RESEARCH DOSSIER: HIV PREVENTION FOR GIRLS AND YOUNG WOMEN

Cameroon

This Research Dossier supports the Report Card on HIV Prevention for Girls and Young Women in Cameroon produced by the United Nations Global Coalition on Women and AIDS (GCWA). It documents the detailed research coordinated for the GCWA by the International Planned Parenthood Federation (IPPF), with the support of the United Nations Population Fund (UNFPA), United Nations Program on AIDS (UNAIDS) and Young Positives. The Report Card provides an at a glance summary of the current status of HIV prevention strategies and services for girls and young women in Cameroon. It focuses on five cross-cutting prevention components: 1. Legal provision 2. Policy context 3. Availability of services 4. Accessibility of services 5. Participation and rights The Report Card also includes background information about the HIV epidemic and key policy and programmatic recommendations to improve and increase action on this issue in Cameroon. This Research Report is divided into two sections: PART 1: DESK RESEARCH: This documents the extensive desk research carried out for the Report Card by IPPF staff and consultants based in the United Kingdom. PART 2: IN-COUNTRY RESEARCH: This document the participatory in-country research carried out for the Report Card by a local consultant in Cameroon. This involved: o Two focus group discussions with a total of girls and young women aged 15-24 years. The participants included girls and young women who are: living with HIV; in/out-of/school; involved in sex work; living in urban and suburban areas; and working as peer activists. Five one-to-one interviews with representatives of organisations providing services, advocacy and/or funding for HIV prevention for girls and young women. The stakeholders were: a country representative of an international NGO; a nurse at a national NGO focusing on sexual and reproductive health; a counsellor at an NGO/government voluntary counselling and testing centre; a programme officer of a United Nations agency; and a Technical Adviser of an international donor agency. Additional fact-finding to address gaps in the desk research.

Contents:
PART 1 - Desk Research Country profile Prevention component 1: Legal Provisions Prevention component 2: Policy Provisions Prevention component 3: Availability of services Prevention component 4: Accessibility of services Prevention component 5: Participation and Rights PART 2 - In-Country Work Focus group discussion with girls and young women, ages 15 19, rural area. Focus group discussion with girls and young women, ages 20 24, urban area. Interview with Reproductive Health Officer, UNFPA Interview with President of United Brothers and Sisters for Hope and Solidarity Association Interview with President of Cameroon Network of People Living with HIV/AIDS (RECAP+) Interview with HIV Officer, Cameroon National Assocation for Family Welfare (CAMNAFAW) Interview with Coordinator Ethics, Law and HIV/AIDS Network (REDS) Interview with President, Cercle des Jeunes Engags dans la lutte contre le SIDA (Union of young people fighting against AIDS) Interview with Executive Assistant, UNAIDS

Abbreviations ACOW AIC AIDS AMREF ART ARV CBOs CCM CEDAW CIA CRC EU FGM FP GFATM GIPA HIV IEC MCH NGOs PEPFAR PLWHA/PLWA PMTCT SRH STD STI TB UN UNAIDS UNDP UNFPA UNGASS UNICEF UNIFEM AIDS Care Orientation Workshop AIDS Information Centre Acquired Immune Deficiency Syndrome African Medical And Research Foundation Anti-Retroviral Therapy Anti-Retroviral Community Based Organisations The Convention on Consent on Marriage The Convention on the Elimination of All Forms of Discrimination against Women Central Intelligence Agency The Convention on the Rights of the Child European Union Female Genital Mutilation Family Planning The Global Fund to Fight AIDS, Tuberculosis and Malaria Greater Involvement of People Living with or affected by HIV/AIDS Human Immunodeficiency Virus Information, Education & Communication Maternal and Child Health Non-Governmental Organisations President' Emergency Plan for AIDS relief s People Living With HIV and AIDS Prevention of Mother to Child Transmission Sexual & Reproductive Health Sexually Transmitted Disease Sexually Transmitted Infection Tuberculosis United Nations The Joint United Nations Programme on HIV/AIDS United Nations Development Programme United Nations Population Fund United Nations General Assembly Special Session The United Nations Children' Fund s The United Nations Development for Women 2

For further information about this Research Report, or to receive a copy of the Report Card, please contact: HIV/AIDS Department, International Planned Parenthood Federation (IPPF) 4 Newhams Row, London, SE1 3UZ, United Kingdom Tel: +44 (0) 207 939 8200. Fax: +44 (0) 207 939 8300. Website: www.ippf.org

PART 1: DESK RESEARCH

COUNTRY PROFILE Size of population: "17,340,702 - CIA (2005) The World Fact book Cameroon , http://www.cia.gov/cia/publications/factbook/geos/cm.html (Date accessed 10/05/06)) Life expectancy at birth: total population: 51.16 years male: 50.98 years female: 51.34 years (2006 est.) - CIA (2005) The World Fact book Cameroon , http://www.cia.gov/cia/publications/factbook/geos/cm.html (Date accessed 10/05/06)) % of population under 15 (0 14 years): 41.2% - CIA (2005) The World Fact book Cameroon , http://www.cia.gov/cia/publications/factbook/geos/cm.html (Date accessed 10/05/06)) Population below income poverty line of $1 per day: 48% (2000 est.) - CIA (2005) The World Factbook Cameroon , http://www.cia.gov/cia/publications/factbook/geos/cm.html (Date accessed 07/04/06)) Female youth literacy (ages 15-24 years): (15 19) 73,3% and (20 24) is 68,2% (Health and Demographic Survey, 2004) Fertility rate: 4.4 (2005) Health expenditure per capita (2002): - (Intl $, 2002): 68 http://www.unaids.org/en/Regions_Countries/Countries/cameroon.asp (date 07/04/06)) Contraceptive prevalence: 7.1% (UNFPA, http://www.unfpa.org/profile/cameroon.cfm (date accessed 26/01/07) Youth unemployment rate: 32% (Leibbrandt and Mlatsheni 2004. Meeting youth unemployment, www.uneca.org/era2005/chap5.pdf (Date accessed 26/01/07) Maternal mortality rate: 730- (WHO, (WHR2004), http://data.unaids.org/Publications/FactSheets01/cameroon_EN.pdf (Date accessed 10/05/06)) Ethnic groups: Cameroon Highlanders 31%, Equatorial Bantu 19%, Kirdi 11%, Fulani 10%, Northwestern Bantu 8%, Eastern Nigritic 7%, other African 13%, non-African less than 1%,http://www.cia.gov/cia/publications/factbook/geos/cm.html (date accessed 10/05/06)) Religions: indigenous beliefs 40%, Christian 40%, Muslim 20% - CIA (2005) The World Factbook Cameroon , http://www.cia.gov/cia/publications/factbook/geos/cm.html (date accessed 10/05/06)) Languages: 24 major African language groups, English (official), French (official) - - CIA (2005) The World Factbook Cameroon , http://www.cia.gov/cia/publications/factbook/geos/cm.html (date accessed 10/05/06)) Adult (15-49) HIV prevalence rate (end of 2005): 6.9%(range: 4.8%-9.8%) - UNAIDS, (2003) Uniting the world against AIDS http://www.unaids.org/en/Regions_Countries/Countries/cameroon.asp (Date accessed 10/05/06)) Number of women (15-49) living with HIV (end of 2003): 290 000 (range: 200 000-420 000) - UNAIDS, (2003) - Uniting the world against AIDS http://www.unaids.org/en/Regions_Countries/Countries/cameroon.asp (Date accessed 10/05/06)) Number of children (0-15) living with HIV (ages 0-14 years, 2003): 43 000 estimates end of 2003) -- UNAIDS, (2004) - Report on the global AIDS epidemic http://data.unaids.org/Publications/Fact-Sheets01/cameroon_EN.pdf (Date accessed 10/05/06) Estimated number of orphans (0-17 years): 240.000 - UNAIDS, (2004) - Report on the global AIDS epidemic - http://data.unaids.org/Publications/Fact-Sheets01/cameroon_EN.pdf (Date accessed 10/05/06) AIDS deaths (adults and children) in 2003: 49 000(range: 32 000-74 000) - UNAIDS, (2003) - Uniting the world against AIDS 5

http://www.unaids.org/en/Regions_Countries/Countries/cameroon.asp (Date accessed 10/05/06)

PREVENTION COMPONENT 1: LEGAL PROVISION (national laws, regulations, etc) Key questions 1. What is the minimum legal age for marriage? Despite the law that fixes a minimum age of 15 years for a bride, many families facilitated the marriage of young girls by the age of 12 years. Early marriage was prevalent in the northern provinces of Adamawa and the North, but it was especially characteristic of the remote Far North Province, where many young women faced severe health risks from pregnancies as early as 13 years of age. There were no statistics on the prevalence of child marriage. Anecdotal evidence indicated that some parents might have promised a female baby to an older male in order to begin receiving dowry payments... Women also faced the issue of forced marriage; in some regions, girls' parents could and did give girls away in marriage without the bride's consent (Released by the Bureau of Democracy, Human Rights, and Labor March 08, 2006 Political and Economic Section Cameroon -- Country Report on Human Rights Practices 2005, http://yaounde.usembassy.gov/cmr_human_rights.html (Date accessed 26/01/07) Lawful marriages must meet the following conditions: women must be at least 15 years old, and men, 18, unless the President of the Republic grants an exemption for serious reasons; 193 the couple must announce their intention to marry one month before the planned marriage date, though the President of the Republic may alter this time frame for serious reasons; the spouses should be of different sexes, have given their free consent, and, if one spouse is a minor, obtain the parents consent; and the spouses should both be living; when one is deceased, the other can celebrate his or her marriage with the deceased only with the President of the Republics express authorization.194The registry official of one of the prospective spouses birthplace or residence performs the ceremony195 after first ascertaining that the parties are not related in a manner prohibited by law.196 Customs are not codified, and vary by ethnic group.(Pg79) Age at First Marriage (Article 52 of Order No. 81-02 of June 29, 1981 on the civil service stipulates that: No marriage may take place if the girl is younger than 15 or the boy is younger than 18, unless the President of the Republic grants an exemption for a serious reason".(Pg83), (Centre for reproductive rights), (2003),http://www.crlp.org/pdf/cameroon.pdf (Date accessed 10/05/06)) 2. What is the minimum legal age for having an HIV test without parental and partner consent? It is not defined. Commonly people will use the age of the majority which is 18 years old. [Article 80 (4) of the Civil Code] However, in most VCT centres we have been told that when students come in for HIV screening they are not asked parental consent even though most of them are below 18 years. (Information provided by in-country consultant) 3. What is the minimum legal age for accessing SRH services without parental and partner consent? Still is not defined. 18 years is considered but not respected. (Information provided by in-country consultant) 7

4. What is the minimum legal age for accessing abortions without parental and partner consent? Abortion is forbidden by law for women in general [Article 337 of Penal Code] 5. Is HIV testing mandatory for any specific groups (e.g. pregnant women, military, migrant workers, and sex workers)? It is not say or written, but it is commonly known to many people that the military apply this for entrance examinations without telling the candidates. (Information provided by in-country consultant) 6. Is there any legislation that specifically addresses gender-based violence? The law prohibits rape, and although rape occurred, police and the courts investigated and prosecuted cases of rape, which resulted in some convictions during the year. Official and private media regularly covered rape cases handled by the courts during the year. In June a couple of newspapers released special issues on the problem of rape, which was becoming acute, especially in Douala and Yaounde. According to one of the reports, the Douala Courts heard approximately 40 cases per month. The law does not prohibit female genital mutilation (FGM), and FGM was not practiced widely; however, it continued to be practiced in isolated areas in 3 of the 10 provinces, including some areas of Far North, Eastern, and South West provinces. Internal migration contributed to the spread of FGM to different parts of the country. The majority of FGM procedures were clitorectomies; however, the severest form of FGM, infibulation, was performed in the Kajifu region of the Southwest Province. FGM usually was practiced on infants and pre-adolescent girls. During the year the government did not conduct programs to educate the population about the harmful consequences of FGM or prosecute any persons who allegedly performed FGM; however, the Association of Women Against Violence continued to conduct a program in Maroua to assist victims of FGM and their families and to educate local populations. (Released by the Bureau of Democracy, Human Rights, and Labor March 08, 2006 Political and Economic Section Cameroon -- Country Report on Human Rights Practices 2005, http://yaounde.usembassy.gov/cmr_human_rights.html (Date accessed 26/01/07) 7. Is there an AIDS Law or equivalent that legislates on issues such as confidentiality for testing, diagnosis, treatment, care and support? There is not such a law. But confidentiality is prescribed in the protocols and during the training of staff on counselling or HIV testing [CNLS, Normes et directives nationals de conseil et dpistage volontaire du VIH, edition de mars 2002: p. 17] 8. Is there any legislation that protects people living with HIV/AIDS, particularly girls and young women, from stigma and discrimination at home and in the workplace? Not yet. A draft law is under study since some few years. Last year a group of NGOs and associations of PLWHA proposed a new version of that draft which is still to be submitted to the Ministry of Public Health and the National AIDS Control Committee. (Information provided by in-country consultant) 9. Are sex workers legally permitted to organise themselves, for example in unions or support groups? 8

While the law prohibits prostitution, it was tolerated. Prostitution was practiced predominately in urban areas by locals, and trafficking for the purposes of commercial sexual exploitation occurred1/07) Released by the Bureau of Democracy, Human Rights, and Labor (Cameroon -- Country Report on Human Rights Practices 2005, March 08, 2006 Political and Economic Section http://yaounde.usembassy.gov/cmr_human_rights.html (Date accessed 26/01/07)10. 10. Are harm reduction methods for injecting drug users (such as needle exchange) legal? No. Drug use is not legal. (Information provided by in-country consultant) Discussion questions: Which areas of SRH and HIV/AIDS responses are legislated for? What are the biggest strengths, weaknesses and gaps in legislation in relation to HIV prevention for girls and young women? Is action taken if laws are broken (e.g. if a girl is married below the legal age)? Is there any specific legislation for marginalised and vulnerable groups1? If yes, is the legislation supportive or punitive? And what difference does it make to peoples behaviours and risk of HIV infection? To what extent are qualitative issues such as confidentiality around HIV testing covered by legislation? How much do girls and young women know about relevant legislation and how it relates to them? Are there any initiatives to raise awareness about certain laws? Overall, how is relevant legislation applied in practice? What are the real life experiences of girls and young women? What difference does it make to their vulnerability to HIV infection? How do the effects of legislation vary among different types of girls and young women, such as those in/out of school, married/unmarried, in rural/urban areas, living with HIV/not aware of their HIV status?

PREVENTION COMPONENT 2: POLICY PROVISION (national policies, protocols, guidelines, etc) Key questions: 11. Does the current National AIDS Plan address the full continuum of HIV/AIDS strategies, including prevention, care, support and treatment? Yes, the National Strategic Plan addresses the full continuum of HIV/AIDS strategies, including care, prevention, support and treatment. [cf. Comit National de Lutte contre le SIDA, Plan Stratgique National de Lutte contre le SIDA 2006 2010] 12. Does the National AIDS Plan specifically address the HIV prevention and SRH needs of girls and young women? Organize workshops to promote safer sexual behavior among youth. Prevent sexual transmission of HIV/AIDS by promoting programs conducted by leaders and PR educators on the following: safer sexual behavior among children aged 5-14 and among adolescents aged 15-24, sexual education among at-risk groups, youth, women, workers, and traditional 9

partition.(pg5) (National Committee for HIV/AIDS, UNAIDS, German Organization for Cooperation(GTZ), National Committee for TB, and Ministry of Health (http://www.aids.harvard.edu/africanow/pdfs/cameroon.pdf (Date accessed 26/01/07) 13. Does the National AIDS Plan specifically address the HIV prevention and SRH needs of marginalised and vulnerable groups, including people who are living with HIV/AIDS? Organize workshops to promote safer sexual behavior among youth. Prevent sexual transmission of HIV/AIDS by promoting programs conducted by leaders and PR educators on the following: safer sexual behavior among children aged 5-14 and among adolescents aged 15-24, sexual education among at-risk groups, youth, women, workers, and traditional partition.(pg5) (National Committee for HIV/AIDS, UNAIDS, German Organization for Cooperation (GTZ), National Committee for TB, and Ministry of Health, http://www.aids.harvard.edu/africanow/pdfs/cameroon.pdf (Date accessed 26/01/07) 14. Does the National AIDS Plan emphasise confidentiality within HIV/AIDS services? Not explicitly mentioned but HIV/AIDS services follow guidelines where confidentiality is highly recommended in all services. (Information provided by in-country consultant) 15. Does the national policy on VCT address the needs of girls and young women? Not in general, but pregnant women needs are taking into account with PMCT (Information provided by in-country consultant) 16. Does the national protocol for antenatal care include an optional HIV test? preventing mother-to-child transmission is being expanded gradually, including voluntary testing and counselling for pregnant women and their partners (World Health Organization 2005, http://www.who.int/hiv/HIVCP_CMR.pdf (Date accessed 26/01/07) 17. Does the national protocol for antenatal care include a commitment that any girl or young woman testing HIV positive should automatically offered PMTCT services? Preventing mother-to-child transmission is being expanded gradually, including voluntary testing and counselling for pregnant women and their partners; prescription of antiretroviral drugs during pregnancy and childbirth; and follow-up and psychosocial support for the mother and child. (World Health Organization 2005, http://www.who.int/hiv/HIVCP_CMR.pdf (Date accessed 26/01/07) 18. Is there a national policy the protects the rights and needs - including HIV prevention, SRH services, employment opportunities and education - of young women or girls at risk or affected by early marriage? Not a national policy specific to girls affected by early marriage. But there is a project from the German-Cameroon Health Programme supported by GTZ for girls and young women who are victims of early and unwanted pregnancies called Projet Tantines (or Aunties project). There exist 115 associations of Aunties in Cameroon with more than 6.000 members trained as Aunties. They are trained on basic SRH issues and later on Adolescents 1

counselling to prevent early and unwanted pregnancies, HIV/AIDS, sexual abuses and traditional harmful practices such as breasts ironing or belly ironing, also know as postpartum massage. [cf. GTZ-RENATA, Schmas de counselling en Sant sexuelle et reproductive, Yaound, PGCSS/REGA, Nouvelle dition, Janvier 2007] 19. Is HIV prevention within the official national curriculum for both girls and boys? No. Just last January an interministerial decree between the Ministries of Basic Education and that of Secondary Education was signed to introduce a programme on Education to Family Life on population and prevention of HIV/AIDS [cf. Arrt Conjoint Interministriel No.281/27/MINEDUB/MINESEC du 18 janvier 2007 portant integration des curricula dEVF/EMP/VIH/SIDA dans les programmes de formation et denseignement au Cameroun] 20. Is key national data about HIV/AIDS, such as HIV prevalence, routinely disaggregated by age and gender? Yes and published on calendars, flyers or in booklets. (Information provided by in-country consultant) Discussion questions: o o o o o o o To what extent are relevant bodies such as the Ministry of Education, NGO networks, religious organisations, etc engaged in policy-making around HIV prevention for girls and young women? To what extent do those bodies work in partnership or in isolation? What areas of HIV prevention responses (e.g. behaviour change, counselling, treatment, home-based care) have national protocols or guidelines? To what extent do those protocols address the needs of girls and young women, including those that are marginalised and vulnerable? What does school-based sex education cover? Does it help to build young peoples confidence and skills, as well as knowledge? To what extent do policies help to reduce stigma and discrimination? For example, do they encourage people to stop using derogatory language or blaming specific groups for HIV/AIDS? To what extent are different areas of policy provision such as for HIV/AIDS and antenatal care integrated or isolated? What policy measures exist in relation to consent, approval and confidentiality? For example, can girls and young women access services such as VCT without having to notify their parents and/or partner? And are they informed of their right to confidentiality? Overall, how are relevant policies applied in practice? What are the real life experiences of girls and young women? How much do they know about them and how they relate to them? What difference do these policies make to their vulnerability to HIV infection? How do the effects of policies vary among different types of girls and young women, such as those in/out of school, married/unmarried, in rural/urban areas, living with HIV/not aware of their HIV status?

PREVENTION COMPONENT 3: AVAILABILITY OF SERVICES1 (number of programmes, scale, range, etc)

21. Is there a national database or directory of SRH and HIV/AIDS services for young people? No (Information provided by in-country consultant) 22. How many SRH clinics or outlets are there in the country? About 49 clinics belonging to NGOs/Associations or private and mostly based in Yaounde and provincial capitals. Also, most of the 143 district hospitals provide some SRH activities, mostly family planning. (Information provided by in-country consultant) 23. At how many service points is VCT available, including for young women and girls? The number of facilities providing services for voluntary counselling and testing increased: from 18 at the end of 2003 to 89 by September 2005 (World Health Organization 2005, http://www.who.int/hiv/HIVCP_CMR.pdf (Date accessed 26/01/07) 24. Are male and female condoms available in the country? Yes, but female condoms are expensive and scarce. They are not even known in most rural areas. Male condoms are well know and accessible. (Information provided by in-country consultant) 25. Is a free HIV test available to all pregnant girls and young women who wish to have one? Create anonymous, voluntary, and free of charge HIV test centers. (9D, Pg6) (National Committee for HIV/AIDS, UNAIDS, German Organization for Cooperation (GTZ), National Committee for TB, and Ministry of Health, http://www.aids.harvard.edu/africanow/pdfs/cameroon.pdf (Date accessed 12/05/06) 26. At how many service points are PMTCT services (such as nevirapine) available for pregnant girls or young women who are HIV positive? The Ministry of Health established the first treatment centre for provision of antiretroviral therapy in March 2001. By December 2004, there were 23 certified treatment centres, mostly based in central and provincial hospitals. The national plan for decentralizing antiretroviral therapy for 20042005 aims to increase the number of sites providing treatment from 23 to 83 by the end of 2005. In addition, eligibility for treatment is being assessed at a number of entry points, including 14 voluntary counselling and testing centres, 160 sites for preventing mother-to-child (WHO, (June 2005) http://www.who.int/3by5/support/june2005_cmr.pdf (Date accessed 12/05/06)) 27. At how many service points are harm reduction services for injecting drug users available None 1

(Information provided by in-country consultant) 28. Are there any specific national projects (such as camps, conferences, and training courses) for boys/girls and young people living with HIV/AIDS? Yes, the Network of PLWHA, RECAP+, organizes training on ARV adherence with the technical assistance of GTZ and the financial support of CARE/GFATM. GTZ also used to organize training on positive living for PLWHA and more than 3000 PLWHA have been trained in this programme. [cf. GTZ, Involoving People Living with HIV: Support to PLWH organisations in Cameroon, Eschborn, GTZ HIV Practice Collection, 2006] 29. At how many service points are ARVs available to people living with HIV/AIDS? As of October 2004, 12 896 people were reported to be receiving antiretroviral therapy. By March 2005, 15 000 people were receiving antiretroviral therapy in Cameroon. The Ministry of Health established the first treatment centre for provision of antiretroviral therapy in March 2001. By December 2004, there were 23 certified treatment centres, mostly based in central and provincial hospitals. The national plan for decentralizing antiretroviral therapy for 20042005 aims to increase the number of sites providing treatment from 23 to 83 by the end of 2005. In addition, eligibility for treatment is being assessed at a number of entry points (WHO, (June 2005), http://www.who.int/3by5/support/june2005_cmr.pdf (Date accessed 12/05/06)) 84 service points. 39 new services points have just been created mostly in district hospitals where ARV treatment will also be available during this year, 2007 . [cf. Ministre de la Sant Publique, Dcision No. 0455 D/MSP/SG/DLM/SDL VIHIST/SPCC/BPECM du 22 septembre 2004 portant dsignation en premire phase des Units de Prise en Charge (UPEC) des Personnes Vivant avec le VIH/SIDA par les antirtroviraux au Cameroun et Ministre de la Sant Publique, Dcision No. 0190/D/MSP/CAB du 30 mars 2001 portant dsignation des centres de traitement agrs pour la prise en charge des Personnes vivant avec le VIH par les antirtroviraux au Cameroun]. 30. Are there specific positive prevention services, including support groups, for young women and girls living with HIV/AIDS? Yes, but in self organized associations or support groups like the Association des Femmes Solidaires (AFASO). Most often men and women living with HIV are mixed in these associations. (Information provided by in-country consultant) Discussion Questions o o What scale and range of HIV prevention services is available for girls and young women? For example, do programmes go beyond ABC strategies? Do programmes cover social issues (e.g. early marriage)? To what extent are SRH, HIV/AIDS and broader community services integrated and able/willing to provide referrals to each other? For example, could most SRH clinics refer a girl testing HIV positive to a support group for people living with HIV/AIDS? To what extent are HIV prevention services available through non-traditional outlets (e.g. religious organisations, youth clubs)? Are there community programmes on gender awareness/dialogue for girls/boys and young women/men? Do they explore power differences and social norms for sexual 1

behaviour? Is there mentoring, peer support and economic development that targets females? No, apart of the Aunties project operating with girls trained at the level of their community who are organised in associations. They discuss issues like gender awareness and explore power differences in norms and sexual behaviour. How available is prevention information and support for girls and young women living with HIV/AIDS? How available are HIV prevention commodities (e.g. condoms)? How are they distributed? How much do girls and young women know about the availability of services, such as where to get condoms or ARVs? Overall, what does the availability of HIV prevention services mean in practice? What are the real life experiences of girls and young women? What difference do these services make to their vulnerability to HIV infection? How do the effects of availability vary among different types of girls and young women, such as those in/out of school, married/unmarried, in rural/urban areas, living with HIV/not aware of their HIV status?

PREVENTION COMPONENT 4: ACCESSIBILITY OF SERVICES (location, user-friendliness, affordability, etc) Key questions: 31. Are all government HIV prevention and SRH services equally open to married and unmarried girls and young women? Yes (Information provided by in-country consultant) 32. Are all government HIV prevention and SRH services equally open to girls and young women who are HIV positive, negative or untested? Yes. HIV positive women are even better taken of in PMCT or treatment centres where their needs are well known to health staff. (Information provided by in-country consultant) 33. Are VCT services free for girls and young women? No. It is only free for pregnant women. (Information provided by in-country consultant) 34. Are approximately equal numbers of females and males accessing VCT services? Always more females than males access VCT services in most of the centres In the Provincial Hospital of Bafoussam in the Western Province, 1004 clients have been received by the counselling service of the hospital out of which 698 were female (69%) and 306 male (30%) between february 2006 and February 2007. (Source Table produced by APICAM, an Association of PLWHA working within the provincial hospital, April 2007) 35. Are STI treatment and counseling services free for all girls and young women? STI treatment is not free but Counselling services are free. 1

(Information provided by in-country consultant) 36. Are condoms free for girls and young women within government SRH services? Free condoms are given out from time to time, but normally they are sold at a very low price in the services. (Information provided by in-country consultant) 37. Are ARVs free for all girls and young women living with HIV/AIDS? No. Each patient has to pay for his drugs. In case the patient is too poor, the hospital and some associations can provide help to purchase treatment. ARVs are not free. (Ministerial Decision No. 00094/C/MSP/CAB du 14 janvier 2005 compltant les dcisions de la Dcision No. 468bis/MSP/CAB du 24/09/2004 fixes the prices of ARV to 3000 FCFA and 7000 FCFA, according to the protocol (that is approx 4,58 and 10,68 Euros per month and per patient). A part of that, the decisions are not explicit or specific at all, neither the standard or documents available. (Information provided by in-country consultant) 38. Are issues relating to HIV/AIDS stigma and discrimination included in the training curriculum of key health care workers at SRH clinics? Yes, issues relating to HIV/AIDS stigma and discrimination are included in the training curriculum of Health workers at SRH clinics. (Information provided by in-country consultant) 39. Are issues relating to young people included in the training curriculum of key health care workers at SRH clinics? Just in the few clinics held by NGOs or Associations (CAMNAFAW, Youth Development Foundation, OFSAD), where the training curriculum is on young people and their sexual and reproductive health needs. (Information provided by in-country consultant) 40. Are there any government media campaigns (e.g. television commercials and newspaper advertisements) about HIV/AIDS that specifically address prevention among girls and young women? Increase the number of TV shows for prevention of HIV/AIDS in local languages. Conduct surveys that measure the impact of media on prevention. (pg4) (National Committee for HIV/AIDS, UNAIDS, German Organization for Cooperation (GTZ), National Committee for TB, and Ministry of Health, http://www.aids.harvard.edu/africanow/pdfs/cameroon.pdf (Date accessed 26/01/07) Yes a TV and radio campaign is currently going on and it targets specifically young women. (Information provided by in-country consultant)

Discussion questions: 1

o o o o

Are HIV prevention services truly accessible to girls and young women, including those that are marginalised and vulnerable? For example, are they: safe? Affordable? Reachable by public transport? in appropriate languages? Non-stigmatising? open at convenient times? What are the cultural norms around prioritizing females and males for health care? To what extent are informed and supportive SRH services accessible for girls or young women living with HIV/AIDS? What are the client/service provider ratios in different types of HIV prevention services? What is the gender ratio for staff in those services? Do services make proactive efforts to attract girls and young women? For example, do SRH clinics have separate rooms for young women so that they do not risk seeing family members or familiar adults? What are the attitudes of service providers to girls and young women, including those who are marginalised and vulnerable? Are they kind, non-judgemental and realistic (for example about young peoples sexual pressures and desires)? Can they encourage girls/boys to assess their risks of HIV infection and change their behaviour? Are attitudes generally getting better or worse? Do HIV prevention information campaigns, etc, target girls and young women? For example, are they culturally and linguistically appropriate? Are materials distributed through appropriate media and outlets? Is there a national monitoring and evaluation framework? Does it encourage data to be disaggregated (according to gender and age) to help assess the extent to which girls and young women are accessing programmes and services? Are referrals and follow-up provided during HIV/AIDS, SRH and antenatal care services for young women and girls? Overall, what difference does accessibility to services mean in practice? What are the real life experiences of girls and young women? What difference is made to their vulnerability to HIV infection? How do the effects of accessibility vary among different types of girls and young women, such as those in/out of school, married/unmarried, in rural/urban areas, living with HIV/not aware of their HIV status?

PREVENTION COMPONENT 5: PARTICIPATION AND RIGHTS (human rights, representation, advocacy, participation in decision-making, etc) Key questions: 41. Has the country signed the Convention on the Rights of the Child (CRC)? Yes, Cameroon has signed the CRC on January 11, 1993 [Cf. Nations Unies, CRC/C/28/Add.16 du 26 mars 2001 sur lExamen des rapports prsents par les Etats parties en application de lArticle 44 de la Convention]. 42. Has the country signed the Convention on the Elimination of all Forms of Discrimination against Women (CEDAW) and the Convention on Consent Marriage, Minimum Age of Marriage and Registration of Marriages (CCM)? Cameroon has also signed CEDAW in 1994 [Ministry of Women Empowerment and Family] 43. In the National AIDS Council (or equivalent), is there an individual or organisation that represents the interests of girls and young women? Contributing towards the implementation within the educational community of the national AIDS plan, which was officially launched by the Minister of National Education on 31 March 2004? 1

The two main actions carried out with the support of the United Nations system have been: 1) Implementation of the PDA (Participation and Development of Adolescents) programme in six provinces, 56 establishments and 22 sites outside schools (Lead agency: UNICEF); 2) The NO AIDS Caravan (Lead agency: World Bank) development of mapping of the risks to a vulnerability of young Cameroonians in respect to HIV and AIDS in each of Cameroon's ten provinces and proposal of lines of intervention in order to reduce them. The report will be ready at the end of January (lead agency: UNICEF) (UNAIDS website 2006, http://www.unaids.org/en/Regions_Countries/Countries/cameroon.asp (Date accessed 30/01/07) 44. In the National AIDS Council, is there an individual or organisation that represents the interests of people living with HIV/AIDS? Developing a communication strategy to popularize the rights and duties of people living with HIV (UNAIDS website 2006, http://www.unaids.org/en/Regions_Countries/Countries/cameroon.asp (Date accessed 30/01/07) Yes, 3 PLWHA members of two networks (RECAP+ and CANEP) represent the interests of PLWHA in the National AIDS Council. 45. Was the current National AIDS Plan developed through a participatory process, including input from girls and young women? Development of mapping of the risks to and vulnerability of young Cameroonians in respect to HIV and AIDS in each of Cameroon's ten provinces and proposal of lines of intervention in order to reduce them. The report will be ready at the end of January (lead agency: UNICEF); contributing towards the implementation within the educational community of the national AIDS plan, which was officially launched by the Minister of National Education on 31 March 2004. The two main actions carried out with the support of the United Nations system have been: 1) Implementation of the PDA (Participation and Development of Adolescents) programme in six provinces, 56 establishments and 22 sites outside schools (Lead agency: UNICEF); 2) The NO AIDS Caravan (Lead agency: World Bank) (UNAIDS, http://www.unaids.org/en/Regions_Countries/Countries/cameroon.asp (Date accessed 26/01/07) 46. Is there any type of group/coalition actively promoting the HIV prevention and SRH needs and rights of girls and young women? Most urban Cameroonian adolescents are exposed to reproductive health messages through mass media channels. In total an estimated 200,000 adolescents received reproductive health information directly through Institut de Recherche et des Etudes des Comportements (IRESCOs) Among Youth campaign. But hearing the messages alone does not necessarily result in behavior change. Peer education combined with mass media campaigns form an important strategy for targeting youth with reproductive health and family planning messages. After the social marketing project was implemented, through direct peer to peer communication efforts, sporting events, informational kiosks and video screenings and discussions, researchers found that the control and intervention groups had similar levels of knowledge, but larger behavioral changes were observed among youth in the intervention site. We attribute these changes to the peer education outreach efforts, which emphasized interpersonal communication and reinforced the reproductive health messages adolescents received from mass media including IRESCOs magazine. Peer education efforts, discussions, and IEC materials can help adolescents translate knowledge into healthy lifestyles. Integration of reproductive health messages into popular youth activities, such as sports and cultural events, was also found to be a successful strategy for reinforcing messages and discussing sensitive issues affecting adolescents lives in greater depth. 1

(Institut de Recherche et des Etudes des Comportements (IRESCO), (July 2002) - Peer Education as a Strategy to Increase Contraceptive Prevalence and Reduce the Rate of STIs/HIV among Adolescents in Cameroon, http://www.popcouncil.org/pdfs/frontiers/FR_FinalReports/Cameroon_Peer_Education.pdf (Date accessed 12/05/06)) 47. Is there any type of national group/coalition advocating for HIV prevention (including positive prevention) for girls and young women? Government Organize workshops to promote safer sexual behavior among youth. Prevent sexual transmission of HIV/AIDS by promoting programs conducted by leaders and PR educators on the following: safer sexual behavior among children aged 5-14 and among adolescents aged 15-24, sexual education among at-risk groups, youth, women, workers, and traditional partition.(pg5) (National Committee for HIV/AIDS, UNAIDS, German Organization for Cooperation (GTZ), National Committee for TB, and Ministry of Health, http://www.aids.harvard.edu/africanow/pdfs/cameroon.pdf (Date accessed 26/01/07) No 48. Is the membership of the main network(s) for people living with HIV/AIDS open to young people, including girls and young women? The group (Ndo Milaiti), supported by Hope for African Children Initiative (HACI) through Plan Cameroon and the Association for the Fight Against AIDS in Rural Areas (AFAARA), supports 17 people living with HIV/AIDS and 225 children impacted by the disease. The groups 87 members meet two times a month to raise resources for assisting orphans and the sick, plan their labor activities and contribute money for its revolving fund, which provides loans to members to start businesses. In a month, the members contribute between 5,000 and 10,000 Cameroonian Francs (between USD 13 and 25). According to AFAARA Secretary general Amadou Buba Jalo, HIV/AIDS has been fuelled by cultural practices which include wife inheritance, scarification and traditional healing. With the support of HACI and Plan, AFAARA provide counseling, treatment of opportunistic infections and medical assistance to people living with HIV/IADS. It has also trained members of Ndo Milaiti on HIV/AIDS. (Hope for African Children Initiative April -September 2005, Ray of Hope, http://www.hopeforafricanchildren.org/Ray_of_Hope_April_2005.pdf (Date accessed 30/01/07) 49. Are there any programmes to build the capacity of people living with HIV/AIDS (e.g. in networking, advocacy, etc)? Not a programme, but training courses are from time to time offered by different organisations (bilateral, multilateral and international NGOs) 50. Are there any girls or young women living with HIV/AIDS who speak openly about their HIV status (e.g. on television or at conferences)? When Florentine Mantho got married at 18, she had high hopes of raising a happy family. Young and energetic, she was determined to work hard and give all to her children. Three months into the marriage, Florentine became pregnant. For her, the news was exciting. Taking no chances with her pregnancy, she visited the local antenatal clinic, where routine tests were carried out. However, when the doctor who carried out the tests discovered she was HIV-positive, he didnt inform her about it, choosing instead to reveal the results to her father-in-law. Immediately he got the news, her father-in-law went home and told her that she was HIV-positive. This was the beginning of problems for Florentine who likens the experience to life in hell. My father-in-law stopped talking to me and if I prepared food, he would not eat it, says Florentine. For three months, Florentine would sit on a stone outside the house and cry. I didnt understand why such a thing would happen to me. People became very hostile and I was separated from my husband, she says. When her baby was born, he tested positive for HIV. This annoyed my father-in-law 1

and he decided to send me away saying there was no room to bury two people, she adds. With a little money given to her by a friend, Florentine returned to her parents, not knowing what the future had for her. However, she soon got to know about the Cameroon Baptist Convention (CBC), a religious organization engaged in assistance to people infected with HIV/AIDS andprevention campaigns.(Pg5) (Hope for African Children Initiative April -September 2005, Ray of Hope, http://www.hopeforafricanchildren.org/Ray_of_Hope_April_2005.pdf (date accessed 30/01/07) Roffine tells a different story. I am really suffering, because for the past four years I have been sick from HIV, she says. My parents discovered I was HIV-positive and they threw me out. I cant pay rent. I cant afford payment for my treatment. I dont have any work. I cant do anything for myself. I do everything to get drugs. At times I beg. Roffine attends one of Yaoundes HIV clinics where she is entitled to free anti-retrovirals. But after giving her the first months supply, the pharmacist told her she would have to pay for any more - because her clinic did not receive enough money to buy the drugs it needed from the national supplier Cename, and the only way to get more was to charge. (BBC World Service, Jenny Cuffe, Cameroon January 3rd, 2007: Cameroon corruption hinders Aids fight, http://news.bbc.co.uk/go/pr/fr/-/1/hi/world/africa/6198337.stm (Date accessed 30/01/07) Discussion questions: o o o How are international commitments (e.g. CRC, CEDAW, and CCM) applied within the country? Is the national response to HIV/AIDS rights-based? For example, does it recognise the SRH rights of women living with HIV/AIDS? Do key decision-making bodies (e.g. the Country Coordinating Mechanism of the Global Fund to Fight AIDS, TB and Malaria) have a set number of seats for civil society? Are any of them specifically for representatives of girls and young women or people living with HIV/AIDS? Are HIV prevention programmes generally developed for or with girls and young women, including those who are marginalised and vulnerable? Are girls and young women seen as implementers as well as receivers of services? To what extent are girls and young women aware of decision-making processes? Are they encouraged to have a voice? Are they seen as an important constituency within committees, management groups, etc? How high are issues relating to HIV prevention for girls and young women (e.g. early marriage and stigma) on the agendas of local leaders and decision-making groups (e.g. district AIDS committees)? To what extent do girls and young women participate in those type of bodies? To what extent are people living with HIV/AIDS organised, for example in networks? Are girls and young women involved in those bodies? How are issues of participation affected by stigma? For example, is it safe for people living with HIV to speak openly about their HIV status? Overall, how are participation and rights applied in practice? What are the real life experiences of girls and young women? What difference is made to their vulnerability to HIV infection? How do the effects of participation and rights vary among different types of girls and young women, such as those in/out of school, married/unmarried, in rural/urban areas, living with HIV/not aware of their HIV status?

o o o

o o o o

PART 1: DESK RESEARCH

Focus group discussions Age group: 15 19 years Number of participants: 10 Profile of participants: the group included girls from a rural area who are in secondary school, peer activists, all spinsters with one single mother among them and from the two main ethnic groups of the area. Place: Loum, Cameroon Date: Saturday, 17th February 2007

Prevention component: Availability of services 1. What sort of HIV prevention services are there for girls and young women in your community? For example, where would you go to get: information? Condoms? Treatment for a sexually transmitted infection (STIs)? An HIV test? It is from magazines dealing with reproductive health of the youths such as ' 100% Jeunes' or ' Entre Nous Jeunes' that most young people from Loum have information on sexuality and particularly on HIV/AIDS or STI' They all find that, these magazines are sold at an affordable s. price and are therefore accessible to most youths in rural areas. Sensitization Campaigns are rather rare in this region. In schools, Form 1 to Form 3 students also visit Health Clubs frequently. But most of them notice that these clubs are a little bit boring for teenagers of Form 4 or Form 5 because sometimes pupils are abandoned to themselves: there is no support from staff and more over, people are not always trained or qualified to talk about health issues which interest youth. Generally, it is among neighborhood friends or in schools that they share information on sexuality, condoms or STI' s. Condoms are available and can be obtained in pharmacies or in shops at every street corner. Some girls have even confirmed that they buy and retail them in their schools and they say that condoms are no longer a taboo: "I often sell it (laughter). Yes, this is no longer a taboo (laughters). We buy and sell in school? I buy and retail. If you want one, I sell it to you." The STI' treatment is done in health units (hospitals or health centers) of the locality. s Participants think that in some of these facilities, the service is fast, whereas in others it is very slow and you have to be very patient. It is mostly classmates and friends who constitute the main source of information and advice for girls: " It' while discussing with friends in class that s she' going to say: I' s have vaginal discharges. Then others will advice her to go and consult at the hospital. Whereas it should normally be the mums duty, but they don' do it." t "It' always among us girls, you read something and you come and ask others ' s Have you also read this?'You start to explain, by doing so, they also have an idea about it ". . A minority of girls also explain that some girls prefer traditional medicine in case of Sexually Transmitted Infections, even though they admit that these treatments are rarely efficient. 2. How much do boys and young men know about HIV prevention services in your community? What is their role in supporting HIV prevention for girls and young women? Majority of the participants hold that most young girls have sexual intercourse with older men (cross-generational sex), simply for money. These men tend to impose sex without protection, and that entails a very elevated rate of unwanted pregnancies and even STI' or s HIV to girls: "If a rich man parks a Mercedes car, whether he' infected or not, we don' care. s t All we want is money". There is also the mobile phone affair that pushes a lot of us to look for "dads" as one says. Therefore a 15, 16 or 17 years old girl sees a man in a "PRADO" car. They talk just a little bit and he gives her 15.000 CFA francs, I swear that is how the next day she' going to search for s him and that' the means by which he will obtain what he wants from her." s 2

"Nowadays, it is difficult to find girls aged between 15 and 30 with only one partner. They are all unfaithful ". Multiple partners and sexual intercourse without protection are a proof that men, especially older men, are not sufficiently sensitized to the risks of HIV/AIDS. Some participants even think that men who are infected and conscious of their serological status, decide to contaminate young girls by giving them cash in exchange of sex without protection. "Yes, it' cash hey! And pedophilia is even already becoming current here. And it' for s s money. When you see a beautiful 15 years old girl dealing with a 50 years old man, what do you think she wants? She wants money! And at that time, she doesn' give a damn! Maybe, t it' later on that she will say: "had I known", when it is already too late". s Most participants think that young boys in Loum are more conscious of STI' / HIV risks and s have the tendency to protect themselves more and more during sexual intercourse: "I can' t imagine that a boy in Loum can have sex with a girl from Loum without condom. If he does it, it means that he' faithful and maybe they have already dated for a long time. And the s majority use condom. Married men are those who rarely use protection". And always according to them, girls in Loum like rather to take risks, because they are money minded and they dont want to accept their condition. 3. What sort of HIV prevention services would you like more of in your community? How would that make a difference to your life? Most of the participants brought up the idea to create a center in their locality, that would take care of the youths in general and the young girls in particular; a center that they could visit without being embarrassed. Some of them encourage the introduction of a program known with it French acronym as EVA (Education to Life and Love) and also recommend that parents must also be sensitized to take care of their daughters in a better way as most of the time, its they who push the girls outside, to look for the family survival means, without being conscious of the risks they are taking. Majority of the participants admit that parents can have an important role to play in the sex education of the youths just by listening to them and by giving them advice. Prevention component: Accessibility of services 4. What are your experiences of using HIV prevention services in your community? In what way have those experiences been good or bad? Most participants don' use any of such services, for example they have never done the HIV t screening test: "To be honest, I personally am afraid. I don' know whether I' HIV positive or t m negative. As long as I' have not done it, I cannot know! Sometimes, I think a lot about it. I' m so scared, I don' have the courage. It' lack of courage. I don' know. I really don' know." t s t t Some girls who have done the test have had a bad experience with counselors who have first given them the impression that their results were positive. They were frightened: "For me, I was going to the market when I met people from the free screening team who proposed to me to do the test and I did it. When I went to pick up my results, the man asked me why I was having sex without condoms. I was shocked. I asked him: what kind of question is that? He replied that facts were already there. These are the results. You are already..." I almost fainted and he then said "No, calm down. There is no problem. Take your result". I took it and I saw that it was negative. 5. What are the main barriers that you have faced when trying to use HIV prevention services in your community? For example, what difference does it make if a service is: expensive? Too far away? Unfriendly? The cost of the screening test is too high for people in the rural area. Most of the participants wished that it was free so it could motivate more people to get themselves tested. Sexually active teenage girls would need their parents help to cover the screening test expenses, but 2

most teenagers would not like their parents to be informed of their desire to be tested, as they would indirectly discover that they are already sexually active. It could cause conflicts with parents leading to psychological torture: "It is not everybody who would like to do it with her parents consent. For example a 15 years old girl who is already sexually active might want to know her serological status. She can' say: "Mummy, I' going to do the HIV t m screening test . She can' say that. t When HIV screening campaigns are launched, free screening tests are offered, but they sometimes take place during school hours, and that is a problem for most of the young girls who are students. So, when these services are available, very few people are informed because there is no effective publicity being carried out to inform the population. Participants also complain about the unwelcoming attitude of the medical staff, especially when it is girls or women. They would behave like real ' upstart'people who have arrived: , "Before attending to you, they stare at you from head to toes. If you have a nice pair of slippers, it would create another problem". Participants from the focus group discussion think that older women are more welcoming and are patient. "I think that we are being minimized, not respected. It' as if we were committing the crime s of the century! That' ... If you dont know someone there, you would not be attended to". s Still talking about nurses attitude, this participant remarked that: If you go there while she' s eating, you will die. Nooh! You will die. She will have to finish eating then digest, before attending to you". Many complain about discriminations in the reception because they would attend to people they know first or to family members of the authorities in the locality. For some services, such as the administration of the contraceptive pills, the staff requires the mothers consent: "We won' give it to you; you have to come here with your mother so we t will explain its consequences to both of you. It' when your mother approves it, that we can s then give it to you". 6. In what way are HIV prevention services easier or harder for particular types of girls and young women to use? For example, what difference does it make if you are: unmarried? out of school? HIV positive? Almost all the participants of the Focus group discussion notice that students or the teenage girls have a lot of difficulties to consult in services where they undergo some unpleasant remarks, or even insults from the health staff. Prevention component: Involvement and rights 7. Have there been any projects in your community to bring together girls and boys or young women and young man to talk about HIV prevention? If yes, what did they involve and what did they achieve? We can suppose that, apart of some discussions among friends and classmates, related to condoms or STI' there is rather no information or exchanges on sexuality. Most of the s, participants were ignorant about pills and some could not even make a difference between pills and vaginal ovules. 8. What would encourage you to get more involved in HIV prevention in your community? Many say that they go towards friends to share information or advice concerning the prevention of the HIV/AIDS, however, they feel the desire to reinforce their knowledge concerning sexual and reproductive health. Prevention component: Legal provision 9. What do you know about laws in Cameroon that might affect how girls or young women can protect themselves from HIV? For example, do you know about any laws that: allow girls to get married at a young age? Do not allow girls or young women to have abortions? prevent girls from using services unless they have the consent of their parents? 2

The participants mentioned that girls of the northern part of Cameroon had the habit of getting married at an early age, but today those who go to school are less and less submissive to the pressure of early marriage. And even, the educated parents refuse to choose a husband for their daughters and give them the choice to get married to whom ever they prefer. Concerning abortion, the participants are not unanimous whether there is a law forbidding it or not: some say that abortion is forbidden by the law and others think the opposite. But whatever is the case, they all admit that, abortion is very common in neighborhoods. It is sometimes done by quacks (women or men) who are not health staff, but also in the health units where they are obliged to be accompanied by an adult (parent, friend or boyfriend, etc). In case of death due to an abortion, the participants admit that they can take the author of the abortion to court, especially if it was done by a health staff. Many participants testified to have lost a sister (elder or younger) from abortion. Prevention component: Policy provision: 10. What type of education have you received about issues such as relationships, sex and AIDS? For example, what have you been taught about your sexual and reproductive health in school? Most girls get unwanted pregnancies here at early age. There is no teaching on sexual or reproductive health issues. They learn from friends or classmates and most often, they have the wrong information or advice. 11. What could the government of Cameroon do to fight fear about AIDS in your community? Participants think that the HIV screening test should be free of charge and the youths and students should be sensitized in order to encourage them to do the test. Summary of discussion 12. What are the 2-3 most importing changes that could be made - for example by the government or community leaders - to help girls and young women in Cameroon to protect themselves from HIV ? Girls in Loum suggest that condoms should be free of charge and accessible to the youths, to create a center for advice and information for the young people, or to introduce the EVA program (Education to Life and Love) in schools, like a compulsory course. They also think that another important measure that could reduce the burden of HIV on girls is to provide them with jobs as it is understood that it is poverty that pushes them to be exposed and become vulnerable. Some also plead for the setting up of training centers that could contribute to reinforce girls capacities in order to make them more competitive in the labor market.

Focus group discussions Age group: 20 24 years Number of participants: 12 Profile of participants: the group included girls and young women all from urban areas who are in secondary school and universities, out-of-school, peer activists, living with HIV, workers or self-employed and jobless, mothers or childless whether married or unmarried, from different ethnic background. Place: Yaounde, Cameroon Date: Saturday, 3rd February 2007

Prevention component: Availability of services 1. What sort of HIV prevention services are there for girls and young women in your community? For example, where would you go to get: information? condoms? treatment for a sexually transmitted infection (STIs)? an HIV test? The main sources of information are Medias (radio, television and youth magazines on sexual and reproductive health, such as "100% Jeunes" or "Entre Nous Jeunes"). Most participants affirm that medias always talk about the HIV/AIDS prevention. We also talk about it in school, but mostly among friends. The manner in which it is being spoken about among classmates could constitute a source of frustration or stress for those who are not sexually active: "Even at school, it wasn' that; it was more frustration. You are afraid that t they would discover you are interested in such things meanwhile you are still young. You are afraid. Me, I have had classmates who spoke about sexuality and I didnt have any boyfriend then. But I always listened to them. They spoke and it was good to listen to them. They gave advice to each other. What frustrated them was that I never said anything. Each time I tell them that I knew nothing, they say "No. Stop it. You know, let' talk". It' at school that I have s s learned about sexuality. My parents have never talked about it with me Just a few girls admit to have talked about sexuality with their parents. All participants acknowledge that it is rather rare to talk about it within the family, particularly between parents and children. There are also these adolescents mothers trained as Aunties (from their French name Tantines) on SRH who go around advising youths on sexuality in their community. Concerning the treatment of the STI' it is mostly done at the hospital. But it also happens s, that people seek advice in pharmacies. It is mostly during screening campaigns (organized during school vacations or on the occasion of the World AIDS) Day that HIV screening tests are offered, most often freely. 2. How much do boys and young men know about HIV prevention services in your community? What is their role in HIV supporting prevention for girls and young women? According to girls and young women, most boys don' like doing the HIV screening test; t many of them prefer sending their girlfriends in order to guess their own status from their results. However, they admit that more men use condoms and try to be faithful: "They have it always in their pockets. They use it more often, they move with it always. I think they are cautious, they are scared". Some old men who they are already infected with HIV want to spread the disease to young girls and destroy their lives Many girls are infected with HIV because there are dishonest men out there who will do everything possible to inflict pains on the girls. They take advantage of their poverty, their naivety and all that, to abuse them 2

In any case, we are exposed each time we have sex. It takes just once to contract the disease. Thats how it is. The participants equally explain that some of their mates whom they think have low brain continue to believe that when ever a boy suggest the use of condoms, it implies that he doesn' trust you or he considers you as a prostitute. t 3. What sort of HIV prevention services would you like more of in your community? How would that make a difference to your life? It would be necessary to reinforce information among young girls, because most often they are not even aware of what is already available as services. Centers for girls and young women should also be created whereby despite their age they could visit and benefit from the services of a welcoming staff who would not judge them. One could also encourage the extension of associations like that of Aunties (Tantines) which help girls in reinforcing their ability to negotiate as well as their self-esteem. Prevention component: Accessibility of services 4. What are your experiences of using HIV prevention services in your community? In what way those experiences been good or bad? Most of the participants have used the HIV prevention services in their communities. Some had good experience, others very bad. Some have done the HIV screening test and have collected their results, whereas others have done the test but have never gone back for their results, reasons being that they are scared. Surprisingly, most participants of the focus group remark that for certain medical check-ups (test samplings, vaginal examination or delivery), they prefer dealing with male medical staff because women are aggressive and unfriendly particularly towards young girls: they have the tendency of insulting young girls especially during prenatal consultations. Yes, they will always say: Look at her, she' not yet s a woman, but she' already pregnant, Did they send you?, What is it? or Hey! Please shut s up. It is also the same thing during the vaginal examination: Dirty girl, Go away, Look at your panties! At your age!. Girls find these words very frustrating and wonder if these female staff do receive salaries because they behave as if they are simply obliged to work. 5. What are the main barriers that you have faced when trying to use HIV prevention services in your community? For example, what difference does it make if a service is: expensive? Too far away? Unfriendly? To see a doctor for example a gynaecologist, it requires a lot of money and young girls don' t always have the means, even if they are in need of these services. Therefore, the cost of services and biological examinations are major obstacles in the utilization of these services: for example it could cost between 5 and 18 Euros to be received by a specialist or to do a test on syphilis or Chlamydia. There is also fear and shame (notably in cases of the STI' that s) hinder young girls to seek for these services, especially as the breaking of confidentiality is a current problem. There are also some counselors in Voluntary Counselling and Testing centers who exaggerate their roles. They make people feel they are HIV positive whereas they are not and this could kill a cardiac patient. Also, when a result is being given to someone as ' Undetermined'he or she is completely destabilized and suffers a lot as a result , of such suspense or doubt. There are also some health units that systematically do HIV test on patients without their consent. Concerning condoms, if a girl presents herself in front of a trader to buy some, he often makes jokes such as: "Are you already going to do it?", "Is he already waiting for you at home?" "You could take two". Girls and young women find those remarks unfriendly and frustrating. "One day, I entered into a pharmacy with my boyfriend, I saw different condoms with lubricants, I said: ' condom has mint. It' good, lets take it". They looked at me. The way this s 2

those people looked at us, It was as if it was something extraordinary. Yet, it is exposed there and not hidden." 6. In what way are HIV prevention services easier or harder for particular types of girls and young women to use? For example, what difference does it make if you are: unmarried? out of school? HIV Positive? Generally, people are received without any distinction. However, there are certain laboratories, such as Centre Pasteur, where almost 50% discount is being made to pupils and students. Health units that manage HIV/AIDS cases, such as the Nkoldongo Catholic Health Center, grant privileges to HIV infected women such as the reduction of certain costs, some free services and much attention is being given to them. Prevention component: Participation and rights 7. Have there been any projects in your community to bring together girls and boys or young women and young man to talk about HIV prevention? If yes, what did they involve and what did they achieve? The participants acknowledge that in some schools there have always been awareness campaigns on HIV/AIDS, during which condoms were being distributed to all the boys and girls. Questions treated during these sessions were on aspects like: how to avoid being contaminated by HIV, how to protect oneself during sexual intercourse or how to abstain, how to care for those living with HIV/AIDS. They are also against the expelling of young pregnant girls from schools. Unfortunately this activity doesnt take place in all schools. For those girls who no longer go to school, it is difficult for them to be exposed to such sensitizations because it is not a regular activity. Informants also have doubts as far as its impact is concerned. 8. What would encourage you to get more involved in HIV prevention in your community? Most of the participants revealed that they are already very active in the sensitization against the HIV in their community; they endeavor to speak about HIV/AIDS to their family members, at school; they encourage friends and classmates to protect themselves; they make them read magazines on youths reproductive health. In order to reinforce their involvement, they wish to have flyers at their disposal to distribute to friends, classmates, so as to give more value to the subjects. Prevention component: Legal provision 9. What do you know about laws in Cameroon that might affect how girls or young women can protect themselves HIV from? For example, do you know about any laws that: allow girls to get married at a young age? do not allow girls or young women to have abortions? prevent girls from using services unless they have the consent of their parents? Participants don' know precisely the law that regulates marriage in Cameroon or the legal t age of marriage for a young girl. However, they acknowledge the fact that it varies: in some regions, girls get married when they feel they are mature, for example from the age of 18, whereas in other regions of the country they get married from birth. Most of the participants think that early marriage saves the girl from needs, therefore prevents poverty that pushes or makes her vulnerable to STI' or early pregnancies. But early marriage doesnt s protect her completely against HIV/AIDS, especially if her husband is not faithful or does not protect himself. The participants acknowledge that there is a law that forbids abortion, but this law doesn' disturb anyone because of generalized corruption that permits people to t obtain what ever they want so long as they can pay for it. Even where the parents consent is requested, people bribe and obtain the service. Prevention component: Policy provision:

10. What type of education have you received about issues such as relationships, sex and AIDS? For example, what have you been taught about your sexual and reproductive health in school? Very little is taught on sexual and reproductive health in schools. Few schools, especially the Catholic mission, have lessons on family life. Generally, students have to be contented with some lessons on child welfare where they are being taught to count their menstrual cycle or with biology where they learn the mechanisms of human reproduction. 11. What could the government of Cameroon do to fight fear about AIDS in your community? Seropositive persons should be taken care of by reducing the prices of their drugs and by making the entire public to understand that these prices have been reduced through publicity. It would be necessary to reinforce sensitization in order to stop making victims guilty, while fighting against stigmatization. It is important to explain to people that HIV no longer means death and that one can live with it. Summary of discussion 12. What are the 2-3 most important changes that could be made - for example by the government or community leaders - to help girls and young women in Cameroon to protect themselves from HIV? The participants think lessons on sexual education should be introduced in schools and not just as an optional subject, but as a subject with a coefficient so that students will take it seriously. They also think that generalized corruption hinders most projects and investments from having their desired impact; that is why, they also recommend the fight against corruption as an important measure liable to help girls and young women in Cameroon to protect themselves against HIV.

One-to-one interview: Dr. Yele Beaunet Flavian (male) Reproductive Health Officer, UNFPA 06/03/07, Yaounde

General What is your impression about the general situation of HIV prevention for girls and young women in Cameroon? Are things getting better or worse and why? The general trend is to the feminisation of the pandemic. With more precise data available today, it will be possible to develop appropriate strategies in order to reduce the incidence of HIV/AIDS Prevention component 1: Legal provision In your opinion, what laws in Cameroon are making HIV prevention for girls and young women better or worse? Early marriage can be considered as something that increases the rate of HIV infection. But it would be difficult to make a law that determines the age of marriage. This wont make any difference because people may not respect it. What is relevant is to clearly explain the consequences of early marriage to women, men or household heads. If habits, behaviours or the environments where the people live dont change, it may be difficult just to make 2

laws to change things. It is deeply rooted in the cultural practices of the people. Early marriage is mostly found in areas of the country where girls are less educated. There is a big advantage to the have the girl child educated: For the basis of change is to provide woman with education so that she becomes autonomous while making decision concerning the age to marriage or problems related to her sexual life Sex work or prostitution is forbidden in Cameroon, but the practice is highly tolerated. Abortion is also forbidden, except for medical reasons. Death of young girls due to induce abortions are registered everyday. For the previous generation, it was a taboo to talk about sex. Parents use to think that what was important for adolescents was domestic duties, schooling or farm work. Nowadays, there are changes, because some parents discuss the issue with their children. Youths are even exposed to radio or TV programmes talking about sex education. How does legislation affect different types of girls and young women and their vulnerability to HIV? For example how does its effects vary among those that are: In/out of school? Married/unmarried? In rural/urban areas? Living with HIV? From marginalised groups (such as sex workers, migrants or orphans)? Some people think that being a student is a status that can render girls vulnerable to HIV. I dont consider it that way. I think what matters is poverty. For me, the main factor of vulnerability is poverty. There are also girls from wealthy families who are exposed to pornographic materials and who will go out just to try it. More than legislation, it is parents responsibility which should be sought. Married women are not less vulnerable to HIV because if one of the partner is not faithful, he can infect the other. Some unmarried people may even be less vulnerable than the married ones. But legislation protects marriage and particularly faithfulness between partners. It is even reinforced by religious principles because the church doesnt accept polygamous unions as a way of protecting marriage. But people dont care about legislation, neither do they respect the rules of the church today. People are also more vulnerable in urban areas, because they live in difficult conditions and their poverty may force them to be involved in sex work thus being exposed to STIs or HIV. PLWHA who go through good counselling and are well taken care of, know they have to manage their health and this make them less vulnerable. Marginal groups are also very exposed, particularly through sex work. A law protecting minority groups exists in Cameroon, but there is no specific legislation about marginal groups. Overall, what laws could the government change, abolish or introduce to bring the greatest improvements to HIV prevention for girls and young women? The institutional approach that consist of making laws to have things work does not produce good results. This approach only has limited results in programmes. It is important to understand the cultural context underlying peoples behaviour, to look for ways to create ownership by the people themselves. Only through cultural approaches could we make things better. Prevention component 2: Policy provision What type of government policies or protocols for example in relation to antenatal care, condoms or voluntary counseling and testing make HIV prevention for girls and young people in Cameroon better or worse? HIV screening is not yet in the habit of the people and the government has made it a priority to encourage the population to go in for voluntary counselling and testing in the 2007 actions plan. Condom is available now and it is easy to find it nearly everywhere. But people dont always use it. Treatment is also available but prevention still need to be reinforced. Antenatal care is available in most health units and is part of minimum packet of activities of each health center. UNFPA supports this in some health districts of the country. 2

Do girls and young women and also boys and young men - receive any type of official sex education? For example, what are they taught about their sexual and reproductive health and rights while in school? UNFPA is helping to introduced education to family life at all levels of education. Curricula have been developed and things just need to be extended in many other schools. The programme is made according to the level of the students and boys and girls are taught the same thing. Overall, what policies or protocols could the government change, abolish or introduce to bring the greatest improvements to HIV prevention for girls and young women? What is important is to try to continue to educate people. If adolescents and particularly girls are well informed at early age, they will be more responsible and they will manage their sexual life better. They need to know what they should do with their bodies as well as their future. Prevention component 3: Availability of services What type and scale of HIV prevention services are available for girls and young women in Cameroon? Male condom is available everywhere whereas female condom is not available and not known to people. Information is given to youth and in some schools with the support of UNFPA in some areas, but this is not yet common everywhere. All health units, health centers or hospitals treat STIs, can treat sexually transmitted infections. Voluntary counselling and testing services are available for both sexes but still need to be scaled up in all health units in the country. Treatment is available in special treatment centers or units and there is hope that very soon, ART will be free of charge for pregnant women. PMCT has already been scaled up during the past 2 years to avoid transmission from mothers to children. What type and scale of HIV prevention services are available for particular types of girls and young women? For example what services are there for those who are: Unmarried? Out of school? Involved in sex work? Orphaned? Injecting drug users? Migrants? Refugees? HIV positive*? There is no special or specific services for people except people living with HIV/AIDS who are received in Day care hospitals. Even there, they try to mix up patients as much as possible to avoid stigmatisation. What type and extent of HIV prevention services and information are available for boys and young men? How does this affect the situation for girls and young women? Nothing special. Overall, what type of services most urgently need to be increased to improve HIV prevention for girls and young women? Voluntary counselling and testing centers should be multiplied and more personnel should be trained in the management of AIDS cases to avoid that people wait so long during HIV screening or for treatment. Prevention component 4: Accessibility of services What are the main barriers to girls and young women using HIV prevention services in Cameroon? There is lack of anonymity in services. People easily identified day care hospitals as places where HIV patients are found. People are afraid of being stigmatised. Populations in rural areas are far from services and may need outreach activities to provide them with 3

treatment. Health units are not very friendly to youths and with the support of UNFPA some youths friendly hospital have been set up. But such initiative need to be owned by the government and scaled up in the 170 districts hospitals around the country. Are HIV prevention services easier or harder for particular types of girls and young women to access? For example, is it easier or harder if they are: Married or unmarried? In school or out of school? HIV positive? Normally people should have access to services without any other consideration. But it happens at times that some staff dont carry out their duty the way they are supposed to do. What role do boys and young men have in making HIV prevention services easier and better for girls and young women? No specific roles for boys since both women and men share the same responsibilities in sexual matters. They should be given different types of knowledge according to their age. Overall, what priority actions could be taken to make HIV prevention services more accessible to girls and young women? Understanding the cultural patterns of the people and development of appropriate messages that take into consideration the context in which they live. Prevention component 5: Participation and rights How are international commitments (such as the Convention on the Rights of the Child and the Convention on the Elimination of all Forms of Discrimination against Women) applied in Cameroon? All these conventions exist but the problem is that they are not applied. The environment is not conducive to their implementation. To what extent is the national response to AIDS rights-based? PLWHA have their associations and fight to have their rights respected. Their national network known as RECAP+ has been very active and has made the government to consider their needs. To what extent are girls and young women including those that are living with HIV involved in decision-making about AIDS at the national level? Girls may not be particularly involved because decisions on HIV/AIDS concern everybody, women and men. They are not taken to please this or that sex. I do not know the structure of the National AIDS Control Committee, but it is obvious that PLWHA should automatically be part of such a committee. They need to be involved so that some results can be obtained. Overall, what priority actions could be taken to support girls and young women to be more involved in national level decision-making about AIDS? In case the level of their involvement is not satisfactory, things should be analysed so as to improve that level. Summary In summary, what are the 3-4 key actions for example by the government, donors or community leaders - that would bring the biggest improvements to HIV prevention for girls and young women in Cameroon? Problem number 1 is lack of information on health issues. People should be informed on what to do so that they can take good decisions. Where necessary, it is good to increase the level of education for girls who can still go to school and those young women who are older could be offered alphabetisation programmes so that all of them would be able to understand life skills.

One-to-one interview: Maurice Abina Eloi (male) President of the AFSUPES (United Brothers and Sisters for Hope and Solidarity Association) 27/02/07, Yaounde General What is your impression about the general situation of HIV prevention for girls and young women in Cameroon? Are things getting better or worse and why? I think that things are getting better. More and more girls seek information or go in for screening test. As chairman of an Association, we receive a lot of girls who are seeking information because they would like to know their HIV status. I think where the problem persists is condom negotiation. Even, in our association of People who are living with HIV, most of our members are young girls: They come to our association because they need more information. In the past they did not know. They would just jump in sexual activities without thinking. With the poverty rate, they would worry about getting money through sexual transactions, without knowing that they can be infected with HIV Prevention component 1: Legal provision In your opinion, what laws in Cameroon are making HIV prevention for girls and young women better or worse? Even in the Northern parts of Cameroon where girls were given out for marriage at an early age, there are measures to discourage that. Girls are encouraged to go to school and measures are being taken to discourage early marriage: Even though girls nowadays get married later, most of them are involved in sexual activities with men earlier than before. Not that they are officially married, but the social life pushes them to be with somebody so that they can at least get their daily bread Prostitution is recognised in Cameroon. It is accepted and well tolerated. For long HIV sensitization has been targeting commercial sex workers: they are very conscious. If you approach them, they will tell you no sex without condom. They became very conscious after all the sensitization that has been carried out on them Women and girls are not free to have abortions because it is forbidden by the law. Even an accomplice would also be taken to court because an abortion includes everybody involved in it. Some girls will do abortions themselves without the help of a medical staff. Family planning units exist and I dont know if parents consent is requested before the services are provided to adolescents. How does legislation affect different types of girls and young women and their vulnerability to HIV? For example how does its effects vary among those that are: In/out of school? Married/unmarried? In rural/urban areas? Living with HIV? From marginalised groups (such as sex workers, migrants or orphans)? It is not clear whether pregnant adolescents who are student can continue to go to school. Some schools accept them but the government wants girls to focus on their education rather than on sex. Young girls and particularly students are more vulnerable to HIV infections. Some married women are less vulnerable to HIV because they stick to one partner. But it is not the case with all of them and others would also be infected by their husbands after they are married. In rural areas, things are rather worse because not only condoms are scarce but also people lack information on prevention issues. Girls living with HIV are said to have a lot of difficulties with male partners. When they disclose their status, their relationship will just badly get to an end. Some say they prefer not to disclose it anymore and others will just prefer to have as partners boys who are also living with HIV, because they feel they understand each other better, particularly as far as condom use is concerned. 3

Although the government is now doing a lot for orphans, it is very important to carry out HIV awareness campaign on them, by explaining to them concretely what their parents died of, making HIV/AIDS issue very clear. They should be provided psychosocial support because they are very vulnerable to HIV. Overall, what laws could the government change, abolish or introduce to bring the greatest improvements to HIV prevention for girls and young women? The government should introduce a law that acknowledges the desire and the right of HIV positive girls and young women to have children. A lot of young women living with HIV are preoccupied by this question: most young girls that I meet really would love to have children. They became HIV positive by the age of 23, 25 or 30 years while still childless. Their only problem is how to have children Prevention component 2: Policy provision What type of government policies or protocols for example in relation to antenatal care, condoms or voluntary counselling and testing make HIV prevention for girls and young people in Cameroon better or worse? The desire for a child is a very serious matter for women who are infected with HIV. They just would like to have children whether with a partner who is HIV negative or positive. PMCT is available and more and more pregnant women are using this service which is offered to them for free. Before, the policy used to encourage free distribution of condoms. People will collect the condom but wont use it. Now it is advertised so that people buy them because one cant go to a shop, buys a condom and at the end doesnt use it. Female condoms are not available and there is more or less no publicity to make it known to women. If it were available, women will not need to negotiate condom use with men, they will just put it on and the partner will accept it or go away. The protocol concerning voluntary counselling and testing is applied but during occasional campaigns carried out in the month of December it is not respected (lack of pre or post test counselling or both, lack o client consent). Do girls and young women and also boys and young men - receive any type of official sex education? For example, what are they taught about their sexual and reproductive health and rights while in school? There is no sex education in schools yet, but it should be introduced. Some schools have lessons on biology and some may use the opportunity to talk about sex education: There are lots of things happening around, children watch all types of programmes on cable TV. When they watch such things especially if they had not got any discussion on them before, they feel they should do them. With so much HIV around, there is an urgent need to introduce sex education in school. Overall, what policies or protocols could the government change, abolish or introduce to bring the greatest improvements to HIV prevention for girls and young women? There is not much need for new policies or protocols. The main problem is to have these protocols applied. Most often they are ignored and people will have the tendency to do what pleases them. For example, HIV screening will be done without client consent at times and drugs will also be sold at a rate different from the official price published and known to all. Prevention component 3: Availability of services What type and scale of HIV prevention services are available for girls and young women in Cameroon? In general, services are mixed and there is no distinction at entry points in health units who is who. It is only later that people can be provided special care according to their needs, like 3

HIV infected patients for example. Things are done that way to avoid that some patients or clients are stigmatised. What type and scale of HIV prevention services are available for particular types of girls and young women? For example what services are there for those who are: Unmarried? Out of school? Involved in sex work? Orphaned? Injecting drug users? Migrants? Refugees? HIV positive? When services are available, it is for everybody without distinction. What type and extent of HIV prevention services and information are available for boys and young men? How does this affect the situation for girls and young women? Women are more conscious then men, because a lot have been done for them. Men are not yet specially targeted in awareness campaigns. They take too much risk, particularly adult men who are rich. Yet, no specific service or information is available for them. Overall, what type of services most urgently need to be increased to improve HIV prevention for girls and young women? Services where women, especially young ones of same age groups could meet and share their experience could be created to help in improving the prevention of HIV among them. This will permit those in school and girls out of school to interact and learn from each other. Making ARV treatment for children available and also scaling up PMCT centres in most rural health units. Public advertisement of these PMCT centres should be done nation wide. Concerning AIDS case management, most girls and young women are complaining about the Triomune protocol. It causes to them a big change on their bodies known as lipodystrophy (the buttocks will disappear, for example). Also, doctors should be trained to listen to patients complains and take that into consideration. Prevention component 4: Accessibility of services What are the main barriers to girls and young women using HIV prevention services in Cameroon? People have to wait for so long in the hospital to obtain services and if most of them had a choice they wont go there. As for most women under AIDS treatment, the cost is a lesser problem than the side effects of some protocol like Triomune that deformes their bodies in a way they dont like at all. Some are having adherence problems just because of that: Some young girls are about to stop treatment; others have already stopped it. They say that ever since they stopped the treatment, they have regained their body shape It is not the cost that has prevented me from taking my treatment. Me, I care for beauty, for my physical appearance. I am HIV positive, now they force me to take a treatment that is deforming my shape. The man I leave together with is starting to wonder what sort of treatment I take, why I am becoming a type. I know that it is my treatment. Me, I would like to change this treatment but my doctor is always saying no Official prices are not always respected and some staff charge patients more than they are supposed to pay. There is so much corruption existing in the system. This causes a serious problem for AIDS patients who can not do their pre-therapeutic tests or check-up on time. Female condoms are not so available like male ones. HIV screening tests are not available in rural areas and people who want this service have to pay an extra transport cost which can even be 5 to 10 times higher than the price of the test itself. It goes the same for treatment units which manage AIDS cases, they are too far for some patients. In towns, AIDS treatment centres are available but have few doctors. Patients wait too long to be received by staff. Are HIV prevention services easier or harder for particular types of girls and young women to access? For example, is it easier or harder if they are: Married or unmarried? In school or out of school? HIV positive? 3

It is more difficult for students as well as non student young girls to have access to HIV prevention services, because these services are not offered in schools or in public places known to them. In rural areas, people do not have easy access to voluntary counselling and testing, as well as treatment. They must go to towns if they need these services. What role do boys and young men have in making HIV prevention services easier and better for girls and young women? For now boys and young men are a problem: Majority use condoms, but it is often a big fight with their partners. Yes, we heard young girls talking about their partners who dont want to use condoms. They strongly have to negotiate for them to accept it Overall, what priority actions could be taken to make HIV prevention services more accessible to girls and young women? AIDS Patients who are under treatment since some months shouldnt be forced to come every month. They could be given treatment for two or three months. There is a lot of corruption in the system. Even though there exist posters of the President of the republic or of the Minister of Health, staff still collect money from clients. This issue could be clearly discussed with them during training sessions in the hospitals. It prevents AIDS patients from being adherent to ARV treatment, because when some are so frustrated, they may go and only come back after months. Prevention component 5: Participation and rights How are international commitments (such as the Convention on the Rights of the Child and the Convention on the Elimination of all Forms of Discrimination against Women) applied in Cameroon? Even though some of these Conventions are not yet promulgated, things are not bad concerning children or women right. To what extent is the national response to AIDS rights-based? There still exists a big fear of discrimination at the level of families or in some services. People will seek care in distant units in their towns or in different towns just because they are afraid someone who knows them will see them and disclose their status. They are afraid their children and the rest of the family will be stigmatised. To what extent are girls and young women including those that are living with HIV involved in decision-making about AIDS at the national level? Women in particular are struggling a lot, they are very active in the fight against HIV/AIDS. Associations of PLWHA are often invited to take part in the development of strategic plans or operational plans on HIV/AIDS. Things are gradually improving because PLWHA are invited here and there, but a lot still need to be done. Most often PLWHA are not listened to. In the CCM, different ministries have their representative for just one or two representatives of the civil society and the community of PLWHA: When it comes to decision making, PLWHA voice is not considered, but rather the well dressed representative from Ministries will impose their views on things they dont understand. Overall, what priority actions could be taken to support girls and young women to be more involved in national level decision-making about AIDS? The number of PLWHA should be increased in commissions or committees dealing with HIV/AIDS to strengthen the participation of PLWHA so that they can also easily voice their concern and needs. Summary In summary, what are the 3-4 key actions for example by the government, donors or community leaders - that would bring the biggest improvements to HIV prevention for girls and young women in Cameroon? 3

Fighting corruption and reducing the price of ARV drugs.

One-to-one interview: Lucie Zambou (female) President Cameroon Network of People Living with HIV/AIDS (RECAP+) 20/02/07, Yaounde

General What is your impression about the general situation of HIV prevention for girls and young women in Cameroon? Are things getting better or worse and why? At the moment, we have the impression that things are going on well. But as chairman of a community based organisation, when discussing with people, it is easy to realise that things do not seem to move, that there are problems. What is being said or written is not what is done, texts and decisions taken are not being implemented. Prevention component 1: Legal provision In your opinion, what laws in Cameroon are making HIV prevention for girls and young women better or worse? In the Muslim families in Cameroon, girls are still being given out to early marriage but the general tendency is late marriage especially among Christians. In fact many young girls get married much later because they want to study and also because after their studies they dont find paid jobs that could guarantee them some independence. Many are obliged to continue living with their parents. But when a woman gets married at a tender age, she has little or no power in decision making at home. She is subjected to all, this makes her vulnerable to HIV/AIDS. Early marriage could also lead to unfaithfulness because the girl could later on discover that her husband is perhaps not the kind of man she wanted so she will want to look elsewhere. The husband on his part will want to behave like a father to his young wife. He believes he is free to jump from one woman to another and she will have nothing to say. Prostitution is illegal in Cameroon but it is very much tolerated because as from a certain hour in the evening precisely in big towns, there are always girls at specific junctions waiting for clients. Everyone sees them and understands, yet nothing is done. Whereas the police used to raid street girls and almost force them to do STIs tests. They were well followed-up and some were being sensitized and advised to the point where they abandoned this job. Abortion still remains forbidden by the Cameroon law but we have fewer deaths as a result of clandestine abortions because doctors have entered the game and perform more and more abortion at high cost (it has become a source of income to them): Therefore clandestine abortion that we use to do in the quarters with herbs and other things is no longer done when I was still young in those times when you had to approach a doctor perhaps because youve had a delay in menses, the doctor will want to know your parents and what you do for a living. It was even difficult to present your problem to a doctor but today, it has really become so common so much so that if a girl can, she aborts whenever she wants and however she wants. It only requires that she has money. Girls can use the services of sexual health centres without their parents consent because if they can pay for those services, they will be served. They could request the parents consent but this will just be done to push them to bribe the staff.

How does legislation affect different types of girls and young women and their vulnerability to HIV? For example how does its effects vary among those that are: In/out of school? Married/unmarried? In rural/urban areas? Living with HIV? From marginalised groups (such as sex workers, migrants or orphans)? It is poverty that renders students vulnerable to HIV/AIDS. They are very much exposed because they have relationships with older partners simply because they need money. People are becoming more and more irresponsible and they adopt behaviours that are risky to themselves and also to their partners. Being unmarried too can expose one to HIV but there is also HIV among many couples because most often the men are unfaithful and they contaminate their wives. Before, the scarcity and the high cost of treatment pushed many infected persons to go to their villages where they live a normal life or wait for death, but with the availability of treatments notably in big towns, PLWHA are rather coming back to towns where they have easy access to treatment. Some PLWHA dont protect themselves and later on become vulnerable. They take advantage of the confidentiality of their status to adopt risky behaviours to themselves and to their partners. Overall, what laws could the government change, abolish or introduce to bring the greatest improvements to HIV prevention for girls and young women? It is good to introduce a law that limits the current wrong-doings, a law that will take confidentiality into consideration and regulate chronic diseases so that patients and non patients behave more responsible. Prevention component 2: Policy provision What type of government policies or protocols for example in relation to antenatal care, condoms or voluntary counselling and testing make HIV prevention for girls and young people in Cameroon better or worse? There are no norms or official policies on this subject and everyone does what he or she wants or can. Condoms are not always available for youth and in some schools the staff forbid discussions on such subjects with students. Sometimes young girls reject the female condoms because they find it difficult to use. They talk of voluntary testing but there are no precise norms and each person is free to do it or not to do it. Do girls and young women and also boys and young men - receive any type of official sex education? For example, what are they taught about their sexual and reproductive health and rights while in school? Presently there is no official programme treating sex education in school. Certain schools have introduced a method of teaching but these methods are shallow and dont permit the youths to ask questions about themselves or about their future. The lessons instead deal with childcare. The government should validate documents and provide to teachers in order to avoid anyone talking what he or she thinks. Overall, what policies or protocols could the government change, abolish or introduce to bring the greatest improvements to HIV prevention for girls and young women? People should understand that when using condoms, it is not to protect the government but to protect themselves. They are used to free condoms and they use it only when they are being given for free. They dont have the habit of buying condoms themselves, to the point that people prefer having unprotected sex than buying condoms they expect the government to provide. Prevention component 3: Availability of services 3

What type and scale of HIV prevention services are available for girls and young women in Cameroon? Male condoms are available in stalls almost every were. The female condom is rather rare and so many people in rural areas have never seen it. What type and scale of HIV prevention services are available for particular types of girls and young women? For example what services are there for those who are: Unmarried? Out of school? Involved in sex work? Orphaned? Injecting drug users? Migrants? Refugees? HIV positive? There are no specific services for this or that group of people. Everyone is received in health units without any distinction. What type and extent of HIV prevention services and information are available for boys and young men? How does this affect the situation for girls and young women? No specific services. Overall, what type of services most urgently need to be increased to improve HIV prevention for girls and young women? Free screening campaigns should be organised in order to enable more girls and young women do the test and above all assure that the tests are sufficiently available because there is always a high demand for it by the population. Prevention component 4: Accessibility of services What are the main barriers to girls and young women using HIV prevention services in Cameroon? As for treatments, it is still not accessible in rural areas. There is also the problem of resistance. Triomune is causing a lot of problems to patients and we dont understand why there is no alternative treatment being introduced in order to replace it. Treatment for babies and children are not available. At times after testing, women are not being referred to appropriate structure capable of supplying the PMCT. We find women who have almost no information because they were not referred where they were supposed to. Another hindrance to the utilisation of services is the cost, which is still very much high, the time to wait which is still too long, insufficient health personnel and at times even the few who are supposed to be there are not always available. Patients who consult for HIV are mixed and they are of different ages. This causes a lot of frustration to the youths below 20 years who find themselves on benches with people as old as their parents or even older. There are also cases where infected youths are obliged to run away from centres in order to go to other centres which are farther from their homes, simply because they are afraid of meeting their parents who are not yet aware of their seropositive status. Are HIV prevention services easier or harder for particular types of girls and young women to access? For example, is it easier or harder if they are: Married or unmarried? In school or out of school? HIV positive? Seropositive women have more and more difficulties to obtain an appropriate management of their childrens condition so as to protect them against the transmission of HIV. It is being announced to them that the treatment is free of charge but an unappropriate protocol is being used (bitherapy). They are asked to pay in order to have a 3

good combination (tritherapy). Generally, services are being offered in the same way to everyone. What role do boys and young men have in making HIV prevention services easier and better for girls and young women? Generally here, men have power and dominate women, they could use their power to sensitize women and to assure them that they also have the right to say no. Overall, what priority actions could be taken to make HIV prevention services more accessible to girls and young women? I think a specific centre should be created for young girls and particularly for students, an environment where they can have family planning and also discuss on sexuality, self-esteem so as to reinforce their capacity for more autonomy. Prevention component 5: Participation and rights How are international commitments (such as the Convention on the Rights of the Child and the Convention on the Elimination of all Forms of Discrimination against Women) applied in Cameroon? These conventions exist but they are not being applied. Few people are even informed about their content. To what extent is the national response to AIDS rights-based? They judge people a lot; they criminalise them especially people living with HIV/AIDS without taking into consideration their rights. To what extent are girls and young women including those that are living with HIV involved in decision-making about AIDS at the national level? Girls participate but generally, their opinions as PLWHA is not taken into account. Even when PLWHA associations have fought to obtain this or that decision in favour of their conditions, this will at the end be presented as an act of kindness of the Minister of Health or of the government. This is felt by PLWHA as big frustration. Overall, what priority actions could be taken to support girls and young women to be more involved in national level decision-making about AIDS? Services should be improved in favour of women. People living with HIV/AIDS should be able to voice their opinion in the decision-making bodies on HIV/AIDS. The government should stop making decisions on behalf of people without even listening to them. Summary In summary, what are the 3-4 key actions for example by the government, donors or community leaders - that would bring the biggest improvements to HIV prevention for girls and young women in Cameroon? Youth centres should be created so that youths go there not only to have fun but also to obtain information on sexuality. There should also be a better follow-up of ministerial decrees because it is often that a decree reduces the price of a drug but in some health units, this drug is still sold at the same former price.

One-to-one interview: Nathalie Nkoume (female) HIV Officer, Cameroon National Association for Family Welfare (CAMNAFAW) 20/02/07, Yaounde

General What is your impression about the general situation of HIV prevention for girls and young women in Cameroon? Are things getting better or worse and why? If things are considered globally, one should say that they are getting better. As concerning prevention for example, a lot is done but in a very global way and problems faced by young girls or HIV positive women are not taken into consideration. Things should be improved so as to respond to the needs of women. Girls between 15 and 24 years old are more infected with HIV, because they are not considered as a group with specific needs. They just put them in global preventive actions by applying the same strategies to them or providing the same information with others without considering their level of understanding or their needs for that moment Prevention component 1: Legal provision In your opinion, what laws in Cameroon are making HIV prevention for girls and young women better or worse? Girls can get married as from 18. Marriage does not seem to protect women from HIV/AIDS because most married women who are HIV positive all said to have always been faithful to their husband, but still found themselves with HIV. Marriage does not prevent one from HIV, neither does it reduce vulnerability to it. Prostitution is forbidden by law but is highly tolerated. Sex work is becoming widespread among youths, even though they dont consider it to be prostitution but they put themselves at risk and most of them underestimate this risk. Abortion is illegal but a lot of young women do it and in conditions that expose quite a number of them to death. Unsafe abortion accounts for 20% in the mother mortality rate in Cameroon. In CAMNAFAW clinics girls are provided with reproductive health services without their parents consent. But in other health units, cultural barriers may make that some staff dont provide these services to young girl. How does legislation affect different types of girls and young women and their vulnerability to HIV? For example how does its effects vary among those that are: In/out of school? Married/unmarried? In rural/urban areas? Living with HIV? From marginalised groups (such as sex workers, migrants or orphans)? People are considered globally and legislation doesnt take into account the specificity of each group. Overall, what laws could the government change, abolish or introduce to bring the greatest improvements to HIV prevention for girls and young women? Introduce a law that will consider the reproductive health of women who are infected with HIV. People should be able to accept that a seropositive woman has the right to have a child if that is her wish and services should be supportive of this. There is a lot of restrictions concerning abortion in the law of Cameroon. It will be good if some of these restrictions could be cancelled (levees) so as to start working towards a totally free abortion law. Prevention component 2: Policy provision 4

What type of government policies or protocols for example in relation to antenatal care, condoms or voluntary counseling and testing make HIV prevention for girls and young people in Cameroon better or worse? Antenatal care is provided in most health units but PMCT are rarely available in rural areas. It is not yet mainstreamed in the daily activity of all health units. Male condoms are not available everywhere and there is stock-out sometimes in government health units. Female condoms are very scarce: How do you want a woman to take the decision of protecting herself while she is even lacking the tool to manage her sexual relationship. HIV screening is available in VCT centers, but people dont use this service much because they are afraid of what will happen then if they were HIV positive, what they will have to spend to be taken care of. Home based care for AIDS patients is lacking.

Do girls and young women and also boys and young men - receive any type of official sex education? For example, what are they taught about their sexual and reproductive health and rights while in school? Most of them lack information on sexual and reproductive health issues. In most catholic schools there used to be a programme on Education for Life and Love (EVA) but based on morals. Other schools receive some teaching about HIV/AIDS or unwanted pregnancies prevention. But not all schools are covered and the government is planning to introduce such course at a larger scale with the support of UNESCO.

Overall, what policies or protocols could the government change, abolish or introduce to bring the greatest improvements to HIV prevention for girls and young women? Work on condoms availabity and make the supplying sustainable. Advertise the services (HIV/AIDS treatment units at district hospitals) where they are available to make them known to populations. People are tested but not all of them are being followed up. Prevention component 3: Availability of services What type and scale of HIV prevention services are available for girls and young women in Cameroon? Information is not always available or doesnt reach young most young people in quarters or remote areas. Treatment for STIs is not a problem because it is provided in all health units and for that people use the syndromic approaches. CAMNAFAW also has youths friendly clinics, where services are provided to youths without them being judged. What matters in these clinics is only their health. This type of service is offered by NGO but just on a limited scale. PMCT is mostly available in urban areas and most women still lack information about this mode of HIV transmission. What type and scale of HIV prevention services are available for particular types of girls and young women? There used to be a sensitization and training for people living with HIV by the GTZ. In some schools information is given to students. In rural areas people are hardly informed. Male condom is available even if there is often stock-out, but the female condom is expensive and very scarce. For example what services are there for those who are: Unmarried? Out of school? Involved in sex work? Orphaned? Injecting drug users? Migrants? Refugees? HIV positive? 4

There arent specific services for this or that group. There is need to move from the global policy directives to specific or sectoral strategies where groups of people could be targeted. What type and extent of HIV prevention services and information are available for boys and young men? How does this affect the situation for girls and young women? There is nothing specific for boys or young men. Overall, what type of services most urgently need to be increased to improve HIV prevention for girls and young women? Existing services need to be better organised and managed in a way that the needs of specific groups could be met. For example, some of these services could open on Saturdays just to receive young people. So, it is not a matter of increasing the number of services, but it is a matter of managing existing services better. Prevention component 4: Accessibility of services What are the main barriers to girls and young women using HIV prevention services in Cameroon? Cultural barriers will make nurses not to provide contraceptives services to young girls because they dont want to accept that these girls could be sexually active. Most youths wont go to public health units if they are infected with STIs because they are afraid they will be judged, they will be criticised. These services are not friendly to youths at all: There is a limit when it comes to sex, people will set barriers on youths. They shouldnt do so, they shouldnt. People shouldnt decide what youths must do or must not do. The reality is now different and this need to be considered. Decisions should be taken according to this reality. Youths are not well received. Hours during which services are opened dont suit most youths. When youths are mixed with adult patients in hospital, they feel shy, disturbed particularly if they are complaining of STIs. There is often stock-outs of male condoms in services and non availability of female condoms. The cost of AIDS management is still not at a level where most people could have access to it and it discourages people from going in for HIV screening test. Costs of services should be reduced to it lowest level, but not cancelled. It is important that there is some fees for the services, so that people dont misuse or neglect what they are being offered free. Are HIV prevention services easier or harder for particular types of girls and young women to access? For example, is it easier or harder if they are: Married or unmarried? In school or out of school? HIV positive? People have more or less the same access to services, except for youths who may find it difficult because of the attitudes of adults health staff or adult patients. Students and particularly girls may find a lot of difficulties in the services because they are judged morally. What role do boys and young men have in making HIV prevention services easier and better for girls and young women? Girls suffer a lot from boys pressures and if these boys were given sex education, they will help in protecting girls and young women. HIV prevention services should equally be given to both girls and boys: we live in an environment where defined roles for boy and girls do not allow boys to protect girls, but rather to protect themselves first Overall, what priority actions could be taken to make HIV prevention services more accessible to girls and young women? To make female condoms available and at low cost to women. 4

Prevention component 5: Participation and rights How are international commitments (such as the Convention on the Rights of the Child and the Convention on the Elimination of all Forms of Discrimination against Women) applied in Cameroon? These conventions are signed but only timidly applied. Women are not protected against discrimition. To what extent is the national response to AIDS rights-based? Little is said about peoples rights. People do not know nor accept that PLWHA have rights like that of reproduction for example. They may be discriminated in heatlh units. Abortion is forbidden and even a pregnant HIV positive woman who would like to terminate her pregnancy does not have the right to it. To what extent are girls and young women including those that are living with HIV involved in decision-making about AIDS at the national level? More and more people living with HIV/AIDS are involved in activities in the field. Some NGOs even involve them in their steering committee. But at the national level, their involvement in decision making is still very poor. They use them than listen to them, because they just want to show to the international community that they are involved in decisionmaking. Associations of PLWHA are really fighting to voice their needs. They fight for things that should normally go to them. When it happened that some PLWHA were hired in the National AIDS Control Committee, they were just taken on temporary basis and even though some are well qualified, they were hardly given management position. There is no clear vision or strategies of how to empower them. Overall, what priority actions could be taken to support girls and young women to be more involved in national level decision-making about AIDS? PLWHA should have their capacity developed so that they become activists and reinforce their activities because we are in a context where rights are not given to people, they must stand up for that. Summary In summary, what are the 3-4 key actions for example by the government, donors or community leaders - that would bring the biggest improvements to HIV prevention for girls and young women in Cameroon? Greater involvement of PLWHA in activities as well as decision making could make a difference. Donors should also come together, coordinate their position and also be more demanding to the government to respect its obligations vis--vis its populations.

One-to-one interview: 4

Talom Jean Marie (male) Coordinator Ethics, Law and HIV/AIDS Network (REDS) 27/02/07, Yaounde

General What is your impression about the general situation of HIV prevention for girls and young women in Cameroon? Are things getting better or worse and why? There is a strong political will of the government to improve on things but the reality has not yet matched with this expectation. Most girls between 15 and 24 years are infected with HIV just because they have completed their education and do not have any hope in future, there is no job for them and so they found themselves vulnerable to HIV/AIDS: Fighting against AIDS is also a political battle to provide job to youths, to reduce social inequalities and to be brief, it is to make progress concerning some challenges the society is facing Prevention component 1: Legal provision In your opinion, what laws in Cameroon are making HIV prevention for girls and young women better or worse? Sexual abuses on youths is severely punished by law in Cameroon, people still need to be informed about this as well as parents should be trained. The legal age for marriage in Cameroon is 15 years for girls and 18 years for boys, but parents should give their consent if the future spouses are below 21 years old. Generally, girls are getting married later today because they go to school first or because there is no one to get married to them since boys who could do that do not find work. But there is still early marriages in the northern parts of the country where girls are given to older men at the age of 8, 9 years old. They lack information about sexuality and this really strongly exposes them to HIV/AIDS. Prostitution is forbidden by the law but it is highly tolerated. It is like homosexuality. The society will one day need to look itself in the mirror. Abortion is also forbidden except for cases where the health of the mother is threatened. Parents consent may be requested for sexual and reproductive health services to girls who are still too young (under 18). How does legislation affect different types of girls and young women and their vulnerability to HIV? For example how does its effects vary among those that are: In/out of school? Married/unmarried? In rural/urban areas? Living with HIV? From marginalised groups (such as sex workers, migrants or orphans)? The vulnerability of girls and young women can not just be attributed to legislation, even though this has an important role to play. Womens unfaithfulness is severely punished by law whereas men are more or less not even blamed for that. School girls are also very vulnerable because they might become pregnant in schools for teachers or for other people who give them money to satisfy their needs. Married women are also as vulnerable as unmarried woman; most married women become vulnerable either because of the carelessness of their husband or because of poverty. If the husband is unable to satisfy the needs of the family, she may involve herself in risky activities. This happens in urban as well as in rural areas. PLWHA are also vulnerable to HIV/AIDS again because at times they may even lack condoms to protect themselves. Strategies focus mostly on those who are HIV negative. Orphans and vulnerable children are vulnerable because they lack social and family support. No institution takes care of their problem on the long run. If orphans find a family where they can grow, a good social environment they wont be vulnerable Overall, what laws could the government change, abolish or introduce to bring the greatest improvements to HIV prevention for girls and young women? 4

The main challenge is to provide available services everywhere they are needed. Prevention component 2: Policy provision What type of government policies or protocols for example in relation to antenatal care, condoms or voluntary counselling and testing make HIV prevention for girls and young people in Cameroon better or worse? Voluntary counselling and testing is offered in centers mostly based at provincial level. The testing procedures are based on confidentiality and some minimum equipment requirements. Do girls and young women and also boys and young men - receive any type of official sex education? For example, what are they taught about their sexual and reproductive health and rights while in school? There is no official programme on sex education in school. For years NGOs have been working on such programme that need to be introduced in the school curriculum so that children could be exposed at least once every year on matters related to sexuality in school. The government should support all community based organisations working on this subject so that they can intervene on youths who are either in school or out of school. Overall, what policies or protocols could the government change, abolish or introduce to bring the greatest improvements to HIV prevention for girls and young women? The main improvement should come from taking into consideration all factors leading to vulnerability: I think they should go beyond all the information campaigns with posters or flyers. They should go beyond and look into factors leading to vulnerability. Thats what should be done today. But this is a difficult task and that is why people prefer easy solutions Moreover, community support and services which are very important in HIV screening are still not given due consideration by the government. They are neglected and people are left with poor quality care. There should be a clear policy for the socio-economic integration of PLWHA. More efforts need to be put on decentralising services, making them available closer to people particularly in rural areas. Prevention component 3: Availability of services What type and scale of HIV prevention services are available for girls and young women in Cameroon? Male condoms are available but not everywhere, in spite of all the efforts to make it sold even by the street side. Female condom is very scarce and expensive. Information is available mostly for youths in some schools like catholic schools with a programme on Education to Live and Love (EVA). It is not extended to all schools and in others some NGOs have punctual interventions that need to be sustained. Few associations around also have information centres where people can go to in case of need. STIs are treated in nearly all health units. Many small private heath centres have been opened around in urban or rural areas and are very active in treating STIs because they dont judge the clients. People like to go where services are discreet, like to the street drugs dealer, traditional healer or directly to private pharmacies. PMCT centres exist but do not always function well because staff complain of lack of basic material to work. Voluntary and counselling and testing centres are available but not everywhere and sometimes their personnel are not even well trained on how to provide pre and post test counselling. Treatment is not easily accessible and not found everywhere. The government is working to make treatment free for adult patients. It is already free for children but the only problem is that it is not always available and not everywhere. What type and scale of HIV prevention services are available for particular types of girls and young women? For example what services are there for those who are: Unmarried? Out of school? Involved in sex work? Orphaned? Injecting drug users? Migrants? Refugees? HIV positive? 4

There is no special care for specific groups. Everybody is received everywhere and even in Day care hospitals dealing with HIV/AIDS treatment, all patients are received there. What type and extent of HIV prevention services and information are available for boys and young men? How does this affect the situation for girls and young women? More or less nothing but it is important that boys should also be well informed because if the girl alone is sensitized, she could be sexually harassed by someone who ignores everything, who doesnt even know that sex can lead to danger. If boys are trained they could be a good information channel in the community. Overall, what type of services most urgently need to be increased to improve HIV prevention for girls and young women? Actors who have with professionalism in the field, even if they are from the civil society, should be given necessary supports to extend their work at all level so that HIV prevention services are improved for girls and young women, even in very remote areas. Youths also need to be considered and if possible special services should be provided or organised for them. There should be a comprehensive strategy of re-thinking the services. Government should make condoms available everywhere and particularly female condoms and if possible make it free of charge. Prevention component 4: Accessibility of services What are the main barriers to girls and young women using HIV prevention services in Cameroon? Insufficient numbers of services like the HIV screening centres which are not available everywhere. Poor training or no training of the staff of these centres who do not respect the national protocol (issues like confidentiality or anonymity of services) Lack of confidentiality during HIV screening because people are obliged to travel to neighbouring towns or provincial capitals just because they know if they do HIV screening in their town, everybody will be informed about their results. The lack of confidentiality then pushes people to spend too much money on transport costs, or extra cost for private clinics. Even in hospital where patients are mixed up to avoid stigmatisation, some health staff will come and congratulate some patients for the increase of their CD4 cells or complain to other patients for the increase of their viral load, thus indirectly disclosing their status. Health staff should respect confidentiality no matter what disease. The attitude of staff is also a problem, because they behave to these youths as if they were their parents, asking too much unnecessary and moralizing questions. The opening hours of services do not give too much flexibility to students to consult; they have to choose between classes and going to a service for any basic information or care. Are HIV prevention services easier or harder for particular types of girls and young women to access? For example, is it easier or harder if they are: Married or unmarried? In school or out of school? HIV positive? Students and adolescents may have a price reduction in some structures like Centre Pasteur or the Chantal Biya Foundation. But this is not a policy, it is just practices aiming at marketing or philanthropic reasons. Most youths have difficulties with services because they are not friendly at all, they dont feel protected and they are questioned about private issue publicly. What role do boys and young men have in making HIV prevention services easier and better for girls and young women? 4

They should be trained to become role model in the community, so that they are less a problem to women than a solution to some of their problems. Overall, what priority actions could be taken to make HIV prevention services more accessible to girls and young women? Make services be youth friendly or create friendly youth centres. Prevention component 5: Participation and rights How are international commitments (such as the Convention on the Rights of the Child and the Convention on the Elimination of all Forms of Discrimination against Women) applied in Cameroon? All this conventions are ratified, but the problem is their application. To what extent is the national response to AIDS rights-based? To what extent are girls and young women including those that are living with HIV involved in decision-making about AIDS at the national level? The National AIDS Control Committee could hire PLWHA as an example to show to other partners and private companies that it is possible to involve them so as to provide them with job opportunities. This also makes sense in the context of HIV/AIDS workplace policy. Generally youths are involved just to please funding agencies or the international community. There is no clear strategy as to make this involvement active or participative, because most often some of these youths represent only themselves and are not mandate by a larger group that they are supposed to represent. Overall, what priority actions could be taken to support girls and young women to be more involved in national level decision-making about AIDS? Supporting the youths and helping them in developing their capacities. Summary In summary, what are the 3-4 key actions for example by the government, donors or community leaders - that would bring the biggest improvements to HIV prevention for girls and young women in Cameroon? There is need to define a clear reproductive health policy for youths and seek appropriate ways of implementing that at large scale. There is a serious problem concerning follow-up of political decisions or laws, they are not respected in the field, because of corruption. There should also be a clear policy concerning youths capacities development. Donors should also consider youths as priority target group and make comprehensive policy concerning them.

One-to-one interview: Gisle Tientcheu (female) President, Cercle des Jeunes Engags dans la lutte contre le SIDA (CEJES) 4

02/02/07, Yaounde

General What is your impression about the general situation of HIV prevention for girls and young women in Cameroon? Are things getting better or worse and why? One can say that things are getting better because people are better informed. More women and young girls are testing themselves especially pregnant women, in order to protect their babies. Young girls too want to know their status before marriage. Prevention component 1: Legal provision In your opinion, what laws in Cameroon are making HIV prevention for girls and young women better or worse? There is no precise law that obliges couples to go in for the HIV screening test. That has always been the initiative of some family members of future couples. And it could badly end up if one of the partners is seropositive, because he/she will then be rejected. In the northern parts of Cameroon, girls are forced to get married early (from the age of 11 or 12 years) and in the South, some girls give birth to a child out of wedlock before getting married in order to prove their fertility. These are traditional practices that still persist nowadays. Prostitution is not authorised by the law, but it is tolerated, very much tolerated that is practically a mess. Young girls do it in different parts of the town under the nose of the police, what could render them vulnerable to HIV/AIDS. Abortion is forbidden, but girls conveniently do away with any pregnancy they dont desire. Generally parents consent is not required during reproductive health services but if the girl is too young for example 11 years, she will be asked to come with her parents. How does legislation affect different types of girls and young women and their vulnerability to HIV? For example how does its effects vary among those that are: In/out of school? Married/unmarried? In rural/urban areas? Living with HIV? From marginalised groups (such as sex workers, migrants or orphans)? Apart from some structures like the Centre Pasteur for example, which reduces prices to pupils and students, everyone is treated in the same way everywhere without taking into account their particularities or difficulties. There are also initiatives of person in charge of certain structures aimed at helping poor groups; but it is not something that is systematic or institutional. Overall, what laws could the government change, abolish or introduce to bring the greatest improvements to HIV prevention for girls and young women? A reduction in the price of HIV test will encourage more young girls and women as well as their partners to do the HIV screening test than any law. Also free biological and gynaecological examinations and subvention of female condoms are measures which could help to ameliorate the situation of prevention in girls and young women. Prevention component 2: Policy provision What type of government policies or protocols for example in relation to antenatal care, condoms or voluntary counseling and testing make HIV prevention for girls and young people in Cameroon better or worse? The availability and accessibility of male condoms is a good thing. There even exist machines to distribute them automatically. But female condoms remain rare and also expensive. Whenever free screening campaigns are offered, the demand always exceed 4

the offer, this indicate the real interest of the population in testing themselves free. Access to free tests remains a problem liable to affect the prevention of HIV and AIDS in girls and young women negatively. And this situation is worse in rural areas. Do girls and young women and also boys and young men - receive any type of official sex education? For example, what are they taught about their sexual and reproductive health and rights while in school? Almost nothing at the secondary or university level, but in some primary schools there is the EVA program (Education to Life and Love) or sexual and reproductive health courses done by the Aunties (Tantines). It is not all classes that are involved. Overall, what policies or protocols could the government change, abolish or introduce to bring the greatest improvements to HIV prevention for girls and young women? Free screening test should be introduced and the coverage of voluntary testing in rural areas should be improved. Prevention component 3: Availability of services What type and scale of HIV prevention services are available for girls and young women in Cameroon? Male condom is largely available and accessible, even if ameliorations have to be done in rural areas. The female condom is still very scarce and expensive. Antiretroviral treatment exists in most big centres, even though they are constantly out of stock. These treatments are less accessible in rural areas. What type and scale of HIV prevention services are available for particular types of girls and young women? For example what services are there for those who are: Unmarried? Out of school? Involved in sex work? Orphaned? Injecting drug users? Migrants? Refugees? HIV positive*? Everyone is treated in the same way in all the different structures. For PLWHA, there have been various seminars on Positive Living organised by the German Technical Cooperation which was a good thing to orientate them and make them share their experiences: These workshops gave a lot of hopes to PLWHA. But for some time now, it has not been done and we are demanding for it. What type and extent of HIV prevention services and information are available for boys and young men? How does this affect the situation for girls and young women? There exist no specific services for boys or young men. Overall, what type of services most urgently need to be increased to improve HIV prevention for girls and young women? For instance, Aunties Associations could be formed at the level of the University, just like it is being done for certain primary schools because at that level too, girls are in need of advice concerning sexual and reproductive health: they all get unwanted pregnancies and since they are already mature, they try to cover up saying that they already wanted childrenIt is shame and they are afraid of insults. They should equally make gynaecological check-ups free, and carry out campaigns on HIV screening test outside hospitals closer to the population in the community. Prevention component 4: Accessibility of services What are the main barriers to girls and young women using HIV prevention services in Cameroon? 4

The cost of tests is a major obstacle towards HIV screening, and also the refusal of personnel in applying instructions given to them by their hierarchy: for example, when there is an order for the reduction of prices of screening test, the personnel in the field have the tendency of opposing it by making customers to believe that the new tests are less reliable whereas it is the same thing (reagents). Young girls with STIs cases are ashamed to go to hospitals: a young level one student went to the hospital and it was discovered he had gonorrhoea. So he was asked to bring his girlfriend who was also in level one. She categorically refused to go to the hospital. It is a problem of shame. I think that if there was a place where she could sneak in easily, she would do that rapidly. The breaking up of confidentiality at times pushes patients to shun HIV services: She told me she was obliged to run away from CHU because there were people there who knew her, she preferred going to the Central Hospital Are HIV prevention services easier or harder for particular types of girls and young women to access? For example, is it easier or harder if they are: Married or unmarried? In school or out of school? HIV positive? Married women have more access to prevention services than students: each time a problem concerns a pupil or a student, they are given less attention. For PLWHA, things are better because the personnel receive a training concerning their management. What role do boys and young men have in making HIV prevention services easier and better for girls and young women? If men were more sensitized, it would have helped young girls since they are the ones deceiving them. More young men should be taught how to be responsible. Overall, what priority actions could be taken to make HIV prevention services more accessible to girls and young women? Parents should be sensitized and encourage to fight against rejection and stigmatisation of their HIV infected children, to fight against discrimination towards girls. Boys are not included in domestic jobs for example, and when they are to live on their own, they feel obliged to go hijack girls in their homes to come and be washing their clothes and be cooking for them: at job sides, man will always impose himself as man. He will always manifest his power, his male authority upon the woman. Things happen as if women are just objects. Prevention component 5: Participation and rights How are international commitments (such as the Convention on the Rights of the Child and the Convention on the Elimination of all Forms of Discrimination against Women) applied in Cameroon? To what extent is the national response to AIDS rights-based? They dont fully respect their rights of PLWHA. To what extent are girls and young women including those that are living with HIV involved in decision-making about AIDS at the national level? PLWHA participate in the process of decision making, but their opinion is not always taken into account. They dont consider their conditions or the fact that they are directly involved and should be considered as main actors in the fight against HIV/AIDS. On the contrary, they have the tendency of giving the chance to people who are not directly concerned: through their associations, they participate, they try to participate, to express themselves in their own way .

Overall, what priority actions could be taken to support girls and young women to be more involved in national level decision-making about AIDS? The capacity of women should be reinforced and they should be given more responsibilities. That could change a lot of things. Summary In summary, what are the 3-4 key actions for example by the government, donors or community leaders - that would bring the biggest improvements to HIV prevention for girls and young women in Cameroon? Give more responsibilities to women so as to provide them with sufficient means and avoid that they are too dependent on men, what makes them vulnerable to HIV/AIDS.

One-to-one interview: Evelyne Nyemeck (female) Executive Assistant, UNAIDS 06/03/07, Yaounde

General What is your impression about the general situation of HIV prevention for girls and young women in Cameroon? Are things getting better or worse and why? Generally things are getting better, for more people are going in for the HIV screening test, more people do use condoms in urban as well as in rural areas. One can however regret the high price of female condoms. Prevention component 1: Legal provision In your opinion, what laws in Cameroon are making HIV prevention for girls and young women better or worse? The legal age for marriage is 15 years for young girls and 18 years for young boys. But, the consent of at least one of the parents is required. Therefore, the law is clearly stated: as from 15 years, a girl could get married provided her parents give their consent. In real facts, nowadays girls get married much later than before. They want to study first, get a job before engaging in married life. And the act of getting married late keeps them away from HIV because they are more conscious of the risk they run. They know the preventive methods and can also make their partners to do the HIV screening test before their marriage. Prostitution is illegal, but it is being practiced in an unofficial way. Everyone knows that it is being done and it is not openly condemned. Abortion could be done within 10 weeks of pregnancy and better in hospitals than elsewhere. The law authorises abortion under certain conditions. If a girl is still underage, her parents consent is required in order to give her services on sexual and reproductive health. How does legislation affect different types of girls and young women and their vulnerability to HIV? For example how does its effects vary among those that are: In/out of school? Married/unmarried? In rural/urban areas? Living with HIV? From marginalised groups (such as sex workers, migrants or orphans)?

Legislation is a minor problem as compared to age and poverty. At a certain age, or under poor conditions, youths adopt behaviours that could render them vulnerable. Orphans too who at times have no support are more exposed than others. Infected persons are sometimes rejected by their families and live without any support, what weakens them: the situation is different for those who have a paid job and can therefore treat themselves without any problem. They could disclose their seropositve status without fear of being punished by their family, because they are entirely on their own . Overall, what laws could the government change, abolish or introduce to bring the greatest improvements to HIV prevention for girls and young women? There is a draft law concerning the protection of PLWHA under study, but it has not yet been adopted. Even though we are covered by Human Rights, it would be better that a specific law protects PLWHA who have particular problems. Prevention component 2: Policy provision What type of government policies or protocols for example in relation to antenatal care, condoms or voluntary counseling and testing make HIV prevention for girls and young people in Cameroon better or worse? Screening tests are offered in the form of free screening campaigns in secondary schools and universities, what ameliorates the situation of prevention in young girls in Cameroon. The access to treatment is being facilitated by the constant reduction in the price of ARV drugs and their decentralisation at the level of District Hospitals. It is even announced that there will soon be free treatment and more reduction in the cost of biological examination. Condoms are widely common, notably in urban areas; we find the prudence mark almost everywhere, in stores and stalls and hawkers. Seropositive pregnant women are being taken care of in most urban centres. All these measures contribute in improving the situation of prevention for girls and young women. Do girls and young women and also boys and young men - receive any type of official sex education? For example, what are they taught about their sexual and reproductive health and rights while in school? That is not done up to now, but the Minister of Basic Education has just signed an agreement for the introduction of such lessons in primary schools as from next academic year. Overall, what policies or protocols could the government change, abolish or introduce to bring the greatest improvements to HIV prevention for girls and young women? It is not all about introducing new texts, but ensuring that things are being followed up, because things could be introduced but remain ineffective. Prevention component 3: Availability of services What type and scale of HIV prevention services are available for girls and young women in Cameroon? All hospitals take care of STIs, in terms of treatment. Screening tests are offered, but their availability should be improved at all levels and prices should also be reduced; antiretroviral treatments are equally available in most urban centres and also in rural areas. What type and scale of HIV prevention services are available for particular types of girls and young women? For example what services are there for those who are: Unmarried? Out of school? Involved in sex work? Orphaned? Injecting drug users? Migrants? Refugees? HIV positive? 5

Structures are open to all, to men, to women, to everybody. Therefore everyone chooses where he wants to go and access is free. Care is given to all. What type and extent of HIV prevention services and information are available for boys and young men? How does this affect the situation for girls and young women? There are no particular services for boys and men. And in my opinion, everyone should be welcomed everywhere without discrimination. Overall, what type of services most urgently needs to be increased to improve HIV prevention for girls and young women? The real problem is that people are not always informed about the availability of services. They should therefore organise information campaigns or publicities on existing services, in order that users should know for example where to go for treatment in case of STI, where to do the HIV screening test, where to obtain family planning services. Prevention component 4: Accessibility of services What are the main barriers to girls and young women using HIV prevention services in Cameroon? People have the tendency of feeling ashamed to go to health units in cases of STI infections. The cost of HIV screening tests remains high and these tests are not provided everywhere. Also the cost of ARV drugs or lab exams is equally high. This can discourage most patients and particularly girls and young women. Are HIV prevention services easier or harder for particular types of girls and young women to access? For example, is it easier or harder if they are: Married or unmarried? In school or out of school? HIV positive? There is no difference in terms of access, but a problem could arise only if we are in a rural area. Generally, patients are being received in the same way and there is no external sign to indicate who is who. What role do boys and young men have in making HIV prevention services easier and better for girls and young women? Boys should be sensitized especially older men who go in for unprotected sex with young girls, who accept this relationship because of their conditions. By this, they contribute in aggravating their vulnerability. If men have the reflex of wearing condoms, they will surely help in protecting these girls. Overall, what priority actions could be taken to make HIV prevention services more accessible to girls and young women? Sensitize doctors together with all health personnel to respect confidentiality towards patients or clients status.

Prevention component 5: Participation and rights How are international commitments (such as the Convention on the Rights of the Child and the Convention on the Elimination of all Forms of Discrimination against Women) applied in Cameroon? 5

These texts exist but are not yet fully respected. To what extent is the national response to AIDS rights-based? The nation wide response envisages assuring some protection to PLWHA, but the law on this subject is still under examination and not yet adopted. However, the training given to the health personnel permits a minimum guarantee of quality services to PLWHA. To what extent are girls and young women including those that are living with HIV involved in decision-making about AIDS at the national level? People living with HIV/AIDS take part in decision making structures on HIV/AIDS, but it would be necessary to find out if their opinion is really being taken into account. It is something that could be verified at the level of their Associations. Overall, what priority actions could be taken to support girls and young women to be more involved in national level decision-making about AIDS? They should be trained and provided paid jobs. Summary In summary, what are the 3-4 key actions for example by the government, donors or community leaders - that would bring the biggest improvements to HIV prevention for girls and young women in Cameroon? Concrete and efficient measures taking care of orphans and other vulnerable children should be put in place. The government should also aim at providing entirely free drugs to patients so as to ensure a wider accessibility to all groups of the population.