly among PLHIV. Moreover, local languages Moore or Dioula and one-third in French. it seems that marital status, specifically conjugal relationships, Four-fifths of the interviewees were Mossi and the others were largely determines the relative fragility of both men and in Gourmantche, Samo, or from the West (mainly Bobo). The Ouedraogo et al 3 interviews were transcribed and back-translated to English to women. Historically, although males were first affected by the ensure consistency. All our interviewees were anonymized disease, females are now easily and more likely to be infected with pseudonyms names in order to ensure strict confidentiality due to their unique biological, behavioral, and physiological of information. vulnerabilities to HIV infection risks, as well as their responses The succession of these 2 research programs has allowed the to therapeutic interventions.9 The transformation occurring in monitoring of changes in life trajectories over 4 years. A large forms of marriage also makes the practices aimed at caring for part of the interviews took place within the nonprofit organi- widows increasingly rare, especially that of the levirate.22 zations, sometimes in pairs or individually. The interview was More women are then obliged to be self-supporting, especially conducted—as much as possible—to get closer to an informal if they were not close to their children. discussion; we first asked very general questions about the time Koudbi was a 68-year-old widow when we meet her in 2007 of the seropositivity diagnosis, the therapeutic pathways, and with her HIV-positive daughter Awa, a 38-year-old widow. the different conditions for medical care. Then, the questions Koudbi seemed very old, she could hardly move and had focused on family life, relationships with children, spouse(s), almost lost her sight. We thought she had reached her 80th year parents, and stepparents, but also with uncles and aunts. The before she gave us her age during the interview. She also dis- key rationale guiding our interviews was to find out who pro- closed how her daughter’s infection with the “bad disease” vided support in terms of financial, time, services, labor, emo- became a major source of her sorrow. Indeed, she believed that tional, and psychological and what were the impact of the the disease resulted from sexual intercourse between females disease’s diagnosis on their living conditions, such as inability and dogs. Witnessing the signs of illness has been a source of to work, increased dependence, and increased vulnerability. sadness and despair for her and had this to say: The material thus collected was rich in the economic (period of inactivity, bankruptcy, change of professional activity, etc), Anytime I go to bed at night, I think deeply about my daughter’s marital (separation, widowhood, etc), and family (birth, death, sad situation ...she’s the only one I’ve. When she started com- etc) events that marked the person’s life before and after the plaining of headaches, I tied her head tightly with loincloth and she diagnosis of his or her infection. It provided a broad description kept saying, ‘Mom, my head is knocking’ and I consoled her that of the relationships that participants enjoyed with their she’ll be fine ...This persisted and I couldn’t sleep for five relatives. days ...I became despaired and shed tears too as her situation The analyses in this article are based entirely on this mate- worsened per each day. rial. In particular, the data collection aimed to highlight the The cries and the burden of managing her daughter’s issue of dependency of the vulnerable and to allow us to see illness largely contributed to the pace of her aging and she under which conditions family ties can provide an insurance explains that function for individuals. The transcripts and field notes were analyzed using thematic analysis approach. We first identified Because of the cries, today I’m not able to see properly from the key themes in the transcripts and fields notes and high- afar ...I don’t see when things are not very close to me. lighted crosscutting themes with specific color. We then ana- lyzed these themes and discussed them with related literature. Koudbi felt that looking at her age, her daughter should have been caring and supporting her, but due to the illness, she had Ethical Approval and Informed Consent no choice than to continue a role of a mother not only to her In line with the Declaration of Helsinki, ethical issues were daughter but also to her 2 grandchildren with her challenges of addressed before the fieldwork. The two research programs growing older. received ethics approval from the Burkina Faso Ethics and ...but what would I do? Do I abandon my daughter and her kids? I Health Research Committee, Ouagadougou (reference nos. had to be with them, care, comfort and support them ...I normally 2006-035 and 2008-042). Study participants gave written go to the mill, gather the unwanted flour from the ground and informed consent, which was either signed or thumbprinted prepare to (note 4) for them. I also prepare peanut doughnuts for (based on the choice of the participant and their literacy levels), sale and the little money I make is used to buy medicine for my after briefing them on the research aims, procedures, and the daughter. voluntary nature of their participation. Koudbi points out the lack of family support making it difficult for her to seek help, as she is a widow, illiterate, and Results and Discussion does not have regular/sustainable sources of income. She does not benefit from a strong extrafamilial social network. Her A Differential Vulnerability to HIV/AIDS daughter was also a widow, but they failed to divulge her There is a clear gendered dimension of HIV infections, on the relationship with her family-in-law. We rather observed that one hand, and being confronted with the pandemic of a relative most of the widows whose husbands died of HIV/AIDS during grandparenthood, on the other hand. First, the disease received any support from their former parents-in-law, despite may increase the widowhood propensities among older the view that they have children. Very often, the deceased’s 4 Journal of the International Association of Providers of AIDS Care parents blame the wife of the illness and death of their son. The best. This was possible because his economic and social posi- burden of Koudbi’s moral, emotional, and financial responsi- tion allowed him to meet people with a high level of social and bilities is such that she felt very exhausted. intellectual capital. However, with the help of community-based organizations, The third case is that of Sidbenewende, a 59-year-old man her daughter was being recovered and the mechanism of and a father of 6 children who lived with HIV infection. mutual aid in the family has been restored to a direction con- Sidbenewende was married and seriously marginalized in his sidered more usual. Awa, while recovering, became one of the family. This was as a result of his poor health condition and counselors of her association. This job was a source of income also the loss of his financial power. He lived in Coˆte d’Ivoire and support for the family. It is important to point out the key for 20 years where his job allowed him to provide support for role of access to treatment in this change. Between 2006 and his wife and children. His illness obliged him to go back to 2015, the number of people accessing antiretroviral therapies Burkina Faso and become inactive, and in fact, to depend on his (ARTs) treatment in Burkina Faso increased significantly. family. Sidbenewende explained that Throughout our research from 2006 to 2010, we have already witnessed a double progression. First, an increase in the num- I was in great shape before and worked very well in Coˆte d’Ivoire. I ber of PLHIV receiving treatment, even in rural areas: 12 842 asked my wife and children to return to Yako, Burkina Faso due to people on ARTs in 2006, 31 543 in 2010, and 65 000 in 2016.23 civil resurgence of war ... Second, a significant decrease in the cost of treatment: from 15 000 CFA francs per month to 5000 CFA and then to free But weakened by illness, he was forced to return to Burkina ARTs, but this does not apply to biological tests. As a result, Faso to live in a family compound. Too weak to work, Sidbe- the people we met and whose treatment trajectories and newende lost his financial autonomy while his wife acquired testimonies are described had, in most cases, just been given one by selling cooked meals. During the first moments, he treatment. Several of them, such as Awa, were dying or in a received help from his relatives, especially his wife as he particularly critical health condition before they were given recounted, treatment. Some of them consider themselves to be real mir- aculous, such as Halimata, 55 years old, met in Yako and living When I came back here with my illness, at least at the beginning, in a village about 10 km away, tells us: my wife really took good care of me because, ah, she too was eating, she was taking advantage of my situation when I was work- ing and since it had become like that, she couldn’t let me down. Usually I used to cultivate my farm with my two 7 and 11 year old girls and the season that just ended (rainy season 2007) I couldn’t When his wife saw his condition deteriorating, she encour- cultivate, I was too weak, my children worked alone on the farm aged him with heartwarming words to go for an HIV test, and I told them to save the money they had from part of the ground- which turned out to be positive. Sidbenewende decided to nuts harvest for my funeral (laughs). And now I’m here, like this inform his wife and children immediately. even in good condition (Halimata speaks in a collective interview with about fifteen women within the Solvie Association, March When I went home, I gathered all my children and my wife and 2008). disclosed my HIV status. To my surprise, they encouraged me, and pledged their utmost support. Indeed, access to care from the organizations significantly 24 improved the conditions of people living with HIV/AIDS. Despite their promise, resentment and bitterness gradually For instance, it helped to reduce the economic burden of pro- emerged. Sidbenewende’s wife accused him of the disease and viding care for the patient for his or her family and friends, such that she felt betrayed. Sidbenewende denied the accusations of as in the case of Awa. unfaithfulness as he bitterly explained, Oumar situation is quite different. This 65-year-old man holds a position in the National Police in Ouagadougou and I told my wife that I can assure her that I did not contact the disease was looking for information about efficient HIV/AIDS care. from another woman, but she didn’t believe anything I said ...that His only daughter, a 21-year-old and youngest of 4 siblings, has use of razor blades might have caused this mess. just learned of her HIV-positive status. He desperately mobi- lized his social network, through common French friends, Sidbenewende’s wife apparently rejected him. Considering anthropologists who worked in his region of origin, he heard the issue of secrecy and confidentiality fosters an understand- about our work and asked to meet us in order to have informa- ing of the patient’s relationships with those around them.5,25 tion on the most effective routes to get the best possible care. We observed that the announcement of the HIV/AIDS infec- Oumar saw his daughter as a victim of HIV because of the tion can change the scope of the support or its direction, but not inconsistency of a man older than her and he does not consider necessarily. The responsibility attributed to the sick person, or her responsible in any way for what she was going through. He conversely the fact of considering him a victim, largely deter- was especially distressed by his daughter’s infection because mines the help within the couple and in the family. The exam- he felt that he has not sufficiently protected her from this kind ple, the case of Sidbenewende illustrates that because of the of risk. In this case, mutual aid from outside the family is at its long separation from the children, they were much more Ouedraogo et al 5 attached to their mother and seemed to support the father’s households are in many cases the only ones who are aware of rejection. their children’s HIV status, as well as parents with several children being HIV positive. The matrimonial context is crucial They put me aside and provided me separate eating bowls and for women. This largely determines the level of vulnerability to drinking cups ...they never shared same utensils with me ... illness and its medical and social treatment. The case of Sidbenewende illustrates how power dynamics Sidbenewende started receiving ARTs in 2006, but his can be renegotiated or recomposed between seniors and cadets exclusion from his family has affected him greatly. We in an HIV situation. Thus, the person holding the financial observed the deterioration of his physical condition, such as resources seems to benefit from the roles usually attributed to progressive loss of sight, difficulty in moving around, and the social elderly individuals. This is expressed, for instance, in social condition during our meetings between 2006 and 2008. the decision-making process and in the assistance provided to The extrafamilial support Sidbenewende can rely upon was others. These mechanisms lead to high vulnerability, because extremely limited, because during the past 20 years, he had those who can no longer participate in the reciprocal exchange been living far away from home. The only support available of donations/services risk being socially marginalized.15 How- to him was provided by nonprofit organization and various ever, without a relationship, there is no social security, no people who benefited from its care. However, Sidbenewende social recognition, and therefore no symbolic capital.15 performed his personal chores such as cooking and washing of his clothes because his relatives feared of the possible contrac- HIV/AIDS as a Catalyst for Changes in the Experience tion of the disease. Unfortunately, Sidbenewende’s condition deteriorated beyond measure and died in 2009 without being of Being Old and Social Elder able to find comfort from his wife and children. Our study demonstrated the contributing factor of HIV/AIDS in Thus, HIV/AIDS can become a factor in aging. Opportunis- changes in the conception and experiences of being old and tic infections and moral burden foster the early onset of signs of social elder in Burkina Faso and contemporary societies in aging in people older than 50 years who live with and affected general. Old age and the attribute of older persons are socially by HIV. As seen in Sidbenewende and Koudbi (and also in constructed notions that take into account both external mar- seven other older people who lived with HIV in our analysis), kers related to sociocultural context and internal markers, per- HIV has contributed to the development of aging signs such as taining to personal experiences.27 Indeed, aging in general is reduced or lost vision, as well as difficulties in moving around. synonymous with new social roles and their conceptions may This seriously increased their vulnerability and predicaments. vary depending on the context of aging. Ellen Corin in the case HIV infection can also lead to a reversal of the direction of of Canada has demonstrated that old age is synonymous with a assistance, as older people may find themselves caring for their change in roles and expectations of the community but is most children, siblings, or grandchildren who are living with the often seen in terms of physiological, psychological, and social disease at an age when the mutual aid mechanism would have loss.27 In the context of Burkina Faso and in the broader context intended people affected by the disease to be the main support- of West African societies, the transition to old age, even if it is ers of older adults.26 associated with loss, particularly on the physical and economic The situations of Koudbi and Sidbenewende reflect a major level is expected to be combined with social or “gray” change, “the conditionality of being.” The economic and social power.28,29 Indeed, within the relationship between elders and status of an individual, and also his or her health status, largely cadets, the former occupy the role of social elders, and as such, determines all the intrafamily relations that he or she has with they are granted a range of powers and privileges at the social, the family. The older person infected with HIV may be rejected symbolic, and normally economic level.28,30 For men, for by relatives, which is often expressed through sharing of sup- instance, seniority, according to Pochet,31 “is doubly valued port and care particularly in performing household chore. socially through the father/son hierarchy and through the posi- Sometimes, the refusal of mutual support between relatives has tion within the siblings, particularly by the opposition between serious material consequences. The rejection is such that it elders/cadets.” Seniority in the family is synonymous with undermines the material conditions of existence of the HIV- authority, wisdom, and knowledge. Seniors can also have a positive person, as the case of Sidbenewende. great deal of decision-making power. They are consulted for Notwithstanding, we met older people whose HIV status has decision-making and educational, moral, and even strictly phi- helped to increase or initiate help. For instance, a 58-year-old losophical values are attributed to their words. The advice they woman, Valentine received support from her children when her are able to provide is generally conceived to contain wisdom husband left her for a younger woman about 15 years. She saw because aging is perceived as a reflection of their experience of this support increase when she became sick and was diagnosis anteriority.32 With the representation of a potential symbolic HIV positive. The vulnerability introduced by HIV is gender- power among older people, older persons are generally expect specific. For example, men who are sometimes ascertain their the younger generation to provide for their needs especially HIV-positive status avoid health facilities for fear of shame and when retired from economic activities and also embattled with stigmatization.20,21 Also, women who are often widowed and ill-health including HIV/AIDS.31 However, the general living who are facing rejection by their husband’s family; heads of conditions of older people are subject to social transformation 6 Journal of the International Association of Providers of AIDS Care and are therefore likely to change over time.31,33-35 It is impor- seems to govern exchanges between generations.15 The pay- tant to recall that if aging still inspires respect in West African ment of this debt is presented by the norm as a social obliga- societies, the gerontocratic organization of society is no longer tion. Marie explains “Debt is therefore the driving force behind appropriate because the oldest people in these societies expe- sociality and community socialization”. The study participants rience too disparate social and economic situations as described duly acknowledged these evidences over 20 years later. No one in this study. In previous research, the analysis of changes in escapes it and everyone maintains the limitless cycle because matrimonial choices has shed light on the main changes in everyone starts by being a debtor, before being able to claim the seniority and elder relationships from both male and female status of a creditor. However, when analyzed from this per- 36 perspectives. Finally, some of the oldest men and women spective, debt is a social investment, an investment on depen- simply have very little authority, both over the younger gen- dents, which is very rational in societies where people are the erations and over their younger siblings because they are in main source of wealth and the only guarantee of social protec- such a situation of economic and sometimes social deprivation tion against the hazards of life, as well as insurance for the that they can only helplessly witness the difficulties their chil- future (Marie, 2009). However, the deterioration of economic dren are facing. This is particularly the case for those among living conditions challenges this generational contract and the poorest segments of the population who are battling with sometimes leads to its reversal.15,41,42 HIV/AIDS, such as Sidbenewende. Older people occupy a position at the articulation of differ- With socioeconomic transformations, particularly the ent social networks, such as village, professional, neighbor- extreme impoverishment and the emergence of a number of hood, and confessional networks. They maintain important chronic diseases, aging constitutes an increasingly less auto- ties with people in their age group, often have lasting ties with matic access to a valued social position. Indeed, in some Afri- people in the neighborhood and their position as social elders. can socioeconomic and relational contexts, this position of This potentially allows extended family members to access older people may be increasingly synonymous with vulnerabil- their social services at least in an advisory role. Their simple ity expressed through economic precariousness, exclusion, age-related prior experience gives them an experience of the abuse, and suffering.29,34,37 In the context of HIV/AIDS, social bond, which exists through various social networks. This “being older” implies many realities and can lead to a reversal makes older adults potentially privileged groups in these in the roles and social relationships prior to the disease. The mutual networks, as illustrated by the case of Omar. experiences from older men and women living with HIV/AIDS Our study revealed that intrafamily assistance is simultane- illustrate how the disease intensifies existing disparities ously elective, multidimensional, and multidirectional due to between older people. This conforms to the concept of differ- the view that member of the family across generations provided ential aging in the context of HIV/AIDS. help to each other in times of need. Also, mutual support that took the form of monetary donations attention and caregiving Pathways and Recomposition of Mutual Support roles were abound within the social networks. This allowed with HIV/AIDS children and young adults to offer the needed support to their 19,43 This study has also revealed the recomposition of support older parents. He´joaka observed how children contribute in within family affected by HIV/AIDS. Indeed, at the heart of reminding their parents to take medication and help performing the issue of HIV/AIDS in terms of experience and care for both a number of domestic tasks including the sales of items in young and old, the data show that the former can occupy pivo- certain cases to support older parents. The provision of emo- tal positions in social networks because they are more easily, tional, moral, and financial support to parents living with HIV/ by the simple fact of their seniority and more durably AIDS was also observed. Mutual aid also appeared multidirec- embedded in social ties. This position makes older men and tional as it was 2-way affair between the younger and older women—the potential captors of the donation and counter- generations and also between gender subgroups. As demon- donation systems that govern part of social relations in a rela- strated by extent literature, these circumstances have a practical tively conspicuous way in West African societies. implications for economic, emotional, relational, and health In the sub-Saharan African context, social norms remind conditions of the frail older adults battling with HIV/ 1,44,45 everyone of their obligations to provide support and care for AIDS. People living with HIV generally show a phenom- close relatives. Assistance, including remittances of monetary enon that is usually not very apparent in the considered soci- and other materials in the view of the actors, takes a clear eties: the effective multilaterality and nonsystemic of direction between gender subgroups, generations, and age intrafamily solidarities that are usually obscured by normative cohorts. A body of socioanthropological evidence in this con- prescriptions relating to support obligations for older adults and text also tends to show that intergenerational relations are children. It must be emphasized that the various supports, for marked by the regime of filial piety: the reciprocity of care/ example, financial depended largely on the density of social debt that children incur toward their parents and grandparents network that the person concerned has been embedded during for having been raised by them.14,38-40 As a result, it is a child’s his or her life course. Thus, the life trajectory is essential to social obligation to support their parents when they become understand the type and level of support older persons are older. Roth points out that an “implicit generational contract” likely to receive. This extrafamily assistance is not only subject Ouedraogo et al 7 to unforeseen circumstances but also punctual, even if it can be caregivers and the other to the reconfiguration of family solidarities very important. with people living with HIV, have been carried out together. 3. The nonprofit organizations we have worked with are in Ouaga- Conclusions dougou, the associations AAS and Vie Positive; in Yako, the asso- ciations Semus and Solvie; in Ouahigouya, the associations Living with HIV/AIDS in later life has a debilitating effect AMMIE and Bonnes Mains; and in Bobo-Dioulasso, a person was particularly due to the inevitable vulnerabilities of older peo- met within the association Revþ. We sincerely thank the leaders of ple. The intergenerational social support in terms of resources these associations and the staff for agreeing to welcome and help and care are, therefore, important for their well-being. Indeed, us. Without their assistance, this work could not have been carried intrafamily mutual support and extrafamily solidarity for these out. older people are perceived as deserving filial piety. However, 4. Polenta-style dish made from ground millet, sorghum, or corn. Toˆ for those like Sidbenewende whose infirmity deteriorated the is served with a sauce. socioeconomic and psychological state, nongovernmental organizations were the main recourse. These situations reflect References a major change in the motivations for interpersonal action and 1. Mumin AA, Gyasi RM, Segbefia AY, Forkour D, Ganle JK. The the development of a supportive relationship. 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TAB 11 Grosso et al. BMC Infectious Diseases (2019) 19:208 https://doi.org/10.1186/s12879-019-3693-0
RESEARCH ARTICLE Open Access Development and reliability of metrics to characterize types and sources of stigma among men who have sex with men and female sex workers in Togo and Burkina Faso Ashley L. Grosso1,2*, Sosthenes C. Ketende1, Shauna Stahlman1, Odette Ky-Zerbo3, Henri Gautier Ouedraogo4, Seni Kouanda4, Cesaire Samadoulougou4, Marcel Lougue3, Jules Tchalla5, Simplice Anato6, Sodji Dometo7, Felicity D. Nadedjo7, Vincent Pitche8 and Stefan D. Baral1
Abstract Background: Stigma is a multifaceted concept that potentiates Human Immunodeficiency Virus and sexually transmitted infection acquisition and transmission risks among key populations, including men who have sex with men (MSM) and female sex workers (FSW). Despite extensive stigma literature, limited research has characterized the types and sources of stigma reported by key populations in Sub-Saharan Africa. Methods: This study leveraged data collected from 1356 MSM and 1383 FSW in Togo and Burkina Faso, recruited via respondent-driven sampling. Participants completed a survey instrument including stigma items developed through systematic reviews and synthesis of existing metrics. Using exploratory factor analysis with promax oblique rotation, 16 items were retained in a stigma metric for MSM and 20 in an FSW stigma metric. To assess the measures’ convergent validity, their correlations with expected variables were examined through bivariate logistic regression models. (Continued on next page)
* Correspondence: [email protected]; [email protected] 1Key Populations Program, Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, 5th Floor, Baltimore, MD, USA 2Research and Evaluation Unit, Public Health Solutions, 40 Worth Street, 5th Floor, New York, NY, USA Full list of author information is available at the end of the article
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Grosso et al. BMC Infectious Diseases (2019) 19:208 Page 2 of 17
(Continued from previous page) Results: One factor, experienced stigma, included actions that were carried out by multiple types of perpetrators and included being arrested, verbally harassed, blackmailed, physically abused, tortured, or forced to have sex. Other factors were differentiated by source of stigma including healthcare workers, family and friends, or police. Specifically, stigma from healthcare workers loaded on two factors: experienced healthcare stigma included being denied care, not treated well, or gossiped about by healthcare workers and anticipated healthcare stigma included fear of or avoiding seeking healthcare. Stigma from family and friends included feeling excluded from family gatherings, gossiped about by family, or rejected by friends. Stigma from police included being refused police protection and items related to police confiscation of condoms. The Cronbach’s alpha ranged from 0.71–0.82. Median stigma scores, created for each participant by summing the number of affirmative responses to each stigma item, among MSM were highest in Ouagadougou and among FSW were highest in both Ouagadougou and Bobo-Dioulasso. Validation analyses demonstrated higher stigma was generally significantly associated with suicidal ideation, disclosure of involvement in sex work or same-sex practices, and involvement in organizations for MSM or FSW. Conclusions: Taken together, these data suggest promising reliability and validity of metrics for measuring stigma affecting MSM and FSW in multiple urban centers across West Africa. Keywords: Burkina Faso, Social stigma, Sex workers, HIV, MSM, Sexual minorities, Togo
Background evidence-based HIV prevention, treatment, and care ser- Stigma has been defined as processes of labeling, stereo- vices [14]. Stigma affecting populations with dispropor- typing, separation, status loss, and discrimination of in- tionate HIV burden has consistently been associated dividuals or groups [1]. Some theories include both with negative health outcomes throughout the world. In psychological and social dimensions of stigma but ex- Uganda, experiencing homophobic abuse was positively clude discrimination from the definition [2]. Structural associated with HIV infection among men who have sex conceptualizations of stigma recognize that macro-level with men (MSM) [15]. Occupational stigma among fe- forces also compound marginalization by placing con- male sex workers (FSW) in Canada was correlated with straints on affected groups themselves as well as influen- experiencing barriers to healthcare access [16]. In The cing social interactions with affected populations [3]. Gambia, internal and experienced stigma toward people Several stigma types have been characterized and studied living with HIV were associated with poorer [4, 5]. Perceived (also called felt [6], or felt-normative self-reported health [17]. At the public policy level, [7]) stigma refers to the impression or belief that individ- stigma may be related to criminalization of key popula- uals or societies treat people differently due to stigma- tions’ practices and lower levels of funding of specific tized characteristics. Enacted or experienced stigma [8, health services for key populations because they are 9] represents the explicit experience of poor treatment deemed unworthy of assistance [18–20]. on the basis of specific characteristics. Internalized or Reliable and valid stigma metrics are needed to assess self-stigma is the acceptance of one’s perceived lesser correlates of stigma and changes in stigma over time status within society and manifests in low self-esteem, [21] in order to evaluate stigma mitigation interventions self-isolation, and social withdrawal [10, 11]. Finally, an- [22] and assess dose-response associations of stigma ticipated stigma [12] is the fear or expectation of dis- with health outcomes. However, there are several gaps in crimination. This is distinct from stigma toward oneself the research literature on measuring stigma specifically and involves worry by the stigmatized individual, which among key populations. This is especially the case across may or may not be based on others’ actual actions. Sec- Sub-Saharan Africa (SSA) [23–28]. Previous studies have ondary [13] or courtesy stigma [5] occurs when people often focused on investigating stigma from others’ per- associated with the person being stigmatized are also ex- spectives rather than from MSM and FSW themselves posed to stigma. Finally, intersecting or compounded [29, 30]. Additionally, many existing studies using or stigmas is the experience or perception of multiple evaluating metrics have focused on assessing forms of stigmas, such as that stigma often experienced HIV-related stigma among key populations [31], though related to identifying as gay or openly living with Human fewer in these contexts have focused on stigma related Immunodeficiency Virus (HIV) [4]. to selling sex or same-sex sexual practices, identities, re- After years of consistent data, there is consensus that lationships or communities [32–37]. Existing studies social and structural factors, including stigma, potentiate have often been completed in high or upper middle in- HIV risks by limiting the provision and uptake of come countries [35, 38–41]. In a recent systematic review Grosso et al. BMC Infectious Diseases (2019) 19:208 Page 3 of 17
on stigma measures, only three articles included both Type of study MSM and FSW participants [42]. Of seven articles meas- Details of the study procedures have been previously re- uring stigma reported by FSW study participants, five ported [56–66]. Briefly, the original purposes of these were about perceived stigma, one was about internalized studies were to develop population-based estimates of stigma, and one was about experienced stigma. These sur- HIV prevalence and determinants of those living with veys did not ask the source of this stigma (e.g., family, HIV at the individual, network, community and policy friends, healthcare workers, or police). None of these stud- levels. ies took place in Sub-Saharan Africa. While more mea- sures of stigma toward MSM were identified, only four Participants were from Sub-Saharan Africa (all from South Africa).- Inclusion criteria for FSW included being assigned the While the HIV epidemics, especially in Southern and female gender at birth and reporting most of their in- Eastern Africa, are more broadly generalized, key popula- come came from selling sex in the past year. Eligible tions have consistently been shown to have higher bur- MSM participants were assigned the male gender at dens of HIV than other reproductive aged men [43, 44] birth and had anal sex with a man in the past year. All and women [45]. participants were 18 years old or older and lived in the In West and Central Africa, the most populous region respective city for at least the past 3 months. of SSA, HIV is more concentrated among key popula- Respondent-driven sampling coupons were required for tions including MSM and FSW compared to what has all participants (except for seeds). Participants in Bur- historically been observed in Southern and Eastern Af- kina Faso provided written informed consent in French, rica [43]. Across the countries of West Africa, enforce- Mooré, or Dioula. In Togo, participants provided oral ment of punitive laws related to MSM and FSW varies informed consent in French, Ewe or Kabiye. significantly. In Burkina Faso, same-sex practices are not mentioned in the law. Selling sex is tolerated and not Data collection prohibited; soliciting and facilitating sex work are crimi- Trained interviewers administered structured question- nalized [46, 47]. However, stigma related to HIV [48, naires including modules on demographics, stigma, 49], sex work [50] and same-sex practices [51] is com- HIV-related knowledge and behaviors, mental health, so- mon. Socially and in the media there are strong expres- cial capital, access to services, and reproductive health. sions against same-sex sexual practices and relationships. For example, 95% of participants from Burkina Faso in the Afrobarometer said they would dis- Stigma measurement like living next to gay or lesbian neighbors [52]. A bill Questions related to stigma were initially informed was introduced (and later rejected) to criminalize through literature reviews, consultations with key stake- same-sex practices. There have been public marches holders including social scientists and nongovernmental against same-sex sexual practices and relationships [53]. organizations, and have been adapted over a decade of – Sex work and same-sex practices are both criminalized studies with key populations across SSA [9, 67 82]. List- in Togo. Specifically, same-sex practices may be pun- wise deletion was used to handle missing data, including “ ’ ” “ ” ished with fines between 100,000–500,000 XOF ($200– don t know and refusal responses. 1000) and 1 to 3 years imprisonment [54]. Selling sex in specific sex work venues is prohibited, with a maximum Analyses fine of 1,000,000 XOF ($2000); however compensated or The analytic approach chosen was exploratory factor transactional sex is not specifically prohibited [55]. analysis [83] given the lack of prior studies with factor In these settings, it remains vital to characterize appro- analysis of these items. Despite the rich body of prior priate tools to measure stigma and inform evaluating the stigma scale development, this inductive method was impact of stigma mitigation interventions. Consequently, used because most of stigma measurement research with this study aims to characterize the reliability and conver- key populations [42] has been conducted with Western, gent validity of stigma metrics for MSM and FSW in Educated, Industrialized, Rich, or Democratic (WEIRD) two West African countries. [84] samples or societies. Other psychometric instru- ments, such as personality measures, have been found to Methods have different factor structures outside of these WEIRD Settings of the study/study sites settings [85]. A recent study comparing reports of Data were collected from January–August 2013 using stigma from surveys administered to MSM in the United respondent-driven sampling of 1356 MSM and 1383 States and Western and Southern Africa found differ- FSW in Ouagadougou, and Bobo-Dioulasso, Burkina ences between settings in prevalence of family exclusion, Faso and Lomé, and Kara, Togo, West Africa. poor health care treatment, and blackmail but did not Grosso et al. BMC Infectious Diseases (2019) 19:208 Page 4 of 17
use factor analysis to compare the structure of stigma validity or test-retest reliability [102]. The present study’s measures [86]. measures’ reliability was assessed using Cronbach’salpha Principal factor analysis (or common factor analysis) [103] and the Kuder-Richardson coefficient [104]. The was used because the goal was not data reduction but overall metrics’ reliability was acceptable, with Cronbach’s rather to describe the underlying latent stigma variables alpha coefficients ranging from 0.71 among MSM in [87]. Promax oblique rotation [88] was used because the Ouagadougou to 0.82 among FSW in Ouagadougou. The factors were hypothesized to be correlated [89]. Data Kuder-Richardson coefficients were the same as the Cron- from each city and population were analyzed separately bach’s alpha except in Lomé, Togo where for the FSW using Stata 13.1 (College Station, Texas) because the metric the alpha was 0.73 and the Kuder-Richardson coeffi- respondent-driven sampling networks were different by cient was 0.70. city and because of the potential value of metrics that To assess the measures’ convergent validity, their cor- can be used with multiple populations in multiple geo- relations with expected HIV-related determinants were graphic areas. Results using combined data were similar examined. This was done to evaluate whether the stigma to those reported below. The sample size in each dataset metrics are useful not only for assessing levels of stigma was sufficient to allow for greater than the recom- but also within models with other HIV-related risk de- mended ten participants per variable [87]. The terminants. The literature suggests stigma would be as- Kaiser-Meyer-Olkin [90] measure of sampling adequacy sociated with increased purposeful or inadvertent was used with the Bartlett’s test of sphericity [91]toas- disclosure represented by family members or health sess the correlation matrices’ suitability for factor ana- workers knowing about the participant’s sex work or lysis. The factors retained were based on Kaiser’s same-sex practices [75, 105]. This study also tested criterion [92], eigenvalues over one, scree plots, Horn’s whether higher stigma is related to having suicidal idea- test [93], and interpretability. Items considered for the tion [32, 106]. Among participants recruited into the final metrics had factor loadings greater than 0.3 [94]in study as MSM, it was further hypothesized that those at least one city for each population. This was done to who identified as men would have lower stigma scores allow for comparisons across groups. Questions were ex- than those who identified as transgender, female or cluded if they loaded on more than one factor [95]or intersex [107]. It was expected that higher stigma would variability in the distributions of responses was under be inversely associated with HIV testing and condom 10% [96]. Questions were also excluded if greater than use [26, 108]. Stigma scores were used as continuous in- 20% of participants had missing data, as this may indi- dependent variables in all models. Separate bivariate lo- cate they were misunderstood or particularly sensitive gistic regression models were used to estimate the [97, 98]. These questions, shown in Table 1 with the ra- relationship between stigma and dichotomous tionales for excluding them, were about discrimination dependent variables (disclosure to family or health in employment and education, being forced to test for workers of selling sex for FSW and having sex with men HIV, being scared to walk in public places, difficulties or being attracted to men for MSM, suicidal ideation, accessing healthcare for FSW, and hearing discrimin- participating in MSM/FSW/HIV organizations, and gen- atory remarks about same-sex sexual practices and rela- der identity). Results were considered statistically signifi- tionships for MSM. Stigma scores were categorized by cant at p < 0.05 using two-sided tests. parceling [99], adding the remaining questions such that The Johns Hopkins School of Public Health Institu- participants who answered “yes” to one included ques- tional Review Board, Burkina Faso Ethics Committee for tion were assigned a score of 1, participants who an- Health Research, and Togo National Ethics Committee swered “yes” to two questions were assigned a score of approved the study. 2, and so on. This technique was chosen because of its simplicity and practical use for community organization Results staff who may not have the skills or software to compute The median age of FSW participants ranged from 23 factor scores [100]. years old in Kara and Ouagadougou to 30 in While some other stigma metrics are comprised of Likert Bobo-Dioulasso (see Table 2). Fewer than half of FSW in items [101], which may increase internal consistency and Burkina Faso and over 70% in Togo completed primary capture more fine-grained differences in frequency of ex- school or higher. The proportion employed outside of posure to stigma, the metrics in the present study are based selling sex ranged from 7.1% in Bobo-Dioulasso to 53.4% on dichotomous items. This approach enables assessment in Lomé. Under 15% were married or cohabitating. Over of the prevalence and correlates of lifetime experiences of half had at least one biological child. One third said a stigma, can be faster to administer (which is important in family member knew about their involvement in sex the context of a long questionnaire that includes multiple work. One fifth voluntarily disclosed. Over one quarter topics in addition to stigma), and may not result in reduced disclosed to a health worker, and 10% reported a health Grosso et al. BMC Infectious Diseases (2019) 19:208 Page 5 of 17
Table 1 Items included and excluded from FSWa and MSMb stigma metrics in Burkina Faso and Togo Variable name Question text Police harassed Have police ever harassed or intimidated you for being a sex worker? Arrested Were you ever arrested on charges related to sex work/ of homosexuality [or other related charge]? Verbally harassed Have you ever been verbally harassed and felt it was because you sell sex/ have sex with men? Blackmailed Have you ever been blackmailed by someone because you sell sex/ have sex with men? Physically abused Have you ever been physically aggressed (pushed, shoved; slapped; hit; kicked; choked; or otherwise physically hurt)? Do you believe any of these experience(s) of physical violence was/were related to the fact that you sell sex/ have sex with men? Tortured Have you ever been tortured by someone? If yes, do you believe this was because you sell sex/ have sex with men? Forced sex Have you ever been forced to have sex when you did not want to? (By forced, I mean physically forced, coerced to have sex, or penetrated with an object, when you did not want to). Do you believe any of these experiences of sexual violence were related to the fact that you sell sex/ have sex with men? Denied care Have you ever been denied health services (or someone kept you from receiving health services) because you sell sex/ have sex with men? Not treated well Have you ever felt that you were not treated well in a health center because you sell sex/ someone knew that you have sex with men? Health workers gossiped Have you ever heard healthcare providers gossiping about you because you sell sex/ have sex with men? Difficulties Have you ever had difficulties in accessing healthcare services because you have sex with men? Afraid to seek care Have you ever felt afraid to go to healthcare services because you worry someone may learn you sell sex/ have sex with men? Avoided care Have you ever avoided going to healthcare services because you worry someone may learn you sell sex/ have sex with men? Family excluded Have you ever felt excluded from family gatherings because you sell sex/ have sex with men? Family gossiped Have you ever felt that family members have made discriminatory remarks or gossiped about you because you sell sex/ have sex with men? Friends rejected Have you ever felt rejected by your friends because you sell sex/ have sex with men? Police refused Have you ever felt that the police refused to protect you because you sell sex/ have sex with men? Avoided carrying condoms Have you ever avoided carrying condoms because you were afraid that they might get you in trouble with the police? Police confiscated Has a police officer ever taken condoms away from you, thrown them on the ground or in the garbage? Witnessed confiscation Have you ever witnessed (i.e. seen) police confiscating or destroying condoms held by a sex worker or outreach worker? Heard about confiscation Have you ever heard about incidents when police confiscated or destroyed condoms held by other sex workers or by outreach workers? Question Reason for excluding Female sex workers Have you ever lost employment or been dismissed from a job Many participants answered “not applicable”; did not load strongly on any (other than sex work) because you sell sex? factor Have you ever been denied educational opportunities, like access Many participants answered “not applicable”; did not load strongly on any to school, because you sell sex? factor Have you ever had difficulties in accessing healthcare services High uniqueness; did not load on any factor in multiple datasets because you sell sex? Grosso et al. BMC Infectious Diseases (2019) 19:208 Page 6 of 17
Table 1 Items included and excluded from FSWa and MSMb stigma metrics in Burkina Faso and Togo (Continued) Have you ever been tested for HIV when you did not want to or did Very rare (9 people in all cities combined) not give permission? If yes, were you forced or pressured to test for HIV because you sell sex? Have you ever refused to take condoms from an outreach worker Very rare (17 total in all cities combined) because you were afraid they might get you in trouble with the police? Have you ever felt scared to walk around in public places because Did not load on any factor; may be measuring something other than you sell sex? stigma Men who have sex with men Have you ever lost employment or been dismissed from a job Loaded on a different factor in every city because you have sex with men? Have you ever been denied educational or training opportunities, Rare (10 people or less per city); did not load on any factors; lowered like access to school, because you have sex with men? the Cronbach’s alpha of the metric Has anyone ever said discriminatory things about homosexuality Did not load on any factors; lowered the Cronbach’s alpha in your presence without knowing you have sex with other men? Have you ever been tested for HIV when you did not want to or Very rare (only 8 people in all cities combined) did not give permission? If yes, were you forced or pressured to test for HIV because you have sex with men? Bold = wording in the female sex worker questionnaire Italics = wording in the men who have sex with men questionnaire afemale sex worker bmen who have sex with men worker found out some other way. Over one fifth ever about their sexual practices. One fifth voluntarily dis- had suicidal ideation. Less than half had condomless va- closed. Over 10% reported suicidal ideation. Over one ginal sex in the past 12 months. Most had tested for quarter identified their gender as transgender, female or HIV more than once ever. intersex. Most had ever had condomless anal sex. Over Across all the cities, the median age of participants in half had tested for HIV more than once ever. the MSM study was under 25 years old (see Table 3). The Bartlett’s test of sphericity was significant (p < Over 90% completed primary school or higher. Most (> 0.05), indicating the data were suitable for factor ana- 50%) were unemployed (including students). Under 10% lysis. The Kaiser-Meyer-Olkin index was greater than were married or cohabitating with a woman or had a the minimum acceptable value of 0.5 in all datasets. A biological child. The majority reported their sexual five-factor solution was identified for the FSW metric orientation as gay. One fifth said a family member knew (20 questions total) and a four-factor solution for the about their sexual practices. One quarter disclosed to MSM metric (16 questions total). Two to seven vari- them. Under 5% reported a health worker found out ables loaded on each factor (Tables 4 and 5). The
Table 2 Selected characteristics of female sex workers in Burkina Faso and Togo City Ouagadougou Bobo-Dioulasso Lomé Kara Median age 23 30 28 23 Completed primary school or higher 46.1% (159/345) 27.7% (97/350) 70.9% (251/354) 86.1% (284/330) Employed (other than sex work) 33.1% (115/347) 7.1% (25/350) 53.4% (189/354) 47.0% (155/330) Married or cohabitating 9.5% (33/349) 12.3% (43/350) 7.3% (26/354) 5.8% (19/330) Has at least one biological child 69.3% (242/349) 83.4% (292/350) 78.5% (278/354) 51.2% (169/330) Told family about sex work 16.3% (57/349) 22.3% (78/350) 19.5% (69/354) 21.5% (71/330) Family found out about sex work 31.0% (102/329) 32.9% (109/331) 19.4% (65/335) 48.8% (157/322) Told health worker about sex work 16.1% (55/342) 22.8% (79/347) 45.0% (159/353) 26.1% (86/330) Health worker found out about sex work 12.9% (44/342) 6.3% (22/347) 15.0% (53/353) 6.1% (20/330) Ever had suicidal thoughts 20.1% (70/349) 22.9% (80/350) 21.2% (75/354) 17.9% (59/330) Participated in female sex worker organization 13.9% (48/346) 24.6% (86/350) 24.4% (86/353) 3.3% (11/330) Had condomless vaginal sex in the past 12 months 37.9% (130/343) 43.3% (151/349) 25.5% (87/341) 46.2% (151/327) Ever tested for HIV more than once 60.2% (209/347) 68.3% (239/350) 58.6% (205/350) 56.1% (185/330) Grosso et al. BMC Infectious Diseases (2019) 19:208 Page 7 of 17
Table 3 Selected characteristics of men who have sex with men (MSM) in Burkina Faso and Togo City Ouagadougou Bobo-Dioulasso Lomé Kara Median age 21 22 22 24 Completed primary school or higher 93.0% (319/343) 90.3% (298/330) 99.2% (351/354) 99.4% (327/329) Employed 19.5% (67/343) 26.4% (87/330) 43.5% (154/354) 23.1% (76/329) Married or cohabitating with a woman 5.0% (17/340) 3.0% (10/329) 8.5% (30/354) 3.0% (10/329) Has at least one biological child 7.6% (26/343) 7.9% (26/330) 5.4% (19/353) 1.8% (6/329) Sexual orientation: Gay or homosexual 51.3% (176/343) 55.8% (184/330) 61.0% (216/354) 68.7% (226/329) Bisexual 44.0% (151/343) 39.4% (130/330) 35.0% (124/354) 31.3% (103/329) Heterosexual or straight 2.0% (7/343) 3.9% (13/330) 0.8% (3/354) 0.0% (0/329) Transvestite/transgender 2.6% (9/343) 0.9% (3/330) 3.1% (11/354) 0.0% (0/329) Told family about same-sex practices 26.0% (89/343) 20.3% (67/330) 24.0% (85/354) 29.8% (98/329) Family found out about same-sex practices 18.1% (58/321) 19.3% (62/321) 18.0% (62/344) 29.1% (93/320) Told health worker about same-sex practices 19.9% (66/332) 20.0% (61/305) 36.3% (128/353) 8.8% (29/329) Health worker found out about same-sex practices 3.3% (11/332) 2.3% (7/305) 10.5% (37/353) 1.5% (5/329) Ever had suicidal thoughts 14.9% (51/343) 17.0% (56/329) 13.9% (49/353) 6.1% (20/329) Participated in MSM organization 17.0% (58/342) 8.0% (26/327) 40.7% (144/354) 1.22% (4/329) Identifies as male 70.8% (242/342) 61.2% (202/330) 72.0% (255/354) 91.5% (301/329) Ever had condomless anal sex 50.4% (173/343) 67.9% (222/327) 43.8% (155/354) 53.8% (177/329) Ever tested for HIV more than once 51.6% (177/343) 55.2% (181/328) 55.9% (195/349) 47.4% (156/329) factors were each significantly correlated with one an- witnessing or hearing about police confiscation of other (p < 0.001). condoms. One factor, experienced stigma, included actions that were carried out by multiple types of perpetrators. Other Convergent validity factors were differentiated by source of stigma (healthcare In both populations, higher stigma was generally signifi- workers, family and friends, or police). Stigma from health- cantly and positively associated with a family member or care workers loaded on two factors. The factors common health worker knowing about involvement in sex work to both populations were: stigma from family and friends; or same-sex practices, regardless of whether the disclos- experienced stigma; experienced healthcare stigma; and an- ure was voluntary or involuntary (Table 8). The excep- ticipated healthcare stigma. The fifth factor in the FSW tion was among MSM in Lomé, who reported less metric was stigma from police (Tables 6 and 7). stigma if they voluntarily disclosed to a health worker. For both populations, experienced stigma included Participants with greater cumulative reports of stigma items for being arrested, verbally harassed, blackmailed, had a greater likelihood of suicidal ideation, though this physically abused, tortured, or forced to have sex. The was not significant among MSM in Kara or FSW in most common perpetrators of forced sex among MSM Bobo-Dioulasso. FSW in Ouagadougou and both popu- were current or past male sexual partners or other MSM lations in Bobo-Dioulasso reported higher stigma if they (data not shown). Police harassing the participant loaded participated in FSW, MSM or HIV-related organizations. on the experienced stigma factor for FSW. Study participants in the MSM sample who identified as Experienced healthcare stigma for both populations in- male had lower stigma scores than those who identified cluded being denied care, not treated well, or gossiped as female, transgender or intersex. The relationships be- about by healthcare workers. Among MSM, difficulties tween stigma and HIV testing and condom use were not accessing healthcare also loaded on the experienced consistent across cities and populations. Final items healthcare stigma factor. Anticipated healthcare stigma retained in each stigma metric are reported in Tables 9 included fear of or avoiding seeking healthcare. Stigma and 10. from family and friends included feeling excluded from family gatherings, gossiped about by family, or rejected Discussion by friends. Stigma from police among FSW included be- The results of this multi-country study illustrate the po- ing refused police protection or experiencing, fearing, tential for brief tools to measure stigma among key Grosso et al. BMC Infectious Diseases (2019) 19:208 Page 8 of 17
Table 4 Stigma item frequencies in the female sex worker stigma metric in Burkina Faso and Togo City Ouagadougou Bobo-Dioulasso Lomé Kara (n = 330) (n = 349) (n = 350) (n = 354) Factor 1: Experienced stigma 1. Police harassed 28.9% (101/349) 48.4% (169/349) 29.7% (105/354) 22.4% (74/330) 2. Arrested 32.6% (113/347) 44.8% (155/346) 25.1% (89/354) 13.3% (44/330) 3. Verbally harassed 63.6% (222/349) 55.4% (194/350) 35.9% (127/354) 37.3% (123/330) 4. Blackmailed 19.9% (69/347) 42.0% (147/350) 20.6% (73/354) 36.2% (119/329) 5. Physically abused 49.9% (163/327) 44.2% (153/346) 22.0% (78/354) 19.4% (64/330) 6. Tortured 13.0% (44/338) 17.6% (61/346) 11.6% (41/354) 4.9% (16/330) 7. Forced sex 27.5% (95/346) 29.1% (102/350) 11.0% (39/354) 16.1% (53/329) Factor 2: Experienced healthcare stigma 1. Denied care 1.2% (4/349) 0.9% (3/350) 0.6% (2/354) 0.0% (0/330) 2. Not treated well 2.0% (7/349) 1.7% (6/349) 1.7% (6/354) 2.7% (9/330) 3. Health workers gossiped 6.6% (23/349) 2.3% (8/350) 1.4% (5/354) 5.8% (19/330) Factor 3: Anticipated healthcare stigma 1. Afraid to seek care 21.0% (73/348) 14.9% (52/349) 5.7% (20/353) 10.0% (33/330) 2. Avoided care 15.5% (54/349) 14.9% (52/349) 4.5% (16/354) 9.7% (32/330) Factor 4: Stigma from family and friends 1. Family excluded 23.0% (80/348) 16.1% (56/349) 4.2% (15/354) 18.8% (62/330) 2. Family gossiped 33.8% (117/346) 30.4% (105/345) 8.5% (30/354) 36.8% (121/329) 3. Friends rejected 16.8% (58/345) 19.4% (68/350) 4.5% (16/354) 20.3% (67/330) Factor 5: Stigma from police 1. Police refused 18.4% (64/347) 16.4% (57/348) 8.5% (30/353) 2.4% (8/330) 2. Avoided carrying condoms 12.3% (43/349) 6.3% (22/349) 3.4% (12/354) 0.9% (3/330) 3. Police confiscated 5.2% (18/348) 6.9% (24/346) 2.5% (9/354) 0.3% (1/330) 4. Witnessed confiscation 7.2% (25/347) 5.4% (19/350) 7.1% (25/354) 3.9% (13/330) 5. Heard about confiscation 13.3% (46/347) 17.7% (62/350) 36.5% (129/353) 7.3% (24/330) populations that work well across country contexts and between the number of stigma events reported and languages. These measures include items related to per- health outcomes. ceived, anticipated and enacted types of stigma. The In this study experienced stigma included both physic- sources of stigma represent multiple levels of the social ally violent and emotionally abusive experiences, demon- ecological model of HIV risk among key populations, in- strating a wide range of severity for this factor. Sexual cluding social (family and friends), community (health- violence related to being MSM loaded on the same fac- care workers), and policy (police) [14]. Though many tor as blackmail. Perpetrators (including other MSM) factors were common to both populations, additional may believe they will not be prosecuted because the po- questions asked of FSW about interactions with police lice will not take action, or the person will not report constituted a separate factor relevant to the overall con- the rape due to being MSM. struct of stigma within this population. The metrics were Among FSW, being arrested for selling sex loaded on significantly related to disclosure of sex work or the experienced stigma factor rather than the stigma same-sex practices to family or a health worker, suicidal from police factor. In countries where aspects of sex ideation, organization participation, and gender identity. work are criminalized, arrests may indicate structural These analyses build on earlier studies using some of stigma from the government or society rather than from the same questionnaire items. Previous studies have police doing their job. The items that loaded on the used these indicators individually in models as inde- stigma from police factor included some that could be pendent variables [75, 109], or reported dichotomous categorized as anticipated stigma (Have you ever avoided aggregate stigma measures such as any social stigma carrying condoms because you were afraid that they [73, 75, 79]. Dichotomized measures may not fully cap- might get you in trouble with the police?), some that ture the granularity of dose-response relationships could be categorized as perceived stigma (Have you ever Grosso et al. BMC Infectious Diseases (2019) 19:208 Page 9 of 17
Table 5 Stigma Item Frequencies in the MSMa Stigma Metric in Burkina Faso and Togo City Ouagadougou (n = 343) Bobo-Dioulasso (n = 330) Lomé (n = 354) Kara (n = 329) Factor 1: Experienced stigma 1. Police refused 5.2% (18/342) 3.3% (11/330) 3.7% (13/354) 0.3% (1/329) 2. Arrested 1.7% (6/343) 1.2% (4/329) 2.8% (10/354) 0.3% (1/329) 3. Verbally harassed 34.7% (119/343) 44.7% (147/329) 18.9% (67/354) 18.2% (60/329) 4. Blackmailed 24.8% (85/343) 14.9% (49/329) 16.1% (57/354) 21.9% (72/329) 5. Physically abused 9.6% (33/343) 15.3% (50/327) 4.2% (15/354) 4.0% (13/329) 6. Tortured 2.9% (10/343) 2.8% (9/326) 3.1% (11/354) 3.0% (10/329) 7. Forced sex 10.5% (36/342) 10.7% (35/328) 3.7% (13/354) 4.3% (14/329) Factor 2: Experienced healthcare stigma 1. Denied care 1.5% (5/342) 0.9% (3/330) 1.1% (4/354) 0.0% (0/329) 2. Not treated well 4.4% (15/343) 3.3% (11/330) 2.0% (7/354) 0.6% (2/329) 3. Health workers gossiped 12.0% (41/343) 2.7% (9/330) 3.4% (12/354) 6.7% (22/329) 4. Difficulties 7.3% (25/343) 1.8% (6/330) 17.0% (60/354) 7.3% (24/329) Factor 3: Anticipated healthcare stigma 1. Afraid to seek care 40.8% (140/343) 23.6% (78/330) 8.5% (30/354) 11.3% (37/329) 2. Avoided care 36.4% (125/343) 20.0% (66/330) 7.1% (25/354) 9.1% (30/329) Factor 4: Stigma from family and friends 1. Family excluded 12.2% (42/343) 8.2% (27/330) 6.5% (23/354) 12.2% (40/329) 2. Family gossiped 37.3% (128/343) 26.4% (87/329) 15.3% (54/354) 19.5% (64/329) 3. Friends rejected 35.9% (123/343) 26.1% (86/330) 8.8% (31/354) 16.4% (54/329) amen who have sex with men felt that the police refused to protect you because you reported higher stigma than cisgender MSM, which may sell sex?), and some that could be categorized as enacted be due to intersecting stigma associated with sexual stigma (police confiscation of condoms). Studies in the practices and gender identity. MSM who are more mas- United States and human rights reports have provided culine or hide their sexual orientation or practices may some indications of police confiscation of condoms as even reject those who are more open about their sexual evidence of sex work [110–112]. This study presented orientation or practices or considered more feminine. quantitative data from a diverse sample of FSW on the Given the unique needs of transgender and cisgender prevalence of experiencing, witnessing, hearing about, populations, valid and reliable stigma measures are and avoiding carrying condoms due to police confisca- needed specifically for transgender women [110, 111]. tion. Given the emergence of stigma from police as one This study has several limitations. Findings may not be components of stigma in the metric for FSW specifically, generalizable to settings outside the cities in West Africa using research and evaluation to identify effective ap- included in this study. This is a secondary analysis of proaches in these countries’ contexts to prevent harmful data collected for a study measuring HIV prevalence policing practices through education, policy, or increased among key populations. For MSM, the inclusion criteria accountability appears to be warranted [113, 114]. of having anal sex with a man in the past year was The stigma metrics showed promising convergent val- chosen due to its relationship with potential HIV acqui- idity in that in bivariate models they generally performed sition or transmission risk. Items in this stigma metric as had been theorized based on conceptual models and may not capture stigma targeted toward MSM commu- existing literature. The findings that higher stigma scores nities or identities rather than sexual practices. Individ- were positively associated with a family member or uals who did not meet the inclusion criteria but are in health worker knowing about participants’ involvement same-sex relationships or identify as sexually diverse, in sex work or same-sex practices is consistent with sexually attracted to the same gender, gay or bisexual prior studies in The Gambia and the United States [75, may face similar or different types of stigma compared 105]. Similarly, stigma was positively associated with sui- to those included in this study. cidal ideation, as other researchers have reported in All self-reported variables may be subject to social de- China [32] and the United States [106]. Transgender sirability bias and inaccurate recall. In the context of participants accrued into the studies focused on MSM limited disclosure of sex work or same-sex practices, Grosso et al. BMC Infectious Diseases (2019) 19:208 Page 10 of 17
Table 6 MSMa stigma metric factor structure and loadings in Burkina Faso and Togo City Ouagadougou Bobo-Dioulasso Lomé Kara Alpha = 0.59 Alpha = 0.48 Alpha = 0.64 Alpha = 0.63 Variance = 1.58 Variance = 1.36 Variance = 2.29 Variance = 2.14 Proportion = 37% Proportion = 24% Proportion = 39% Proportion = 36% Factor 1: Experienced stigma 1. Police refused 0.471 0.530 0.123 0.995 2. Arrested 0.588 0.572 0.291 0.995 3. Verbally harassed 0.121 0.105 0.605 −0.004 4. Blackmailed 0.175 0.124 0.481 −0.006 5. Physically abused 0.206 0.194 0.096 −0.080 6. Tortured 0.562 −0.126 0.281 0.260 7. Forced sex 0.410 0.074 0.646 −0.076 Alpha = 0.39 Alpha = 0.78 Alpha = 0.33 Alpha = 0.18 Variance = 1.53 Variance = 2.69 Variance = 1.24 Variance = 1.87 Proportion = 36% Proportion = 46% Proportion = 21% Proportion = 27% Factor 2: Experienced healthcare stigma 1. Denied care 0.199 0.808 0.488 N/A 2. Not treated well 0.564 0.694 0.464 0.178 3. Health workers gossiped 0.370 0.697 0.474 0.196 4. Difficulties 0.249 0.700 0.239 0.051 Alpha = 0.87 Alpha = 0.92 Alpha = 0.88 Alpha = 0.88 Variance = 1.51 Variance = 2.22 Variance = 2.12 Variance = 1.75 Proportion = 35% Proportion = 38% Proportion = 36% Proportion = 25% Factor 3: Anticipated healthcare stigma 1. Afraid to seek care 0.833 0.913 0.832 0.850 2. Avoided care 0.837 0.907 0.794 0.859 Alpha = 0.55 Alpha = 0.60 Alpha = 0.77 Alpha = 0.76 Variance = 2.01 Variance = 1.70 Variance = 2.89 Variance = 2.52 Proportion = 47% Proportion = 29% Proportion = 50% Proportion = 36% Factor 4: Stigma from family and friends 1. Family excluded 0.352 0.580 0.737 0.748 2. Family gossiped 0.648 0.619 0.748 0.773 3. Friends rejected 0.521 0.509 0.720 0.589 Total Alpha = 0.71 Alpha = 0.71 Alpha = 0.77 Alpha = 0.75 KRb=0.71 KR = 0.71 KR = 0.77 KR = 0.75 Mean (SD) 2.753 (2.407) 2.053 (2.151) 1.220 (1.971) 1.350 (1.975) Median 2 1 0 0 amen who have sex with men bKuder-Richardson coefficient stigma may be lower than expected because participants’ MSM and FSW, which may differ from stigma toward families, friends, healthcare providers or others are not these groups reported by others. Future research meas- aware of these practices. However, MSM may also ex- uring stigma from both perspectives of those within and perience stigma because of their relationships, gender outside the population of interest may inform stigma re- non-conformity, mannerisms, or friends who are also duction programs. If, for instance, MSM or FSW report sexual minorities. For example, others may know that experiencing stigma from healthcare workers but health- the participant is not dating a woman, getting married, care providers do not report stigmatizing attitudes, mak- acting “masculine”, or fulfilling other heteronormative ing these providers aware of actions that may be expectations, and this may be another source of stigma. unintentionally stigmatizing could result in improved This study investigated stigma from the perspective of services. Grosso et al. BMC Infectious Diseases (2019) 19:208 Page 11 of 17
Table 7 Female sex worker stigma metric factor structure and loadings in Burkina Faso and Togo City Ouagadougou Bobo-Dioulasso Lomé Kara Alpha = 0.72 Alpha = 0.69 Variance = 2.82 Alpha = 0.75 Variance = 2.60 Alpha = 0.76 Variance = 2.80 Variance = Proportion = 36% Proportion = 38% Proportion = 39% 2.97 Proportion = 41% Factor 1: Experienced stigma 1. Police harassed 0.485 0.510 0.531 0.612 2. Arrested 0.574 0.600 0.557 0.500 3. Verbally harassed 0.485 0.280 0.638 0.598 4. Blackmailed 0.411 0.403 0.506 0.671 5. Physically abused 0.695 0.371 0.671 0.612 6. Tortured 0.216 0.127 0.563 0.409 7. Forced sex 0.377 0.399 0.421 0.542 Alpha = 0.37 Alpha = 0.72 Variance = 1.95 Alpha = 0.56 Alpha = 0.31 Variance = Proportion = 25% Variance = 1.56 Variance = 0.97 1.18 Proportion = 23% Proportion = 14% Proportion = 16% Factor 2: Experienced healthcare stigma 1. Denied care 0.558 0.849 0.675 N/A 2. Not treated well 0.200 0.814 0.728 0.285 3. Health workers 0.365 0.409 0.308 0.463 gossiped Alpha = 0.89 Alpha = 0.85 Variance = 2.62 Alpha = 0.74 Alpha = 0.92 Variance = Proportion = 33% Variance = 1.67 Proportion = 25% Variance = 2.06 2.53 Proportion = 29% Proportion = 35% Factor 3: Anticipated healthcare stigma 1. Afraid to seek care 0.889 0.856 0.648 0.894 2. Avoided care 0.883 0.858 0.764 0.914 Alpha = 0.76 Alpha = 0.73 Variance = 3.31 Alpha = 0.59 Alpha = 0.68 Variance = Proportion = 42% Variance = 1.17 Variance = 1.76 2.75 Proportion = 17% Proportion = 25% Proportion = 38% Factor 4: Stigma from family and friends 1. Family excluded 0.816 0.842 0.590 0.625 2. Family gossiped 0.815 0.802 0.592 0.700 3. Friends rejected 0.423 0.436 0.163 0.449 Alpha = 0.67 Alpha = 0.69 Variance = 3.39 Alpha = 0.32 Variance = 1.28 Alpha = 0.48 Variance = 1.54 Variance = Proportion = 43% Proportion = 19% Proportion = 22% 2.79 Proportion = 39% Factor 5: Stigma from police 1. Police refused 0.327 0.284 0.113 −0.070 2. Avoided carrying 0.430 0.551 0.088 0.034 condoms 3. Police confiscated 0.583 0.614 0.649 0.245 4. Witnessed 0.672 0.818 0.637 0.788 confiscation Grosso et al. BMC Infectious Diseases (2019) 19:208 Page 12 of 17
Table 7 Female sex worker stigma metric factor structure and loadings in Burkina Faso and Togo (Continued) City Ouagadougou Bobo-Dioulasso Lomé Kara 5. Heard about 0.712 0.678 0.369 0.816 confiscation Total Alpha = 0.82 Alpha = 0.82 Alpha = 0.73 Alpha = 0.77 KRa=0.82 KR = 0.82 KR = 0.70 KR = 0.77 Mean (SD) 4.313 (3.651) 4.277 (3.575) 2.444 (2.366) 2.679 (2.739) Median 3 3 2 2 aKuder-Richardson coefficient
Because of the question wording, it is not possible to in studies in different contexts. These metrics do not determine whether issues related to stigma from family specifically measure secondary stigma, with mental and friends were experienced (e.g., the participant actu- health being measured in lieu of internalized stigma. In- ally heard the discriminatory remarks) or perceived (e.g., ternalized stigma is often preceded by experienced the participant heard a family member whispering to an- stigma [117] and has been shown to be less closely cor- other and assumed it was about the participant selling related with avoiding or delaying seeking healthcare than sex). Other items potentially assessing felt normative or experienced stigma [17]. Future analyses could leverage perceived stigma (e.g., Have you ever felt scared to walk these developed metrics to explore intersectionality around in public places because you sell sex?) were ex- through intra- and inter-categorical approaches. cluded for the reasons mentioned above. Some studies Potential confounding variables were not included in have shown that perceived stigma is more commonly re- these analyses because the primary purpose was the de- ported than other types of stigma [115] and is signifi- velopment of the metrics. Stratified analyses by age, HIV cantly and negatively associated with quality of life [116]. status, and socioeconomic status will enable compari- Questionnaire items excluded from these metrics may sons to better understand the effects of privilege and be important stigma indicators that should be assessed marginalization and the distribution of the burden of
Table 8 Correlates of the FSWa and MSMb Stigma Metrics in Burkina Faso and Togo Ouagadougou Bobo-Dioulasso Lomé Kara OR 95% CI OR 95% CI OR 95% CI OR 95% CI FSW Told family about sex work 1.12 1.03, 1.21 0.97 0.90, 1.04 1.03 0.92, 1.15 1.15 1.05, 1.26 Family found out about sex work 1.15 1.08, 1.24 1.44 1.31, 1.59 1.34 1.20, 1.50 1.07 0.99, 1.16 Told health worker about sex work 1.17 1.08, 1.27 1.09 1.02, 1.17 0.98 0.90, 1.07 1.15 1.06, 1.26 Health worker found out about sex work 1.12 1.02, 1.22 1.10 0.99, 1.23 0.97 0.86, 1.10 1.20 1.04, 1.39 Ever had suicidal thoughts 1.15 1.07, 1.24 1.04 0.97, 1.11 1.20 1.08, 1.33 1.26 1.14, 1.40 Participated in FSW organization 1.12 1.03, 1.21 1.30 1.20, 1.40 0.97 0.87, 1.08 1.16 0.96, 1.40 Had condomless vaginal sex in the past 12 months 0.94 0.88, 1.00 0.93 0.87, 0.99 1.15 1.04, 1.27 1.06 0.98, 1.15 Ever tested for HIV more than once 1.04 0.97, 1.11 0.97 0.91, 1.03 1.07 0.98, 1.18 0.98 0.90, 1.06 MSM Told family about same-sex practices 1.24 1.12, 1.37 1.12 0.99, 1.25 1.27 1.13, 1.43 1.12 1.00, 1.26 Family found out about same-sex practices 1.24 1.11, 1.38 1.35 1.19, 1.54 1.31 1.16, 1.48 1.35 1.19, 1.52 Told health worker about same-sex practices 1.27 1.14, 1.42 1.25 1.10, 1.41 0.87 0.77, 0.99 1.32 1.13, 1.54 Health worker found out about same-sex practices 1.14 0.91, 1.42 1.18 0.91, 1.52 0.94 0.77, 1.14 1.42 1.03, 1.96 Ever had suicidal thoughts 1.37 1.22, 1.55 1.45 1.26, 1.66 1.38 1.22, 1.58 1.08 0.87, 1.33 Participated in MSM organization 1.05 0.94, 1.18 1.25 1.07, 1.45 1.02 0.92, 1.13 1.04 0.65, 1.67 Identifies as male 0.84 0.76, 0.93 0.83 0.74, 0.93 0.75 0.66, 0.84 0.82 0.69, 0.96 Ever had condomless anal sex 1.10 1.00–1.20 1.04 0.93, 1.17 1.38 1.21, 1.59 1.09 0.98, 1.23 Ever tested for HIV more than once 1.04 0.96, 1.14 1.16 1.04, 1.30 1.06 0.95, 1.18 0.95 0.85, 1.06 afemale sex worker bmen who have sex with men; bold text indicates significance at the p<0.05 level Grosso et al. BMC Infectious Diseases (2019) 19:208 Page 13 of 17
Table 9 Final items included in the female sex worker stigma Table 10 Final items included in the men who have sex with metric men stigma metric 1. Have police ever harassed or intimidated you for being a sex 1. Were you ever arrested on charges of homosexuality [or other worker? related charge]? 2. Were you ever arrested on charges related to sex work? 2. Have you ever been verbally harassed and felt it was because you have sex with men? 3. Have you ever been verbally harassed and felt it was because you sell sex? 3. Have you ever been blackmailed by someone because you have sex with men? 4. Have you ever been blackmailed by someone because you sell sex? 4. Have you ever been physically aggressed (pushed, shoved; slapped; 5. Have you ever been physically aggressed (pushed, shoved; hit; kicked; choked; or otherwise physically hurt)? Do you believe slapped; hit; kicked; choked; or otherwise physically hurt)? any of these experience(s) of physical violence was/were related to Doyoubelieveanyoftheseexperience(s)ofphysical the fact that you have sex with men? violence was/were related to the fact that you sell sex? 5. Have you ever been tortured by someone? If yes, do you believe this was because you have sex with men? 6. Have you ever been tortured by someone? If yes, do you believe this was because you sell sex? 6. Have you ever been forced to have sex when you did not want to? (By forced, I mean physically forced, coerced to have sex, or 7. Have you ever been forced to have sex when you did not want to? penetrated with an object, when you did not want to). Do you (By forced, I mean physically forced, coerced to have sex, or believe any of these experiences of sexual violence were related to penetrated with an object, when you did not want to). Do you the fact that you have sex with men? believe any of these experiences of sexual violence were related to the fact that you sell sex? 7. Have you ever been denied health services (or someone kept you from receiving health services) because you have sex with men? 8. Have you ever been denied health services (or someone kept you from receiving health services) because you sell sex? 8. Have you ever felt that you were not treated well in a health center because someone knew that you have sex with men? 9. Have you ever felt that you were not treated well in a health center because you sell sex? 9. Have you ever heard healthcare providers gossiping about you because you have sex with men? 10. Have you ever heard healthcare providers gossiping about you because you sell sex? 10. Have you ever had difficulties in accessing healthcare services because you have sex with men? 11. Have you ever felt afraid to go to healthcare services because you worry someone may learn you sell sex? 11. Have you ever felt afraid to go to healthcare services because you worry someone may learn you have sex with men? 12. Have you ever avoided going to healthcare services because you worry someone may learn you sell sex? 12. Have you ever avoided going to healthcare services because you worry someone may learn you have sex with men? 13. Have you ever felt excluded from family gatherings because you sell sex? 13. Have you ever felt excluded from family gatherings because you have sex with men? 14. Have you ever felt that family members have made discriminatory remarks or gossiped about you because you sell sex? 14. Have you ever felt that family members have made discriminatory remarks or gossiped about you because you have sex with men? 15. Have you ever felt rejected by your friends because you sell sex? 15. Have you ever felt rejected by your friends because you have sex with men? 16. Have you ever felt that the police refused to protect you because you sell sex? 16. Have you ever felt that the police refused to protect you because you have sex with men? 17. Have you ever avoided carrying condoms because you were afraid that they might get you in trouble with the police? 18. Has a police officer ever taken condoms away from you, thrown Conclusions them on the ground or in the garbage? There are ongoing and planned stigma mitigation interven- 19. Have you ever witnessed (i.e. seen) police confiscating or tions in SSA that would benefit by the ability to consistently destroying condoms held by a sex worker or outreach worker? measure stigma across key populations and over time using 20. Have you ever heard about incidents when police confiscated or these reliable and valid stigma measures [22, 114]. Stigma destroyed condoms held by other sex workers or by outreach may be addressed through implementing nondiscrimination workers? policies and increasing police protection of vulnerable popu- lations to hold perpetrators of violence and blackmail ac- stigma [113]. Future studies should use confirmatory countable. Comprehensive stigma reduction interventions factor analysis to assess whether the metrics’ structure should also work directly with MSM and FSW individuals is applicable in other samples of key populations and community groups to address stigma, given the level of across SSA. Moreover, additional approaches for val- anticipated stigma found in this study and association be- idating and assessing the metrics’ psychometric prop- tween stigma and suicidal ideation. Continued stigma meas- erties including assessing predictive validity and urement and evaluation of stigma reduction interventions test-retest reliability would add strength to the must urgently be addressed in order to realize the goals of conclusions. achieving an AIDS-Free generation in our lifetimes. Grosso et al. BMC Infectious Diseases (2019) 19:208 Page 14 of 17
Abbreviations Publisher’sNote AIDS: Acquired Immune Deficiency Syndrome; FSW: Female sex workers; Springer Nature remains neutral with regard to jurisdictional claims in HIV: Human Immunodeficiency Virus; MSM: Men who have sex with men; published maps and institutional affiliations. SSA: Sub-Saharan Africa; WEIRD: Western, Educated, Industrialized, Rich, or Democratic Author details 1Key Populations Program, Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Acknowledgements 2 The authors thank the women and men who participated in the studies, the Health, 615 North Wolfe Street, 5th Floor, Baltimore, MD, USA. Research and research staff, and the community who collaborated on this project. These Evaluation Unit, Public Health Solutions, 40 Worth Street, 5th Floor, New 3 ’ include AIDSETI, Association African Solidarity, Alternative Burkina, York, NY, USA. Programme d Appui au Monde Associatif et Communautaire (PAMAC), 11 BP 1023, Avenue du Pr Joseph Ki-Zerbo, Ouagadougou, Burkina Reponsabilité, Espoir, Vie, Solidarité (REVS+) and Association Laafi la Viim 4 (ALAVI). We also thank the Burkina Faso Ministry of Health for approving the Faso. Institut de Recherche en Sciences de la Santé (IRSS), 03 BP 7192, Ouagadougou 03, Burkina Faso. 5Lomé, Togo. 6Arc-en-ciel, BP 805000, Lomé, study. We thank the team from USAID and USAID West Africa for their help 7 8 in the overall success of this study. We also acknowledge Erin Papworth and Togo. FAMME, BP 12.321 Ville, Lomé, Togo. Conseil National de Lutte Benjamin Liestman for their support in implementing these studies. contre le SIDA et les IST, 01 BP 2237, Lomé 01, Togo. Received: 30 August 2017 Accepted: 8 January 2019 Funding This work was supported by the USAID and Project SEARCH, Task Order No. 2, is funded by the US Agency for International Development under Contract No. GHH-I-00-0700,032-00, beginning September 30, 2008, and supported by References the President’s Emergency Plan for AIDS Relief. The Research to Prevention 1. Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001;27: (R2P) Project is led by the Johns Hopkins Center for Global Health and man- 363–85. aged by the Johns Hopkins Bloomberg School of Public Health Center for 2. Deacon H. Towards a sustainable theory of health-related stigma: Communication Programs (CCP). SDB is supported by a grant from the Na- lessons from the HIV/AIDS literature. J Community Appl Soc Psychol. tional Institute of Mental Health (R01 MH110358-02). The funding body had 2006;16:418–25. no role in the design of the study or collection, analysis, and interpretation 3. 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RESEARCH ARTICLE Open Access Uptake of HIV testing in Burkina Faso: an assessment of individual and community- level determinants Fati Kirakoya-Samadoulougou1*, Kévin Jean2,3,4 and Mathieu Maheu-Giroux5
Abstract Background: Previous studies have highlighted a range of individual determinants associated with HIV testing but few have assessed the role of contextual factors. The objective of this paper is to examine the influence of both individual and community-level determinants of HIV testing uptake in Burkina Faso. Methods: Using nationally representative cross-sectional data from the 2010 Demographic and Health Survey, the determinants of lifetime HIV testing were examined for sexually active women (n = 14,656) and men (n = 5680) using modified Poisson regression models. Results: One third of women (36%; 95% Confidence Interval (CI): 33–37%) reported having ever been tested for HIV compared to a quarter of men (26%; 95% CI: 24–27%). For both genders, age, education, religious affiliation, household wealth, employment, media exposure, sexual behaviors, and HIV knowledge were associated with HIV testing. After adjustment, women living in communities where the following characteristics were higher than the median were more likely to report uptake of HIV testing: knowledge of where to access testing (Prevalence Ratio [PR] = 1.41; 95% CI: 1.34–1.48), willing to buy food from an infected vendor (PR = 2.06; 95% CI: 1.31–3.24), highest wealth quintiles (PR = 1.18; 95% CI: 1.10–1.27), not working year-round (PR = 0.90; 95% CI: 0.84–0.96), and high media exposure (PR = 1.11; 95% CI: 1.03–1.19). Men living in communities where the proportion of respondents were more educated (PR = 1.23; 95% CI: 1.07–1.41) than the median were more likely to be tested. Conclusions: This study shed light on potential mechanisms through which HIV testing could be increased in Burkina Faso. Both individual and contextual factors should be considered to design effective strategies for scaling-up HIV testing. Keywords: HIV/AIDS, Contextual determinants, Human immunodeficiency virus, Multilevel models, Voluntary counselling and testing, West Africa
Background care [2], and testing is considered one of the most cost- HIV testing uptake is a key component of UNAIDS’ newly effective ways to decrease HIV transmission [3, 4]. adopted strategic framework. This framework calls for However, across sub-Saharan African countries, high pro- 90% of people living with HIV (PLWH) being aware of portions of PLWH are still unaware of their status, with their status (diagnosed), 90% of those diagnosed receiving large within-country variations [5]. Important HIV testing treatment, and 90% of those receiving treatment being scale-up efforts, and subsequent rapid linkage to care [6], virally suppressed by 2020 (i.e., the 90–90-90 objective) are thus needed to reach UNAIDS’ objectives [7]. [1]. Voluntary counseling and testing (VCT) services for Expanding HIV testing requires a fine understanding HIV represents the main entry point for prevention and of the individual and contextual variables that can act as barriers or facilitators to its uptake. Some individual * Correspondence: [email protected] predictors of HIV testing uptake, including wealth and 1Centre de Recherche en Epidémiologie, Biostatistiques et Recherche Clinique, École de Santé Publique, Université Libre de Bruxelles, Brussels, education, have been consistently identified across sub-- Belgium Saharan Africa [8–15]. On the other hand, factors such Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kirakoya-Samadoulougou et al. BMC Public Health (2017) 17:486 Page 2 of 11
as sexual behaviors, and knowledge and attitudes toward housing census conducted in 1996 (the average cluster HIV/AIDS have been found to be more variable across populations were 1000 and 1200 in rural and urban areas, gender, as well as social and epidemiological settings [9, respectively). The second stage involved the systematic 16–21]. The health of individuals and their behaviors are sampling of households from the selected clusters. A shaped not only by individual factors, but also by the so- nationally representative sample of 14,957 households was cial environment’s structure in which they live [22, 23]. thus obtained. All women aged 15 to 49 years were eligible An analysis of the importance of contextual factors on to be interviewed. For men, a sub-sample of half of the health outcomes could allow for a better understanding selected households was randomly selected, from which of the complex linkage between individual and contextual all men aged 15 to 59 were eligible to be interviewed. determinants of HIV testing uptake and, ultimately, lead Hereafter, the term community refers to all respondents to innovative community level interventions [24]. A previ- living within the same geographical environment, corre- ous study from eight African countries (not including Bur- sponding to the PSU of the survey. kina Faso) highlighted the association between HIV testing uptake and community-level demographic, eco- nomic, and behavioral determinants [25]. However, the Measures study only examined testing uptake among married men The main outcome for this study was the participants’ and efforts to assess community-level predictors of HIV self-reports of having ever been tested for HIV. Our inde- testing have been limited [18]. pendent variables were individual-level or community- HIV seroprevalence in Burkina Faso was estimated in level characteristics. 2010 at 1.2% and 0.8% among women and men, respect- Individual variables covering socio-demographical, eco- ively [26]. Substantial regional variations were observed, nomical and behavioral dimensions, as well as knowledge ranging from 0.2% in the Plateau Central to 2.0% in and attitudes toward HIV/AIDS, were considered in the Central. Nearly 60% of PLWH in Burkina Faso reported analyses. Socio-demographic covariates included: age, having never been tested for HIV [26], highlighting an education, marital status, religion, occupational status, important gap to reach UNAIDS’s targets. The govern- media exposure, location of residence (urban/rural), and ment of Burkina Faso - with international donors and an asset-based index of wealth [28]. The number of chil- many non-governmental organizations – have recently dren ever born was also included for women. Sexual introduced and implemented programs to increase testing behavior was measured by self-reported lifetime number [27]. In this context, improving our understanding of indi- of sexual partners. HIV/AIDS knowledge was assessed by vidual and contextual barriers to HIV testing could con- creating an index of correct responses to five (for men) tribute to its scale-up. and nine (for women) questions related to HIV transmis- This study aims to examine individual and community sion. Those sets of questions were summarized using prin- determinants associated with lifetime HIV testing in cipal component analysis, where the first axis explained Burkina Faso using a nationally representative sample of 34% and 32% of the variance for women and men, respect- Burkinabè men and women. Understanding HIV testing ively. This first axis was used to create a three-category uptake in relation to community characteristics, over index of HIV knowledge. Stigma towards PLWH was and above individual factors, may provide new insights proxied using a set of four questions included in the DHS into the dynamics of HIV testing and help the national questionnaires: 1) willingness to share a relative’sHIV HIV program to more efficiently allocate their resources. infection status, 2) willingness to care for an infected rela- tive, 3) belief that a female teacher infected with HIV Methods should teach, and 4) willingness to buy food from an HIV Data infected vendor. This choice of independent variables was This study uses data collected during the 2010 Burkina guided by prior research on HIV testing in sub-Saharan Faso Demographic and Health Survey (DHS), the first Africa countries [18, 25]. nationally-representative survey in Burkina Faso to The main explanatory community-level variables of inter- collect information on previous HIV testing among both est were: HIV prevalence, knowledge of HIV testing service, women and men. The survey protocol has been HIV/AIDS knowledge, HIV-related stigma (percentage of published elsewhere [26]. Briefly, the survey used a strati- respondents with accepting attitudes towards people living fied, two-stage cluster sampling design. The country was with AIDS), and community socio-demographic charac- stratified into rural and urban areas. Among each stratum, teristics (proportion of respondents who are at least the first stage consisted of a random sample of clusters high-school educated in the community, proportion of (primary sampling unit, PSU) using sampling probabilities households belonging to the poorest quintiles of wealth, proportional to the number of households in the cluster. and proportion of individuals reporting low media Clusters were established by a general population and exposure). Consideration of these variables was based Kirakoya-Samadoulougou et al. BMC Public Health (2017) 17:486 Page 3 of 11
on their potential to be modified and their known or to vary between women and men [32, 33]. Statistical hypothesized association with HIV testing [22, 25]. analyses were performed using the R statistical software Community-level variables were aggregated from indi- and the “geepack” package was used to fit the regression vidual responses pertaining to individuals of the same sex models [34]. and the same PSU (except for HIV prevalence which was aggregated at the regional level due to low number of Results cases). To avoid endogeneity problems related to the The sample of the 2010 Burkina Faso DHS consisted of double inclusion of variables in the model – firstatthe 14,536 households, among 14,957 identified ones (421 individual-level and again at the aggregate-level – households were unoccupied), and 17,087 women and community-level variables were calculated by excluding an 7307 men completed interviews. The participants’ individual’s own response from the numerator and denom- response rate was 98.4% for women and 97.3% for men. inator of the aggregate-level variables. Indicators from each Inferences are thus based on the analyses of 14,373 of the community-level determinants of HIV testing women and 5680 men who reported having had sexual uptake were dichotomized using the median as a cut-off intercourse and without missing observations. point. The stigma question regarding willingness to care for an infected relative was not considered at the commu- Characteristics of the study population nity level because preliminary analyses showed that, for The sociodemographic characteristics of the study popu- both women and men, the communities had low levels of lation are presented in Table 1. About half of the male stigma with small between-community variations that were participants were aged 35 years or older whereas only a not deemed qualitatively important. third of female respondents were in this age group. About two thirds of respondents had no schooling and Statistical analysis pproximatively 90% of women and 80% of men were For descriptive statistics at the individual and commu- married or living in a union. More than half were nity levels, estimates accounted for the complex survey Muslims and two thirds lived in rural areas. design using the sampling weights provided by DHS Among men and women, three-quarters of partici- [29]. Prevalence ratios (PR) were obtained using a modi- pants knew where they could get an HIV test (Table 2). fied Poisson regression model that used Generalized Men were more educated, had higher level of media Estimating Equation to take into account clustering of exposure, and higher HIV/AIDS knowledge than women. observations and perform the unbiased variance estima- Additionally, men were more likely to have views that stig- tion [30, 31]. We did not adjust for survey weighting in matized HIV/AIDS than women (21% vs. 9% expressed the regressions. Univariate and multivariable analyses stigmatizing views to all four stigma-related questions) of individual-level covariates were first conducted. A but few individuals had no stigmatizing views on all ques- complete case analysis was used and missing observa- tions (7% and 6% of women and men, respectively). tions for women (n = 385) and men (n = 100) were dis- regarded. This was followed by multilevel models HIV testing uptake integrating the community-level variables. All multi- The proportion of women reporting having ever been level models were adjusted for the following individual- tested for HIV was 35.6% (95% Confidence Interval [CI]: level covariates: age, education, number of children 32.9–37.4%) while this proportion was 10% lower for ever born (for women only), marital status, religion, men (25.6%; 95% CI: 24.2–26.6%). Among women hav- wealth index, place of residence, media exposure, HIV ing ever been tested, 90.8% have had an HIV test as part knowledge, lifetime number of sexual partners, and the of an antenatal care visit. HIV testing differed greatly four personal stigma questions. Two multilevel models geographically and was highest for both genders in the were fitted for both gender. The first multilevel model department of Central Region, where the capital adjusted for individual-level variables and each of the Ouagadougou is located, at 61.9% for women and 46.6% main community-level determinants hypothesized to be for men (Figs. 1a, b). Lowest uptake of HIV testing was related to the community variation in HIV testing sep- found in in the Sahel for women (16.4%) and the Boucle arately: 2010 HIV prevalence, knowledge about VCT du Mouhoun departments for men (13.9%). service, HIV/AIDS knowledge and HIV related stigma (model 1). The second multilevel model is fully Individual-level determinants of HIV testing uptake adjusted for all individual-level and community-level For both genders, uptake of HIV testing was associated variables enumerated above (model 2). Analyses were with age, education, religious affiliation, household wealth restricted to participants reporting having ever had index, being employed year-round, media exposure, sexual intercourse. All analyses were stratified by number of lifetime sexual partners, and level of HIV gender because attitudes toward HIV testing are likely knowledge (Table 3). The probability of having been tested Kirakoya-Samadoulougou et al. BMC Public Health (2017) 17:486 Page 4 of 11
Table 1 Socio-demographic characteristics of women and men was highest among women aged 15–24 and men aged participated in the Burkina Faso 2010 Demographic and Health 25–34 years. Having non-stigmatizing views on PLWH Survey was associated with HIV testing uptake but this was not Variables Women Men consistent for all stigma-related questions. For women, N Proportion (%)a N Proportion (%)b the number of children ever born was significantly associ- Age groups ated with HIV testing. 15–24 4403 30.3 1072 18.4 Community-level determinants of HIV testing uptake 25–34 5441 36.9 1791 31.4 Table 4 presents results of the community-level determi- ≥ 35 4914 32.9 2917 50.2 nants of HIV testing. For model 1, community-level Education determinants are adjusted only for selected individual- No school 11,393 78.0 3722 65.6 level variables. On the other hand, model 2 is fully Primary 1877 12.2 1076 18.5 adjusted for individual and all community-level determi- Secondary/higher 1488 9.9 982 15.9 nants listed in Table 4. Results from this fully adjusted model (model 2) suggested that women were signifi- Number of children ever born cantly more likely to report testing in communities 0 1655 11.3 where a larger percentage of respondents knew the loca- 1–2 4052 27.3 tion of a VCT service, where views towards buying food 3+ 9051 61.4 from HIV positive vendors were less stigmatizing, where Marital status the proportion of respondents in the highest wealth Married/in union 13,236 90.6 4528 79.5 quintile was higher, and in communities with the highest media exposure. Furthermore, women residing in com- Single 1522 9.4 1252 20.5 munity where the proportion of respondents not work- Religion ing year-round was higher than the median were 10% Muslim 8961 62.5 3458 61.0 less likely to report having ever been tested. For men, Christian 4330 28.6 1681 28.5 few community determinants reached statistical signifi- Animist/others 1426 8.6 635 10.4 cance for both model 1 and 2. Men were more likely to Missing 41 0.2 6 0.1 report previous testing in communities where respon- dents were more educated. Wealth index Poorest 2475 17.7 940 17.1 Discussion Poor 2747 19.3 1058 19.0 Using nationally representative data of sexually active Middle 2900 19.6 1032 18.1 women and men from Burkina Faso, we observed low Richer 3160 20.4 1182 19.3 levels of HIV testing uptake in 2010 with only a third of Richest 3476 23.1 1568 26.4 women and a quarter of men reporting having ever been tested for HIV. We identified several determinants of Place of residence HIV testing uptake acting at individual and community Urban 4385 25.2 1967 29.2 levels, and their effect often varied by gender. Individual Rural 10,373 74.8 3813 70.8 factors associated with HIV testing uptake included Working year-round socio-demographic, economic, behavioral factors as well Yes 3081 20.0 2133 36.8 as knowledge and attitudes related to HIV. Community- No 11,632 79.7 3633 62.9 level variables associated with HIV testing uptake were mostly related to education, wealth, occupational status, Missing 45 0.3 14 0.3 b media exposure, and stigma. Media exposure Our study identified various individual correlates of HIV Low (0–1) 6165 42.2 998 18.3 testing uptake. As previously documented, we observed Middle (2–3) 6271 42.1 3053 53.3 among both men and women that testing uptake increased High (4–6) 2258 15.4 1715 28.2 with educational level and wealth [13, 25, 35, 36]. Similarly, Missing 64 0.4 14 0.2 high HIV-related knowledge and access to broader infor- aProportions take into account sample weights mation channels, through media exposure, was associated bExposure to mass media was measured through a composite index of three with HIV testing [35–39]. These results highlight the survey items that assessed whether the respondent reads newspapers or importance of providing health education to both women magazines, listens to the radio, or watches television. The additive scale is split into a three-level categorical variable: low media exposure (score of 0–1), and men while deploying targeted efforts to reach popula- medium media exposure (2–3), and high media exposure (4–6) tions with low uptake of HIV testing. Some of the barriers Kirakoya-Samadoulougou et al. BMC Public Health (2017) 17:486 Page 5 of 11
Table 2 Knowledge of access to HIV testing, HIV knowledge, sex behaviors, and HIV stigma in women and men of Burkina Faso, 2010 Variables Women Men N Proportion (%)a N Proportion (%)a Access/HIV knowledgeb Know a place to get tested No 3345 24.3 1295 24.6 Yes 11,400 75.6 4481 75.3 Missing 13 0.1 4 0.1 HIV knowledge score Low 4888 34.2 1731 31.8 Medium 4881 34.6 1588 26.8 High 4867 30.4 2440 40.9 Missing 122 0.8 21 0.4 Sexual behavior Lifetime number of sexual partners 1 11,026 75.4 1169 21.4 2 2812 18.7 1454 26.0 3 or more 904 5.8 3121 51.9 Missing 16 0.1 36 0.7 Personal stigma If a relative would become HIV positive, No (stigma) 10,894 73.9 3193 57.6 willing to share his/her infection status Yes 3860 26.1 2587 42.4 Missing 4 0.0 0 0.0 Willing to care for an HIV positive relative No (stigma) 2314 16.5 473 9.3 in their own house Yes 12,443 83.5 5307 90.7 Missing 1 0.0 0 0.0 Believes that an HIV positive female teacher No (stigma) 5466 38.9 1917 35.4 (without symptoms) should teach Yes 9292 61.1 3862 64.4 Missing 0 0.0 1 0.0 Willing to buy food from an HIV positive vendor No (stigma) 9402 64.8 3078 56.2 Yes 5355 35.2 2694 43.6 Missing 1 0.0 8 0.1 aProportions take into account sampling weights bThe five (men) and nine (women) questions entering the HIV knowledge index are: people can protect themselves from contracting HIV by (1) using condoms; (2) having sex only with one faithful, uninfected partner; (3) people knowing that mosquitoes can’t transmit HIV and (4) that it cannot be transmitted by sharing food with an HIV-infected person; (5) a healthy looking person can have the AIDS virus; and, for women only, (6) people who report that HIV can be transmitted from mother to child during pregnancy, (7) delivery, and (8) through breastfeeding; and (9) know drugs to avoid AIDS transmission to baby during delivery and breastfeeding to HIV testing uptake that we identified in this study may living in communities with larger proportions of respon- be related to the HIV testing offer modalities, however. For dents with secondary/higher education. example, lower testing levels among participants living in We observed that uptake of VCT was generally rural areas may be related to lower accessibility of HIV higher among individuals with less stigmatizing views. testing sites in these regions. Decision-making about HIV testing are often linked to The present study expands upon previous literature by an individual’s social network influences and addressing providing evidence of gendered patterns of association HIV-related stigma could improve community norms between community determinants and HIV testing. Our about testing. The recent HPTN-043 ACCEPT cluster- results suggest that tested women were more likely to live randomized trial demonstrated how addressing HIV-related in communities with high access to testing resources/facil- community norms may translateintolowerHIV-related ities, where women are wealthier, and with better media stigma and increase uptake of HIV testing [40, 41]. This is exposure. For men, uptake of VCT was higher for those especially relevant for Burkina Faso where levels of stigma Kirakoya-Samadoulougou et al. BMC Public Health (2017) 17:486 Page 6 of 11
Fig. 1 Uptake of HIV testing in Burkina Faso. Proportion of a women and b men that reported having ever been tested for HIV in the country’s13 administrative regions in 2010. (Map is our own) Kirakoya-Samadoulougou et al. BMC Public Health (2017) 17:486 Page 7 of 11
Table 3 Univariate and multivariable analyses of individual-level determinants of HIV testing uptake, stratified by gender Variables Women (N = 14,373) Men (N = 5680) Univariate Multivariable Univariate Multivariable PRa (95% CI) PRa (95% CI) PRa (95% CI) PRa (95% CI) Socio-demographic Age groups 15–24 Referent Referent Referent Referent 25–34 1.06 (1.01–1.11) 0.87 (0.83–0.92) 1.21 (1.07–1.35) 1.20 (1.06–1. 35) >35 0.69 (0.65–0.74) 0.61 (0.57–0.66) 0.80 (0.71–0.90) 0.99 (0.86–1.14) Education No school Referent Referent Referent Referent Primary 1.80 (1.70–1.90) 1.16 (1.10–1.23) 2.22 (1.96–2.51) 1. 35 (1.18–1.54) Secondary/higher 2.53 (2.42–2.65) 1.29 (1.21–1.37) 4.83 (4.39–5.31) 2. 01 (1.76–2.30) Number of children ever born 0 Referent Referent Not applicable 1–2 1.33 (1.23–1.43) 1.63 (1.51–1.75) 3+ 0.93 (0.86–1.00) 1.78 (1.63–1.94) Marital status In Union Referent Referent Referent Referent Single 1.24 (1.17–1.32) 0.95 (0.89–1.01) 1.35 (1.23–1.49) 0.95 (0.86–1.06) Religion Muslim Referent Referent Referent Referent Christian 1.28 (1.22–1.34) 1.09 (1.05–1.14) 1.49 (1.36–1.62) 1.11 (1.03–1.20) Animist/others 0.72 (0.64–0.80) 0.99 (0.89–1.11) 0.49 (0.38–0.62) 0.79 (0.63–1.00) Wealth index Poorest Referent Referent Referent Referent Poorer 1.33 (1.19–1.48) 1.26 (1.13–1.40) 1.37 (1.04–1.81) 1.12 (0.85–1.47) Middle 1.48 (1.33–1.64) 1.30 (1.18–1.44) 2.02 (1.56–2.62) 1.50 (1.16–1.94) Richer 1.88 (1.70–2.08) 1.44 (1.31–1.59) 3.23 (2.54–4.12) 1.91 (1.48–2.46) Richest 3.28 (3.00–3.60) 1.57 (1.41–1.76) 6.69 (5.33–8.40) 1.90 (1.45–2.49) Place of residence Urban Referent Referent Referent Referent Rural 0.44 (0.42–0.46) 0.75 (0.71–0.80) 0.34 (0.31–0.37) 0.90 (0.80–1.01) Working year-round Yes Referent Referent Referent Referent No 0.62 (0.59–0.65) 0.90 (0.86–0.94) 0.48 (0.44–0.53) 0.86 (0.79–0.94) Media exposure Low Referent Referent Referent Referent Middle 1.39 (1.31–1.47) 1.13 (1.07–1.20) 1.66 (1.37–2.03) 1.23 (1.01–1.49) High 2.52 (2.38–2.67) 1.21 (1.13–1.30) 4.9 (4.06–5.93) 1.49 (1.20–1.84) HIV knowledge Low (1–3) Referent Referent Referent Referent Medium (4–5) 1.56 (1.46–1.66) 1.31 (1.23–1.39) 1.55 (1.32–1.82) 1.18 (1.00–1.38) High (6–7) 2.10 (1.98–2.23) 1.45 (1.37–1.54) 3.22 (2.81–3.68) 1.29 (1.12–1.49) Kirakoya-Samadoulougou et al. BMC Public Health (2017) 17:486 Page 8 of 11
Table 3 Univariate and multivariable analyses of individual-level determinants of HIV testing uptake, stratified by gender (Continued) Sexual behavior Lifetime sexual partners 1 Referent Referent Referent Referent 2 1.25 (1.19–1.32) 1.09 (1.04–1.14) 1.12 (0.96–1.31) 1.06 (0.93–1.22) 3 and + 1.71 (1.60–1.82) 1.18 (1.11–1.25) 1.59 (1.40–1.80) 1.22 (1.08–1.37) Stigma-related questions Willing to share a relative’s HIV infection status No (stigma) Referent Referent Referent Referent Yes 0.94 (0.89–0.99) 0.93 (0.89–0.98) 1.33 (1.22–1.45) 1.06 (0.98–1.14) Willing to care for an infected relative No (stigma) Referent Referent Referent Referent Yes 1.94 (1.78–2.12) 1.24 (1.14–1.36) 2.68 (2.06–3.48) 0.99 (0.73–1.34) Believe female teacher infected with HIV should teach No (stigma) Referent Referent Referent Referent Yes 1.91 (1.80–2.01) 1.16 (1.09–1.24) 2.97 (2.60–3.40) 1.32 (1.14–1.54) Willing to buy food from an infected vendor No (stigma) Referent Referent Referent Referent Yes 2.13 (2.04–2.23) 1.36 (1.29–1.43) 2.97 (2.68–3.29) 1.38 (1.23–1.56) Statistically significant results are bolded. aPrevalence Ratios (95% Confidence Interval)
Table 4 Multivariable analysis of community-level determinants of HIV testing uptake in Burkina Faso women and men Variable0073 Women (N = 14,373) Men (N = 5680) Model 1a Model 2a Model 1a Model 2a PR (95% CI) PR (95% CI) PR (95% CI) PR (95% CI) Community with higher HIV prevalence 0.97 (0.93–1.02) 1.00 (0.96–1.05) 1.06 (0.97–1.16) 1.06 (0.97–1.16) Community with higher knowledge 1.43 (1.36–1.50) 1.41 (1.34–1.48) 1.01 (0.92–1.10) 1.01 (0.93–1.11) of place to get tested Community with lower HIV/AIDS knowledge 0.96 (0.91–1.00) 1.01 (0.96–1.06) 1.03 (0.94–1.13) 1.04 (0.95–1.14) Community more willing to share a 1.02 (0.98–1.06) 1.01 (0.97–1.06) 0.97 (0.89–1.05) 0.97 (0.89–1.06) relative’s infection HIV status Community believing female teacher 1.18 (1.07–1.30) 1.01 (0.92–1.12) 0.84 (0.68–1.04) 0.81 (0.64–1.04) infected with HIV should teach Community more willing to buy food 2.17 (1.39–3.36) 2.06 (1.31–3.24) 0.83 (0.55–1.24) 0.91 (0.57–1.43) from an infected vendor Community with more educated respondents 1.17 (1.10–1.25) 1.01 (0.94–1.08) 1.24 (1.09–1.41) 1.23 (1.07–1.41) Community with higher proportion of 0.82 (0.77–0.87) 0.90 (0.84–0.96) 0.90 (0.79–1.03) 0.95 (0.82–1.10) respondents not working year-round Community with more respondents in the 1.29 (1.21–1.38) 1.18 (1.10–1.27) 1.10 (0.95–1.26) 1.00 (0.85–1.17) highest wealth quintile Community with higher media exposure 1.22 (1.15–1.30) 1.11 (1.03–1.19) 1.12 (0.97–1.28) 1.06 (0.91–1.22) Statistically significant results are bolded PR Prevalence Ratio, 95% CI 95% Confidence Interval aModel 1 has each community variable included separately in the model and adjusted for the following individual-level determinants: age, education, number of children ever born (for women only), marital status, religion, wealth index, place of residence, media exposure, HIV knowledge, lifetime number of sexual partners, and personal stigma. Model 2 is fully adjusted for all variables listed in the table and the individual-level determinants adjusted for in Model 1 Kirakoya-Samadoulougou et al. BMC Public Health (2017) 17:486 Page 9 of 11
were found to be high: only 7% of women and 5% of men providers, especially the adult male population [48]. expressed no stigmatizing attitudes about PLWH. Attempts to offer HIV testing outside health facilities may We acknowledge some limitations in this study. The thus be an effective way to increase uptake [49]. Especially, measures used in this paper were self-reported and self-testing for HIV may be a relevant option to be consid- therefore susceptible to social desirability biases. The use ered in contexts of high HIV-related stigma [50]. of cross-sectional data also makes the temporal sequences Reaching the undiagnosed PLWH in a timely manner between some covariates and testing uptake in this study is a crucial and necessary step for individuals to benefit unknowns. Furthermore, communities were defined based from antiretroviral treatment and to sustainably reduce on PSU memberships. Because social networks do not population-level HIV transmission [51, 52]. Implementing necessarily follow the dimensions of a PSU, we might have effective policies to address individual and community- under or overestimated effect size measures of the level barriers to testing is required to achieve this community-level determinants. Additionally, we were not objective. able to account for the availability and proximity of health infrastructures, as well as the quality of their health Abbreviations services. Finally, female sex workers and men who have CI: Confidence intervals; DHS: Demographic and Health Survey; HIV: Human immunodeficiency virus; PLWH: People living with HIV; PR: Prevalence ratios; sex with men, key populations at high risk of HIV acquisi- PSU: Primary sampling unit; VCT: Voluntary counselling and testing tion and transmission, could be underrepresented in population-based household surveys such as this one. Acknowledgments Strengths of this study included its large sample size and We thank the DHS Program for access to the Burkina Faso Demographic ’ ’ high response rate. To our knowledge, this study is the Health Survey s unrestricted data files. MMG s research is supported by the Bisby prize and a postdoctoral fellowship from the Canadian Institutes of first to identify correlates of HIV testing uptake among a Health Research. nationally-representative sample of the Burkinabè popula- tion. Furthermore, by aggregating data at the PSU level we Funding examined community-level determinants while avoiding This study did not receive funding. issues of ecological fallacy. Availability of data and materials The dataset containing individual-level records are in the public domain and Conclusions can be obtained from The DHS Program (http://dhsprogram.com//). To reach UNAIDS’ 90–90-90 target, HIV testing in Burkina Faso should be considerably scaled-up in the coming Authors’ contributions years. Among individuals who were found to be HIV FKS developed the original study idea. FKS and MMG managed the positive in the 2010 seroprevalence survey, about 60% databases. MMG and KJ completed the data analyses. FKS, KJ, and MMG interpreted the results and wrote the manuscript. All authors read and reported having never been tested for HIV. This points approved the final manuscript. to a potentially important gap in the national response. Giventhatmorethan50%ofnewHIVinfectioninBurkina Competing interests Faso occur among stable couples [42], interventions to The authors declare that they have no competing interests. scale-up testing will need to focus on these partnerships. HIV testing interventions among members of key popula- Consent for publication tions, such as female sex workers and men who have sex Not applicable. with men, also warrants further consideration [43–46]. Ethics approval and consent to participate To increase HIV testing uptake, several interventions The survey received ethical approval from the Internal Review Board of ICF and policies could be considered. First, accessibility to International, in the USA, and from the Burkina Faso National Ethics HIV diagnosis should be improved in rural areas with Committee. Informed consent was obtained from all adult subjects or from their parents/guardian for minors. high HIV prevalence. Testing campaigns in particular have been shown to reach high population coverage and uptake. Furthermore, mobile HIV testing cam- Publisher’sNote paignsmaybeparticularlyeffectiveinincreasingHIV Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. testing coverage in rural settings, among men, and young adults [47, 48]. Socio-economic inequalities in Author details 1 HIV testing could be reduced by the implementation of Centre de Recherche en Epidémiologie, Biostatistiques et Recherche Clinique, École de Santé Publique, Université Libre de Bruxelles, Brussels, specific testing modalities such as the systematic prop- Belgium. 2Department of Infectious Disease Epidemiology, Imperial College osition of an HIV test by health care workers [12]. London, St Mary’s Hospital, London, UK. 3Laboratoire MESuRS (EA 4628), 4 However,restrictingtheofferofHIVtestingtohealth Conservatoire National des Arts et Métiers, Paris, France. Conservatoire National des Arts et Métiers, Unité PACRI, Institut Pasteur, Paris, France. facilities would not be sufficient to increase HIV testing 5Department of Epidemiology, Biostatistics, and Occupational Health, McGill among populations having few contacts with healthcare University, Montréal, Canada. Kirakoya-Samadoulougou et al. BMC Public Health (2017) 17:486 Page 10 of 11
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TAB 13 Méda et al. BMC Res Notes (2016) 9:373 DOI 10.1186/s13104-016-2183-3 BMC Research Notes
RESEARCH ARTICLE Open Access Patients infected by tuberculosis and human immunodeficiency virus facing their disease, their reactions to disease diagnosis and its implication about their families and communities, in Burkina Faso: a mixed focus group and cross sectional study Ziemlé Clément Méda1,2, Télesphore Somé3, Issiaka Sombié4,5, Daouda Maré6, Donald E. Morisky7 and Yi‑Ming Arthur Chen8,9*
Abstract Background: Patients facing tuberculosis (TB) and human immunodeficiency virus (HIV) infection receive particular care. Despite efforts in the care, misconceptions about TB and HIV still heavily impact patients, their families and com‑ munities. This situation severely limits achievement of TB and HIV programs goals. This study reports current situa‑ tion of TB patients and patients living with HIV/AIDS (PLWHA) facing their disease and its implications, by comparing results from both qualitative and quantitative study design. Methods: Cross sectional study using mixed methods was used and excluded patients co-infected by TB and HIV. Focus group included 96 patients (6 patients per group) stratified by setting, disease profile and gender; from rural (Orodara Health District) and urban (Bobo Dioulasso) areas, all from Hauts-Bassins region in Burkina Faso. Quantitative study included 862 patients (309 TB patients and 553 PLWHA) attending TB and HIV care facilities in two main regions (Hauts-Bassins and Centre) of Burkina Faso. Results: A content analysis of reports found TB patients and PLWHA felt discriminated and stigmatized because of misconceptions with its aftermaths (rejection, emotional and financial problems), mainly among PLWHA and women patients. PLWHA go to healers when facing limited solutions in health system. There are fewer associations for TB patients, and less education and sensitization sessions to give them opportunity for sharing disease status and learn‑ ing from other TB patients. TB patients and PLWHA still need to better understand their disease and its implication. Access to care (diagnosis and treatment) remains one of the key issues in health system, especially for PLWHA. Indi‑ vidual counseling is centered among PLWHA but not for TB patients. With research progress and experiences sharing, TB patients and PLWHA have some hope to implement their life project, and to receive psychosocial and nutritional support. Conclusion: Despite international aid, TB patients and PLWHA are facing misconceptions effects. There is a need to reinforce health education towards patients and healers, inside community, health centers and associations, and for specific settings. International aid must be adapted to specific targets and strategies implementing programs.
*Correspondence: [email protected] 9 Center for Infectious Disease and Cancer Research (CICAR), Kaohsiung Medical University, Kaohsiung City, Taiwan Full list of author information is available at the end of the article
© 2016 Méda et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Méda et al. BMC Res Notes (2016) 9:373 Page 2 of 10
Maintaining psychosocial and nutritional support is crucial for better outcomes of medication adherence. Individual counseling has to be centered among TB patients and PLWHA. Keywords: Tuberculosis, HIV, Discrimination, Stigmatization, Healer, Gender, Preventive medicine, Global health
Background the support received, the geographical access to care, Tuberculosis (TB) and human immunodeficiency virus the poverty, and the experience about the use of health (HIV) infection remain among public health priorities services [17]. Moreover many HIV-infected patients do throughout the world. TB prevalence rate was 397 (179– not understand the importance of the diagnosis and may 654) per 100,000 populations with 20 % of cases tested look for alternative care, such as consulting village heal- HIV positive in 2009 [1]. The prevalence of HIV among ers [18]. adults aged 15–49 years in Burkina Faso was 2.1 % in The purpose of this study is to report the current situ- 2001 and 1.6 % in 2007 [2]. ation of TB patients and patients living with HIV/AIDS Facing high rates of TB and HIV infection, Burkina (PLWHA) facing their disease and its implications in Faso receives different aid from international (bilat- Burkina Faso. eral and multilateral) levels. Indeed, the financing of TB (90–100 %) [3, 4] and HIV (62.6 %) [4] programs are pri- Methods marily from international level (from bilateral and mul- Study setting tilateral cooperation, international non-governmental This cross sectional study was undertaken in health cent- organizations-NGOs mainly Global Found, and interna- ers and NGOs located in the Centre and Hauts-Bassins tional foundations and firms). Despite the efforts from regions of Burkina Faso. These two regions represent national and international levels, new TB cases are grow- about 40 % of the total annual TB cases nationwide, have ing to 2660 in 2006 at 3041 cases 2010 [1, 5]. The per- the highest HIV prevalence and have the largest number centage of TB treatment failure is growing with 7.0 % in of NGOs providing antiretroviral treatment (ART) in the 2007 and 8.5 % in 2009 [1, 5] with an estimated multi- country Ref. [5, 19]. drug resistance cases to anti-tuberculosis drugs (MDR- TB) 2009 among new pulmonary TB cases notified of 34 Study design (0–92) and among retreated pulmonary cases notified Cross sectional study using mixed method (qualitative of 88 (0–230) [1]. The percentage of population in need and quantitative) was used; TB and HIV co-infected of treatment with access to antiretroviral drugs in Bur- patients were excluded. The qualitative study was been kina Faso was 60 % in 2009 [2]. There is a need to deeply conducted before the quantitative one; it highlighted the understand the specific context and needs about TB and attitudes and opinions of the interviewees. The quantita- HIV infection. tive study measured the amount of interviewees who had Misconceptions exist related to the knowledge, atti- a certain behavior. tude, perception and practices about TB at the individual and community level [6–13]. The consequences of the The qualitative study design misconceptions are discrimination and stigmatization Planned for the period from 2nd to 10th July 2010, a total and the interpretations of the illness and the wellness of 16 focus groups were held with 6 persons per group. about TB and HIV infection in rural and urban commu- Patients were selected in Hauts-Bassins region, both nity. Additionally, this can lead to lack of compliance in from rural area (Orodara Health District) and urban continuing treatment [14] resulting in drug resistance. area (Bobo Dioulasso). These patients were not involved The percentages of confirmed TB multi-drug resistance in design of the quantitative study. Patients were strati- (MDR-TB) among the TB cases tested for MDR-TB in fied into groups by setting and by gender. The 16 focus 2009 and 2010 are growing with 34 and 39 % respectively groups included 2 TB female and 2 TB male groups from [1]. the rural area; 2 TB female and 2 TB male groups from Women facing TB infection fear more the psycho- urban area; 2 patients living with HIV/AIDS (PLWHA) social consequences and their social isolation [15, 16] male and 2 PLWHA female groups from rural area; 2 than the actual disease itself. Issues related especially to PLWHA male and 2 PLWHA female groups in urban TB infection, additional problems include the TB case area. The group members were recruited with the help of management (the organization around the case diagno- health workers who informed the patients and negotiated sis, the treatment, and the care), the characteristics of the appointment time. Another appointment was nego- the patient, the patient in his community and his family, tiated for the focus group. The place of the focus group Méda et al. BMC Res Notes (2016) 9:373 Page 3 of 10
was in the TB detection and treatment Center (TDTC) The quantitative study design for the TB patients and the NGOs for the PLWHA. The In the Centre region, TB patients were identified from focus group were conducted to emphasize relevant ques- data provided by the National TB Diagnosis, Treat- tions related to attitude, beliefs, stigmatization, relation ment and Research Centre, and by the Health Districts patient-to-patient, community support. PLWHA with TB (HDs), of Boulmiougou, Baskuy, Sig-Noghin, Bogo- co-infection were excluded. dogo, and Nongr-Massom. In the Hauts-Bassins region, A standardized list of open-ended questions was used TB patients were identified from data provided by the for discussions. This list was created by using themes Regional TDTC, Souro Sanou National Teaching Hospi- retained for the discussions. Some of these themes tal (SSNTH) and by theHDs of Orodara, Do, Dafra, Lena, derived from individuals interviews we undertake prior Houndé, and Karangasso-Vigué. the focus group discussions. Some of the themes used PLWHA patients were identified from data provided by are listed below: patient reaction to disease diagnosis, various NGOs and HDs, which were the same as those perception of the disease (self-esteem, quality of life, con- for the TB patients. The NGOs were the Association- tamination by disease, prevention of the disease, hope Espoir-Vie (AES) and Responsabilité-Espoir-Vie-Solidar- of the patients, etc.); the life experiences and the shar- ité (REVS+) from Bobo Dioulasso in the Hauts-Bassins ing of the disease status; the aspects related to gender; region and the Association des Jeunes pour la Promotion the behavior patient-others-patient; the observance of des Orphelins (AJPO) from Ouagadougou in the Centre the treatment (difficulties, constraints, life experiences, region. HIV and TB statuses were confirmed from the etc.); diagnosis and treatment costs; changing needs due medical records of each patient. to the disease (family support/aid, participation in social The sample size was calculated using the online sam- activities, work status, etc.); and the relationships and the ple size calculation software provided by RASOFT [24]. future of the patient. A common margin of 5 % was used. Thus a confidence Discussion on a specific topic area continued until no level of 95 % was chosen, with a response distribution of new information was generated. Group discussions were 50 % and a power of 80 %. The distribution was assumed tape-recorded and transcribed, and themes were identi- to be normal and, knowing that the total TB cases for the fied through independent content analysis of the tran- regions were 1832 in 2008 [5, 19], the smallest TB sample scriptions and assistant moderator notes. size expected was 316 TB cases for the two regions. In One moderator with great experience in focus groups, terms of HIV sample size, the normal rule of having one facilitated all the discussions undertaken in local lan- case for at least two controls was applied, thus at least guage (Dioula) or in French. He was assisted by a nurse 600 HIV cases were needed. also fluent in Dioula and French. We used a focus group This study has been planned for the period from 1st guide, ensured consistent data collection across groups to 30th August 2010 after advice and guidance were and provided flexibility to obtain clarification [20, 21]. obtained from the National TB program of Burkina Faso, To minimize ‘social desirability’ [22], participants were together with expert opinion from the West African reminded that the facilitators had no link with the health Health Organization. department. They were not working in the health centers A consecutive (successive) method was used for patient and associations-NGOs concerned by the survey. recruitment. The inclusion criteria were met when the Focus groups were audio recorded and transcribed patient was a confirmed TB case from a TB clinic and verbatim for analysis using a computer-based qualitative was undergoing anti-tuberculosis treatment. Similar cri- software program (QSR NVIVO 2.0). All French tran- teria were used for HIV cases from AIDS clinics under scripts were translated in English by the moderator to HAART. The patients were required to be 15 years or ensure accuracy. older and living in the study setting. Cases from both Content analysis was run by examining the major sexes were included. After the cases were identified, this themes and patterns that emerged from the data, using study included two profiles of patients: HIV infected ‘Concept Analysis’, an inductive approach for construct- patients and TB patients only. The co-infected patients ing and confirming theory through systematic data cod- for TB and HIV are excluded. ing [23]. After obtaining informed consent from each patient, To control for subjectivity during analysis and ensure a face to face interview was conducted using a semi- inter-coder agreement, two researchers independently structured questionnaire. For that, we used the infor- coded the data and then the two researchers compared mation gathered by qualitative study to elaborate the the results. Inconsistencies and disagreements in coding semi-structured questionnaire consisting of two parts: were discussed and resolved before final analysis. the socio-demographic information of the patient and Méda et al. BMC Res Notes (2016) 9:373 Page 4 of 10
general questions about the self and social experience of and costs of diagnosis and treatment, and patient needs the disease: adapted attitude index [25], adapted percep- and perspectives. tion index (discrimination, stigma and isolation) [26], Both results have been presented using ad-hoc and awareness of disease transmission. Additional infor- approach. mation was gathered about psychosocial and behavioral information. Research approval and ethics The interviewer recorded and completed the individ- The present study was approved by the Research Ethics ual’s information during the interview (15–20 min). The Committee of Burkina Faso and the Ministry of Health in remaining section of the questionnaire lasted approxi- July 2010. These approvals contributed a lot for the carry- mately 25–30 min. ing out of the study in the Target regions. Before conducting the final survey, the question- Informed consent of the interviewees was sought and naire underwent pre-testing in order to reduce bias granted. Also, participants’ anonymity and confidential- and to better control the time needed to complete the ity were ensured. questionnaire. The data was entered into EPIDATA and analyzed Results using the SPSS PC statistical package, version 18.0. The Participants and samples characteristics cut-off point for continuous variables was the median. The qualitative study has been conducted from 7th to The level of significance was 0.05. A comparison of the 14th July 2010. Table 1 shows the characteristics of the 96 variables, between the HIV only infected patients and participants recruited to the qualitative design study. those having tuberculosis, was carried out using the Chi About the quantitative study conducted from 1st square test for categorical data and t test for continuous August to 8th October 2010, a total of 862 patients, data. The p value is identified significance between TB including 309 (35.8 %) TB patients and 553 (64.2 %) and HIV patients. PLWHA participated in this study. 52.0 % were from Hauts-Bassins region and 48.0 % from Centre region. The mixed methods design strategies There was no difference statistics between both Cen- An initial phase of qualitative data collection and analysis tre and Hauts-Bassins settings; even the Hauts-Bassins has been conducted and followed by a phase of quantita- region is more rural than the Centre region. In brief, the tive data collection and analysis: sequential exploratory mean age of the PLWHAs was 36.5 ± 10.6 years old, and design. The purpose was to specify and quantify findings 57.1 % were female gender (see Table 2 for more details). from other methods. From the attributes used for the qualitative study, the Triangulation of results from both quantitative same were used as the guidance for the redaction both and qualitative study qualitative and quantitative studies matching the trend For reactions facing to disease diagnosis, perception of of the results. The data were from the following themes the disease and experiences lived with the relatives of the or attributes: reactions to disease diagnosis, perception patient and his community about the disease, patients of the disease, experiences lived with the relatives of the from both quantitative and qualitative study perceived as patient and his community about the disease, aspects grave diseases and faced stigma, perceived bad attitude related to gender, sharing of the disease status and behav- towards TB/HIV and were discriminated against or iso- ior patient-others-patient, observance of the treatment lated. Related to gender, women were exposed to social
Table 1 Characteristics of study participants in the qualitative study Type of participants Focus group Gender Number of Zones Age [mean discussions (n 16) patients (n 96) represented (range)] = = TB 2 Male 12 Rural 34 (16–52) 2 Male 12 Urban 35 (17–56) 2 Female 12 Rural 32 (15–49) 2 Female 12 Urban 33 (16–50) Patients living with 2 Female 12 Rural 34 (17–58) HIV (PLWHA) 2 Female 12 Urban 34 (18–55) 2 Male 12 Rural 35 (16–54) 2 Male 12 Urban 37 (17–57) Méda et al. BMC Res Notes (2016) 9:373 Page 5 of 10
Table 2 Socio-demographic variables, association member status and cost of diagnosis and treatment by patient profile Items TB (n 309) HIV (n 553) Total (n 862) p* = = = Region Hauts-Bassins 150 (48.5) 298 (53.9) 448 (52.0) 0.151 Centre 159 (51.5) 255 (46.1) 414 (48.0) Area Rural 227 (73.5) 149 (26.9) 376 (43.6) <0.001 Urban 82 (26.5) 404 (73.1) 486 (56.4) Sex Female 87 (28.2) 405 (73.2) 492 (57.1) <0.001 Male 222 (71.8) 148 (26.8) 370 (42.9) Age group <36.5 years old 203 (65.7) 280 (50.6) 483 (56.0) <0.001 36.5 years old 106 (34.3) 273 (49.4) 379 (44.0) ≥ Education level No educated 144 (46.6) 270 (48.8) 414 (48.0) 0.579 Educated 165 (53.4) 283 (51.2) 448 (52.0) Profession Others 238 (77.0) 490 (88.6) 728 (84.5) <0.001 Private and public sector 71 (23.0) 63 (11.4) 134 (15.5) Member of health mutual No 305 (98.7) 534 (96.6) 839 (97.3) 0.099 Yes 4 (1.3) 19 (3.4) 23 (2.7) Member of association since you know your disease status No 286 (92.6) 263 (47.6) 549 (63.7) <0.001 Yes 23 (7.4) 290 (52.4) 313 (36.3) First choice for consultation when sick Healers 47 (15.2) 118 (21.3) 165 (19.1) 0.038 Clinics 262 (84.8) 435 (78.7) 697 (80.9) How expensive do you think TB diagnosis and treatment is in your country? Free of charge 175 (56.6) 0 (0.0) 175 (20.3) <0.001 Reasonably priced 47 (15.2) 27 (4.9) 74 (8.6) Somewhat/moderately expensive 63 (20.4) 204 (36.9) 267 (31.0) Very expensive 24 (7.8) 322 (58.2) 346 (40.1)
* The p values were performed based on the calculation of the Chi square test
and financial problems. HIV groups participated in edu- “spider”, are still perceived as grave diseases. At the cation and sensitization sessions related to activities from announcement of their status, all patients felt bad and associations-NGOs than TB patients. For both TB and associated the diagnosis to a death sentence. Moreo- HIV patients, treatment emerged as key challenge for ver, they expressed fear because they thought about the patients. Related to their needs and perspectives, PLWHA interpretation of the disease in the community: “having were more expressed than TB patients and support can TB means you may have HIV, and vice versa”. Indeed, be encouragement, advice, psychosocial support, food, 30.6 % of TB and PLWHA patients from the total sample health education, and home visits, was really helpful. All size feared that other persons would know their disease patients still hoped to receive support primarily in the status, especially about TB patients (37.5 %) as shown in form of medicines and supplemental nutrition. Table 4. TB and PLWHA patients faced stigma, perceived bad attitude towards TB/HIV and were discriminated or Reactions to disease diagnosis, perception of the disease isolated (Table 4). For TB and PLWHA patients in focus All patients were shocked hearing about having TB group, some symptoms such as losing weight, fatigue and or HIV. TB and HIV, locally called “white cough” and fever were perceived to indicate the existence of one of Méda et al. BMC Res Notes (2016) 9:373 Page 6 of 10
both TB and HIV infections. Some people with TB and Table 3 Description of the variables related to psycho- HIV infections had misconceptions of the way in which social and behavioral variables by patient profile they can transmitted the disease, for example, by simple Items TB HIV Total p* (n 309) (n 553) (n 862) contact, or from eating from the same plate or utensils. = = = The gravity of the HIV infection is greater expressed by Did your housing change since you know that you are sick? PLWHA patients who seek care with healers, as con- No 286 (92.6) 483 (87.3) 769 (89.2) 0.018 firmed by 21.3 % of PLWHA patients (Table 2); because Yes 23 (7.4) 70 (12.7) 93 (10.8) they think that medical facilities do not have solution for Do you lose your job because you are TB or HIV patient? them. No 270 (87.4) 492 (89.0) 762 (85.3) 0.099 Yes 39 (12.6) 61 (11.0) 131 (14.7) Experiences lived with the relatives of the patient and his Do you stay away from people in order to avoid rejection? community about the disease Totally agree 14 (4.5) 2 (0.4) 16 (1.9) <0.001 Across all focus groups, TB patients and PLWHA felt Rather agree 53 (17.2) 55 (9.9) 108 (12.5) that their friends and relatives distanced themselves after Neutral 75 (24.3) 262 (47.4) 337 (39.1) learning their status. They still perceived stigmatization Rather disagree 78 (25.2) 232 (42.0) 310 (35.9) and some (more related to PLWHA) lost their home and Totally disagree 89 (28.8) 2 (0.4) 91 (10.6) job because of their status. Indeed, about 93 (10.8 %) Do you think that you will share you TB or HIV disease experience with oth- patients had to change their housing after contracting ers patients? their illness. Indeed, up to 12.7 % of PLWHA patients Totally agree 147 (47.6) 8 (1.4) 155 (18.0) <0.001 pointed out this fact (Table 3). There was a proportional Rather agree 94 (30.4) 200 (36.2) 294 (34.1) difference between patient groups (p = 0.018). Unfortu- Neutral 44 (14.2) 87 (15.7) 131 (15.2) nately, 131(14.7 %) patients revealed that they had lost Rather disagree 21 (6.8) 233 (42.1) 254 (29.5) their job following their disease diagnosis (Table 3); there Totally disagree 3 (1.0) 25 (4.5) 42 (3.2) was no proportion difference between patient groups Do you ask your partner to use the condoms during the sexual intercourses? (p = 0.484). Up to 683 (79.2 %) of TB and PLWHA hid Never 171 (55.3) 309 (55.9) 480 (55.7) 0.005 their disease status from others (Table 3); among the Almost never 27 (8.7) 15 (2.7) 42 (4.9) 683 TB patients and PLWHA who revealed their sta- Sometimes 44 (14.2) 36 (6.5) 80 (9.3) tus, 19.5 % informed their partners, 32.5 % informed Often 21 (6.8) 22 (4.0) 43 (5.0) family members, 15.4 % informed health workers, and All the time 46 (14.9) 171 (30.9) 217 (25.2) 23.7 % informed a staff of the association. Furthermore, Do you tell to someone something about your TB status? 668 (77.5 %) patients felt that the relatives and friends No 24 (7.8) 155 (28.0) 179 (20.8) <0.001 talked about them when they were not present (Table 3). Yes 285 (92.2) 398 (72.0) 683 (79.2) At least 124 (14.4 %) patients said that they stayed away Do you think that one says something about your status? from people in order to avoid rejection (Table 3); There Nothing 15 (4.9) 87 (15.7) 102 (11.8) <0.001 was proportion difference between patient groups Neutral 58 (18.8) 34 (6.1) 92 (10.7) (p < 0.001). Some patients recognized that not all people Something 236 (76.4) 432 (78.1) 668 (77.5) behaved this way, as revealed by focus groups. To avoid Do you think to receive the support from others? being discovered as TB patients, some of the TB patients, Not at all 32 (10.4) 60 (10.8) 92 (10.7) <0.001 mainly from rural setting, preferred to go outside their A little 102 (33.0) 111 (20.1) 213 (24.7) community for treatment because under DOTS, they will A moderate 73 (23.6) 134 (24.2) 207 (24.0) be identified as TB patients by the daily appointments at amount the health centers. Indeed 737 (85.5 %) patients agreed Very much 95 (30.7) 218 (39.4) 313 (36.3) that they were bothered by others because they are TB An extreme 7 (2.3) 30 (5.4) 37 (4.3) patients or PLWHA; and 58.2 % of PLWHA patients amount (were more concerned by this issue (Table 4). There was * The p values were performed based on the calculation of the Chi square test proportion difference between patient groups (p < 0.001). for categorical data Although all patients reported that they received infor- mation on how to avoid transmitting the disease to oth- ers; only 703 (81.6 %) patients were afraid of spreading 480 (55.7 %) patients never asked their partners to use the disease to others (Table 4). Indeed, up to 483 (56.0 %) condoms during sexual intercourse (Table 3). And, all patients never used condoms (Table 4). In addition, patients had on average, more than one sexual partner. Méda et al. BMC Res Notes (2016) 9:373 Page 7 of 10
Table 4 Comparison of psycho-social and behavioral Aspects related to gender aspects between TB and HIV patients Participants reported stereotypical gender roles and still Items TB HIV Total p* perceived stigmatization but less discrimination. Related (n 309) (n 553) (n 862) = = = to gender aspects, women remained financially depend- Are you afraid to transmit your disease to others? ent on their husbands and were subsequently exposed to Not at all 14 (4.5) 0 (0.0) 14 (1.6) <0.001 social and financial problems when having TB or HIV infec- Neutral 53 (17.2) 92 (16.6) 145 (16.8) tion. Women said they were abandoned by their husbands. A bit afraid 38 (12.3) 133 (24.1) 171 (19.8) Worse, they were more marginalized when their husbands Very afraid 137 (44.3) 241 (43.6) 378 (43.9) were suspected of having died of HIV. Widowed women Extremely afraid 67 (21.7) 87 (15.7) 154 (17.9) with HIV, even those abandoned by their husbands, faced Do you (your-self) regularly use condoms (female for female and male for emotional and economic burdens of the entire family. They male)? had to take care of children and household, and some times Never 173 (56.0) 310 (56.1) 483 (56.0) 0.003 of the husband when he was sick (from TB or HIV infec- Almost never 29 (9.4) 16 (2.9) 45 (5.2) tion). Men generally hid their status from their wives. More- Sometimes 48 (15.5) 45 (8.1) 93 (10.8) over, women complained that when they were infected by Often 17 (5.5) 22 (4.0) 39 (4.5) TB or HIV, their husbands did not take care of them. Rather, All the time 42 (13.6) 160 (28.9) 202 (23.4) husbands could be remarried when they were not sick. Do you fear that other persons know your disease status? From the quantitative data, TB patients and PLWHA Totally disagree 75 (24.3) 106 (19.2) 181 (21.0) <0.001 perceived isolation by their community (45.5 %) and from Rather disagree 49 (15.9) 140 (25.3) 189 (21.9) their family (53.2 %), as showed in Table 4; in addition, Neutral 69 (22.3) 199 (36.0) 268 (31.1) patient isolation was identified as an important issue for Rather agree 74 (23.9) 74 (13.4) 148 (17.2) women (38.1 %), but less so for men. The issue of isola- Totally agree 42 (13.6) 34 (6.1) 76 (8.8) tion was more emphasized by PLWHA in community, in Do you think that you will share your disease experience with others family and related to female gender. patients? Totally disagree 147 (47.6) 233 (42.1) 380 (44.1) <0.001 Sharing of the disease status and behavior Rather disagree 94 (30.4) 200 (36.2) 294 (34.1) patient‑others‑patient Neutral 44 (14.2) 87 (15.7) 131 (15.2) TB patients rarely shared their status or talked to other Rather agree 21 (6.8) 8 (1.4) 29 (3.4) TB patients. Indeed as TB patients said, there were less Totally agree 3 (1.0) 25 (4.5) 28 (3.2) associations-NGOS for them, and less education and Are you bothered because you are TB patient? sensitization sessions to give them opportunity to share Never 74 (23.9) 51 (9.2) 125 (14.5) <0.001 their disease status and to learn from other TB patients. Sometimes 68 (22.0) 132 (23.9) 200 (23.2) It was more common to hear from HIV groups that they Often 92 (29.8) 100 (18.1) 192 (22.3) participated in education and sensitization sessions All the time 75 (24.3) 270 (48.8) 345 (40.0) related to activities from associations-NGOs. Are TB and HIV patients isolated by their community? In the perspective of sharing TB or HIV disease expe- Yes 102 (33.0) 290 (52.4) 392 (45.5) <0.001 rience with others patients, about 440 (52.1 %) patients No 207 (67.0) 263 (47.6) 470 (54.5) said they would do it (Table 3). Are TB and HIV patients isolated by their family? Yes 101 (32.7) 358 (64.7) 459 (53.2) <0.001 Observance of the treatment and costs of diagnosis No 208 (67.3) 195 (35.3) 403 (46.8) and treatment Are TB and HIV female patients isolated by their family? Across the discussions, treatment emerged as key chal- Yes 92 (29.8) 236 (42.7) 328 (38.1) <0.001 lenge for TB patient. Even if the treatment is free of No 217 (70.2) 317 (57.3) 534 (61.9) charge, there is other problems: the long length of the Attitude index 14.0 1.8 9.4 4.2 11.0 4.1 <0.001 treatment, the daily geographical access to health center, (mean SD) ± ± ± ± the quantity and the size of the medicines, the injections Discrimination and 4.2 2.1 3.8 1.6 3.9 1.8 0.006 for those under retreatment, the need to not take break- isolation index ± ± ± (mean SD) fast before taking medicines, side effects of medicines, ± Stigma 9.4 2.5 6.3 1.9 7.4 2.6 <0.001 and the need to eat well 1 h after treatment. For PLWHA, (mean SD) ± ± ± they got aid from associations-NGOs for the treatment ± SD standard deviation and some medical and biological examinations. * The p values were performed based on the calculation of the Chi square test Patients were interviewed about the reasons why for categorical data and t test for continuous data patients would stop receiving the treatment. Reasons Méda et al. BMC Res Notes (2016) 9:373 Page 8 of 10
were: considering that patient was cured even if the treatment, need support from health workers and work- treatment was not finished (48.7 %); stigmatization by ers from associations-NGOs, etc.). Women with TB and entourage (46.3 %); having a problem of transportation HIV were especially vulnerable because they experienced (38.5 %); difficulty of going daily to the treatment center additional emotional and financial problems. (44.7 %); financial problems (24.6 %). Other reasons Related to perceptions, a study showed that 54.8 % had (29.1 %) were: physical weakness of the patient and need- negative attitudes and practices towards TB [6]. Miscon- ing help to go to health center, raining period/season, ceptions exist in such situation: patients stop treatment long distance and remote health area, beliefs, insufficient when the symptoms decrease [7] or when they feel bet- information and ignorance, travel, forgetting, too much ter [8], about the necessity to separate the utensils used pills to swallow, unwillingness to go to the health center. for eating in general population [9, 10] or hospitalization About the costs of diagnosis and treatment, the data of patients [10], about the erroneous transmission routes from quantitative study showed that 56.6 % of TB such as blood and sexual fluids [9] and hereditary trans- patients think it is free of charge whilst that is not at all mission [11]. For them, tuberculosis infection is incur- free for PLWHA (Table 2). Indeed 95.1 % of PLWHA said able and dangerous [12, 13], transmittable and associated that the costs were expensive (Table 2). with HIV/AIDS leading to the understanding that TB is a very dangerous disease [13]. The consequences of Patient needs and perspectives the misconceptions are stigmatization and social isola- All patients indicated that at the announcement of their tion of TB patients and their families [12]. For example results, they were very concerned about the future but, they in the study from Shrestha-Kuwahara and colleagues, were strongly encouraged by health workers (especially for TB patients felt that “Friends will run away from you.” TB patients) and counselors from associations-NGOs (for or “They point to you with a finger and say that you have PLWHA); they improved their mood or outlook. something ugly” [22]. According to Baral and colleagues, Related to social support and perspectives, only 2.7 % the causes of discrimination by members of the general of the patients were health insurance members (Table 2). public were the fear of a perceived risk of infection: per- 36.3 % of the patients were association’ members since they ceived links between TB and other causes of discrimina- know their disease status (Table 2); that was more the case tion particularly poverty and low caste, perceived links for PLWHA (52.4 %) and fewer for TB patients (7.4 %). between TB and disreputable behavior, and perceptions About the question “Do you think you need to receive that TB was a divine punishment [27]. Related to TB and support from others?”, 350 (40.6 %) of TB patients and HIV infections, one study in Zambia showed that there is PLWHA needed it (Table 3). About the question “From a new feature of stigma: a trigger for TB-HIV stigma [28]. whom do you receive support?”, TB patients pointed out That was the same feeling found in the present study and the support from relatives and family members (51.9 %) emphasized for PLWHA. and government through health facilities (67.6 %). About the use of traditional healers services, about PLWHA received support from association or NGOs 60–80 % of African people rely on traditional healers for (51.3 %) and relatives and family members (51.9 %). their health needs [29, 30]. Facing HIV infection, some of The support from the patient’s workplace was very low patients confided to the healers because they think that (4.9 %). the health facilities cannot save them from death; that During the focus group discussions, PLWHA expressed was the case in the present study. In Burkina Faso, a study that support from associations-NGOs, such as encour- showed strong correlation between consulting heal- agement, advice, psychosocial support, food, health edu- ers (first time being sick) and the region setting among cation, and home visits, was really helpful. HIV patients [18]. And about 15 % of traditional healers PLWHA and TB patients stated that they feel hope for said they do not refer patients to health centers [31]. This the future and have some ongoing projects. This positive shows the necessity to reinforce sensitization towards outlook was based on the hope in research and the pre- patients and healers related to HIV/AIDS for specific sent medical therapy, particularly because the situation in settings. the past was worse for PLWHA. All patients still hoped Related to gender aspects among TB patients, the find- to receive support primarily in the form of medicines and ings of the present study were confirmed by Onifade et al. supplemental nutrition. [32]. Indeed, the negative perceptions were the rejection and the burden on both sexes even if women reported Discussions feeling the burden of tuberculosis stigma more heavily This study shows that TB patients and PLWHA still than men [32]. Moreover according to Sudha and col- faced many problems and difficulties (discrimination and leagues, men and children were perceived to get prefer- stigmatization, need an access to disease diagnosis and ential attention by their families during illness [33]. For Méda et al. BMC Res Notes (2016) 9:373 Page 9 of 10
Weiss et al. [34] men frequently focused on financial with its aftermaths such as rejection and emotional and concerns. For women, a diagnosis of TB can have serious financial problems. That was more emphasized about repercussions for families and households [35]. PLWHA and women patients. With the research pro- Related to the observance of the treatment, Cor- gress and the experiences sharing, TB patients and less et al. found that treatment failure has been related PLWHA have some hope and would like to be able to to inappropriate regimens, the unavailability of drugs, implement their life project in future. There is a need to or lack of access to health care [36, 37]. Moreover, the reinforce health education towards patients and heal- adverse effects of anti-tuberculosis drugs, sex and occu- ers, inside communities, in health centers and NGOs pation are also predictive factors of successful treatment and associations, and for specific settings. The interna- [38]. In addition to the importance of the regimens and tional aid can be used for adapting to specific targets access to drugs, the patients in the present study pointed for an effective fight against TB and HIV infection. The out the importance of food. That was already emphasized need is to address issues regarding patients who drop by some studies which showed that the lack of food has out of care when they are no longer symptomatic and also been noted to impact treatment adherence [37, 39]. patients not regularly taking their medication, result- Regarding the needs, the prior support needed was finan- ing in drugs resistance and the spread of disease. This is cial, transportation and follow by psychological, social, med- one of the most important issues in controlling chronic ical and physiological factors [40]. That was pointed out in communicable diseases such TB and HIV in the world. the present study with additional point about food. Another In addition, it is crucial to maintain psychosocial and important need was the opportunity for sharing experi- nutritional support to TB patients and PLWHA in order ences with other HIV patient groups so that patients could to reach better outcomes of the medication adherence gain some hope from the associations and NGOs. Through and programs results. Individual counseling before, dur- associations and NGOs, PLWHA receive education and ing and after testing has to be centered among patients sensitization about their disease, and psycho-social support infected with TB. from other HIV patients with experience sharing. There is a need to re-organize health centers to consider this issue Abbreviations for TB patients. It is less the case for HIV patients for whom PLWHA: patients living with HIV/AIDS; NGO: Non-Governmental Organization; the guidelines foreseen individual counseling before, during MDR-TB: tuberculosis multi-drug resistance; ART: anti retroviral treatment; TDTC: TB detection and treatment Center; NTDTRC: National TB Diagnosis, and after the HIV test. TB and HIV patients face challenges Treatment and Research Center; HD: health district; SSNTH: Souro Sanou regarding how to maintain the gains, especially considering National Teaching Hospital; AES: Association-Espoir-Vie; REVS : Responsabil‑ + the financial constraints of principal donor in the field who ité-Espoir-Vie-Solidarité; AJPO: Association des Jeunes pour la Promotion des Orphelins; NTP: National TB program; WAHO: West African Health Organization. is unable to continue funding programs. Even though these findings are relevant, despite Authors’ contributions attempts to reduce biases by excluding co-infected All authors contributed to the study. MZC, MDE and CYMA initiated this study. All authors substantially contributed to the conception, design and feasibility patients and follow rigorous methodology, the interpreta- of the study. MZC and ST wrote the protocol and questionnaires used in the tions of these findings can be subject to criticisms linked study. ST, SI and MD tested the questionnaires. MZC coordinated the study. ST to the nature of the study using focus group and cross was responsible for management of data. MZC, ST and SI performed statistical analyses and presented results. All authors participated in interpretation of sectional design. The stratification of the patients per results. MZC, MDE and CYMA drafted the article. All authors critically revised group did not consider the status of the patient and its manuscript for important intellectual content and approved the final version. disease experience (example TB patient in retreatment). All authors read and approved the final manuscript. As observed by Shrestha-Kuwahara and colleagues, focus Author details group methodology is inherently limited in its generaliz- 1 Ministry of Health, Ouagadougou, Burkina Faso. 2 International Health ability to broader populations and the conclusions drawn Program, Institute of Public Health, Bobo Dioulasso, Burkina Faso. 3 Muraz Research Center, Bobo Dioulasso, Burkina Faso. 4 Research Office of West from this study apply only to the participating sites [22]; African Health Organization (WAHO), Bobo Dioulasso, Burkina Faso. 5 National and the focus group method does not allow specific attri- Institute of Health Sciences, Polytechnic University, Bobo Dioulasso, Burkina bution of responses to specific respondents, thus barring Faso. 6 Association Responsabilité-Espoir-Vie-Solidarité (REVS ), Bobo Diou‑ lasso, Burkina Faso. 7 Department of Community Health Sciences,+ University quantification of formation, but may recruit those who of California Los Angeles (UCLA), School of Public Health, Los Angeles, USA. were cooperative and willing to participate in the study. 8 Department of Microbiology and Institute of Medical Research, Kaohsiung Medical University, Kaohsiung City, Taiwan. 9 Center for Infectious Disease Conclusions and Cancer Research (CICAR), Kaohsiung Medical University, Kaohsiung City, Taiwan. Burkina Faso receives different aid from international (bilateral and multilateral) level. It still remains that TB Acknowledgements The authors wish to thank all subjects who participated in this study. Addition‑ patients and PLWHA are subject to some key issues fac- ally, we wish to thank the peer educators and social workers from the NGOs, ing their disease: stigmatization due to misconceptions and the health workers from public clinics for their assistance in collecting the Méda et al. BMC Res Notes (2016) 9:373 Page 10 of 10
questionnaires. We greatly appreciate the assistance provided by the staff of 19. PNT. Programme National de lutte contre la tuberculose (PNT): Rapport the International Health Program at National Yang-Ming University, Taiwan. sur la surveillance de la co-infection tuberculose-VIH 2008. Ministère de la Finally, we would like to express special thanks to Mr. Yahaya Nombré for super‑ Santé, Burkina Faso. 2009. vising the data collection; to Mr. Ibrahima R. Diallo for creating the EPIDATA file 20. Krueger R. Focus groups: A practical guide for applied research. 2nd ed. for the study; and to Mr. Cyprien Diarra and Mr. Bakyono François for entering Thousand Oaks: Sage Publications; 1994. the data. 21. Dudley T, Phillips N. Focus Group Analysis. A guide for HIV community planning group members. University of Texas Southwestern Medical Competing interests Center Web site. http://www8.utsouthwestern.edu/vgn/images/portal/ The authors declare that they have no competing interests. cit_56417/19/62/205397Guide_for_Focus_Group_Analysis.pdf. 22. Shrestha-Kuwahara R, Wilce M, DeLuca N, Taylor Z. Factors associ‑ Received: 8 June 2014 Accepted: 23 July 2016 ated with identifying tuberculosis contacts. Int J Tuberc Lung Dis. 2003;7(12):S510–6. 23. Strauss AL. Qualitative analysis for social scientists. Cambridge: Cam‑ bridge University Press; 1987. 24. RASOFT. A sample size calculation software online. RASOFT. 2011. http:// www.raosoft.com/samplesize.html References 25. WHO. Advocacy, communication and social mobilization (ACSM) for 1. WHO. Tuberculosis country profiles: Epidemiology and strategy, case of tuberculosis control: a handbook for country programmes. WHO Stop Burkina Faso 2009 and 2010. 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TAB 14 Bakiono et al. BMC Public Health (2015) 15:1119 DOI 10.1186/s12889-015-2444-4
RESEARCH ARTICLE Open Access Quality of life in persons living with HIV in Burkina Faso: a follow-up over 12 months Fidèle Bakiono1*, Patrice Wendpouiré Laurent Guiguimdé2, Mahamoudou Sanou2, Laurent Ouédraogo2,3 and Annie Robert1
Abstract Background: In Burkina Faso, very little is known about the quality of life of persons living with HIV through their routine follow- up. This study aimed to assess the quality of life of persons living with HIV, and its change over a 1-year period. Methods: Four hundred and twenty four (424) persons living with HIV were monitored during twelve (12) months from September 2012 to September 2013 in Ouagadougou, the capital city of Burkina Faso. Three interviews were conducted in order to assess the quality of life of patients and its change over time, using the World Health Organization Quality of Life assessment brief scale in patients with Human Immunodeficiency Virus infection (WHOQOL HIV-BREF). The Friedman test was used to assess significant differences in quantitative variables at each of the three follow-up interviews. Groups at baseline, at 6 months and at 12 months were compared using Wilcoxon signed rank test for quantitative data and McNemar test for qualitative variables. Pearson Chi2 was used when needed. Multivariable logistic regression models were fit to estimate adjusted odds ratio (OR) and 95 % confidence intervals (95 % CI). Trends in global quality of life score and subgroups (status related to Highly Active Anti Retroviral Treatment (HAART) using univariate repeated measures analysis of variance were assessed. A p-value less than 0.05 was considered significant. Results: At baseline, quality of life scores were highest in the domain of spirituality, religion and personal beliefs (SRPB) and lowest in the environmental domain. This trend was maintained during the 12-month follow-up. The global score increased significantly from the beginning up to the twelfth month of follow-up. Over the 12 months, the baseline factors that were likely to predict an increase in the global quality of life score were: not having support from relatives for medical care (P = 0.04), being under HAART (P = 0.001), being self-perceived as healthy (P = 0.03), and having a global quality of life score under 77 (P < 0.001). Conclusions: Our findings suggest the need to promote interventions to empower people living with HIV/AIDS through income generating activities. Such activities will enhance the quality of life of persons living with HIV in Burkina Faso. This could focus mostly on treatment-naïve HIV patients, lacking support from relatives and those who perceive themselves as ill. Keywords: Quality of life, HIV/AIDS, Burkina Faso, WHOQOL HIV-BREF
* Correspondence: [email protected] 1Pôle Epidémiologie et Biostatistique, Institut de Recherche Expérimentale et Clinique (IREC), Faculté de Santé Publique, Université catholique de Louvain, Clos Chapelle-aux-Champs 30, 1200 Brussels, Belgium Full list of author information is available at the end of the article
© 2015 Bakiono et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Bakiono et al. BMC Public Health (2015) 15:1119 Page 2 of 10
Background up interviews, this sample size was increased by 10 %, giv- Epidemiological studies have shown that early treatment ing a total sample size rounded up to 424 PLWHA. The of persons living with HIV/AIDS (PLWHA) using number of interviewees per structure was determined ac- Highly Active Anti-Retroviral Treatment (HAART) sub- cording to the size of the structure. The numbers were stantially reduces their risk of transmitting the virus 150, 135, 64, 39 and 36, respectively for the DHB, the Day and/or developing HIV-related illness [1, 2]. HAART Hospital Unit, the CICDoc, the AAS and the ALAVI. In has also proven its efficacy in PLWHA by decreasing each facility, recruitment was done through the daily rou- HIV-associated mortality and morbidity rates [3]. Given tine check-up, using a systematic sampling technique. Se- the improved life-expectancy of people living with HIV, lected patients were then followed for 12 months. To there is a need to assess their quality of life on a long assess the quality of life, the World Health Organization’s term basis. In Burkina Faso, UNAIDS reported in 2012 a Quality of Life HIV brief scale [WHOQOL HIV- BREF] seroprevalence of 1.1 % in the general population [4]. [7], the short version of the World Health Organization’s The same year, 45000 PLWHA were under HAART, Quality of Life HIV [WHOQOL HIV] [8] was used. The which accounted for 45 % of the total estimated number following reasons justified the choice of this scale: 1) the of PLWHA in need of treatment [4]. A previous cross scale is specific to PLWHA; 2) by its length (31 questions), sectional study on the quality of life of PLWHA, with or the WHOQOL HIV-BREF is well suited for investigation without treatment, showed that treated individuals were and for routine consultation; 3) French is the official lan- likely to have a better quality of life compared to treat- guage in Burkina Faso and there is a validated French ver- ment naïve-infected subjects in Burkina Faso [5]. Another sion of the WHOQOL HIV-BREF [9]; 4) Moore is the longitudinal study which assessed the quality of life of per- national language spoken by the majority of Burkinabe sons initiating the treatment showed the trends of their [10], and a Moore version of WHOQOL HIV-BREF with quality of life over a 12-month period [6]. However, very good psychometric properties is available [11]; and 5) un- little is known about the trend of the quality of life over like most quality of life assessment scales, which are usu- time in untreated PLWHA compared to treated patients. ally developed in the western world, the WHOQOL HIV Exploring quality of life trends in treated and untreated and its short version were developed in centers around patients will help the health care system develop adapted the world, including two centers in Africa, making them strategies to better manage the PLWHA in low-income cross-culturally sensitive [12]. The reliability of the scale countries. used in our study was assessed through the internal This study aimed to assess the quality of life of persons consistency using the Cronbach’salpha. living with HIV in Burkina Faso, in their routine follow- The WHOQOL HIV- BREF is a scale with 31 ques- up and its change over time. tions asking the respondent to assess his/her own quality of life in various ways during the 2 weeks preceding the Methods survey. It explores six domains of the quality of life A longitudinal study was conducted from September (physical, psychological, level of independence, social re- 2012 to September 2013, in Ouagadougou, capital city of lationships, environment and spirituality, religion, and Burkina Faso, in the following five healthcare facilities, personal beliefs (SRPB)). Each domain explores a certain chosen for the high number of PLWHA under their number of facets of daily life. The physical domain refers care: two (2) public healthcare facilities (under the na- to pain and discomfort, energy and fatigue, sleep and tional healthcare system) and three (3) community-based rest, as well as symptoms of HIV. The psychological do- healthcare organizations. The public healthcare facilities main includes positive feelings thinking, learning memory were as follows: the District Hospital of Boulmiougou and concentration, self-esteem, body image and appear- (DHB) and the University Hospital Yalgado Ouédraogo ance, and negative feelings. As for the level of independ- (UHYO, Day Hospital Unit). The community-based orga- ence domain, it explores mobility, activities of daily living, nizations were as follows: the Center for Information, dependence on medication or treatments, and work cap- Counseling and Documentation on AIDS and Tubercu- acity. The social relationships domain covers personal re- losis (CICDoc), the Association African Solidarity (AAS), lationships, social support, sexual activity and social and the Association Laafi la Viim (ALAVI). The PLWHA inclusion. The environment domain refers to physical followed up by these five (5) facilities accounted for safety and security, home environment, financial re- 35.03 % of the cohort followed up nationwide. sources, health and social care (accessibility and quality), Based on a 95 % confidence level, assuming that 50 % of opportunities for acquiring new information and skills, PLWHA should experience an increase in their quality of participation in and opportunities for recreation/leisure life during the 12-month follow-up, with 5 % precision, activities, physical environment (pollution, noise, traffic, the required sample size was 385. In order to account for climate), and transport. Finally, the spirituality, religion the possibility of patients who will not attend the follow- and personal beliefs domain includes spirituality, religion Bakiono et al. BMC Public Health (2015) 15:1119 Page 3 of 10
and personal beliefs, forgiveness and blame; concerns duration under treatment was 5 ± 3.1 years. Approxi- about the future; as well as death and dying. mately 1/3 of the respondents did not attend school. Just Answers to the questions were rated on a Likert scale over half of the patients (50.7 %) worked in small trading from 1 (very negative) to 5 (very positive). Twenty-nine or in the informal sector. Over 80 % (81.4 %) of the re- questions were used to construct a score per domain spondents had shared their HIV status with a family and an global quality of life score. The score of a specific member. domain was obtained by multiplying the average score of Out of the 424 people at baseline, 351 took part in the the domain by 4, leading to scores ranging from 4 to 20. last interview (month 12). When comparing the charac- One question explores quality of life in general and an- teristics of respondents who participated in the last other one explores general health. The global quality of interview and those who did not, we did not find signifi- life score is obtained by summing scores of domains, cant differences, apart from HAART status. Neverthe- leading to scores ranging from 24 to 120. Higher scores less, the proportion of respondents not yet under indicate better quality of life in the domain or better HAART, who participated in the third interview, was quality of life overall. lower (23.8 %) than the proportion of the respondents Data were collected through 3 interviews by well- not yet under HAART who did not participate in the trained interviewers. The first interview was conducted third interview (37 %) (Table 1). at the beginning of the study; the second was conducted The assessment of the reliability of the whole scale at at 6 months and the third was conducted at 12 months baseline gave a Cronbach’s alpha set at 0.85. At baseline, after the baseline interview. All the 424 PLWHA an- the highest scores of quality of life were recorded in the swered the questionnaire at the first interview. Only 384 domain of spirituality, religion and personal beliefs answered at the second interview and 351 answered at (SRPB) and the lowest scores were in the environment do- the third interview. Among people who did not answer main. This trend was maintained during the 12-month the third interview, one refused to continue the study at follow-up (Figs. 1 & 2). the second interview and two died. Eleven patients who From the beginning of the follow-up to the sixth had not attended the second interview came to the third. month, four domains increased significantly (Table 2): These 11 were excluded from matched analyses. the psychological domain (+0.7), level of independence Analyses were performed using IBM SPSS 21.0. The (+2.2), social relationships (+1.4) and the environmental Friedman test was used to assess significant differences domain (+2.6). The global quality of life score also sig- in quantitative variables at each of the three follow-up nificantly increased from baseline to month 6 (from interviews. Groups at baseline, at 6 months and at 82.9 ± 10.9 to 84.6 ± 10.2). When comparing the domain 12 months were compared using Wilcoxon signed rank scores from baseline to the twelfth month of the follow- test for quantitative data and McNemar test for quali- up, the following domains showed significant progress: tative variables. Pearson Chi2 was used when needed. the psychological domain (+0.8), level of independence Multivariable logistic regression models were fit to es- (+1), social relationships (+1.2) and the environmental timate adjusted odds ratio (OR) and 95 % confidence domain (+2.1). The global score not only increased intervals (95 % CI). A p-value less than 0.05 was con- significantly from baseline to the twelfth month (from sidered significant. We assessed trends in the global 82.9 ± 10.9 to 87.0 ± 9.1), but also from the sixth month to quality of life score and subgroups (status related to the twelfth month (from 84.6 ± 10.2 to 87.0 ± 9.1). HAART) using univariate repeated measures analysis Regarding HAART status, consistently high global of variance. The present study was approved by the quality of life score in patients under treatment for at Ethics Committee for Health Research from the Ministry least 1 year was observed (Fig. 3); they started with the of Health of Burkina Faso. All participants who were best scores (83.6) and they ended the follow-up with the contacted agreed to participate in the study and best scores (89.2). Those not yet under treatment signed a free and informed consent. showed a trend of a consistently low global quality of life score in the 12-month follow-up; they started with the Results second best scores (81.3) and they ended the follow-up Four hundred and twenty four (424) individuals agreed to with the worst scores (80.4). As for patients under treat- participate in the study. At baseline, 12.5 % were male. ment for less than 3 months at baseline, their global 67.2 and 32.8 % of participants were respectively recruited quality of life score leapt between recruitment and the in public healthcare facilities and community-based sixth month of the follow-up (from 80.9 to 86.5) before facilities. Over 40 % (44.8 %) of patients were living stabilizing (86.1 at the end of the follow-up). Starting with another person and 27.1 % were treatment-naive with the lowest score (80.9), patients under treatment HIVsubjects.Fewerthan70%(67.9%)ofpatients for less than 3 months at baseline ended the follow-up had undergone treatment for at least 1 year. The mean with the second best scores (86.1), while those not under Bakiono et al. BMC Public Health (2015) 15:1119 Page 4 of 10
Table 1 Baseline characteristics of the participants of the all recorded (Table 3). Using univariate repeated measures study compared to those who didn’t attend the third interview analysis of variance, a linear trend was observed over Characteristics at Third interview Participants who P-value time and the HAART status significantly affected the baseline participants didn’t attend 3rd global quality of life score over time (F = 8.04; p < 0.001). (n = 351a) interview (n =73a) In a logistic regression, a global quality of life score >77 Mean ± SD Mean ± SD was strongly associated with a lesser increase over time %% (OR:0.06 95 % CI [0.02–0.16]; P < 0.001). Although not Age (mean) in years 37.5 ± 8.2 37.8 ± 10.0 0.81 statistically significant, the longer a patient stayed under Gender 0.99 HAART, the more he/she experienced an increase of his/ Male 12.5 12.5 her global quality of life score. Having no support from Female 87.5 87.5 relatives for medical care at baseline was significantly as- sociated with an increase in the global quality of life score Marital status 0.94 over time. In addition, being under HAART was associ- Alone 55.3 54.8 ated with an increased global quality of life score In couple 44.7 45.2 (OR:3.08, 95 % CI [1.59–5.96];P = 0.001). Finally, self per- Matrimonial system 0.41 ception as healthy was also associated with an increased Monogamus 75.4 68.6 global quality of life score over time (Table 4). Polygamous 24.6 31.4 Discussion Level of education 0.57 At baseline, the highest scores were recorded in the do- Illiterate 32.2 35.6 main of spirituality, religion and personal beliefs (SRPB) Literate 67.8 64.4 and the lowest scores were seen in the environmental Religion 0.42 domain. The environmental domain includes aspects re- Muslims 44.3 37.0 lated to the home environment, financial resources, acces- Catholics 41.1 49.6 sibility to health and social care, physical environment and recreational activities. Burkina Faso is a country where Protestants 14.6 13.7 46.5 % of people live below the national poverty line [10]. Profession 0.03 The socio-economic profile of the country and the profes- Public, private employee 16.2 15.1 sional profile of our respondents dominated by the infor- Trade & informal sector 52.4 42.5 mal sector and small business could justify those low Housewives 23.6 23.3 scores recorded in the environmental domain. In previous Farmers 2.0 8.2 studies, similar results with lowest scores in environmen- tal domain and highest scores in SRPB domain were also Students 2.3 5.5 found in Burkina Faso [5] and in Ethiopia [13, 14]. At the Jobless 3.4 5.5 third interview, the lowest and highest scores remained HIV services provider 0.79 respectively in the environmental domain and in the spir- Hospital 67.0 68.5 itual domain. These results are consistent with what was Community-based 33.0 31.5 found at baseline. Over the 12 months, the fact that the HAART status 0.01 religious practices of the respondents and their environ- ments did not change could justify the sameness of scores Under treatment 76.2 63.0 in these domains of quality of life. Other previous No treatment 23.8 37.0 longitudinal studies have shown the same trends. In a Sexual behavior 0.36 study looking at HIV-Tuberculosis co-infected patients, Risky 38.5 44.3 the spirituality domain showed the highest scores and the No risk 61.5 55.7 environmental domain held the lowest scores after a 6- aTotal may differ according to characteristics month follow-up [14]. In the same study, patients with HIV but not co-infected with tuberculosis showed the treatment started with the second best scores (81.3) and same trends at the end of the 6 month follow-up. ended with the worst scores (80.4). In our study, four domains of quality of life showed pro- When considering the global quality of life score ac- gression at month 6 and at month 12 when comparing to cording to PLWHA characteristics, significant increases baseline. These domains were the psychological domain, were recorded, except in men and people with an AIDS level of independence, social relationships and the envir- status. In people not yet under treatment, a decreased, onmental domain. These increased scores could be partly yet non-significant, of global quality of life score was explained by the support that PLWHA benefited from in Bakiono et al. BMC Public Health (2015) 15:1119 Page 5 of 10
Fig. 1 Cumulative frequency polygon of quality of life domain scores at baseline. *SRPB: Spirituality, Religion and Personal Believes
Fig. 2 Cumulative frequency polygon of quality of life domain scores at month 12. *SRPB: Spirituality, Religion and Personal Believes Bakiono et al. BMC Public Health (2015) 15:1119 Page 6 of 10
Table 2 Changes in quality of life’s domains scores over showed a steadily rising global quality of life score over 12 months in persons living with HIV in Burkina Faso (n = 340) 12 months. In patients who started treatment at the begin- Quality of life’s domains Interview 1 Interview 2 Interview 3 ning of our study, the global quality of life score, after (Baseline) (Month 6) (Month 12) undergoing a jump in the sixth month, showed a relative mean ± SD mean ± SD mean ± SD decline, subsequently leading to stabilization. This trend Physical 14.9 ± 2.7 13.1 ± 2.6a 14.8 ± 3.0b can be explained by the national context and the issues Psychological 13.7 ± 2.7 14.4 ± 2.5a 14.5 ± 2.0a PLWHA are facing. Usually, people in need of treatment Level of independence 13.4 ± 2.5 15.6 ± 3.2a 14.4 ± 2.7ba in Burkina Faso wait a long time before treatment be- comes available, due to financial limits. Starting treatment Social relationships 13.5 ± 2.8 14.9 ± 3.5a 14.7 ± 2.8a a ba appears to be a solace for them. This situation, in addition Environmental 11.0 ± 2.2 13.6 ± 2.7 13.1 ± 1.9 to the physiological benefits of HAART, can justify the a ba Spirituality 16.3 ± 2.6 13.3 ± 3.1 15.2 ± 3.5 leap made in the sixth month in HIV patients who started Global score of quality of life 82.9 ± 10.9 84.6 ± 10.2a 87.0 ± 9.1ba the treatment at the beginning of the study. In their longi- aCompared with scores at baseline, Wilcoxon test (p < 0.05) tudinal study, Solomon et al. showed how quality of life b Compared with scores at Month 6, Wilcoxon test (p < 0.05) increased, even if the increase diminished with time, with best increase which occurred between baseline and the the HIV-care facilities, where our investigation was con- sixth month of their 12-month follow-up [17]. ducted. These facilities offer, among others, support Our study showed that being under HAART was asso- groups such as psychological and social support, where ciated with an increased global quality of life score. In PLWHA come together and support one another in deal- addition, the longer a patient stayed under HAART, the ing with their HIV status [15, 16]. Even if the environmen- more he/she experienced an increase of his/her global tal domain recorded increased scores, it remained, over quality of life score. The fact that people under HAART time, the domain with the lowest scores. In our study, the experienced a greater increase in their global score is physical domain, the religion, spirituality and personal be- consistent with what was found by Liu et al. [18]. Their liefs domain, showed a sawtooth pattern. Deribew et al., study showed that HAART was associated with a short on the other hand, showed a significant increase in all do- term (6 month) improvement in the summary score of mains of quality of life after a 6 month follow-up of quality of life using the Medical Outcome Study (MOS)- PLWHA initiating HAART [14]. According to HAART HIV. But, they also showed that there was no evidence status, our respondents under treatment for at least 1 year that HAART modifies trends in a long term follow-up.
Fig. 3 Trends of global score of quality of life over 12 months by treatment group. *HAART: Highly Active Anti Retroviral Treatment Bakiono et al. BMC Public Health (2015) 15:1119 Page 7 of 10
Table 3 The global score of quality of life at baseline and at conducted offer the following services to PLWHA: an- month 12: comparison based on the characteristics of persons onymous voluntary counseling and testing (VCT), pre- living with HIV in Ouagadougou, Burkina Faso vention counseling, medical treatment and monitoring, Variables at baseline Global score Global score p-valuea nutrition counseling, psychological and social support. of Quality of of Quality of Among other specific services offered, there is also life at baseline life at Month 12 medication, medical care for opportunist infections, Mean ± SD Mean ± SD home visits, support groups, and food. These specific ac- Gender tivities undertaken by professionals or by peer educators Male (n = 44) 87.4 ± 9.4 88.3 ± 10.8 0.66 provide those with no family support with another op- Female (n = 307) 82.2 ± 10.8 87.1 ± 8.9 <0.001 tion. The support received from the facilities can explain HAART started why, despite having no support from relatives for med- Before 2005 (n = 52) 82.4 ± 10.4 90.4 ± 6.9 <0.001 ical care, the global quality of life score grew, even if it stayed lower than the global score of those who have 2005 and later (n = 209) 83.7 ± 11.0 88.9 ± 7.9 <0.001 support from families for their medical care. Psycho- Education logical support received from HIV facilities may explain No school (n = 113) 79.6 ± 10.3 86.0 ± 9.5 <0.001 the association between self perception as healthy and School (n = 238) 84.4 ± 10.6 87.8 ± 8.9 <0.001 increased global quality of life score. Self perceived as healthy InalargestudyinvolvingfoursouthernAfricancoun- No (n = 204) 85.4 ± 9.6 87.6 ± 8.3 0.021 tries, people with lower education reported higher scores of satisfaction with life [20]. Such a result is in line with our Yes (n = 115) 78.7 ± 11.3 86.5 ± 10.0 <0.001 study, where illiterate people recorded better proportion Serology status with increased score, although not statistically significant. Asymptomatic (n = 268) 84.0 ± 10.3 87.3 ± 10.3 0.02 Studies on the quality of life of persons living with Symptomatic (n = 63) 80.0 ± 10.8 87.7 ± 9.0 <0.001 HIV in developing settings have shown the association AIDS (n = 14) 80.5 ± 12.0 83.7 ± 7.9 0.38 between, on one hand, the quality of life and, on the HIV services provider other, biological tests, in particular viral load and CD4 cell count [21–23]. In our study, it was not possible to Hospital (n = 235) 82.8 ± 10.4 88.0 ± 9.3 <0.001 analyze such association because very few patients have n 0.03 Community based ( = 116) 82.9 ± 11.4 85.5 ± 8.6 updated biological data in their routine follow-up. We Marital status assessed quality of life of persons living with HIV in Alone (n = 194) 82.2 ± 11.1 86.6 ± 9.2 <0.001 their routine life, which is the daily experience of these In couple (n = 157) 83.7 ± 10.3 88.0 ± 9.0 0.001 people in HIV clinics. Even if the Government of Bur- HAART status kina Faso declared free HAART for those in need since January 1, 2010, PLWHA continue to face problems for No treatment (n = 83) 82.0 ± 9.8 81.4 ± 10.7 0.62 getting blood work done (viral load and CD4 count), n <0.001 Under treatment ( = 266) 83.2 ± 11.0 89.1 ± 7.8 which are key to monitor the health. While biological Sexual behavior risk monitoring certainly allows for better medical follow-up, No risk (n = 214) 83.1 ± 10.9 87.4 ± 9.4 <0.001 it is out of reach for our patients because of the high Risk (n = 134) 82.6 ± 10.6 86.8 ± 8.7 <0.001 cost. Some patients manage to do their tests through ’ aWilcoxon test used studies which pay for patients laboratory tests. Unfortu- nately, at the end of such studies, they are faced once Although not statistically significant, better increase again with the cost and discontinued tests. Once re- was observed in women. In line with gender, Jaquet et search goals are achieved in the context of HIV/AIDS, al. in their study in Burkina Faso, showed that an in- patients’ medical care is sometimes thwarted by sudden crease in Mental Health Status score was significant in costs. According to national guidelines, these tests have women and not in men [6]. to be done on a 6-month basis [24, 25]. Recent findings In our study, having no support from relatives for showed that annual monitoring of CD4 instead of every medical care was associated with an increase in the glo- 6 months in persons with a CD4 above 250 cells/mm3 was bal quality of life score. Because HIV is still considered sufficient to detect any clinical problem early enough [26]. as a family shame, living with HIV puts people on the Such results, associated with the fact that new guidelines margins of society or their family. In a previous study in suggest starting HAART when CD4 reaches 500 cells/ Burkina Faso, Ouedraogo et al. showed that 57.5 % of mm3 [1], instead of previously indicated levels of 250 or PLWHA were living without any financial support from 350 cells/mm3, will probably reduce the frequency of CD4 families [19]. All facilities where our follow-up was tests in PLWHA in their routine follow-up. As a result, Bakiono et al. BMC Public Health (2015) 15:1119 Page 8 of 10
Table 4 Factors associated with an increase of the global score of quality of life over 12 months in PLWHA in Ouagadougou, Burkina Faso Total People with increased Univariate Multivariate P for score of QOL Unadjusted Adjusted Adjusted OR na n (%) OR (95 % CI) OR (95 % CI) Gender Man 42 21(50.0) 1 Woman 298 193(64.8) 1.83(0.96–3.52) Support for medical care No 134 92(68.7) 1 1 Yes 205 121(59.0) 0.65(0.41–1.04) 0.56(0.32–0.97) 0.04 Highly Active Antiretroviral Treatment status No 80 39(48.8) 1 1 Yes 258 174(67.4) 2.17(1.30–3.62) 3.08(1.59–5.96) 0.001 School No 112 79(70.5) 1 Yes 228 135(59.2) 0.60(0.37–0.98) Self perceived as healthy No 198 111(56.1) 1 1 Yes 110 80(72.7) 2.09(1.26–3.46) 1.90(1.05–3.43) 0.03 Global score of QOL at baseline < =77 90 84(93.3) 1 1 >77 250 130(52.0) 0.07(0.03–0.18) 0.06(0.02–0.16) <0.001 Treatment group at baseline No Treatment 80 40(50.0) 1 Less than 3 months 19 12(63.2) 1.71(0.61–4.80) 1 year or more 241 162(67.2) 2.05(1.22–3.42) aTotal may differ accordingly significant cost savings may be made by PLWHA, giving According to the latest data in the general population, them more opportunity to do this key test. the prevalence of HIV is not statistically different by In our study, about 17 % of patients were lost to gender (1.2 % in women and 0.8 % in men from 15 to follow-up. Most of them were not under HAART. This 49 years old) [30]. Our study was comprised of 87.5 % can be explained by the fact that when people are not women. According to the data from the Ministry of under treatment in a facility, they tend to leave that fa- Health, people living with HIV attending HIV facilities cility and look for another one in which they can find in the country were 69.7 % women [31]. In a previous treatment. Such patients, considered as lost to follow-up study in Burkina Faso, a high proportion (72 %), but in our sample, are probably in other facilities, except for lower than ours, was recorded, even when the preva- two of them who were known to have died during the lence of HIV was higher in men than in women [32]. follow-up and one who openly refused to continue the The proportion of women in our study is therefore study. The proportion of patients lost to follow-up was partly explained by the profile of PLWHA attending lower than what was recorded by Solomon et al. in their HIV structures of the city, dominated by women. study, with 61.8 % of lost to follow-up [17]. The internal consistency of the scale used in our study Limitations gaveaCronbach’s alpha set at 0.85. This value is higher Our study was conducted in Ouagadougou, which is not than values usually recommended (ranging from 0.7 to 0.8) representative of the whole country. However, the facilities [27, 28], which means our scale has good reliability. where the study was conducted may be a good portrayal In a study conducted in South Africa using the same of the urban reality of the country. Our sample was based scale we used, the Cronbach’ alpha found was 0.88, on a systematic sampling method, using the daily queue which is near to ours [29]. for routine follow-up in each facility. The number of Bakiono et al. BMC Public Health (2015) 15:1119 Page 9 of 10
interviewees per structure was reached after a 1-month en- (Tuberculosis); UHYO: University Hospital Yalgado Ouédraogo; WHOQOL- rolment period. Given enrolment was over such a short HIV: World Health Organization Quality of Life assessment scale in patients with Human Immunodeficiency Virus infection; WHOQOL HIV-BREF: World period, our sample may not be representative of patients in Health Organization Quality of Life assessment brief scale in patients with the HIV facilities of the city all year round. Moreover, the Human Immunodeficiency Virus infection. proportion of women in our sample, which was higher than what had been found elsewhere in other studies, can Competing interests The authors declare they have no competing interest. limit the representativeness of our sample. Our study did not use biological tests. Nevertheless, an intervention with Authors’ contributions biological follow-up based on laboratory tests could have FB, LO and AR contributed to the conception of the study. FB, MS and PWLG been useful for the relationship between quality of life, coordinated the data collection. FB analyzed data and drafted the manuscript. All authors discussed the results, read and approved the final items such as CD4 count and viral load, and clinical status. manuscript.
Conclusions Acknowledgements Our findings suggest conducting interventions linked to We thank all investigators, interviewees and the staff of the following institutions for their contribution to this study: District Hospital of the environmental domain to enhance the quality of life Boulmiougou; Day Hospital Unit-University Hospital Yalgado Ouedraogo; of persons living with HIV/AIDS in Burkina Faso. Such Center for Information, Counseling and Documentation on AIDS and interventions should be directed towards empowering Tuberculosis, Ouagadougou; the Association African Solidarity, persons living with HIV instead of making them Ouagadougou; the Association Laafi la Viim, Ouagadougou. dependent on ad hoc support. Particular attention could Author details be paid to women, illiterate people, people who perceive 1Pôle Epidémiologie et Biostatistique, Institut de Recherche Expérimentale et Clinique (IREC), Faculté de Santé Publique, Université catholique de Louvain, themselves as ill, symptomatic patients and those not yet Clos Chapelle-aux-Champs 30, 1200 Brussels, Belgium. 2Unité de Formation under treatment. A pilot initiative to make affordable et de Recherche en Sciences de la santé, Université de Ouagadougou, loans available to PLWHA to enable them to start in- Ouagadougou, Burkina Faso. 3Institut Régional de Santé Publique de Ouidah, come generating activities was initiated by the Support Ouidah, Bénin. Programme to Associative and Community World Received: 20 March 2015 Accepted: 23 October 2015 (PAMAC) in Burkina Faso [33]. This operation, with a 98 % repayment rate, has enabled 783 persons living References with HIV to have access to these micro credits. The re- 1. 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Psychometric properties of Mooré version Syndrome; PLWHA: Person Living With HIV/AIDS; QOL: Quality of Life; of WHOQOL HIV-BREF in persons living with HIV in Burkina Faso. J AIDS HIV SRPB: Spirituality, Religion and Personal Beliefs; TB: Tubercle Bacillus Res. 2015;7:36–43. Bakiono et al. BMC Public Health (2015) 15:1119 Page 10 of 10
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TAB 15 1/29/2021 Rachel’s HIV Revolution | HIV/AIDS News | Al Jazeera Rachel’s HIV Revolution In Burkina Faso, one women challenges stigma and educates mothers on how to prevent transmitting HIV to their children.
Rachel is a HIV-positive mother whose goal it is to educate pregnant women in Burkina Faso so that they will not pass on the virus to their children.
Her activities take place around the clinics of Ouagadougou, Burkina Faso, where she found the help of Agnes, a nurse who teaches pregnant women the protocol of HIV prevention.
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One of the main obstacles in Rachel’s journey is to overcome the problem of social exclusion for these HIV-positive women.
In this culture, the HIV question is considered by many to be a woman’s problem. They need to make sure that their babies will not be infected, but by doing the HIV test they worry that their community will learn about their illness and eventually ostracise them.
Rachel realises that raising awareness in the clinics of the capital is no longer enough. She has to extend her fight to the remote area in the outskirts of Ouagadougou where the level of education is much lower and therefore the women face a higher level of discrimination.
FILMMAKERS’ VIEW
By Gianpaolo Bigoli and Mariachiara Illica Magrini https://www.aljazeera.com/program/witness/2016/11/27/rachels-hiv-revolution 1/6 1/29/2021 Rachel’s HIV Revolution | HIV/AIDS News | Al Jazeera The first time we heard about Rachel, we were in the Neonatology Department of Saint Camille Hospital in Ouagadougou, working on a video project on the progress made on motherhood in Burkina Faso.
We were focusing on women who, day after day, were taking part in a series of silent little revolutions to improve their social situations.
One day an Italian doctor approached us. He knew what we were looking for, and he told us that we “just had to meet Rachel”.
Rachel was making an invaluable, unexpected contribution to the hospital’s programme for the prevention of mother-to-child transmission of HIV during pregnancy.
Rachel is determined to educate women in Burkina Faso so that they will not pass on HIV to their children [Al Jazeera]
We met Rachel that very afternoon and found a strong, pragmatic woman; full of resolve, yet at the same time ironic and sweet-natured.
She was pregnant with her second child, Ibrahim. She didn’t yet know if her baby was going to be born free from HIV, but she was determined to follow the prevention protocol, and had faith in the https://www.aljazeera.com/program/witness/2016/11/27/rachels-hiv-revolution 2/6 1/29/2021 Rachel’s HIV Revolution | HIV/AIDS News | Al Jazeera future.
Similarly, she did nothing to hide the fact she was HIV-positive; she was determined to combat any form of stigma by setting an example herself.
We were profoundly struck and motivated by her determination to change things, and we decided we would tell the story of Rachel and those women who, like her, never give up – not even in the face of the seemingly impossible.
Ibrahim was born a few months later, healthy and with no trace of the virus. Healthy, full of life and determined, just like his mother, Ibrahim symbolises the hope of a new African generation that can now imagine and dream of a different future; a future free from the nightmare of Aids/HIV.
Right from our first meeting, Rachel understood our intentions, and was willing to help, remaining faithful to her strength, her independence, and her role as a woman and mother.
She made this clear to us every day, as she accompanied us deeper and deeper into the world of HIV-positive women, who – in Burkina Faso and in a number of countries in West Africa – end up being the first to fall victim to discrimination, and risk being thrown out, excluded and repudiated by their own families.
Rachel showed us the importance of educating these women towards a new awareness. She then showed us how she herself was able to hold her head high when, even with minor, everyday gestures, she showed her readiness to lay claim to her right to make her own choices.
This was demonstrated by her fondness of wigs. Burkinabe women wear wigs, which they often change several times during the same week. We asked Rachel if she could avoid changing wigs while we were filming, so as not to make it difficult for viewers to recognise her. She said no. She had the right to dress as she pleased, and we would have to accept that. So we did.
We met many women, including Agnes and Alima, who allowed us to get a closer look at Burkinabe culture and its fascinating traditions linked to birth and motherhood.
https://www.aljazeera.com/program/witness/2016/11/27/rachels-hiv-revolution 3/6 1/29/2021 Rachel’s HIV Revolution | HIV/AIDS News | Al Jazeera Others showed us their loneliness and their fear of stigma. We were not always able to collect their stories, because their husbands often prevented them from talking about themselves.
So behind this film is a desire to use Rachel’s story to illustrate the key role played by women in defending life and developing civil rights. Hence the decision to turn our eyes to Africa, the place where, more than anywhere else, the commitment of women often shapes emblematic actions and experiences.
Rachel’s decisions in defence of life have a universal value, and we believe they carry a message of hope, as well as a strong driving force to spur on those battling for women’s rights all over the world.
The two women behind Burkina Faso’s revolution against HIV
Rachel Yameogo
Rachel, centre [Al Jazeera]
https://www.aljazeera.com/program/witness/2016/11/27/rachels-hiv-revolution 4/6 1/29/2021 Rachel’s HIV Revolution | HIV/AIDS News | Al Jazeera “Some revolutions happen because of loud screams and great actions. Others go forward in a slow silence. They are revolutions that need time and love. And in Africa, these revolutions belong to the women because they know the value of life and are ready to defend it.”
Rachel, 46, is a mother of two based in Ouagadougou where she carries out voluntary activities to educate HIV-positive women about preventing the transmission of the virus onto their children.
In 1992 she discovered that she had HIV. Two years later, she lost her first husband and daughter to AIDS was forced to rebuild her life from scratch. Despite not having any money and facing stigma, Rachel found a job and studied to become a midwife. She later remarried and in 2005 gave birth to a child without passing on the virus thanks to PTME (Prevention of Transmission of HIV from Mother to Child).
The joy of giving birth to a healthy child inspired her to start a movement to educate other women in the same situation. Her goal is to ensure pregnant women get tested for HIV, and if they test positive, she helps them begin the PTME programme, whist providing them with moral support.
Agnes Thiombiano
Agnes [Al Jazeera] https://www.aljazeera.com/program/witness/2016/11/27/rachels-hiv-revolution 5/6 1/29/2021 Rachel’s HIV Revolution | HIV/AIDS News | Al Jazeera “Agnes is a fighter,” according to Rachel. The nurse, widow and mother of five children, supported Rachel with the PTME programme throughout two pregnancies, which is how the two women got to know one other. They began working together to inform future mothers about the importance of HIV testing and prevention.
Agnes studied in Italy and then returned home to Burkina Faso to work as a nurse practitioner at one of the first neonatology wards of the country. She has worked at the Saint Camille Hospital in Ou‐ agadougou for 39 years.
In 2000, the Burkina Faso government chose the hospital to pilot the PTME programme to prevent mother-child HIV transmission during pregnancy. This programme was launched jointly with the World Health Organisation and was also supported by the Italian Government.
When it launched, Agnes was the head nurse at the neonatology ward and she immediately played a key role mediating between pregnant women, or new mothers, and the hospital’s PTME team.
Now she trains the staff and, passionate about what she does, she continues working although she has already reached the age of retirement. Her long experience and gentle nature have earned her the nickname Iaba or grandmother among the staff and patients.
https://www.aljazeera.com/program/witness/2016/11/27/rachels-hiv-revolution 6/6
TAB 16 Afrobarometer Round 6 New data from across Africa
Dispatch No. 74 | 1 March 2016
Good neighbours? Africans express high levels of tolerance for many, but not for all
Afrobarometer Dispatch No. 74 | Boniface Dulani, Gift Sambo, and Kim Yi Dionne
Summary Scholars have argued that tolerance is “the endorphin of the democratic body politic,” essential to free political and cultural exchange (Gibson & Gouws, 2005, p. 6). Seligson and Morino-Morales (2010, p. 37) echo this view when they contend that a democracy without tolerance for members of other groups is “fatally flawed.” In this dispatch, we present new findings on tolerance in Africa from Afrobarometer Round 6 surveys in 33 countries in 2014/2015. While Africa is often portrayed as a continent of ethnic and religious division and intolerance, findings show high degrees of acceptance of people from different ethnic groups, people of different religions, immigrants, and people living with HIV/AIDS (PLWHA). Proximity and frequent contact with different types of people seem to nurture tolerance, as suggested by higher levels of tolerance in more diverse countries and a strong correlation between acceptance of PLWHA and national HIV/AIDS prevalence rates. A major exception to Africa’s high tolerance is its strongly negative attitude toward homosexuals. Even so, while the discourse on homosexuality has often painted Africa as a caricature of homophobia, the data reveal that homophobia is not a universal phenomenon in Africa: At least half of all citizens in four African countries say they would not mind or would welcome having homosexual neighbours. Analysis using a tolerance index based on five measures of tolerance points to education, proximity, and media exposure as major drivers of increasing tolerance on the African continent. This is consistent with socialization literature that suggests attitudes and values are not immutable; instead, they can be learned and unlearned.
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Afrobarometer survey Afrobarometer is a pan-African, non-partisan research network that conducts public attitude surveys on democracy, governance, economic conditions, and related issues across Africa. Five rounds of surveys were conducted between 1999 and 2013, and results from Round 6 surveys (2014/2015) are currently being released. Afrobarometer conducts face-to-face interviews in the language of the respondent’s choice with nationally representative samples, which yield country-level results with a margin of sampling error of +/-2% (for a sample of 2,400) or +/-3% (for a sample of 1,200) at a 95% confidence level. Round 6 interviews with about 54,000 citizens in 36 countries represent the views of more than three- fourths of the continent’s population. This dispatch draws mainly on Round 6 data from more than 50,000 interviews in 33 countries (see Appendix Table A.1 for a list of countries and survey dates). The questions on tolerance were not asked in Algeria, Egypt, and Sudan because research partners deemed the question about tolerance for homosexuals too sensitive. Results presented in this dispatch thus exclude these three North African countries.
Key findings
. Across 33 countries, large majorities of African citizens exhibit high tolerance for people from different ethnic groups (91%), people of different religions (87%), immigrants (81%), and people living with HIV/AIDS (68%). . Tolerance levels are particularly high in regions and countries that are ethnically and religiously diverse, suggesting that experience is an important factor in inculcating an attitude of tolerance among African citizens. . Similarly, tolerance for people living with HIV/AIDS is highest in countries with high HIV/AIDS prevalence, providing further evidence that intolerance and stigmatization can be unlearned through personal encounters. . A large majority of Africans, however, are intolerant of homosexual citizens. Across the 33 countries, an average of 78% of respondents say they would “somewhat dislike” or “strongly dislike” having a homosexual neighbour. . But not all of Africa is homophobic. Majorities in four countries (Cape Verde, South Africa, Mozambique, and Namibia), and more than four in 10 citizens in three other countries, would like or not mind having homosexual neighbours. . Christians, urban residents, and younger citizens tend to be more tolerant than, respectively, Muslims, rural residents, and older people.
Measuring tolerance in Africa Tolerance is commonly measured in one of three ways. One is the “fixed-group” approach, in which survey respondents are asked to indicate whether groups at the fringes of politics, identified by the researchers, should be allowed to take part in political activities (Stouffer, 1955). Second is the “least-liked” approach proposed by Sullivan, Piereson, and Marcus (1982). This technique asks respondents to pick, from a list provided to them, the groups they dislike most. The respondents are then asked whether they would tolerate a range of political activities by their disliked groups. In a study by Peffley and Rohrschneider (2003), for example, respondents were asked whether their disliked groups should be allowed to hold office or to conduct demonstrations. A third technique has moved away from limiting questions to categories the respondent dislikes. Instead, respondents answer questions about whether they approve of policies that would limit civil liberties of all citizens (Gibson & Bingham, 1985).
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In the African context, high-quality data measuring tolerance on a continental scale and on a regular basis have been scarce. This is the case despite wide-ranging debates on issues nested within the context of tolerance, such as ethnic conflict, acceptance of migrants, and, more recently, rights for sexual minorities. Writing specifically about the paucity of data gauging public attitudes toward lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations, Dionne, Dulani, and Chunga (2014) note that data from the African context are sporadic and cover only a handful of the continent’s 54 countries. As a contribution to the many debates on aspects of tolerance, the Afrobarometer module asks respondents whether they would like, dislike, or be indifferent to having as neighbours 1) people of a different religion, 2) people from a different ethnic group, 3) homosexuals, 4) people living with HIV/AIDS, and 5) immigrants or foreign workers. Response options are “strongly dislike,” “somewhat dislike,” “would not care,” “somewhat like,” “strongly like,” and “don’t know.” This approach to studying tolerance most closely matches the “least-liked” approach.
The state of tolerance in Africa A common narrative of Africa is that most citizens are intolerant of people who are different – whether that difference be based on ethnicity, religion, nationality, political affiliation, or sexual orientation. Responses to the Afrobarometer questions on tolerance suggest that this generalization is incorrect. Instead, majorities in the 33 countries say they would like or would not mind living next to people from four of five categories: someone from a different ethnicity (91%), someone with a different religion (87%), an immigrant or foreign worker (81%), and a person living with HIV/AIDS (68%). It is only on the question of homosexuality that a majority (78%) of Africans exhibit deeply intolerant attitudes (Figure 1).
Figure 1: Tolerance in Africa | 33 countries | 2014/2015
100% 6%
31% 15% 80% 42% 53% 50%
60%
37% 40% 39% 78% 38% 38% 20% 31% 18% 9% 12% 0% Ethnicity Religion Immigrants HIV/AIDS Homosexuals
Somewhat/Strongly dislike Would not care Somewhat/Strongly like
Respondents were asked: For each of the following types of people, please tell me whether you would like having people from this group as neighbours, dislike it, or not care: People of a different religion? People from other ethnic groups? Homosexuals? People who have HIV/AIDS? Immigrants or foreign workers? (Note: Due to rounding, categories may not always add up to 100%.)
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On a continent that has become synonymous with ethnic conflict, it is telling that the least- disliked group – liked or tolerated as neighbours by nine of 10 respondents – are people of a different ethnicity. While this does not imply the end of ethnic conflicts, it suggests that decades of close interaction and inter-marriage could gradually be helping to dilute the power of ethnicity as a source of division and conflicts. Only slightly more respondents object to living next to people of a different religion or next to immigrants; both are accepted by more than eight in 10 Africans. Considerably fewer citizens – though still a two-thirds majority – would like or accept having neighbours who are living with HIV/AIDS, which suggests that there is still a significant level of stigma attached to the HIV/AIDS epidemic in some parts of the continent. At the negative extreme, the average citizen in the 33 countries is opposed to having homosexual neighbours. This is perhaps not surprising, given that a majority of the continent’s countries criminalize homosexual activities. Only about one in five respondents (21%) say they would not be opposed to having homosexuals as neighbours. (For detailed response frequencies, see Appendix Tables A.2-A.6.) The data show marked differences in tolerance between urban and rural Africans, with the former exhibiting higher degrees of tolerance on all five measures (Figure 2].
Figure 2: Urban-rural differences in tolerance levels | 33 countries | 2014/2015
100% 93% 90% 91% 90% 85% 84% 79% 80% 76%
70% 62% 60% 50% 40% 30% 27% 20% 17% 10% 0% Ethnicity Religion Immigrants HIV/AIDS Homosexuals
Urban Rural
(% of respondents who say they would “strongly like,” “somewhat like” or “not care” if they lived next to people of a different ethnic group or religion, immigrants, PLWHA, or homosexuals)
A similar picture obtains for comparisons of responses by gender, education level, and religion. On all five questions, men are more likely than women, the better educated more likely than the less educated, and Christians more likely than Muslims to express tolerant views. This suggests that societal values are contributing to the nurturing of tolerance values among African citizens.
National and regional differences in tolerance Levels of tolerance on the five items show notable differences by country and region. In general, North African countries show the lowest tolerance on all indicators except homosexuality, where the region ranks above East and West Africa (Figure 3).
Copyright © Afrobarometer 2016 4
Figure 3: Tolerance levels by region1 | 33 countries | 2014/2015
100% 94% 95% 95% 94% 93% 88% 88% 88% 90% 87% 85% 86% 81% 79% 81% 80% 75% 74% 71% 70% 66%
60% 53% 48% 50% 40% 32% 30% 25% 20% 17%15% 12% 10% 0% Ethnicity Religion Immigrants HIV/AIDS Homosexual
North Africa West Africa Southern Africa East Africa Central Africa
(% of respondents who say they would “strongly like,” “somewhat like” or “not care” if they lived next to people of a different ethnic group or religion, immigrants, PLWHA, or homosexuals)
Country-level differences suggest that proximity and frequent contact between different groups may contribute to tolerance. This points to an important aspect that is often overlooked in the literature: Tolerance, and its flipside, intolerance, are not fixed but are subject to change. This is broadly consistent with Allport’s (1954) “contact theory,” which posits that under certain conditions, interpersonal contact can lead to a reduction of prejudice between groups.
Tolerance for people of a different ethnicity The discourse on African politics often highlights how ethnic fractionalization contributes to political polarization and inter-ethnic conflicts. These inter-ethnic rivalries threaten democratic consolidation, undermine nation-building efforts, and impair economic performance (Posner, 2004; Branch & Cheeseman, 2009; Bertocchi & Guerzoni, 2012; Jackson, 2002; Berman, 1998; Easterly & Levine, 1997; Goren, 2005; Bratton, 2011). While this perspective suggests high levels of intolerance for people from different ethnic groups, Afrobarometer findings show that this is not the case. Instead, 91% of respondents across 33 countries say they would not mind or would actually like having people from a different ethnic group as their neighbours. The lowest proportion of respondents who express tolerance for people of different ethnic groups is 74% in Morocco and Swaziland, while nearly every Senegalese and Gabonese citizen (99%) would welcome or accept non-coethnic neighbours (Figure 4).
1 Regional groupings are: North Africa (Morocco, Tunisia), Central Africa (Cameroon, Gabon, São Tomé and Principe), East Africa (Burundi, Kenya, Tanzania, Uganda), West Africa (Benin, Burkina Faso, Cape Verde, Côte d'Ivoire, Ghana, Guinea, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leone, Togo), Southern Africa (Botswana, Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, South Africa, Swaziland, Zambia, Zimbabwe),.
Copyright © Afrobarometer 2016 5
Figure 4: Tolerance for people of other ethnicities | by country | 33 countries | 2014/2015
Senegal 99% Gabon 99% Togo 98% Côte d'Ivoire 98% Burundi 98% Benin 97% Sierra Leone 97% Namibia 96% Tanzania 96% Burkina Faso 96% Ghana 96% Liberia 95% Cameroon 95% Botswana 94% Cape Verde 94% Zimbabwe 94% Mauritius 93% Madagascar 93% Uganda 93% South Africa 93% São Tomé and Príncipe 92% Kenya 91% Average 91% Mali 91% Guinea 90% Malawi 89% Niger 86% Zambia 85% Nigeria 85% Mozambique 81% Lesotho 79% Tunisia 77% Swaziland 74% Morocco 74% 0% 20% 40% 60% 80% 100%
(% of respondents who say they would “strongly like,” “somewhat like” or “not care” if they lived next to people of a different ethnic group)
Levels of tolerance for different ethnic groups are lower in North Africa than in other regions of the continent (Figure 5). North Africa also happens to be the most ethnically homogeneous African region. The lower tolerance levels for ethnic pluralism in this region might thus be explained by the limited interaction between people of different ethnic origins. Contact with different ethnic groups, in other words, might be driving tolerance for ethnic pluralism in Africa, helping to undermine age-old barriers that previously fuelled ethnic intolerance.
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Figure 5: Tolerance for people of other ethnicities | by region | 33 countries | 2014/2015
100% 95% 95% 94% 91% 88% 90%
80% 75%
70%
60%
50%
40%
30%
20%
10%
0% Central East West Southern North Average Africa Africa Africa Africa Africa
(% of respondents who say they would “strongly like,” “somewhat like” or “not care” if they lived next to people of a different ethnic group or religion, immigrants, PLWHA, or homosexuals)
Consistent with trends seen above, better-educated people, the younger generation, and urban dwellers show more tolerant attitudes than the less educated, the older generation, and rural residents.
Tolerance for people of a different religion Among Afrobarometer Round 6 respondents, 55% identify as Christians while 32% identify as Muslims. Of all 36 countries surveyed in Round 6, 25 have a majority Christian population, 10 have a majority Muslim population, and one (Mauritius) has a Hindu majority. Although most African countries have a dominant religion, most also have a sizeable number of citizens who belong to minority religions.2 In half of the 36 surveyed countries, at least 10% of the population belong to a minority religious grouping. Within this context of religious pluralism, tolerance for people belonging to different religions is crucial for social harmony and peaceful coexistence. While almost nine in 10 Africans (87%) express tolerance for people belonging to different religions, citizens in majority Muslim countries, especially countries with low religious diversity, are relatively less tolerant of having neighbours of different religions. This is particularly true for Niger, Tunisia, and Morocco (all with 100% Muslim populations), as well as Guinea (88% Muslim) (Figure 6).
2 A recent study found that five of the world’s 12 most religiously diverse countries are in sub-Saharan Africa (Pew Research Center, 2014).
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Figure 6: Tolerance for people of a different religion | by country | 33 countries | 2014/2015
Côte d'Ivoire 98% Burundi 97% Tanzania 96% Gabon 96% Cape Verde 96% Namibia 96% Sierra Leone 95% South Africa 95% Uganda 95% Ghana 95% Togo 95% Benin 94% Mauritius 94% Burkina Faso 93% São Tomé and Príncipe 93% Zimbabwe 93% Madagascar 93% Malawi 92% Liberia 91% Cameroon 90% Kenya 90% Botswana 89% Senegal 88% Average 87% Zambia 85% Mali 83% Mozambique 82% Lesotho 81% Nigeria 81% Swaziland 73% Morocco 67% Guinea 67% Tunisia 65% Niger 51% 0% 20% 40% 60% 80% 100%
(% of respondents who say they would “strongly like,” “somewhat like” or “not care” if they lived next to people of a different religion)
In contrast to the two North African countries where this question was asked, which rank near the bottom in religious tolerance, East Africa is the most tolerant region, with 94% of citizens, on average, accepting people of different religions. Again, more educated individuals and urbanites tend to be more tolerant of religious difference than people with less education and rural residents.
Tolerance for immigrants Although very few African countries are net recipients of immigrants, the findings suggest that there is a high level of acceptance of immigrants among citizens on the continent. Overall, 81% of Africans say they would like or not mind having neighbours who are
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immigrants or foreign workers (Figure 7). This places Africans among the most migrant- tolerant people in the world. For example, in the most recent wave of the World Values Surveys (2010-2014), more than one-third of Middle Easterners (36%) and Asians (34%) expressed opposition to having migrant neighbours, compared to less than one-fifth of Africans. Only in a handful of African countries do sizeable minorities express rejection of immigrants: Lesotho (42%), Zambia (35%), Mauritius (34%), Madagascar (33%), Morocco (33%), and South Africa (32%). The case of Lesotho is particularly interesting, as a large proportion of the country’s male workforce is employed as migrant labour in neighbouring South Africa, and yet more than four in 10 citizens don’t want to live next to immigrants. South Africa, which in recent years has experienced widespread xenophobic attacks against foreigners, illustrates the violent implications of anti-immigrant attitudes (Chingwete, 2016).
Figure 7: Tolerance for immigrants/foreign workers | by country | 33 countries | 2014/2015
Cape Verde 94% Burkina Faso 94% Benin 94% Togo 93% Senegal 90% Burundi 90% Côte d'Ivoire 89% São Tomé and Príncipe 88% Ghana 88% Zimbabwe 87% Mali 87% Guinea 87% Sierra Leone 86% Liberia 86% Namibia 85% Botswana 85% Malawi 84% Gabon 84% Cameroon 84% Swaziland 82% Average 81% Kenya 80% Uganda 78% Nigeria 76% Tunisia 75% Tanzania 75% Niger 73% Mozambique 70% South Africa 68% Madagascar 67% Morocco 66% Mauritius 66% Zambia 64% Lesotho 57% 0% 20% 40% 60% 80% 100%
(% of respondents who say they would “strongly like,” “somewhat like” or “not care” if they lived next to immigrants or foreign workers)
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Tolerance for people living with HIV/AIDS The notion that proximity and regular interaction between different groups can help to break down intolerant attitudes is also reflected in tolerance levels for HIV-positive people. In 26 of the 33 countries surveyed, a majority of citizens say they would like or would not mind having PLWHA as their neighbours (Figure 8). This still leaves substantial proportions of the population (31% on average) who would object to having HIV-positive neighbours, an indication of the continued power of HIV-related stigma. Moreover, almost eight in 10 respondents in Niger (79%) and Madagascar (77%) express intolerance for PLWHA, which is also the majority view in Sierra Leone (73%), Guinea (69%), Morocco (57%), and Mali (53%).
Figure 8: Tolerance for people living with HIV/AIDS | by country | 33 countries | 2014/2015
Botswana 96% Namibia 94% Zimbabwe 94% Swaziland 93% South Africa 91% Malawi 91% Gabon 90% Burundi 87% Tanzania 87% Zambia 87% Kenya 86% Lesotho 84% Cape Verde 83% Uganda 83% Cameroon 77% Côte d'Ivoire 76% São Tomé and Príncipe 75% Togo 71% Ghana 68% Average 68% Mozambique 66% Burkina Faso 60% Liberia 56% Senegal 56% Tunisia 55% Mauritius 53% Nigeria 52% Benin 49% Mali 47% Morocco 42% Guinea 30% Sierra Leone 23% Madagascar 23% Niger 22% 0% 20% 40% 60% 80% 100%
(% of respondents who say they would “strongly like,” “somewhat like” or “not care” if they lived next to PLWHA)
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Tolerance for PLWHA is strongly correlated with HIV/AIDS prevalence at the country level.3 Put simply, citizens in countries that have high HIV/AIDS prevalence tend to exhibit high tolerance levels for PLWHA. This is perhaps not very surprising, as among countries where HIV/AIDS prevalence is very high, especially in the Southern Africa region, intolerance for PLWHA might be tantamount to rejecting one’s close family members or friends. Although the strong correlation between tolerance and prevalence does not imply causality, we speculate that proximity and frequent interaction might be important in influencing tolerant attitudes toward PLWHA.
Tolerance for homosexuals Africa’s negative attitudes toward homosexuals are documented in the news media and, to a lesser extent, the academic literature (Reddy, 2001, 2002; Potgieter, 2006). Afrobarometer survey data suggest this narrative to be true, as only 21% of all citizens across the 33 countries say they would like or would not mind having homosexual neighbours (Figure 9). However, there are important country-level differences that may be overlooked in the aggregate numbers. In four African countries, a majority of citizens express acceptance of neighbours who are homosexual: Cape Verde (74% who would strongly/somewhat like or would not care), South Africa (67%), Mozambique (56%), and Namibia (55%). In three other countries, more than 40% of citizens say they are not opposed to having homosexual neighbours: Mauritius (49%), São Tomé and Principe (46%), and Botswana (43%). The portrayal of Africa as universally homophobic is thus not supported by these findings. Still, intolerance toward homosexuals remains widespread, reaching near-unanimity in Senegal (97%) as well as Guinea, Uganda, Burkina Faso, and Niger (all 95%). The case of Mozambique offers an interesting demonstration of how policy change may interact with popular attitudes. In 2014, Mozambique adopted a new penal code that decriminalizes homosexuality (BBC News, 2015). Since there are no available data on Mozambicans’ attitudes toward homosexuals prior to decriminalization, we may debate as to whether relatively high acceptance precipitated decriminalization or the legal Do your own analysis of Afrobarometer reform has had the added benefit of data – on any question, for any country influencing attitudinal change among the and survey round. It’s easy and free at wider citizenry. The two countries expressing www.afrobarometer.org/online-data- the highest tolerance for homosexual citizens, analysis. Cape Verde and South Africa, also do not criminalize homosexuality. However, in some cases, ordinary citizens are ahead of law reform by embracing LGBTQ rights at a time when some practices are illegal in their countries. This is true in Namibia and Mauritius, two countries with comparatively high acceptance of homosexuals despite legislation that make homosexuality a crime. The data further suggest an important link between tolerance for homosexuals and respondents’ age and education levels. Younger and more educated Africans tend to be more tolerant of homosexuals than older Africans and less educated citizens (Figure 10). This finding suggests that while current attitudes are largely negative, it is possible that Africa will become progressively less homophobic over time.
3 Pearson’s r=0.629, p=<.001
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Figure 9: Tolerance for homosexuals | by country | 33 countries | 2014/2015
Cape Verde 74% South Africa 67% Mozambique 56% Namibia 55% Mauritius 49% São Tomé and Príncipe 46% Botswana 43% Swaziland 26% Average 21% Tanzania 21% Côte d'Ivoire 18% Benin 17% Gabon 17% Tunisia 17% Morocco 16% Nigeria 16% Liberia 16% Lesotho 16% Kenya 14% Madagascar 12% Cameroon 11% Ghana 11% Zimbabwe 10% Togo 10% Burundi 10% Mali 10% Zambia 7% Sierra Leone 6% Malawi 6% Niger 5% Burkina Faso 5% Uganda 5% Guinea 4% Senegal 3%
0% 20% 40% 60% 80% 100%
(% of respondents who say they would “strongly like,” “somewhat like” or “not care” if they lived next to homosexuals)
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Figure 10: Tolerance for homosexuals | by education level, age, and urban-rural residence | 33 countries | 2014/2015
No formal education 11% Primary 18% Secondary 26% Post-secondary 31%
18-25 25% 26-35 22% 36-45 21% 46-55 18% 56-65 17% Over 65 17%
Urban 27% Rural 17%
Average 21%
0% 10% 20% 30% 40% 50%
(% of respondents who say they would “strongly like,” “somewhat like” or “not care” if they lived next to homosexuals)
The tolerance index Responses to the battery of tolerance questions in the Afrobarometer survey can be combined to calculate average scores for each respondent and each country to generate an index of tolerance that captures overall levels of tolerance across the five items (different ethnicity, different religion, immigrants, PLWHA, and homosexuals). Scores on the tolerance index range along a five-point scale from 1 (for an individual who is completely intolerant) to 5 (reflecting a constant tolerant attitude across all five items). The mean tolerance index score across all 33 countries surveyed in 2014/2015 is 3.08, which suggests that the average African respondent leans more toward tolerant than intolerant. However, consistent with the cross-national variations in tolerance for the different categories of people, there are important national variations around the mean (Figure 11). The most tolerant countries on the index are Namibia (3.71), Malawi (3.69), and Burundi (3.68), while the least tolerant countries are Niger (2.30), Tunisia (2.35), and Morocco (2.36). In general, North African and Central African countries have some of the lowest tolerance scores, while other regions are represented all along the spectrum.
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Figure 11: Index of tolerance in Africa | 33 countries | 2014/2015
Namibia 3.71 Malawi 3.69 Burundi 3.68 Ghana 3.48 Togo 3.46 Tanzania 3.43 Sierra Leone 3.36 South Africa 3.34 Botswana 3.32 Liberia 3.3 Zimbabwe 3.2 Kenya 3.18 Mali 3.17 Benin 3.11 Average 3.08 Burkina Faso 3.08 Zambia 3.06 Uganda 3.06 Mozambique 3.06 Senegal 3.04 Guinea 3.04 Côte d'Ivoire 3.03 Cape Verde 2.96 Lesotho 2.95 São Tomé and Príncipe 2.92 Gabon 2.92 Nigeria 2.91 Cameroon 2.91 Swaziland 2.79 Mauritius 2.76 Madagascar 2.63 Morocco 2.36 Tunisia 2.35 Niger 2.3 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5
Figure shows average country scores along a five-point scale for responses across all five tolerance questions (different ethnic groups, different religions, immigrants, PLWHA, and homosexuals)
Drivers of tolerance In addition to the likely positive effects of proximity and contact mentioned above, tolerance appears to be driven, at least in part, by several socio-demographic characteristics (Figure 12). Education, in particular, shows an important effect in inculcating a culture of tolerance. Overall, people who have at least a secondary school education tend to exhibit higher tolerance than the less educated. The younger generation exhibits higher tolerance than its
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elders.4 Similarly, men and urban residents express higher tolerance levels than women and rural residents. Another variable that shows a positive, albeit weak, relationship with tolerance is media exposure.5 On average, African citizens who are regularly exposed to news through radio, television, newspapers, the Internet, and social media are more likely to demonstrate tolerant attitudes than those who have no or low media exposure. These findings suggest important policy lessons in the quest to promote tolerant attitudes on the continent. First, investment in education matters in nurturing a tolerant population. Second, news media with broad coverage can play an important role in promoting tolerance among African citizens. With regard to religion, the findings suggest substantial differences in tolerant attitudes between Africans who identify as Christians and those who identify as Muslims. The mean tolerance scores for Christians (3.19) and Muslims (2.87) reflect a 10% difference between the continent’s two main religious groups.
Figure 12: Drivers of tolerance in Africa | 33 countries | 2014/2015
Post-secondary 3.14 Secondary 3.13 Primary 3.08 No formal education 2.94
18-25 3.1 26-35 3.09 36-45 3.09 46-55 3.03 56-65 3.03 Over 65 3.02
Male 3.1 Female 3.05
Urban 3.12 Rural 3.04
High media exposure 3.13 Moderate media exposure 3.07 No/Low media exposure 3.06
Christians 3.19 Muslims 2.87 Other religions 3.02 1 1.5 2 2.5 3 3.5
Figure shows average scores by socio-demographic group along a five-point scale for responses across all five tolerance questions (different ethnic groups, different religions, immigrants, PLWHA, and homosexuals)
4 For education: Pearson’s r=0.83, p=<0.001; for age: Pearson’s r=-0.34, p=<001. 5 Pearson’s r=-0.037, p=<001. (Media exposure is an additive index based on how often respondents receive news from radio, television, newspapers, the Internet, and social media.)
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Conclusion Africans express high levels of tolerance for people of different ethnicities, religions, and nationalities. A large majority also express tolerance for people living with HIV/AIDS, though HIV-related stigma remains a reality in most countries. Africans are far less tolerant of homosexuals, though even on this issue, country-level variations prevent the continent from being painted as uniformly intolerant. While our data do not yet permit analysis of trends over time, the findings of this study tell us that tolerance in Africa is not a constant. Rather, it can be nurtured and learned. In addition to the likely effects of contact with people of different backgrounds, education and news media exposure are drivers of a tolerant society, as more educated individuals and those who have greater exposure to the media tend to embrace more tolerant attitudes. The fact that younger citizens are more tolerant than their elders also bodes well for an increasingly tolerant future in Africa.
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References BBC News. (2015). Mozambique decriminalises gay and lesbian relationships. Available at http://www.bbc.co.uk/news/world-africa-33342963. Accessed 8 February 2016. Berman, B. (1998). Ethnicity, patronage and the African state: The politics of uncivil nationalism. African Affairs, 97(388), 305-341. Bertocchi, G., & Guerzoni, A. (2012). Growth, history, or institutions: What explains state fragility in sub-Saharan Africa. Journal of Peace Research, 49(6), 769-783. Branch, D., & Cheeseman, N. (2009). Democratisation sequencing and state failure in Africa: Lessons from Kenya. African Affairs, 108(340), 1-26. Bratton, M. (1989). Beyond the state: Civil society and associational life in Africa. World Politics, 41(3), 407-430. Chingwete, A. (2016). Immigration remains a challenge for South Africa’s government and citizens. Afrobarometer Dispatch No. 72. Available at http://afrobarometer.org/ publications/ad72- immigration-remains-challenge-for-south-africas-government-and-citizens. Dionne, K., Dulani, B., & Chunga, J. (2014). Attitudes toward homosexuality in sub-Saharan Africa, 1982-2012. Unpublished research note. Easterly, W., & Levine, R. (1997). Africa’s growth tragedy: Policies and ethnic divisions. Quarterly Journal of Economics, 112(4), 1203-1250. Gibson, J., & Gouws, A. (2005). Overcoming intolerance in South Africa: Experiments in democratic persuasion. Cambridge: Cambridge University Press. Gibson, J., & Bingham, R. (1985). Civil liberties and nazis: The Stokie free speech controversy. New York: Praeger. Goren, P. (2005). Party identification and core political values. American Journal of Political Science, 49(4), 849-863. Jackson, R. (2002). Violent internal conflict and the African state: Towards a framework for analysis. Journal of Contemporary African Studies, 20(1), 29-52. Peffley, M., & Rohrschneider, R. (2003). Democratization and political tolerance in seventeen countries: A multi-level model of democratic learning. Political Research Quarterly, 56(3), 243-257. Pew Research Center. (2014). Global religious diversity. Available at http://www.pewforum.org/ 2014/04/04/global-religious-diversity/. Posner, D. (2004). Measuring ethnic fractionalization in Africa. American Journal of Political Science, 48(4), 849-863. Potgieter, C. (2006). The imagined future for gays and lesbians in South Africa: Is this it? Africa Agenda: Empowering women for gender equity, 20(67), 4-8. Reddy, V. (2001). Homophobia, human rights and gay and lesbian equality in Africa. Africa Agenda: Empowering women for gender equity, 16(50), 83-87. Reddy, V. (2002). Perverts and sodomites: Homophobia as hate speech in Africa. Southern African Linguistics and Applied Language Studies, 20, 163-175. Seligson, M., & Moreno-Morales, D. (2010). Gay in the Americas. Americas Quarterly, Winter 2010, 37-41. Stouffer, S. (1955). Communism, conformity and civil liberties. New York: Doubleday.
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Sullivan, J., Piereson, J., & Marcus, G. (1982). Political tolerance and American democracy. Chicago: University of Chicago Press. World Values Survey. (2010-2014). Available at http://www.worldvaluessurvey.org/ WVSDocumentationWV6.jsp.
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Appendix
Table A.1: Afrobarometer Round 6 fieldwork dates and previous survey rounds
Months when Round 6 fieldwork Country Previous survey rounds was conducted
Algeria May-June 2015 2013 Benin May-June 2014 2005, 2008, 2011 Botswana June-July 2014 1999, 2003, 2005, 2008, 2012 Burkina Faso April-May 2015 2008, 2012 Burundi September-October 2014 2012 Cameroon January-February 2015 2013 Cape Verde November-December 2014 2002, 2005, 2008, 2011 Côte d'Ivoire August-September 2014 2013 Egypt June-July 2015 2013 Gabon September 2015 N/A Ghana May-June 2014 1999, 2002, 2005, 2008, 2012 Guinea March-April 2015 2013 Kenya November-December 2014 2003, 2005, 2008, 2011 Lesotho May 2014 2000, 2003, 2005, 2008, 2012 Liberia May 2015 2008, 2012 Madagascar December 2015-January 2015 2005, 2008, 2013 Malawi March-April 2014 1999, 2003, 2005, 2008, 2012 Mali December 2014 2001, 2002, 2005, 2008, 2013 Mauritius June-July 2014 2012 Morocco November 2015 2013 Mozambique June-August 2015 2002, 2005, 2008, 2012 Namibia August-September 2014 1999, 2003, 2006, 2008, 2012 Niger April 2015 2013 Nigeria December 2014-January 2015 2000, 2003, 2005, 2008, 2013 São Tomé and Principe July-August 2015 N/A Senegal November-December 2014 2002, 2005, 2008, 2013 Sierra Leone May-June 2015 2012 South Africa August-September 2015 2000, 2002, 2006, 2008, 2011 Sudan June 2015 2013
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Months when Round 6 fieldwork Country Previous survey rounds was conducted
Swaziland April 2015 2013 Tanzania August-November 2014 2001, 2003, 2005, 2008, 2012 Togo October 2014 2012 Tunisia April-May 2015 2013 Uganda May 2015 2000, 2002, 2005, 2008, 2012 Zambia October 2014 1999, 2003, 2005, 2009, 2013 Zimbabwe November 2014 1999, 2004, 2005, 2009, 2012
Table A.2: Tolerance for people of a different ethnicity | 33 countries | 2014/2015
Strongly Somewhat Would Somewhat Strongly Don’t Country dislike dislike not care like like know
Algeria N/A N/A N/A N/A N/A N/A Benin 1% 3% 38% 14% 45% 0% Botswana 3% 3% 46% 19% 29% 0% Burkina Faso 2% 2% 39% 11% 46% 0% Burundi 1% 1% 14% 12% 72% 0% Cameroon 2% 3% 52% 18% 25% 0% Cape Verde 3% 3% 81% 7% 6% 1% Côte d'Ivoire 1% 1% 53% 16% 29% 0% Egypt N/A N/A N/A N/A N/A N/A Gabon 0% 1% 63% 19% 17% 0% Ghana 3% 2% 15% 15% 66% 0% Guinea 7% 3% 9% 11% 70% 0% Kenya 3% 5% 33% 20% 38% 0% Lesotho 14% 7% 35% 11% 32% 1% Liberia 2% 3% 15% 38% 42% 1% Madagascar 1% 6% 54% 24% 16% 0% Malawi 5% 6% 6% 17% 66% 0% Mali 4% 6% 19% 13% 59% 0% Mauritius 1% 6% 68% 18% 7% 0% Morocco 12% 14% 63% 7% 3% 1%
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Strongly Somewhat Would Somewhat Strongly Don’t Country dislike dislike not care like like know
Mozambique 5% 11% 44% 16% 22% 4% Namibia 1% 2% 30% 19% 47% 0% Niger 9% 5% 43% 16% 27% 0% Nigeria 6% 8% 28% 31% 26% 1% São Tomé and Principe 4% 3% 66% 12% 15% 1% Senegal 0% 1% 37% 6% 56% 0% Sierra Leone 2% 1% 3% 11% 82% 1% South Africa 3% 4% 44% 20% 29% 0% Sudan N/A N/A N/A N/A N/A N/A Swaziland 9% 17% 49% 20% 5% 0% Tanzania 2% 2% 23% 21% 52% 0% Togo 1% 1% 22% 15% 61% 0% Tunisia 21% 3% 63% 8% 6% 0% Uganda 4% 4% 40% 17% 35% 0% Zambia 8% 7% 28% 16% 41% 0% Zimbabwe 3% 4% 41% 19% 35% 0% AVERAGE 4% 4% 38% 16% 37% 0%
Respondents were asked: For each of the following types of people, please tell me whether you would like having people from this group as neighbours, dislike it, or not care: People from other ethnic groups?
Table A.3: Tolerance for people of a different religion | 33 countries | 2014/2015
Strongly Somewhat Would Somewhat Strongly Don’t Country dislike dislike not care like like know
Algeria N/A N/A N/A N/A N/A N/A Benin 2% 4% 38% 13% 43% 0% Botswana 5% 6% 45% 18% 26% 0% Burkina Faso 4% 3% 40% 10% 44% 0% Burundi 1% 2% 15% 11% 71% 0% Cameroon 4% 5% 51% 17% 22% 1% Cape Verde 2% 2% 82% 7% 7% 1% Côte d'Ivoire 1% 1% 54% 14% 29% 0% Egypt N/A N/A N/A N/A N/A N/A Gabon 1% 3% 67% 17% 12% 0%
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Strongly Somewhat Would Somewhat Strongly Don’t Country dislike dislike not care like like know
Ghana 3% 2% 14% 14% 67% 0% Guinea 27% 6% 8% 9% 50% 0% Kenya 5% 6% 35% 17% 38% 0% Lesotho 13% 5% 32% 10% 39% 1% Liberia 3% 6% 13% 40% 38% 1% Madagascar 2% 5% 52% 26% 16% 0% Malawi 3% 5% 7% 16% 70% 0% Mali 10% 7% 22% 10% 52% 0% Mauritius 1% 5% 68% 18% 7% 0% Morocco 15% 18% 57% 7% 3% 1% Mozambique 7% 9% 43% 14% 24% 3% Namibia 1% 3% 30% 18% 48% 0% Niger 37% 12% 35% 7% 9% 0% Nigeria 7% 10% 28% 27% 26% 2% São Tomé and Principe 4% 2% 67% 11% 16% 1% Senegal 8% 4% 40% 6% 42% 0% Sierra Leone 3% 1% 3% 7% 86% 1% South Africa 2% 3% 45% 19% 31% 0% Sudan N/A N/A N/A N/A N/A N/A Swaziland 11% 16% 50% 18% 5% 1% Tanzania 2% 2% 22% 20% 54% 0% Togo 2% 3% 22% 15% 57% 0% Tunisia 31% 4% 51% 7% 7% 0% Uganda 3% 3% 42% 13% 40% 0% Zambia 10% 5% 30% 14% 41% 0% Zimbabwe 2% 5% 40% 15% 38% 0% AVERAGE 7% 5% 38% 15% 35% 0%
Respondents were asked: For each of the following types of people, please tell me whether you would like having people from this group as neighbours, dislike it, or not care: People of a different religion?
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Table A.4: Tolerance for immigrants/foreign workers | 33 countries | 2014/2015
Strongly Somewhat Would Somewhat Strongly Don’t Country dislike dislike not care like like know
Algeria N/A N/A N/A N/A N/A N/A Benin 2% 4% 47% 17% 30% 0% Botswana 8% 7% 45% 17% 23% 0% Burkina Faso 2% 4% 47% 15% 32% Burundi 6% 4% 20% 20% 50% 0% Cameroon 6% 8% 52% 19% 13% 2% Cape Verde 3% 3% 82% 6% 6% 1% Côte d'Ivoire 7% 4% 56% 16% 16% 0% Egypt N/A N/A N/A N/A N/A N/A Gabon 6% 10% 63% 16% 5% Ghana 7% 5% 23% 19% 46% 1% Guinea 9% 4% 9% 18% 60% 0% Kenya 8% 11% 40% 20% 21% 1% Lesotho 32% 11% 27% 9% 21% 1% Liberia 5% 8% 17% 44% 26% 1% Madagascar 13% 20% 40% 17% 10% 0% Malawi 9% 6% 8% 24% 53% 1% Mali 6% 7% 23% 19% 45% Mauritius 10% 24% 59% 6% 1% 1% Morocco 14% 19% 56% 7% 3% 1% Mozambique 13% 13% 35% 16% 19% 5% Namibia 6% 8% 30% 21% 35% 0% Niger 19% 8% 47% 13% 13% 0% Nigeria 11% 11% 32% 27% 17% 2% São Tomé and Principe 8% 3% 66% 13% 9% 1% Senegal 6% 4% 42% 15% 33% 0% Sierra Leone 9% 3% 8% 16% 63% 2% South Africa 16% 16% 40% 13% 14% 0% Sudan N/A N/A N/A N/A N/A N/A Swaziland 5% 13% 58% 20% 5% 0%
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Strongly Somewhat Would Somewhat Strongly Don’t Country dislike dislike not care like like know
Tanzania 12% 12% 25% 21% 29% 1% Togo 3% 4% 22% 23% 48% 1% Tunisia 21% 4% 60% 10% 5% 0% Uganda 10% 11% 41% 19% 19% 1% Zambia 21% 14% 29% 15% 20% 2% Zimbabwe 6% 7% 47% 17% 23% 0% AVERAGE 10% 9% 39% 17% 25% 1% Respondents were asked: For each of the following types of people, please tell me whether you would like having people from this group as neighbours, dislike it, or not care: Immigrants or foreign workers?
Table A.5: Tolerance for people living with HIV/AIDS | 33 countries | 2014/2015
Strongly Somewhat Would Somewhat Strongly Don’t Country dislike dislike not care like like know
Algeria N/A N/A N/A N/A N/A N/A Benin 34% 16% 27% 11% 12% 1% Botswana 2% 2% 48% 17% 31% 0% Burkina Faso 26% 14% 38% 8% 14% 0% Burundi 8% 5% 17% 16% 55% 0% Cameroon 12% 9% 53% 14% 11% 1% Cape Verde 10% 6% 79% 3% 2% 1% Côte d'Ivoire 13% 10% 56% 12% 8% 0% Egypt N/A N/A N/A N/A N/A N/A Gabon 5% 4% 61% 15% 15% 0% Ghana 23% 8% 20% 18% 31% 1% Guinea 62% 7% 8% 7% 16% 0% Kenya 7% 6% 47% 16% 24% 1% Lesotho 10% 5% 39% 12% 33% 1% Liberia 25% 17% 15% 30% 11% 2% Madagascar 49% 28% 18% 4% 0% 0% Malawi 5% 4% 8% 18% 66% 0% Mali 41% 12% 17% 9% 21% 0% Mauritius 22% 24% 50% 3% 1% 1% Morocco 35% 22% 37% 3% 2% 2%
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Strongly Somewhat Would Somewhat Strongly Don’t Country dislike dislike not care like like know
Mozambique 20% 10% 46% 10% 10% 4% Namibia 2% 4% 32% 16% 46% 0% Niger 69% 9% 17% 3% 1% 0% Nigeria 29% 18% 26% 17% 9% 2% São Tomé and Principe 17% 8% 64% 7% 4% 1% Senegal 32% 12% 34% 9% 13% 1% Sierra Leone 62% 11% 8% 5% 9% 4% South Africa 3% 6% 53% 15% 24% 0% Sudan N/A N/A N/A N/A N/A N/A Swaziland 3% 4% 64% 21% 8% 0% Tanzania 8% 5% 34% 18% 34% 1% Togo 19% 10% 22% 20% 30% 0% Tunisia 39% 5% 47% 5% 4% 0% Uganda 9% 8% 51% 14% 18% 0% Zambia 8% 4% 41% 13% 33% 1% Zimbabwe 2% 4% 50% 15% 29% 0% AVERAGE 22% 10% 37% 12% 19% 1%
Respondents were asked: For each of the following types of people, please tell me whether you would like having people from this group as neighbours, dislike it, or not care: People who have HIV/AIDS? Table A.6: Tolerance for homosexuals | 33 countries | 2014/2015
Strongly Somewhat Would Somewhat Strongly Don’t Country dislike dislike not care like like know
Algeria N/A N/A N/A N/A N/A N/A Benin 70% 10% 12% 2% 3% 3% Botswana 46% 10% 25% 8% 9% 1% Burkina Faso 92% 3% 4% 0% 1% 0% Burundi 82% 4% 5% 1% 4% 4% Cameroon 80% 5% 10% 1% 1% 3% Cape Verde 19% 6% 70% 2% 2% 1% Côte d'Ivoire 74% 7% 15% 2% 1% 0% Egypt N/A N/A N/A N/A N/A N/A Gabon 78% 5% 16% 1% 0% 0%
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Strongly Somewhat Would Somewhat Strongly Don’t Country dislike dislike not care like like know
Ghana 81% 8% 5% 3% 4% 1% Guinea 94% 1% 2% 1% 2% 1% Kenya 72% 12% 11% 2% 1% 2% Lesotho 77% 5% 8% 2% 6% 2% Liberia 70% 13% 5% 7% 4% 1% Madagascar 64% 24% 10% 2% 1% 0% Malawi 89% 4% 1% 2% 3% 1% Mali 87% 3% 4% 2% 4% 0% Mauritius 24% 27% 45% 3% 1% 1% Morocco 57% 25% 14% 1% 1% 2% Mozambique 24% 12% 39% 11% 6% 8% Namibia 29% 15% 29% 9% 17% 0% Niger 91% 4% 5% 0% 0% 0% Nigeria 72% 11% 9% 5% 2% 1% São Tomé and Principe 42% 10% 39% 5% 2% 3% Senegal 96% 1% 3% 0% 0% 0% Sierra Leone 87% 3% 2% 1% 4% 4% South Africa 19% 13% 44% 11% 13% 1% Sudan N/A N/A N/A N/A N/A N/A Swaziland 57% 16% 21% 4% 1% 1% Tanzania 70% 7% 11% 5% 4% 2% Togo 86% 3% 5% 2% 3% 1% Tunisia 76% 7% 15% 1% 2% 0% Uganda 90% 5% 3% 1% 1% 0% Zambia 86% 6% 5% 1% 1% 1% Zimbabwe 83% 6% 9% 1% 1% 0% AVERAGE 69% 9% 15% 3% 3% 1%
Respondents were asked: For each of the following types of people, please tell me whether you would like having people from this group as neighbours, dislike it, or not care: Homosexuals?
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Other Round 6 global releases
. Where to start? Aligning sustainable development goals with citizen priorities. Bentley, T., Olapade, M., Wambua, P., & Charron, N. (2015). Afrobarometer Dispatch No. 67. Available at http://afrobarometer.org/sites/default/files/publications/ Dispatches/ab_r6_dispatchno67_african_priorities_en.pdf.
. Building on progress: Infrastructure development still a major challenge in Africa. Mitullah, W. V., Samson, R., Wambua, P. M., & Balongo, S. (2016). Afrobarometer Dispatch No. 69. Available at www.afrobarometer.org/publications/ad69-building- progress-infrastructure-development-still-major-challenge-africa. . Africa’s growth dividend? Lived poverty drops across much of the continent. Mattes, R., Dulani, B., & Gyimah-Boadi, E. (2016). Afrobarometer Policy Paper No. 29. Available at http://www.afrobarometer.org/publications/pp29-africas-growth- dividend-lived-poverty-drops-across-the-continent.
Boniface Dulani is a senior lecturer in the Department of Political and Administrative Studies at the University of Malawi and Afrobarometer’s operations manager for fieldwork (southern and francophone Africa). Email: [email protected]. Gift Sambo is a research associate at the Institute of Public Opinion and Research in Zomba, Malawi. Email: [email protected]. Kim Yi Dionne is Five College Assistant Professor of Government at Smith College, Northampton, Massachusetts, United States. Email: [email protected]. Afrobarometer is produced collaboratively by social scientists from more than 30 African countries. Coordination is provided by the Center for Democratic Development (CDD) in Ghana, the Institute for Justice and Reconciliation (IJR) in South Africa, the Institute for Development Studies (IDS) at the University of Nairobi in Kenya, and the Institute for Empirical Research in Political Economy (IREEP) in Benin. Michigan State University (MSU) and the University of Cape Town (UCT) provide technical support to the network. Core support for Afrobarometer Rounds 5 and 6 has been provided by the UK’s Department for International Development (DFID), the Mo Ibrahim Foundation, the Swedish International Development Cooperation Agency (SIDA), the United States Agency for International Development (USAID), and the World Bank. For more information, please visit www.afrobarometer.org. Follow our Round 6 global releases on social media at #VoicesAfrica. Infographic designed by Soapbox, www.soapbox.co.uk Afrobarometer Dispatch No. 74 | 1 March 2016
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