Journal of Social Aspects of HIV/AIDS/Journal des Aspects Sociaux du VIH/SIDA
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EDITORIAL INFORMATION/INFORMATION RÉDACTIONELLE
Journal of Social Aspects of HIV/AIDS/Journal des Aspects Sociaux du VIH/SIDA
ISSN 1729-0376
Editors/Les rédacteurs en chef: Dominique Meekers (USA), Elias Mpofu
Prof Karl Peltzer, Social Aspects of HIV/AIDS and (USA/Zimbabwe), Kathleen Myambo (Egypt,
Health, Human Sciences Research Council (HSRC), Zimbabwe), Charles Nzioka (Kenya),Walter
Private Bag X9182, Cape Town 8000, South Africa. Odhiambo (Kenya), Kim Richards (USA, Zimbabwe),
E-mail: KPeltzer@hsrc.ac.za Brooke G Schoepf (USA), Pieter Streefland (The
Netherlands), Issiaka Sombie (Burkina Faso),
Prof Cheikh Niang,West African SAHARA Office, Adegbenga M Sunmola (Nigeria), Jacques Philippe
Institut des Sciences de l’Environnement, Faculté des Tsala-Tsala (Cameroon), Negussie Taffa (Kenya),
Sciences, Université Cheikh Anta Diop, Dakar, Marleene Temmerman (Belgium), Leana Uys (South
Senegal. Africa), Eliya Zulu (Kenya)
E-mail: cniang1@yahoo.fr or ciniang@sentoo.sn
Publisher/Éditeur:
Managing Editor / Le responsable de la SAMA Health and Medical Publishing Group
rédaction: (HMPG)
Yoesrie Toefy, HSRC, e-mail: ytoefy@hsrc.ac.za Tel: +27(0)21-530-6520
Fax: +27(0)21-531-4126
Technical Editor/Rédacteur Technique E-mail: publishing@samedical.org
Prof Anna Strebel
Published quarterly (hard copy and online)
Editorial Board/Le comité de rédaction: Publication trimestrielle (sur papier ou Internet)
Collins O Airhihenbuwa (USA), Lewis Aptekar
(USA), Peter Baguma (Uganda),Tony Barnett (UK), Funded by the Department For International
Don H Balmer (Kenya),Yosiah DM Bwatwa Development (DFID) (UK)
(Lesotho), Frikkie Booysen (South Africa), David Sponsorisé par le Department for International
Celentano (USA), Maureen Chirwa (Malawi), Soura B Development (DFID) (UK)
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Winnie Mpanju-Shumbusho (Switzerland),
SAHARA Journal Mission Statement
The journal publishes contributions in English and French from all fields of social aspects of HIV/AIDS (care,
support, behaviour change, behavioural surveillance, counselling, impact, mitigation, stigma, discrimination,
prevention, treatment, adherence, culture, faith-based approaches, evidence-based intervention, health
communication, structural and environmental intervention, financing, policy, media, etc).
Déclaration de la mission du journal SAHARA
Le journal publie des communications en Anglais et en Français de tous les domains des aspects sociaux du
VIH/SIDA (le soin, le soutien, le changement du comportement, la surveillance comportementale, la
consultation, l’impact, la réduction, le stigmate, la discrimination, la prévention, le traitement, l’adhésion, la
culture, les approches basées sur la foi, l’intervention évidence-basée, la communication sur la santé,
l’intervention structurale et de l’environnement, le financement, la politique, le média, etc).
VOL. 1 NO. 3 NOVEMBRE 2004 Journal des Aspects Sociaux du VIH/SIDA 131ORIGINAL ARTICLE
Preventing mother-to-child transmission: factors affecting mothers’
choice of feeding — a case study from Cameroon
K N Muko, G K Tchangwe,V C Ngwa, L Njoya
ABSTRACT
This paper reports on factors influencing the decision of mothers regarding the type of feeding method for their
babies in a rural setting in Cameroon.The aim of the study was to ascertain the proportion of mothers choosing
the different methods of feeding, to determine the various factors influencing their choices, and to ascertain the
relationships of these factors to their respective choices. Questionnaires were used on 108 HIV-positive mothers
who had delivered babies and who were administered nevirapine at least 3 months prior to the study. A focus
group discussion with mothers also took place. Findings were that more mothers (84%) chose breastfeeding than
artificial feeding (16%), while a minority (4%) selected mixed feeding. Factors found to militate against artificial
feeding were cost (69%), stigma (64%), family pressure (44%), inconvenience in preparation/administration
(38%), prior education from health workers (23%), and loss of special attention from family (8%). On the other
hand, advice of health worker (44%), ill health (19.5%), free milk (12.5%), job pressure (12.5%) and loss of
beauty (12.5%) were found to militate against breastfeeding. A direct relationship was also found between age,
educational level, income size, marital status and choice of feeding. Policies targeting stigma reduction and socio-
cultural factors affecting the choice of feeding are needed to optimise uptake of the less risky methods of
feeding which could in turn contribute to a reduction in transmission.
Keywords: HIV/AIDS, mother-to-child transmission prevention, feeding.
RÉSUMÉ
Cette communication présente des facteurs qui influencent la décision des mères concernant la méthode
d’allaitement de leur nourrissons, en zone rurale au Cameroun. Le but de cette étude était de s’assurer de la
proportion de mères qui choisissent de méthodes différentes d’allaitement, de déterminer les facteurs influençant
leur choix et d’étudier la relation entre ces facteurs et les méthodes d’allaitement choisies. Pour recueillir des
données, un questionnaire a été utilisé auprès de 108 mères séropositives qui ont des nourrissons. Ces mères
étaient sur le traitement de la névirapine depuis au moins 3 mois avant le début de cette étude. Une discussion
d’un groupe de foyer de mères a eu lieu. Les résultats ont montré que plus de 84% de mères ont choisi
l’allaitement maternel contre 16% qui ont choisi l’allaitement artificiel alors qu’une minorité (4%) ont choisi
l’allaitement mixte (maternel et artificiel). Les raisons contre l’allaitement artificiel sont les suivants: le coût
(69%); la stigmatisation (64%); les pressions familiales (44%); les inconvénients liés à la préparation et
l’administration du lait artificiel (38%); une éducation préliminaire de la part du personnel soignant (23%) et le
manque de soins particuliers de la part de la famille (8%). D’autre part, les facteurs qui favorisent l’allaitement
artificiel sont les suivants: les conseils du personnel de santé (44%); la mauvaise santé (19.5%); du lait artificiel
gratuit (12.5%) et la perte de beauté (12.5%). Nous avons constaté une relation entre l’âge de la femme, le
Kenneth Ngwambokong Muko (M Pharm, MPH) is a clinical pharmacist of the Catholic Health Service of the archdiocese of Bamenda,Cameroon. A
former assistant lecturer of the faculty of pharmaceutical sciences University of Nigeria Nsukka, he is also the acting project administrator for Inter
Care/Njinikom Project Hope, an HIV/AIDS prevention/care/treatment and impact mitigation programme in Cameroon.
Koubitim Ginnette Tchangwe (MB BS, D Paed) is paediatrician at the St Martin de Porres Hospital, Njinikom. She also heads the mother-to-child
HIV transmission prevention phase of Inter Care/Njinikom Project Hope.
Valentine Che Ngwa (BSc, MB BS ) is undergoing postgraduate medical training in infectious diseases in St James University Hospital, Leeds, UK. He
was the programme officer of the mother-to-child transmission phase of Project Hope and physician in charge of HIV treatment of the Catholic Mission
General Hospital, Njinikom, Cameroon.
Laah Njoya (MB BS) is the chief medical officer of the Fundong District Hospital, Cameroon.
Correspondence to: KN Muko, Inter Care/Njinikom Project Hope, BP 16 Njinikom, Boyo Division, Cameroon. E-mail: ngwamuko_70@yahoo.fr
Journal of Social Aspects of HIV/AIDS VOL. 1 NO. 3 NOVEMBER 2004
132ARTICLE ORIGINAL
Preventing mother-to-child transmission: factors affecting mothers’ choice of feeding
— a case study from Cameroon
niveau d’éducation, le niveau du revenu, le statut civil et le choix d’allaitement. Il est nécessaire de mettre en
place des politiques visant la réduction de la stigmatisation et les facteurs socioculturels qui influencent le choix
d’une méthode d’allaitement afin de maximiser une compréhension de méthodes d'allaitement à moindre risque
qui par la suite pourrait contribuer à la réduction de transmission.
Mots clés :VIH/SIDA, prévention de la transmission mère-enfant, allaitement.
Introduction liquids or solids, there is continued concern that if no
The majority of people living with HIV/AIDS are drugs are administered, the risk of infection is about
women.Women aged 15 and older make up 58% of 30 - 35%.The risk is reduced to 20% if the child is
the 42 million people who are living with HIV/AIDS not breastfed. Complete avoidance of breastfeeding
(UNAIDS, 2002). Over 90% of these women live in (using artificial feeding) is considered the most reliable
the developing world. Mother-to-child transmission way to avoid neonatal transmission.There is evidence
(MTCT) of the virus — also known as vertical to suggest that exclusive breastfeeding for the first 3
transmission — is the main route of HIV infection in months may result in lower transmission rates than
children under 10 years of age, with more than 600 000 mixed feeding (Coutsoudis, Pillay, Spooner, Kuhn &
infants becoming infected with HIV yearly. Since the Coovadia, 1999). Improper use of breast-milk sub-
beginning of the epidemic, an estimated 5.1 million stitutes (if mixed with tainted water or if over-diluted)
children worldwide have been infected. Of those, the can cause severe malnutrition and fatal infectious
overwhelming majority are in Africa.This is due to diseases.The risks associated with replacement feeding
high fertility rates and high HIV prevalence in may outweigh the benefits. In sub-Saharan Africa,
pregnant women, reaching levels of 40% in some cases diarrhoea is the leading cause of death in children
(UNICEF/UNAIDS, 1999).The virus can be trans- under 5 years. A sound assessment of the safety of
mitted during pregnancy, labour and delivery replacing breastfeeding depends on access to clean
(perinatal transmission), or through breastfeeding. water, a reliable supply of formula, and availability of
Among infected infants who are not breastfed, two- instruction.
thirds are believed to have contracted HIV around the
time of delivery. Some conditions that may increase The World Health Organisation (WHO) recommends
risk of transmission during breastfeeding are the the following for mothers with HIV:
advanced disease stage of the mother, maternal vitamin • avoid breastfeeding entirely when replacement
A deficiency, breast abscesses or infections, certain feeding is acceptable, feasible, affordable, sustainable
patterns of breastfeeding, and oral infection in the and safe
infant. • breast-milk should be fed exclusively during the
first months in cases where the mother chooses to
Until recently, there was no means of preventing breastfeed
MTCT for those HIV-positive women who wished to • if mothers choose not to breastfeed from birth or
give birth.Two interventions using antiretrovirals stop breastfeeding later, they should be provided
(nevirapine and azidothymidine) concurrently with with specific guidance and support for at least the
feeding adjustments have proven to be very effective first 2 years of the child’s life to ensure adequate
in reducing MTCT of HIV (Guay, Musoke, Fleming replacement feeding.
et al., 1999; Shaffer, Chuachoowong, Mock et al., 1999;
UNAIDS, 1999).The successful implementation of Other preventive measures jointly proposed by the
these programmes is highly dependent on the choice WHO, UNICEF and UNAIDS include the
and effective implementation of an appropriate expression of colostrum, artificial feeding with
feeding regimen. For women who are HIV-negative, formula or animal milk, pasteurisation of maternal
breastfeeding is the preferred child survival strategy for milk, reduction of breastfeeding duration or resorting
providing nutrition and avoiding infectious diseases to a seronegative wet-nurse (WHO, 1998a;WHO,
during the first 2 years of life.When a baby of an 1998b; UNAIDS, 2001).
HIV-positive mother is breastfed and given other
VOL. 1 NO. 3 NOVEMBRE 2004 Journal des Aspects Sociaux du VIH/SIDA 133ORIGINAL ARTICLE
Preventing mother-to-child transmission: factors affecting mothers’ choice of feeding —
a case study from Cameroon
As is the case with most countries south of the Sahara, and testing (VCT) surveys indicated 16.2%
prevention of MTCT (PMTCT) is a target of seropositivity with 12.2% prevalence among pregnant
Cameroon’s National Aids Control Committee.The women. Over the years (since November 2000) 2 864
country’s 11.8% HIV prevalence reflected a drastic rise mothers have been counselled and tested for HIV in
among pregnant women between 1998 and 2000, and the health institution, and over 166 have been
almost doubled from 6% to 11% among those aged administered nevirapine during labour.The
20 - 24 (UNAIDS, 2002).With pilot sites set up as programme currently has a nevirapine coverage rate of
early as 2000, a gradual scaling up is taking place. One 63% (ascertained within the past year), as many
province (North West) had 16 sites as at June 2002 mothers deliver elsewhere where their HIV status is
(Kube, 2002).The policy with regard to choice of not known.
feeding is artificial feeding as a first choice and
exclusive breastfeeding if the first is not feasible. Even The study was carried out using questionnaires.
though nevirapine is given free of charge, the mothers Trained health personnel administered tested
have to pay for artificial food and other related costs, questionnaires to 104 mothers, and a randomly
including treatment with antiretrovirals (ARV). selected focus group discussion with 18 mothers was
held.The purpose of the study was explained to the
Even though the WHO/UNAIDS guidelines on mothers and their consent sought prior to
feeding in HIV/AIDS settings are quite clear, many administration of the questionnaire.The criteria
factors affect mothers’ choice of feeding. Desclaux and excluded mothers who refused to participate and
Taverne (2000) have argued that preventive measures those who were too sick to take part or had lost their
applied successfully in developed countries cannot be babies.The inclusion criterion was all mothers who
generalised. Some of these measures (like formula participated in the PMTCT programme, i.e. had been
feeding) entail infectious and nutritional risks in counselled, tested positive, administered nevirapine and
health contexts of low-income countries, where they delivered live babies at least 3 months prior to the
are not economically or socially accessible for all study.
women. Furthermore, HIV/AIDS-related stigma, and
its associated discrimination, is known to negatively Results
affect all aspects of HIV prevention, diagnosis, Of the 348 mothers who had tested positive for HIV
treatment and care (Brown,Trujillo & Macintyre, prior to the study, 144 had been lost (had moved,
2001). Increased uptake of PMTCT services in delivered their babies elsewhere or died). A total of 38
general and improved adherence to optimum feeding had not yet been delivered of their babies and 62 were
practices can be attained if factors affecting the choice either not eligible for the study or did not participate.
of feeding of mothers are identified and appropriate Results indicated that the majority of mothers in the
interventions put in place.This has not been done in study (84%) were breastfeeding their children, while
Cameroon.Thus the current study seeks to identify the remaining 16% were using formula feed. However
such factors and suggest plausible interventions for it emerged from the focus group discussion (FGD)
improved uptake. that some mothers had initially used formula feeding
before switching to breastfeeding.
Methodology
The St Martin De Porres Catholic Mission Hospital The age group 20 - 30 years had the highest number
Njinikom is located in the North West part of of mothers (39%), followed by the age group of less
Cameroon. More than 90% of the inhabitants of the than 18 years (30%), with fewest mothers in the age
area are subsistence farmers with over 76% living on group above 40 years (7%).Table 1 shows the
less than $1 per day.The institution provides health correlation of age of the mothers involved in the
care services to over 170 000 people. In late 2001 an study and the choice of feeding. Exclusive breast-
HIV/AIDS prevention, treatment and care programme feeding was found to decrease with increasing age and
(Inter Care/Njinikom Project Hope) was put in place conversely an increase of artificial feeding was
with the help of the British-based organisation Inter observed with increasing age.
Care, Medical Aid for Africa. PMTCT has been a core
component of the project. Free voluntary counselling
Journal of Social Aspects of HIV/AIDS VOL. 1 NO. 3 NOVEMBER 2004
134ARTICLE ORIGINAL
Preventing mother-to-child transmission: factors affecting mothers’ choice of feeding —
a case study from Cameroon
of artificial milk. Conversely it was observed that the
TABLE I. AGE OF MOTHERS AND CHOICE OF FEEDING
more educated the mother, the greater the chances of
Age Number Artificial milk Breastfeeding
her choosing breastfeeding.
< 18 29 (30%) 3 (11%) 26 (89%) Table 4 shows the marital status of the respondents
18 - 30 38 (39%) 4 (11%) 34 (89%) and their choice of feeding. A majority of respondents
31 - 40 24 ((24%) 7 (30%) 17 (70%) (55%) were married (71% of them from monogamous
> 40 7 (7%) 2 (29%) 5 (71%) homes and 29% of them from polygamous homes).
Widowed mothers constituted 19% of the group and
it emerged from the FGD that some of them accepted
The relationship between the income-earning that their husbands had died of HIV/AIDS. It was also
capacities of the respondents and their choice of revealed from the FGD that some of the widows had
feeding is shown in Table 2. Most of the mothers been inherited by their brothers-in-law, while some
earned less than 1US$ per day. It was observed from had remarried. In half of the cases the present hus-
the FGD that some of the mothers did not carry out bands did not know the HIV status of their wives
any income-generating activity and were totally prior to marriage. It was observed that a greater
dependent on their husbands or partners. Overall an proportion of single mothers involved in the study
increase in income was observed to relate directly to chose to breastfeed their babies than the married
an increase in the number of mothers opting for mothers.This was much higher among those who
artificial milk.The relationship to income was not were widows.
very strong for those who decided to breastfeed their
babies. TABLE 4. MARITAL STATUS AND CHOICE OF FEEDING
Marital status Number Artificial milk Breastfeeding
TABLE 2. INCOME OF MOTHERS AND CHOICE OF FEEDING Single 17 (17%) 3 (18%) 14 (82%)
Married 55 (55%) 10 (19%) 45 (81%)
Income Number Artificial milk Breastfeeding (Monogamous = 39, polygamous = 15)
< 1 US$/day 52 (53%) 6 (12%) 46 (88%) Divorced (separated) 8 (8%) 1 (13%) 7 (87%)
Widowed 19 (19%) 2 (11%) 17 (89%)
1 - 2US$/day 23 (24%) 4 (18%) 19 (82%)
2 - 5US$/day 13 (11%) 4 (37%) 10 (70%)
5 - 10US$/day 7 (7%) 1 (15%) 6 (86%)
> 10US$/day 3 (3%) 1 (33%) 2 (67%)
Table 5 demonstrates the occupation of the mothers
and feeding choice. A majority (40%) were farmers,
followed by housewives (22%).The FGD revealed that
Table 3 shows the educational levels of the respon- some housewives were also farmers and a clear-cut
dents with their choice of feeding method. A large demarcation was not possible. Furthermore some
proportion (41%) had less than 7 years of formal housewives also responded that they had no
education.This was closely followed by those with occupation. No direct relationship was observed
8 - 12 years of formal education (29%).The smallest between mode of feeding and occupation. It was
group (3%) was those with above 18 years’ formal however observed that among those who choose
education, who held university degrees. Higher breastfeeding, the highest number were teachers
education was found to relate directly to decreased use followed by farmers and housewives.
TABLE 3. EDUCATIONAL LEVEL AND CHOICE OF FEEDING TABLE 5. OCCUPATION AND CHOICE OF FEEDING
Formal education Number Artificial milk Breastfeeding Occupation Number Artificial milk Breastfeeding
1 - 7 years 41 (41%) 8 (20%) 33 (80%) Housewives 22 (22%) 4 (19%) 18 (81%)
8 - 12 years 29 (29%) 5 (18%) 24 (82%) Farmers 39 (40%) 7 (18%) 32 (82%)
Teachers 11 (11%) 1 (9%) 10 (91%)
13 - 14 years 16 (16%) 2 (13%) 14 (87%)
Students 14 (14%) 2 (15%) 12 (85%)
14 - 17 years 9 (9%) 1 (12%) 8 (88%) Other civil servants 6 (6%) 0 (0%) 6 (100%)
> 18 years 3 (3%) – – No occupation 6 (6%) 2 (33%) 4 (67%)
VOL. 1 NO. 3 NOVEMBRE 2004 Journal des Aspects Sociaux du VIH/SIDA 135ORIGINAL ARTICLE
Preventing mother-to-child transmission: factors affecting mothers’ choice of feeding —
a case study from Cameroon
Table 6. FACTORS MILITATING AGAINST ARTIFICIAL FEEDING Table 7. FACTORS MILITATING AGAINST BREASTFEEDING
Cost 57 (69%) Advice of health worker 7 (44%)
Stigma 53 (64%) Sickness 3 (19.5%)
Family pressure 36 (44%) Free milk 2 (12.5%)
Inconvenience in preparation/administration 31 (38%) Job 2 (12.5%)
Prior education from health workers 19 (23%) Physical appearance 2 (12.5%)
Loss of special attention from family 6 (8%)
Discussion
Table 6 reports some of the factors that militate Breastfeeding prior to the advent of HIV/AIDS was
against artificial feeding.The most common factor was popular and this is reflected in the fact that the
found to be cost (69%), closely followed by stigma majority of mothers were breastfeeding their babies.
(64%). It emerged from the FGD that on average the Mothers who initiated formula feed and switched to
cost of a tin of artificial feed on the local market was 4 breastfeeding reportedly did so because of cost and
US$ and a baby needed approximately 36 tins within stigma.The fact that mothers took this decision in
the first 3 months. Furthermore some mothers had spite of the awareness of the consequences of such a
resorted to over-diluting the milk so that it would last decision shows the strong role these factors (cost and
longer.The FGD also indicated that the perception of stigma) have to play in choice of feeding.
stigma was greater than actual experience of stigma.
Most mothers had not directly experienced stigma as A majority of the mothers were less than 30 years of
such.Their fears were mostly based on experiences of age, which reflects the fact that in the area of study
friends and colleagues.The FGD highlighted the women get married at an early age. Most of the
connection between artificial feeding and stigma. teenage mothers were not yet married and the
Historically, health workers have told mothers (and the majority preference here for breastfeeding could be
community) that breastfeeding was the healthiest attributed to the fact that choosing artificial feeding
choice for the baby. Many people are now aware that was synonymous to a declaration of their seropositive
breastfeeding is not recommended for HIV-positive status and thus could decrease their chances of getting
mothers.Therefore if a mother is using artificial feed, married. Furthermore strong family support has been
relatives and neighbours suspect the reason is HIV- shown to increase adherence to feeding method and
related. Furthermore it emerged from the FGD that the older mothers, most of whom were married, could
breastfeeding mothers had a prominent status in the more comfortably adhere to artificial feeding as a
society, so that they were given special food (sweet result of support from their immediate family, unlike
palm wine which is erroneously thought to replace the spouses of single mothers who in some cases
artificial milk) and a special diet that included eggs. refuse to accept their parental roles (Bassett, 2000).
Mothers on artificial milk automatically lost this status. The programme in place encourages spouses to come
for testing, and 36% of legally married husbands had
Table 7 presents some of the factors that militate responded to this, while less than 5% of the unmarried
against breastfeeding.The most prominent factor spouses of HIV-positive mothers had been tested.Thus
(44%) was advice from health workers on the risk the legally married mothers had more family support
involved in breastfeeding the baby. Some mothers and were more predisposed towards choosing artificial
(19.5%) were too sick to breastfeed their babies, while feeding.
others ascribed not breastfeeding their babies to their
jobs and also the availability of free milk at the initial With 52% of mothers earning less than $1 per day it
stage of the programme. Notable too were the was difficult for mothers to raise the $144 needed for
mothers who would not breastfeed their babies a 3-month supply of exclusive formula feed. However
(12.5%) because they were concerned that the the fact that some mothers resorted to diluting the
appearance of their breasts would change and they milk rather than breastfeeding their babies showed a
would look less attractive. strong commitment to adhering to artificial feeding in
spite of the stigma. Increased level of education was
Journal of Social Aspects of HIV/AIDS VOL. 1 NO. 3 NOVEMBER 2004
136ARTICLE ORIGINAL
Preventing mother-to-child transmission: factors affecting mothers’ choice of feeding —
a case study from Cameroon
expected to lead to an increased understanding of the mothers were more aware of the impact of their sero-
greater risk of transmission in artificial feeding. How- status on their lives as a result of increased education.
ever the study found that the higher the level of In the area of study, the higher the educational level,
education, the less the chance of choosing breast- the greater the chances of getting a job, thus ‘working
feeding. It is likely that the educated mothers inter- mothers’ are generally more educated.This is not the
acted with peers of a similar education level who case with the farmers, most of whom had fewer years
might have been more informed regarding the of formal education.
rationale for artificial feeding and thus more prone to
stigma.Thus reticence to use artificial milk may be a Apart from cost and stigma, which have been
result of stigma and cost rather than the level of discussed as factors militating against breastfeeding,
education. pressure from family relatives was observed to be a
strong factor (44%).The FGD disclosed that relatives
The fact that more single mothers than married who were aware of the importance of artificial feeding
mothers chose to breastfeed their babies shows the in an area where breastfeeding was the norm were
strong role that support from the family plays in worried that their families would be subjected to
choice of feeding.The external family system provides stigma. Most members of the FGD felt that there was
a strong financial resource, which is available when a no difference in perception between a mother who
relative is sick. It would thus be expected that these gave the infant expressed milk and one who was
married mothers would have greater access to artificial feeding the infant with artificial milk.This was
milk than their unmarried colleagues. Unfortunately because the societal stigma would still be there and in
in situations were stigma is high, it would be difficult some cases would be accentuated for a mother who
for mothers to disclose their status, thus making it gave the infant expressed milk. Furthermore, the
difficult for family or friends to help (Muko, Ngwa, inconvenience of preparing artificial milk (38%) was
Chingang, Anke & Shu, 2003). In the area of study it mostly attributed to lack of time, rather than other
is not uncommon for the disease to be referred to as drawbacks to artificial milk, such as the fear of
‘women’s disease’, an implication that women are diseases, e.g. diarrhoea and unavailability of clean
solely responsible for the infection of their children, water, as reported in other studies (Desclaux &
which contributes to misconceptions about the disease Taverne, 2000). Prior to the advent of HIV/AIDS, a
and its effects, even though women often become great deal of emphasis was placed on the importance
HIV-positive without ever having another relationship of breastfeeding; thus it will take many years for
outside of their marriage. It has been suggested that people to accept artificial feeding as a valid alternative
parent-to-child transmission (PTCT) would be a more free of stigma.
realistic description that may lessen the stigma women
experience (Brown et al., 2001). In the study, a mother who had recently delivered was
given special status in the community.This was
The preference for breast-milk in this study was accentuated for those who were breastfeeding, and
associated more with stigma than cost. However more included a special diet with eggs, sweet palm wine, less
widows chose to breastfeed their babies, probably work, etc. Mothers reportedly felt that giving the child
because they did not have strong financial support artificial food would lead to loss of this special status.
from their families, compared with their married
colleagues. In the area where the study was Apart from the advice for mothers not to breastfeed
conducted, the death of a husband entails huge given by the counsellors in the health institutions, the
expenditure on funerals.Thus in most cases, the family clinical state of mothers was another factor. Less than
finances would be spent on treatment for the deceased 2% of mothers were on ARV therapy, thus the chances
husband. of infection from opportunistic diseases were great for
a majority of mothers.The fact that some mothers
Career mothers with stable jobs preferred to would give their children artificial milk if it was free
breastfeed rather than to give their babies artificial further accentuates the issue of cost and availability as
milk, in spite of the fact that they would be expected factors that could discourage breastfeeding. Few
to do so less, due to the time spent at work.These mothers (12.5%) attributed their decision to give
VOL. 1 NO. 3 NOVEMBRE 2004 Journal des Aspects Sociaux du VIH/SIDA 137ORIGINAL ARTICLE
Preventing mother-to-child transmission: factors affecting mothers’ choice of feeding —
a case study from Cameroon
artificial milk to their babies to pressure from their be naïve to assume that a pregnant mother could be
jobs and some (12.5%) felt that breastfeeding would taking ARVs and replace breastfeeding with artificial
cause them loose their beauty. Interestingly, these were milk without her relatives knowing her status.The
the younger mothers who were not yet married. traditional values and their impact need to be recog-
nised and impact-mitigation interventions put in
Conclusion place.
The study has shown that apart from cost and stigma,
other sociocultural factors affect mothers’ choice of References
feeding. For seropositive mothers, this decision is an Bassett, M.T. (2000). Psychosocial and community perspectives on alternatives to
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Journal of Social Aspects of HIV/AIDS VOL. 1 NO. 3 NOVEMBER 2004
138ARTICLE ORIGINAL L’ascenseur et l’escalier — la lutte contre le SIDA au Cameroun Jacques-Philippe Tsala Tsala ABSTRACT HIV/AIDS infection has spread like wildfire in the countries of sub-saharan Africa. In order to fight that pandemic, Cameroon has organised itself by setting up, with the assistance of bilateral and multilateral partners, a national structure with the aim to reduce the spread of the disease.Two years after the launch of the National Plan for the Fight Against HIV/AIDS, an advocacy campaign targetting social leaders made it possible to assess the difficulties encountered by such an entity in a social and cultural environment as complex as that of Cameroon.The paper presents the initiatives taken by the government and analyses the major specific obstacles which are met on the ground.They include beliefs, social structures, gender issues, the status of women and the social representations of sexuality. If consensus and compromise are the usual ways of solving the problems raised at the national level, the analysis stresses the need for a more courageous political will adapted to the urgency of the prevailing situation. Keywords: HIV/AIDS, Cameroon, National AIDS Control Committee, National Plan for Fight against HIV/AIDS, resistance to change, public health policy. RÉSUMÉ L'infection au VIH/SIDA s'est répandue comme une traînée de poudre dans les pays d'Afrique subsaharienne. Pour lutter contre cette pandémie, le Cameroun s'est organisé en mettant en place, avec l'aide de ses partenaires bilatéraux et multilatéraux, une structure nationale ayant pour objectif de réduire la progression de la maladie. Deux ans après le lancement du Plan National de Lutte contre le VIH/SIDA, une campagne de plaidoyer visant les leaders sociaux a permis de mesurer les difficultés auxquelles une telle entreprise est confrontée dans un environnement socioculturel aussi complexe que celui du Cameroun. L'article présente les initiatives gouvernementales et analyse les principaux obstacles spécifiques qui surviennent sur le terrain. Ils vont des croyances aux structures sociales en passant par la problématique du genre, le statut de la femme, les représentations sociales de la sexualité. Si le consensus et le compromis sont les modes de résolution habituels des problèmes nationaux, l'analyse aboutit à la nécessité d'une volonté politique plus courageuse, adaptée à l'urgence de la situation. Mots clés:VIH/SIDA, Cameroun, Comité National de Lutte contre le SIDA, Plan National de Lutte contre le SIDA, résistance au changement, politique de santé publique. Jacques-Philippe Tsala Tsala is a professor of Psychology in the Department of Psychology, University of Yaoundé I and Catholic University of Central Africa (Cameroon). He has been Senior Consultant for the National AIDS Control Committee (NACC) since 2002. He has lead several researches and missions in the field in Cameroon. Correspondence to: Prof. Jacques-Philippe Tsala Tsala, Université de Yaoundé I, Université Catholique d’Afrique Centrale, BP 7011 Yaoundé, Cameroun. E-mail: jptsala@uycdc.uninet.cm/tsalatsala2003@yahoo.fr VOL. 1 NO. 3 NOVEMBRE 2004 Journal des Aspects Sociaux du VIH/SIDA 139
ORIGINAL ARTICLE
L’ascenseur et l’escalier — la lutte contre le SIDA au Cameroun
Introduction de l’Afrique à vouloir nier les spécificités de chaque
Sur les quarante huit millions de personnes pays. Si la catégorisation sommaire a pour avantage de
séropositives recensées dans le monde, les trois quarts rendre les actions plus rapides, elle est loin de parvenir
vivent en Afrique, un continent qui ne représente que à l’efficacité qui suppose une observation patiente,
12% de la population mondiale (ONUSIDA - OMS, différentielle et contextuelle.
2003)! Face à une telle pandémie, de nombreux États
africains se sont mobilisés, chacun à son rythme et à sa Qu’il s’agisse de la pauvreté, de la mauvaise
manière, pour lutter contre ce qui apparaît de plus en gouvernance, de la gestion de la santé publique, des
plus clairement comme une hypothèque sur l'avenir du problèmes de genre, de la démocratie ou des traditions,
continent (Gruénais, 1999). Il est bien loin le temps de chaque pays se situe par rapport à son passé, à son
la dérision qui faisait du SIDA ‘le syndrome inventé histoire politique, à ses susceptibilités historiques et à
pour décourager les amoureux’. Les chiffres et ses cosmogonies spécifiques.
l’ampleur de la maladie sont aussi venus à bout des
stériles polémiques géopolitiques qui accusaient les Ces réalités n’ont pas les mêmes significations au regard
Occidentaux d’avoir fabriqué le SIDA pour décimer de leur vécu et de leur gestion face à l’autorité
l’Afrique ! La paranoïa de certains intellectuels et publique de l’État. Bien plus, certains pays doivent
dirigeants africains proposant des théories les unes plus gérer des différences culturelles importantes au sein de
étonnantes que les autres s’est réduite face à la cruauté leur population. Il s’agit donc de découvrir au
des faits et à la réalité de la pandémie. L’Afrique bien préalable la finesse des situations derrière l’apparente
pensante a courageusement cru qu'elle pouvait similitude des cas.
rapidement donner une réponse médicale à la maladie.
Malheureusement, l’utilisation du Virodène issu des L’objectif de cet article est de montrer comment un
laboratoires de l’Université de Pretoria, le MMI d’un pays africain, le Cameroun en l’occurrence, réagit
scientifique congolais (RDC) (1987), le Kemron du concrètement face à la complexité d’une population
Kenya (1992), le Therastim de Côte d'Ivoire (2001) et spécifique et diverse. Entrepris dans l’urgence, les
le Vanhivax du professeur camerounais Anomah Ngu différents programmes et actions de lutte contre le
(2002) n’ont pas encore fait preuve d'efficacité. Ces VIH/SIDA ont révélé les insuffisances voire la faiblesse
tentatives sont encouragées, soutenues et récupérées par et l’impuissance de l’État. L’incoordination des actions
une idéologie africaniste qui caresse l’espoir de trouver — taxée par d’aucuns de ‘modèle dissonant de
une solution africaine à un problème devenu politique publique’ — au niveau national et les
‘africain’ par la force des choses ! Face à l’ampleur et à injonctions contradictoires des partenaires
la vitesse de propagation de la pandémie, la revendi- internationaux ont régulièrement été dénoncées avant
cation politicienne doit momentanément céder la place la mise en route du plan national en cours (Eboko,
à une action efficace et courageuse, à la mesure de 1999; 2000; 2002; 2003; Mbembe, 2000). Les enjeux
l’enjeu. politiques de la lutte contre le SIDA au Cameroun
sont réels. Mais ils ne sont pas suffisants pour que ce
De nombreuses institutions nationales ont progressive- combat soit sommairement réduit à la seule
ment vu le jour aux fins de barrer la voie à la instrumentalisation politique. Néanmoins, le
progression de la maladie. L’ampleur du défi est telle gouvernement camerounais semble avoir pris
que, vu la modicité générale des moyens financiers et conscience de ses lacunes en mettant en place — à la
humains des états concernés, elles n’auraient pas pu demande injonctive de ses partenaires internationaux
réagir sans le soutien de la communauté internationale. — un nouveau plan multisectoriel aux fins de limiter
Ce soutien pose pourtant le problème de la marge de les contradictions et de reconstruire une cohérence
manœuvre des États aux prises avec leurs populations indispensable au succès de son action. Notre intérêt
et leurs difficultés spécifiques. De sorte que le SIDA portera sur les problèmes que rencontre l’application
devient un enjeu de politique nationale et de ce nouveau plan sur le terrain.
internationale (Gruénais, Delaunay, Eboko & Gauvrit,
1999). En effet, deux ans après avoir lancé son Plan National
de Lutte contre le VIH/SIDA (PNLS), le Comité
En effet, les divers programmes de lutte sont confrontés National de Lutte contre le SIDA (CNLS) a entrepris
aux réalités d'un terrain dont la complexité ne cesse de d’organiser dans les dix provinces du Cameroun des
dévoiler les contours. Elle reste pourtant vive, la ateliers de sensibilisation et de plaidoyer auprès des élus
tendance des organismes internationaux et des ‘experts’ locaux, des parlementaires, des autorités administratives,
Journal of Social Aspects of HIV/AIDS VOL. 1 NO. 3 NOVEMBER 2004
140ARTICLE ORIGINAL
L’ascenseur et l’escalier — la lutte contre le SIDA au Cameroun
traditionnelles et religieuses. La participation à ces 253 ethnies pour près de 180 langues nationales,
ateliers des représentants des associations des personnes dialectes et parlers à côté des deux langues officielles
vivant avec le VIH/SIDA (PVVS) et des représentants que sont le français et l’anglais.
des divers comités locaux de lutte contre le VIH/SIDA
(CLLS) a transformé ces ateliers en lieux d’échanges Sur le plan de son organisation politique, le Cameroun
fructueux, parfois ardus entre les participants, est une république démocratique et laïque. Les
animateurs y compris. Les PVVS et les acteurs sur le religions dominantes sont le Christianisme et l’Islam.
terrain ont fait des rapports détaillés des divers L’option républicaine de l’État laïc s’accommode tant
problèmes administratifs et sociaux auxquels ils sont bien que mal des institutions traditionnelles que sont
confrontés. De sorte que, à la fin des ateliers, les divers les sultanats, les cités — États musulmanes du Nord, les
représentants et leaders communautaires ont fait des principautés territoriales de culture et de religiosité
propositions concrètes aux fins de rendre plus efficace Bantou, les polyarchies fondées sur l’existence des
la lutte contre le VIH/SIDA dans leur zone d’influence lignages dans le reste du Cameroun. Ces différents
et de compétence. Les données à caractère autorités traditionnelles sont aujourd’hui intégrées à
ethnographique que nous mentionnons viennent de des degrés divers dans le système de l’administration
ces observations sur le terrain. Elles sont certes connues territoriale. On observe habituellement que
des ethnologues et anthropologues et certaines se l’intégration dans la hiérarchie administrative a très peu
retrouvent ailleurs en Afrique. entamé leur ascendante influence sur les populations et
les sujets qui se réclament de leur autorité. En clair,
Mais, au Cameroun, elles sont d’abord des éléments dans de nombreuses régions, aucune campagne de
régionalisés et différentiés dont le PNLS devrait tenir sensibilisation ou d’information — fût-elle d’ordre
compte. L’analyse que nous en faisons tient compte des sanitaire, éducatif ou politique, ne saurait se passer de
divers contextes et de notre expérience de chercheur l’assentiment même tacite de ces personnalités relais
et de clinicien en milieu camerounais diversifié. sans prendre le risque rater ses cibles et ses objectifs.
D’où la délicatesse des campagnes de sensibilisation
Après avoir décrit les mesures que le gouvernement contre la propagation du VIH/SIDA dans les provinces
camerounais a mis en place pour lutter contre la et en zones rurales.
pandémie, nous rendrons compte de la situation
spécifique qui se dégage de ces nombreux et divers Une population jeune et irrégulièrement répartie
échanges auxquels nous avons personnellement La population camerounaise se caractérise par sa très
participé. Notre approche consistera essentiellement à grande diversité. On distingue: dans la partie
exposer les principaux problèmes que doivent résoudre septentrionale majoritairement animiste et islamisée, les
les différents acteurs de la lutte sur le terrain. Il s’agira Soudanais, les Hamites et les Sémites; dans le Sud
non pas de mener une étude ethnologique ou majoritairement animiste et christianisé, les Bantous, les
anthropologique des différents us et coutumes, mais semi Bantous et les Pygmées.
plutôt de montrer la spécificité d’un terrain par rapport
à un plan dit ‘national’. Nous reviendrons dans notre Le taux de croissance annuelle de la population du
analyse sur les éléments qui nous semblent mériter plus Cameroun est passé de 3.0% en 1976 à 2.9% en 1987
d'attention pour rendre la lutte contre le VIH/SIDA et à 2.87% 2000 selon les projections (DSCN, 1987).
plus efficace dans un pays africain, le Cameroun en Toujours à partir des mêmes sources et suivant les
l’occurrence. calculs effectués par le FMI en octobre 2000 la
population camerounaise est théoriquement passée à
LA RÉPONSE CAMEROUNAISE À LA plus de 17 106 000 habitants. Les différentes
PANDÉMIE projections donnent les chiffres de 18 000 000 pour
SIDA et société camerounaise 2005, 23 000 000 pour 2014 et 25 000 000 pour 2020
Généralités sur le Cameroun dont 51% de femmes et 49% d’hommes.
Rappelons à toutes fins utiles que le Cameroun est un
pays d’Afrique Centrale d’une superficie d’environ 475 C’est une population essentiellement jeune dont les
650 km2. Il s’étire du Golfe de Guinée au Lac Tchad. moins de 14 ans représentent 43.7% de la population
Ses principaux voisins sont le Nigeria, le Tchad, la totale. Ceux dont l’âge est compris entre 15 et 24 ans
République Centrafricaine, le Congo, le Gabon et la représentent 20.5%. Soit un effectif cumulé de 64.2%!
Guinée Equatoriale. Le Cameroun compte environ Le groupe des 25 à 64 ans représente 32.55%, tandis
VOL. 1 NO. 3 NOVEMBRE 2004 Journal des Aspects Sociaux du VIH/SIDA 141ORIGINAL ARTICLE
L’ascenseur et l’escalier — la lutte contre le SIDA au Cameroun
que les personnes âgées de 65 ans et plus représentent (café, cacao, coton), la dévaluation du franc CFA et une
3.26%. gestion peu rigoureuse des affaires publiques ont
conduit le pays à un seuil de pauvreté jamais atteint
On observe par ailleurs un mouvement d’urbanisation auparavant. Les années 90 ont été difficiles. Les
important dans le pays. Ainsi, de 1976 à 1987, la différents programmes d’ajustement structurel (PAS)
population urbaine a crû à un rythme annuel moyen imposés par les bailleurs de fonds et la communauté
de 5.75%. Ce qui a entraîné le doublement de la internationale visaient à rétablir l'équilibre de la
population urbaine en 12 ans. Celle-ci atteignait balance des paiements et les grands équilibres macro-
3 968 919 habitants en 1987, soit 38% de la population économiques. Il consistait en fait à réduire les dépenses
totale. En 1995 la population urbaine était estimée à publiques et la demande intérieure. A ce jour, l’impact
45.3%. En 2000 taux est estimé à 50.4%. Les deux de ce plan sur le bien-être des populations commence
grandes villes cosmopolites de Douala et Yaoundé à peine à être perceptible. Mais il apparaît clairement
totalisent à elles seules 35.08% de la population urbaine que certaines mesures du PAS ont négativement affecté
du Cameroun, soit respectivement 1 452 400 et 1 237 le bien-être des populations appartenant aux couches
500 habitants. L’enquête EDS (1998) donne les les plus vulnérables. Le secteur public a connu son lot
indicateurs démographiques de base et les projections de difficultés. Des vagues de déflations du personnel et
(cf.Tableau 1). une double baisse des salaires ont précipité les
Mais une autre caractéristique de cette population est fonctionnaires et les employés des entreprises publiques
la très grande diversité de sa densité en fonction des et parapubliques dans la précarité et la pauvreté.
régions.
En effet, selon les estimations de diverses sources
Les données socioéconomiques (ECAM II, 1998; MINEFI, 2003), entre 1984 et 1991,
Le Cameroun est un pays agricole qui connaît une le niveau de l'emploi a baissé de 10% et le chômage
certaine autosuffisance alimentaire. Producteur de atteint le taux de 17% en 1995. Il frappe principale-
pétrole, il exporte aussi le cacao, le café, la banane, le ment les jeunes et les femmes entraînant un fort
coton. Mais la baisse des cours des matières premières développement du secteur informel.
En 2001, par exemple, le chômage touche 8% de la
TABLEAU I. DISTRIBUTION ET ÉVOLUTION DES INDICATEURS population active, dont 18.9% en milieu urbain et 2.3%
DÉMOGRAPHIQUES DE BASE
en zone rurale avec les pointes dans les villes de
Indicateurs 1976 1987 2000 Douala et Yaoundé qui enregistrent des taux de
chômage de 25.6% et 21.5% respectivement.
Population
Urbaine 2 184 242 3 968 919 7 668 000 La récession a gravement limité les moyens des familles
Rurale 5 479 004 6 524 736 7 624 000
Ensemble 7 663 246 10 493 655 15 292 000
à prendre en charge l’éducation, la santé et la
Taux d’urbanisation (%) 28.5 37.8 50.14 scolarisation de leurs enfants. La demande en éducation
Densité de la population au km2 16.4 22.5 32.81 est limitée par le chômage endémique des aînés. En
Taux de croissance annuelle (%) 3.0 2.9 2.87 effet, le taux de scolarisation qui était de 90% en 1990
Rapport de masculinité 95.9 97.0 97.3
Indice synthétique de fécondité
est tombé à 76% en 1996. La déscolarisation et la non
(1/1000) 6.0 5.6 5.14 scolarisation sont habituellement imputées à la
Mortalité paupérisation des parents et à l’insuffisance de l’offre
Taux brut de mortalité (1/1000) 20.4 13.7 10.1 d’éducation. Cette situation a aussi pour conséquence
Taux de mortalité infantile (1/1000)156.5 82.9 77.0
Espérance de vie à la naissance
de réduire l’autorité parentale et de pousser les jeunes à
Hommes 43.2 52.4 56.7 abandonner l’école pour gagner plus rapidement de
Femmes 45.6 56.2 61.3 l’argent dans le secteur informel et/ou dans la
Ensemble 44.4 54.3 59.0 prostitution (chez les femmes et les jeunes filles).
Structure de la population par groupe d’âge (%)*
0 à 14 ans 42.21 46.46 43.70
S’agissant de la prostitution comme effet de la
15 à 24 ans 18.94 17.77 20.49 pauvreté, elle concerne les femmes jeunes, mûres et
25 à 64 ans 35.65 32.49 32.55 parfois mariées (Garcia, 1992; Songue, 1993; Njikam,
65 ans et plus 3.20 3.32 3.26 1998; IRESCO, 1998). D’où le risque d’une plus
*P = projections.
Source: INS, RGPH (1976 et 1987) et EDS 98.
grande exposition à l’infection au VIH/SIDA.
Journal of Social Aspects of HIV/AIDS VOL. 1 NO. 3 NOVEMBER 2004
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