French Guiana is a French territory located in South America, surrounded by Brazil, Suriname, and the Atlantic Ocean. Despite the progress of France regarding HIV and AIDS services, French Guiana remains active with 907 new cases each year for every 10 000 inhabitants . Furthermore, although progress has been made in urban areas, the rate of contamination continues to increase in rural and border regions . Indeed, border areas represent a particular challenge, containing a high-risk population  with 37% of people living with HIV (PLHIV) diagnosed at an advanced stage (< 200 CD4+ cells/μl) , 46.6% of seropositive patients lost to follow-up (unpublished data from French Guiana primary health center – CDPS – and AIDS coordination – COREVIH, 2015). Similarly, Brazil is also a country demonstrably committed to HIV/AIDS prevention and care, making history in 1996 when its national HIV/AIDS program introduced universal access to HIV antiretrovirals. However, its borders remain vulnerable to HIV, particularly the North, which is more rural and whose HIV services and infrastructure are less developed . Thus, two countries with different health systems committed to fight HIV have struggled to control HIV at their shared border. Personnel scarcity, rapid turnover, language and HIV-recommendation differences have hampered communication but both sides have recognized common goals. In the past decade, this has generated a growing level of interactions between health professionals and nongovernmental organizations (NGOs) from both countries, ultimately leading to a shared solution.
The complexity of this region and the current failure to deliver optimal care called for an innovative and global approach, with an emphasis on cooperation between French Guiana and Brazil . Currently, the French Guianese NGO !Dsanté, the Brazilian NGO DPAC Fronteira, and the main French Guianese hospital, Centre Hospitalier Andrée Rosemon, are working together to implement an ongoing project: Oyapock Cooperation Health (OCS in French and Portuguese). These field notes discuss the OCS project and its personalized approach in controlling the HIV epidemic in this area.
The artificial limit dividing care at the Oyapock border
The French and Brazilian border is defined by the Oyapock river, with small towns and villages clustered along its shores on either side. On the French side, the largest of these towns is St Georges, official population 4065 . Not far along river, lies the Brazilian city of Oiapoque, with around 25 000 inhabitants  (Fig. 1). This region presents as continuous in climate, culture and people, mostly of Brazilian or indigenous (wayampi, teko, karipuna and palikur) descent. It is a site of interconnected movement and exchange, with nothing more than a short boat ride, drive or even swim to attain the other shore (Fig. 2). The Brazilian border represents a site of fallback for clandestine gold miners, originating from Brazil and working in French Guiana, and canoemen, resulting in over half of the population being transient . The undocumented and illegal gold miners from unsanitary mining sites flock to Oiapoque for supplies, medical care or leisure . Furthermore, the canoemen whose work demands movement along the Oyapock river present high rates of HIV infection and sexually risky behavior [2,8]. The population is largely illiterate and predominantly men . Prostitution for miners and sexual tourists is particularly developed, resulting in many female sex workers with high percentages of HIV seropositivity and many who never get tested for HIV . In addition, the population is vulnerable because of addictions or financial insecurity . The Oyapock region, therefore, presents unstable populations and elevated risks for HIV promulgation .
In the Oyapock border area, resources to fight HIV are limited. On the French side, a ‘Centre Délocalisé de Prévention et de Soins’ (CDPS), or Primary Care Center, is located in St Georges. There, 40 PLHIV are treated, 28 of whom live in the city of Oiapoque (CDPS unpublished data, June 2017). The nearest hospital in French Guiana is in Cayenne, is 3 h away. On the Brazilian side, a hospital is present, but lacks an infectious disease physician and the capacities to screen, follow-up and treat HIV. Residents of Oiapoque must either go to the hospital in Macapa, which, if the road is passable, may take up to 12 h in the rainy season, or cross the river to the CDPS to obtain treatment (Fig. 1). Being treated in Macapa demands that patients take an employment leave, pay for housing and food and stay several days to complete tests. Some PLHIV from the Brazilian side, therefore, choose to be treated in French Guiana, or are simply lost to follow-up. Some are treated on both sides, without communication or continuum of care between both systems. Clearly, care needs to be drastically improved in this area, but most importantly it needs to happen in a coordinated fashion [4,10].
Breaking limits and innovating in response to the particularities of the area
OCS is an ongoing 3-year project that proposes several improvements to the existing measures taken against HIV/AIDS. Its main goal consists of stopping the HIV epidemic along the border by developing a cross-border prevention and care network (Fig. 1). An infectious disease physician has been stationed in this border area to coordinate the combination of different approaches to stop HIV transmission.
First and foremost, OCS aims to spearhead a rigorous screening campaign to uncover a largely invisible epidemic (Fig. 1). By 2018, every person seeking care of any sort at the CDPS will be systematically offered an HIV test. Targeted screening is being carried out on both sides of the border at sites frequented by particularly high-risk populations. OCS adopts UNAIDS's 90-90-90 goals in uncovering at least 90% of the hidden epidemic, treating 90% of the known PLHIV, with 90% of those treated with an undetectable viral load . To accomplish this, OCS also aims to develop availability and accessibility of care.
OCS takes a multilateral approach in ensuring accessibility to care. In Oiapoque, OCS aims to help implement the necessary infrastructure to screen, follow-up and treat HIV. On both sides of the border, mediators facilitate communication between institutions of care and HIV-positive patients, as well as aid patients in accessing their rights. DPAC Fronteira, one of the contributors of OCS, is one of the organizations, which provides such mediators. It is currently putting workshops into place concerning sexual and reproductive health (SRH) and HIV prevention for the general population and key groups (Fig. 3). In the future, such mediators will equally be present at the site of DPAC Fronteira's ‘centro de apoio,’ which is in the planning process. This will be a ‘housing first’ initiative providing around 10 beds to individuals who need medical, therapeutic and social assistance at certain key instances in their lives. Considering the low level of stability in the region, particularly concerning housing, and the mobility of the population, this sub-project will address an important issue specific to the area. Another way OCS aims to empower the patient is through therapeutic education currently being introduced at the CDPS.
Other preventive measures are to be reinforced or put into place by OCS. Postexposure prophylaxis (PEP) and preexposure prophylaxis (PrEP) will be offered as a preventive treatment measure at the CDPS at St Georges. PrEP promises to be particularly beneficial for at-risk populations such as sex workers and men who have sexual relations with men.
Furthermore, OCS has already begun training key members of the community in SRH education. As much of the community is not comfortable with reading, OCS strategically recruits key individuals (ex. health professionals, teachers) already in place as verbal and visual educators. This includes equipping them with knowledge about SRH and the available care in the area, as well as granting them a set of tools to effectively communicate this knowledge. For example, they are trained in the Theater of the Oppressed, which is a style of theatre, which allows interaction with the audience (Fig. 4). Each trained individual is then supported in creating their own project contributing to the education and sexual well being of the community. For example, one middle school teacher from St Georges plans to train groups of students in the Theater of the Oppressed such that they can present SRH on both sides of the border (students in St Georges are bilingual). We hope that the interactive quality of this type of theater will allow students to witness different experiences and perspectives concerning SRH in the area.
The Franco-Brazilian border, like many borders worldwide, is a unique region presenting challenges unique to its geography, populations and political climate. Its specificities have led to suboptimal care in the past for PLHIV in the area, and therefore, calls for a deviation from traditional approaches. OCS is a binational, multicultural and multidisciplinary project that aims to create an area of cohesion and health, and to do so it tailors its actions to the particularities of the area. As OCS remains both innovative and extremely ambitious considering the political and logistical challenges it has taken on, the project will have to be evaluated once carried out. With hope, this approach will prove successful, thus, promising adaptation by other areas.
We thank the project team: Paul Brousse, Carolina Nakano, José Gomes, Marie Auz, Dr Carlos Carrera, who made this project and work possible.
E.M. and S.R. are the Principal investigators of the OCS project and were responsible for all phases of the project, including design, data collection, analysis, and interpretation of the public health findings and issues. B.B., S.M., N.G., A.M.M., F.L., F.H., L.A., M.N. provided technical expertise and contributed to interpretation of project prospects. A.S.B. and E.M. wrote the manuscript. All co-authors reviewed, contributed and approved the final manuscript.
This project was funded by the European Regional Development Fund (FEDER, SYNERGIE CTE: 3895), the Territorial Collectivity of French Guiana, the Regional Health Agency of French Guiana, Fundo Posithivo, and the Panamerican Health Organization. These sources of support had no role in the writing of or the decision to publish the manuscript.
Conflicts of interest
There are no conflicts of interest.
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