[Sociological perspectives on the management of TB/HIV co-infection in Burkina Faso]. / Mise en perspective sociologique de la prise en charge de la co-infection TB/VIH au Burkina Faso.

In Burkina Faso, the management of TB/HIV co-infection presents a challenge for policy-makers and the health-care system, with its psychological, sociocultural and biomedical issues. The purpose of this paper is to describe the concerns caused by this co-infection and propose a management strategy for these patients. These findings result from a qualitative socio-anthropological study during a public health project in three health districts from 2006 to 2008 and from the observation of care practices in health centres. Patients face a double burden: the negative social image of both diseases and complicated difficult treatment. They deal with problems of social integration, with their social relations impaired by humiliation and marginalisation. The painful experience of daily doses of antiretroviral and anti-TB drugs creates bitterness against drugs, aggravated sometimes by apparently capricious care. In addition to economic insecurity, these chronically ill patients face social stigma and marginalisation, all damaging to their self-esteem.

[Understanding and reaching young clandestine sex workers in Burkina Faso to improve response to HIV]. / Comprendre et atteindre les jeunes travailleuses du sexe clandestines du Burkina Faso pour une meilleure riposte au VIH.

In 1998, researchers in Burkina Faso enrolled 300 women more or less involved in commercial sex work in an open cohort to determine whether adequate management of their sexually transmitted infections and exposure to well-designed, well-delivered, and plentiful communication for behaviour change (CBC) might reduce their vulnerability to HIV. In 2000, they observed that the non-professional sex workers (occasional or clandestine sex workers) were more difficult to reach, to mobilize and to keep involved in the project's different activities. This group was also infected at the same or higher rates than professional sex workers because they did not use condoms routinely. To accomplish the project objectives, they therefore chose to recruit more non-professional sex workers in the new cohort of 700 women. This social-anthropological study was conducted to help them to enrol young clandestine sex workers. The overall objective of this study was to understand the life of this category of sex workers and to identify strategic actors to reach them. Using a qualitative method, social anthropologists reviewed literature, identified and geo-referenced all local places suitable to encountering these women, obtained life stories from some of them and interviewed key informants and participants in the field. The results showed that in Bobo-Dioulasso (Burkina Faso): - most young women who are clandestine sex workers are Burkinabe, and girls entering the sex trade are increasingly young and increasingly uneducated; - most of them come from families with low capital (financial, cultural, or social). The parents' socioeconomic status (contextual poverty) results in unmet financial needs, which in turn exposes them to starting work early, including commercial sex work; - of all the income-generating activities available to unskilled young girls, commercial sex work is one of the most profitable and easily accessible; - in the three-fold context of an HIV epidemic, poverty, and unemployment, clandestine commercial sex work is a rational action, insofar as condom use reduces the risk of HIV infection, "clandestinity" reduces the risk of social stigma, and earnings increase financial capital; - girls are coopted into sex work through an initiation process and the initiator explains to the initiate how sex workers think, act, and live, as well as the rules of the trade; - young clandestine commercial sex workers use various strategies to do their work in secret, unidentified, by changing the time, place, period, district, city or country of their work; - young clandestine commercial sex workers maintain friendly relations with men or boys in but have no or conflictual relationships with women and girls. Thus, only other participants in this trade, peer counsellors, and room renters can serve as strategic actors to reach, mobilize and keep these young girls in HIV programmes. Social anthropologists have concluded that one problem in the fight against official or professional commercial sex work is the development of clandestine commercial sex work, which is more dangerous, firstly for its practitioners, who are harder to reach by messages about HIV and thus do not change their behaviour, secondly, for their sexual partners who do not use condoms systematically, and finally for society as a whole, to the extent that social actors are embedded in an informal network, more or less extensive, of sexual partners.

[Communicating with vulnerable women for positive behaviour change: the Yerelon project in Bobo Dioulasso (Burkina Faso)]. / Communiquer avec les femmes vulnérables pour un changement positif de comportement : l'exemple du projet Yêrêlon de Bobo-Dioulasso (Burkina Faso).

CONTEXT AND OBJECTIVES: Since 1998, researchers in Burkina Faso have enrolled about 760 vulnerable women (sex workers, bar waitresses, pedlars, students, etc.) in an open cohort (the Yerelon cohort) to determine whether adequate management of sexually transmissible infection and exposure to well-designed, well-delivered, and plentiful communication for behaviour change (CBC) can reduce their vulnerability to HIV. This qualitative social anthropology study was conducted to: i) analyse the messages assimilated by the women who follow CBC sessions; ii) determine the impact of these messages on the women's behaviour. METHODS: The researchers observed CBC sessions in the clinic, in women's homes and at their places of work for 45 days. They also conducted 37 individual in-depth interviews, 8 group interviews and a focus group, selecting a "reasoned" sample of 80 women from the cohort. The data were entered with Word software and analyzed with the 'Atlas TI' qualitative data analysis software. RESULTS: This study shows that: i) these vulnerable women have good knowledge of the themes raised during CBC sessions with the Yerelon peer-leaders and are quite able to reproduce the messages. Most can repeat and explain them; ii) the women find the messages presented during CBC, by peers who live similar lives and speak their "language", to be understandable and applicable to them; iii) they learned much about condom use and negotiation, HIV/AIDS, genital herpes, and other STIs. They know for example that condoms have two sides, one lubricated and the other not, and that condoms effectively protect against pregnancy and some STIs; iv) they negotiate condom use better with all types of sexual partners, thus improving their relation to it; v) a large majority report new positive behaviour, selecting clients and partners, and using condoms routinely, taking it off after intercourse themselves. They also now routinely use modern medical care for any STIs; vi) Of 524 women seronegative at inclusion in 2003, only 0.8% became infected in the first three months of the study, and no others in the year that followed. CONCLUSION: In Bobo-Dioulasso, Burkina Faso, the communication offered in the CBC programme to vulnerable women by peer-advisers trained by a multidisciplinary team, improved to varying degrees the women's knowledge of the various topics covered. This improvement changed their behaviour positively, leading to routine condom use, especially with occasional partners. This has resulted in low HIV incidence. This model can and must be spread to other vulnerable populations. Admittedly, the free services and products provided in the programme make it harder to perpetuate and disseminate. The promotion of health mutuals is one method to provide funding.

[Traditional enema for newborns and infants in Bobo Dioulasso: health practice or socialisation]. / Hygiène et socialisation du nourrisson: le lavement rectal en milieu urbain à Bobo Dioulasso.

Kanki demonstrated a high prevalence and frequency of enema practised with newborns in the South-West of Burkina Faso. Little is known about the risks on children's health possibly associated with this practice and about its impact on other treatments in paediatrics. In this study, the authors describe daily administered enema (DAE) and analyse local conceptual frameworks underlying this practice through in-depth-interviews and focus group discussions with 30 mothers, 5 traditional healers and 5 health agents. Various medications are used to compose the liquid introduced by the mothers in the child's anus. Many of these substances are prone to irritate intestinal mucus, others are simply toxic. Practically, enema aims at curing or preventing a variety of diseases caused by an accumulation of impurities (nògò) in the intestines due to the consumption of inappropriate food. With newborns, diseases are transmitted by mothers through breastfeeding after eating food which is too sweet or too fat. In addition to provoking diseases, the nògò also "block" the child's physical and psychic development during his/her first year of life. Therefore, as soon as the child has excreted for the first time, most mothers give enema daily both to protect their children from diseases and to speed their development. In fact, beside prophylaxy and therapy lies a "didactic" function of enema as a medication used to help the child to stand up, to get teeth..., to gain independence from his/her mother. DAE therefore plays an important role in the process of acquiring bio-social aptitudes, i.e., important educational virtues to achieve a successful first step in the socialisation process. Exploring more deeply local perceptions explaining the origin of the n g , the authors found an interesting relationship with religious taboos. Beside prohibited food, the n g are also due to transgression of various taboos surrounding birth and breastfeeding and even suggest a religious, rather than hygienic, explanation for the food prohibited. DAE ultimately consists in re-adjusting the child and his mother according to moral and cultural rules, avoiding the negative consequences of transgression. Consistently, DAE also facilitates the process of acquiring bio-social aptitudes for the child and therefore help him to enter his/her family as a fully accepted member. Moreover, religious prohibitions surrounding birth end as soon as the child is able to eat solid food and free him/herself. Therefore, DAE also helps the parents to get back to their normal life conditions. In conclusion, in addition to prophylactic and therapeutic explanations, the DAE participates in a general process of socialisation of newborns. To a certain extent, the child's health depends on the respect of the social and religious system and rules. The study reveals the important conceptual gap that may exist between two different logical frameworks--biomedical and popular--prone to explain health risk for newborns. The authors then reflect on the possible impact of health education programmes seeking to intervene at the hygienic level and ultimately facing an important set of cultural values aiming at keeping the social and cultural organisation coherent.

Spectrum of commercial sex activity in Burkina Faso: classification model and risk of exposure to HIV.

OBJECTIVE: Before designing a sexually transmitted infection (STI)/HIV intervention study targeting female commercial sex workers in Bobo Dioulasso, Burkina Faso, we conducted a socioanthropologic survey to analyze the prostitution network in the city in 1998. According to social characteristics, women were classified in six different categories, including four groups of nonprofessional sex workers. The aim of the current study is to assess HIV exposure across this classification model. METHODS: A total of 447 women belonging to the six categories were enrolled in the study. After collection of social and behavioral data by means of a questionnaire, each woman received a physical examination and a blood sample was taken for HIV serologic testing. RESULTS: The category of "seaters" was the most often infected, with an HIV prevalence of 57% (58 of 101 women). Nonprofessional "sellers" and "bar waitresses" were more often infected than professional "roamers," with an HIV prevalence of 37% (24 of 65 women), 40% (27 of 67 women), and 29% (27 of 92 women), respectively, despite a much lower number of clients per week (average of 2.6 clients, 3.3 clients, and 18.6 clients, respectively). Finally, "students" and "cabarets" (women making and selling local beer in huts) were infected with an HIV prevalence of 15% (9 of 62 women and 9 of 60 women, respectively), which remains higher than the prevalence measured recently in the general female population in the city (6.4%). CONCLUSION: Our results highlight the high level of vulnerability of nonprofessional sex workers, who need to be considered in the design of any program targeting this population for STI/HIV control purposes.