HIV/AIDS is rapidly emerging as one of the worst epidemics Africa has ever faced. At year-end of 2004, an estimated 26 million people in Africa were living with HIV, comprising 66.5% of the total HIV infections worldwide. The disease claimed the lives of an estimated 2.3 million and 3.1 million new infections occurred in sub-Saharan Africa during 2004. Women, particularly between ages 15-25, and children are disproportionately affected by HIV/AIDS. Nearly 60%, or 13.3 million infected adults are women and of those, 76% are between ages 15-25. Approximately three million children under age 15 are living with HIV/AIDS and more than 12 million have been orphaned.

Even though Mali continues to rank among the few sub-Saharan African countries with a low prevalence of HIV/AIDS in the general population, it is estimated that over 120,000 adults and children in Mali are infected. Estimated HIV prevalence in females and males is 2.0% and 1.3%, respectively. Malian women ages 25-29 have the highest prevalence of HIV infection, at 3.2%, and the nation's capital, Bamako, has a higher prevalence of HIV/AIDS, compared to other Malian cities.

Prisons
Of the more than 45 jails and prisons in Mali, the largest men's prison is located in downtown Bamako. The facility incarcerates 1,400 inmates, including domestic prisoners and individuals from France, Senegal, Nigeria, Liberia, Benin, and Togo.

The prison's medical facility is centrally located within the compound and consists of one outbuilding containing two small rooms. The first room is used for patient examinations, is approximately 80 square feet, and is furnished with one bed and one desk. The second room contains a single metal cabinet with minimal medical supplies; a few rolls of gauze, scissors, tape, and Aspirin.

The prison's clinic is staffed by one technician from the Institut National de la Recherche en Santé Publique, who is charged with the medical care of all 1,400 inmates. He is available to examine patients twice per week and during times when the technician is unavailable, five inmates who serve as medical nurses staff the clinic. These staff members are not trained in counseling, diagnosis, or treatment of HIV or other diseases. As a result, while minor illnesses are treated within the prison walls, more severe infirmities are referred to Hospital Gabriel Touré. HIV-infected patients who present with severe illnesses are referred to Centre de Soins, d'Animation et de Consei (CESAC) for treatment. Unfortunately, most patients are not transferred until they are extremely sick, and many do not survive.

While HIV, TB, and other infectious disease prevalence rates are unknown in the prison, the technician employed by the prison has estimated that HIV prevalence may be as high as 5%.

Sick inmates obtain medications only if they have the financial resources to pay for them. In such cases, the technician travels to the pharmacy and retrieves the prescription. Most inmates lack sufficient funds to pay for medications and as a result, they are forced to rely on the limited charity of others. Typically, such charity comes from relatives and medical students who visit the prison facility to conduct thesis research and patient visits. Hama Diallo, a medical student at the University of Bamako Medical School, commented, "The medical students have no money because they spend it all on supplies for their patients. If the patient has no money, they die."

Hospitals
Point G Hospital, which is affiliated with Hospital Gabriel Touré, offers free antiretroviral therapy (ART) to HIV-infected patients. The hospital currently monitors 747 HIV/AIDS patients, and of these, 489 patients are receiving ART. While Mali is making great strides in offering free ART, standard therapy provided is not equivalent to the recommended treatments in the United States. The Malian Ministry of Health does, however, base its' guidelines for HIV/AIDS treatment on the current guidelines recommended by the World Health Organization (WHO) for resource-constrained settings. Triple drug therapy is prescribed for HIV-infected adults and infants and nevirapine is the standard for prevention of mother-to-child-transmission (MTCT).

The hospital's lack of resources, including medications, beds for patients, soap, and doctors, plays a large role in diminishing the quality of care patients receive. In addition to this lack of resources, there are several other differences between Point G Hospital and its American counterparts. Hospital rooms are small, dark, unventilated, and house two patients per room on thin mattresses. Patients must rely on family members to provide food and pay for medical treatment, including syringes and intravenous fluids. Additionally, patient confidentiality is often difficult to maintain due to the over-crowding that exists within many hospitals and clinics.

HIV Testing
The Malian national policy on HIV testing is based on the World Health Organization's HIV testing recommendations for resource-constrained settings. After pre-test education and counseling, an HIV rapid test, used as a screening test, is performed. When a positive test result occurs, a second HIV rapid test, used as a confirmatory test, is performed. If the first and second test results are contradictory, a third and different HIV rapid test is utilized. Since availability and access to HIV rapid tests is limited, especially in areas outside of the nation's capital, HIV testing often consists of one rapid test. Many HIV-infected patients remain undetected despite the high (>99%) specificity and sensitivity of HIV rapid tests. Non-detection of these patients is most likely attributed to non-testing due to a lack of tests, and reluctance to get tested.

Access
Social stigma, limited financial resources, lack of education, pharmaceutical shortages, and lack of transportation are the realities for Malians attempting to access HIV testing and treatment resources. HIV remains extremely taboo throughout Mali, particularly in segments of society where religion plays a large role in cultural beliefs. Accordingly, many Malians do not seek testing or treatment.

The stigmatization associated with HIV/AIDS is so great that many individuals do not want to learn their HIV status, for fear of likely negative reactions of family members and the community. While ART is free, financial resources still play a dominating role in limiting access to HIV care. The average Malian's monthly income is US $30, which is not enough money to support the financial responsibility that accompanies transportation to and from the hospital and/or pharmacy, HIV testing, and medical care costs, excluding antiretroviral (ARV) medications. For many Malians, the final decision to seek HIV care is based on having enough money available for both food and HIV care. Lack of education also contributes to many Malians hesitation when it comes to HIV testing; understanding of the importance of HIV testing is lacking in large portions of the population and common misconceptions concerning HIV include that the virus is acquired from bad food, and that HIV -infected men can be cured by having sex with a virgin. Additionally, Malian pharmacies often accidentally stock counterfeit ARVs, and dosing and quality in these counterfeit medications are often compromised. Transportation difficulties can hinder scheduled deliveries of ARV medications, leading to inadequate stock and the development of resistance in those who have time lapses in their treatment regimen. Additional factors which hinder the fight against the HIV/AIDS epidemic in Africa include inadequate nutrition, infrastructure of the health care system, and diagnostic capability.

When access to treatment is possible, tests that measure if treatment is working, including viral load and T-cell count tests, are unavailable in the majority of Mali. Furthermore, access to opportunistic infection (OI) prevention and treatment is limited. Unlike ARV medications, drugs to combat OIs, excluding anti-tuberculosis drugs, are not free. OIs that are common in Mali include Cryptococcus neoformans, Candidia, and Isospora belli infections, and also Toxoplasmosis and Cytomegaolvirus.

Recommendations: Accelerating Access to Treatment in Mali
ART is free to all HIV-infected Malians who receive prescriptions from medical doctors. However, the social situations, financial resources, limited number and locations of pharmacies, and unreliable ARV stock discussed above, combine to create enormous barriers for patients when accessing ARV medications.

Recommendations on how to best address these problems and how to accelerate access to HIV testing and treatment were discussed at the 2nd Annual Conference of HIV/AIDS Specialists held in Bamako, Mali, on January 11-13, 2005.

Recommendations included the establishment of a location that houses both hospital and pharmacy facilities, which would decrease patients' travel time and costs associated with transportation and increase access to pharmacies. Other recommendations included the implementation of a quality control system for ARVs, the development of an MTCT prevention program that includes counseling, and education programs tailored to different risk groups that discuss responsible sexual behavior. It was further recommended that a national reference center for TB and other OIs prevalent in Mali, be developed, and that human resources be mobilized and techniques for supplementary finances be explored. Lastly, conference participants were in agreement that collaboration between the public, private, and political sectors, clinicians and pharmacies, non-government organizations, universities, and laboratories needs to improve for greater efficiency, increased pace, and improved coordination of our efforts. The American, French, and Malian collaborators who attended the conference are currently assessing ways in which these recommendations can be implemented.

Disclosures:
*Nothing to dislcose.

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