ZEMIO, C.A.R. - Violence in the southeastern part of the Central African Republic, where five U.N. peacekeepers were killed this month, has made it tougher for HIV-positive residents in the remote, lawless region to get treatment.
The prevalence rate of HIV in southeastern C.A.R. is 13 percent, nearly three times the national average.
The migration of people between the bordering areas of South Sudan and the Democratic Republic of the Congo contributes to the spread of the disease in all three countries.
"Here, it's a crossing where everything converges. It's why the level of HIV is high," said Bienvenu Sapioko, a government nurse who works at the only hospital in Zemio. He said the rebels and refugees in the area also increase the high prevalence.
An internal U.N. report obtained by VOA found HIV rates increased following the arrival of the Ugandan security forces in the C.A.R. in 2009. The Ugandan and American forces tasked with tracking down Joseph Kony and his Lord's Resistance Army ended their mission in April and are heading home.
With prostitution, polygamy and effectively no state authority in the area, weak education contributes to the problem.
"People believe in the power of nature and traditional doctors. So bush doctors, shamans are also very common in the community," said Olivier Pennec, the Doctors Without Borders project coordinator in Zemio.
Stigma compounds the problem.
"Before, the people didn't treat themselves. The people would hide the microbes, this disease," said Marcel Elonga, a community leader. They would hide and "speak about this parasite, parasite, parasite."
HIV-positive people in local communities can also find themselves shunned by their peers.
"They don't want him in the community," community leader Pierre Yakanza said, describing how some people here see an HIV-positive person. "They don't want to be close to him. 'Leave him over there. We don't want to associate with him or have him in the community meetings or give him a job.' He's rejected."
Local health workers spread information about safe sex, but even access to condoms remains a challenge.
More than 1,500 people now come to Zemio's hospital from nearby and as far away as Uganda, South Sudan and the Democratic Republic of the Congo for the free HIV treatment offered by Doctors without Borders.
Hospital officials said previously one person would die every month or so from the disease, but they haven't registered a death since 2014.
In 2012, Agnes Davouragouni said she used to be sick all the time.
"When I did the test and found out I was positive, my husband said he doesn't have HIV, so he left me the same day," said the 35-year-old woman, who now lives alone with her three children, selling wood and charcoal to get by.
Once a year, Davouragouni walks 45 kilometers to Zemio over the course of two days in order to get a checkup as part of her treatment. She walks mostly at night and sleeps under a tree along the way.
"The roads are very insecure. I don't have a motorcycle or the money to pay to get here," she said. "There's a lot of fear to travel on these roads."
Bandits and rebel groups, including the remnants of the Lord's Resistance Army, all move around the area. The security void will worsen with the departure of Ugandan and American forces in the next few months.
Recognizing the challenges of getting medication, Doctors Without Borders developed a new community approach in which HIV-positive patients work in groups to bring back antiretroviral drugs in bulk every six months, reducing travel time, costs and exposure to risk.
Farmer Moïse Ouele picks up the antiretroviral drugs for his group of about 30 people and drives them two hours down the road to his village Kitesa, about 50 kilometers away.
"It was really tiring for me to come each month to the hospital," Ouele said. "But now, this program helps a lot with this problem, despite the insecurity of the LRA that is growing."
Doctors Without Borders is transitioning out of the area at the end of the year and is handing over the administration of the program to the Ministry of Health.