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War is over but Ivorians are still paying the price

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A plank studded with rusty nails lies across the road as the Médecins sans Frontières car enters rebel territory after passing a UN checkpoint. Two young men in fatigues step out of the shade as we stop in front of this makeshift roadblock. Each gestures, using both hands as if to pull a bag over his head. After repeating this baffling movement several times, one comes up to the car window and says in French: "Give us condoms."

The mime is explained, but I am surprised by the demand. "It happens all the time," says the MSF nurse sitting behind me. She politely tells the soldiers they can go to any MSF clinic for condoms. It is MSF policy never to give anything out at roadblocks.

That some young men in Ivory Coast know about condoms is not down to MSF alone. In the first decades after independence from France the government created one of the best-equipped health systems in west Africa and in the 1990s started a national HIV awareness campaign. But everything stopped when the civil war broke out in November 2002. International pressure produced a ceasefire in 2003 but the country remains split and foreign peacekeepers maintain a fragile truce.

The government relaunched its HIV programme this year, but in the north of the country, which is in the hands of the rebel movement New Forces, MSF carries the main burden of education work. Every Monday Saskia Ohlin, the project coordinator in Danane, where MSF runs a 90-bed hospital and several outpatient departments, goes to the New Forces headquarters to hand out condoms, which are rarely available on the market.

The government abandoned the hospital in 2002 and most of its former doctors, nurses, and midwives, who came from Abidjan or other southern cities, are afraid to return. Danane was the only referral hospital in a region of almost 400,000 people. MSF chose to work in the west because the war hit this region hardest, and an MSF study in April 2005 found "an alarmingly high number of sexually transmitted infections", which it said was "not a side-effect of personal behaviour but a symptom of conditions fuelled by war, displacement and economic desperation".

Two years ago MSF arrived and has re-equipped the looted hospital. "For the sake of my family's health I'm ready to pay," says a large sign outside one of the inpatient wards, a reminder of the government's socially unjust cost-recovery programme. MSF care is free.

MSF also holds mobile clinics in the villages which include local MSF-trained staff. In the past the sick had to walk for hours to reach help. Three clinics are in the "confidence zone", a belt of demilitarised land 20 to 30 miles wide which divides the New Forces from the government army and its militias. It is patrolled by about 7,500 UN peacekeepers and 4,000 French troops. MSF also works in government territory. At Bin Houye, a sad town of bombed buildings and shuttered shops with less than half its prewar population, MSF has a small headquarters and a team which visits abandoned government health posts in each of 12 villages once a week.

The war shattered the economy and a collapse in cocoa prices forced hundreds to abandon their fields. Families in the western regions split as men went to Abidjan to look for work. Young women are tempted into sex work and many soldiers are clients. HIV prevalence, estimated at at least 10%, is twice as high as in Nigeria, which has had no recent war.

"You can assume there is more HIV around than before the conflict," says Ms Ohlin. "The medical infrastructure collapsed totally at the start, meaning there was no education on HIV/Aids so people did not know how to protect themselves. The availability of condoms was less and then there is the grey zone. I wouldn't even call it prostitution but survival sex, forms of survival that are related to offering sexual services because of people becoming poorer. Obviously sex workers are more at risk than people with normal jobs."

On most weekday mornings the hospital holds a class on sexually transmitted infections. An instructor shows pictures of inflamed and sore-ridden sexual organs. The rate of infection is astonishing. A third of all pregnant women seen at Danane's antenatal clinic have STIs.

The programme started last month, and 21 people out of 85 tested were found to be HIV-positive. None has been given antiretroviral drugs, but that will change next year when the programme goes into full gear. MSF expects to test up to 3,600 people in Danane and 1,000 in Bin Houye and hopes to have enough drugs for all who need them.

Some in the hospital are known to have Aids. They lie wasting beside other patients in the tuberculosis and malaria wards. "Five of the 30 adults are positive and we have high suspicions that between 10 and 15 others are," says David Tu, a Canadian doctor.

MSF has shown it can move faster than government in restoring general medical services in the post-conflict chaos.