peripheries

HIV Prevention: Condoms work!

Despite an increase in intergenerational sex amongst female teenagers, despite an increase in the number of multiple partners amongst men age 15-24, despite a decrease in HIV prevention knowledge, the third South African National HIV survey conducted in 2008 showed a promising decline in the number of HIV infections amongst the 15-24 years old.

“HIV prevalence among adults aged 15-49 has declined between 2002 and 2008 in the Western Cape, Gauteng, Northern Cape and the Free State, with the largest decline of 7.9 percentage points in the Western Cape.”

This may well be explained by an increase in condom use:

“The proportion of the population who reported using a condom at their last sexual encounter was particularly high among young people aged 15-24 years: from 57% in 2002 to 87% in 2008 among young males, and from 46% to 73% among young females. This trend was also obvious in condom use among people in the 25-49 age group, where condom use among males aged 25-49 at last sex has nearly doubled, while among females in the same age group it has tripled.”

The survey conducted by by the Human Sciences Research Council (HSRC), in conjunction with the Medical Research Council (MRC) and the Centre for AIDS Development, Research and Evaluation (CADRE), sends a clear message:

Condoms work!

It also hints at a very different kind of HIV prevention intervention as suggested by another observation:

“The good news is that the change in HIV prevalence in children is most likely attributable to the successful implementation of several HIV-prevention interventions,” said Dr Olive Shisana, CEO of the Human Sciences Research Council (HSRC) and one of the two principal investigators of the study. “These interventions are related to addressing HIV in early childhood, particularly programmes to prevent mother-to-child transmission in the Western Cape, where the largest decline of 6 percentage points occurred.”

This is a completely different way of tackling the HIV epidemic with a dramatic shift from prevention to treatment and a focus on addressing sexual behaviours that most contribute to the spread of the epidemic such as multiple partnership and intergenerational sex.

The survey also confirmed that drug users and Men who have Sex with Men (MSM) are amongst those most vulnerable to HIV infection and that specific interventions are needed to reach these groups.

“For the first time, the report provides information on high-risk groups, defined in this study as people who drink excessively, those who take drugs, men who have sex with men and people with disabilities as well as women aged 20-34 and men aged 25-49. More attention should be paid to these categories in the NSP” said Shisana.

Evidences are piling up, action is urgently needed, starting by knowing your status (if the South African can do it and they did – “The percentage of people in the age group 15-49 who reported awareness of their HIV status has doubled from 2005 to 2008”, we can do it too) and by insuring human rights for those most vulnerable.

Money alone is not going to treat us out of the HIV epidemic

Why HIV “prevention does not work” has been the subject of recurrent discussions during the past weeks. It all started with a thought-provoking article published online by Frontiers in LA, “a one-stop source of content for Southern California’s LGBT community” (welcome to the Ghetto) by Michael Liberatore who wrote that “if pharmaceutical companies were supplying the cash to develop [HIV/AIDS] treatments, couldn’t they just as easily stall the development of newer, less profit-friendly treatments to assure that their bank accounts continue to swell?”

The article is worth reading and raises some serious questions, and though peripheries is no friend of the “Big pharma”, one cannot always agree with the columnist. Nevertheless, the recurring conversation was about the belief that money or drugs will “make prevention work” and “treat us out of the epidemics”.

Indeed, it is not just about money or the Pharmaceutical industry but about how the money is used. PEPFAR with its numerous and often criticised ties is a good example but there are many others. For example, in an interview for the Singapore-based network Fridae.com Jan Wijngarden emphasises some very important issues on how to do prevention in the MSM population which is more vulnerable than other to HIV infection. Wijngarden’s main point is that prevention has to reach those who are supposed to be reached and I would add something often overlooked, that the target need to have a stake in the fight.

When it comes to Africa where AIDS is “hyperpandemic”, bending the arm of the Big Pharma or throwing money at African Governments or local NGOs to buy drugs is one thing, but if there is no supply chain (from road to clinics and to nurses) or even no identified people to treat,or worse, no political will, it won’t work. We often talk about corporate responsibility but what about non-profit responsibility? It is often “implied and obvious” but how accountability is there in the non-profit sector? The one that goes beyond “we have provided ARV to 3 million people” (Are these people still on ARV? Alive? How is their health? Did that change something in their community? What was the impact on a larger scale?). In a paper on the impact of PEPFAR the authors, carefully underlining their own limitations, concluded that “After 4 years of PEPFAR activity, HIV-related deaths decreased in sub-Saharan African focus countries compared with control countries, but trends in adult prevalence did not differ.”

Accountability in the non-profit sector is finally being recognised and emphasised and it needs to be discussed further and translated into something real. Indeed, there are reasons to be afraid and sceptical when reading statement such as “UNAIDS estimates that the funds needed annually to deliver adequate prevention programs to sub-Saharan Africa alone would be approximately US$2 billion”. Lest we forget, several world economists (and rock stars) have been telling us that for some time that we “only” need to put X million dollars in African country Z to lift it out of poverty. 50 years and 3.5 trillion dollars later, the African people are still waiting for this to work. Meanwhile, GAP, Motorola and Armani are making profit selling (Red) branded products and rock stara are lecturing us, tax payers whose contribution to the World Bank and IMF, constitute the largest amount of money given to fight HIV/AIDS in Africa with various level of success.

We really need to think hard, look at what has been done during the last 25 year, probably throw away most of it and start again from the bottom: Who is most vulnerable ? Strikingly, MSM have just been “officially” recognized (or rediscovered) as most-at-risk at the last AIDS Conference in Mexico. What will make people practice safe sex? What will make someone vulnerable come forward to take an HIV test? What will make them accept to start treatment and adhere to it? How can treatment be delivered and patients reached, then how much will it cost, rather than blanket covering whole population with impersonal messages and dollars hoping the epidemic will treat itself out.

Re-stating the obvious, HIV prevention and treatment is a complex problem and as much as requesting more money to buy more drugs is much more appealing than requesting dollars to built roads, there is little point of shelving drugs that can be distributed or having brand new and shiny clinics in the middle of nowhere with no staff and no road leading to them.

Some governments have started to understand some of this. The UK Department for International Development (DFID) recently recognised that “Trade is critical for generating economic growth and reducing poverty. Without good quality infrastructure – roads, rail, and ports – the cost of trade and transport rises”. DFID Minister of State Gareth Thomas then announced “£100 million for the implementation of an innovative and comprehensive transport and cross-border trade reform programme along the ‘North-South Corridor’, combined with a broader package of regional trade-related reforms.” Recognizing that trade can’t happen without adequaye infrastructure comes late but is welcomed. It is regrettable that the Minister did not go one step further and recognised that the fight against HIV can’t be won without similarly good infracstructure and also aknowledge that trade development could contribute to the HIV/AIDS epidemic (both in a positive and negative way) and then implement along the North South corridor of trade a corridor of HIV prevention and treatment.

This is were mainstreaming HIV/AIDS (and the money to fight the epidemic) comes into the big picture, but we are not there yet. Money and drugs are still needed to fight AIDS, probably more than ever with increasing HIV prevalence, but what you do with it is as important if not more than as how much you get.

Stigma and discrimination in death

We live in a sad world where stigma and discrimination follow people even in death.

Yesterday the BBC reported that the body of a senegalese man had been dug up twice from his grave because he was believed to be homosexual. As in many other African countries, homosexuality is outlawed in Senegal. In Uganda “the offence” carries a life sentence on conviction, and according to the government, international NGO (including UNICEF and Amnesty International) are accused of promoting it. In Burundi, the government recently adopted a law criminalising homosexual conduct. in Kenya, homosexual behaviour and attempted homosexual behaviour between men, which is referred to as “carnal knowledge against the order of nature” is penalised by 5 to 14 year of imprisonment.

At the same time, several African countries have jumped on the bandwagon of the criminalisation of HIV transmission.

However, on 27 June 1981, the Organisation of African Unity (now called the African Union) adopted an African Charter on Human and Peoples’ Rights (also known as the Banjul Charter) which purpose was to promote and protect human rights and basic freedoms in the African continent. It was drafted in the spirit of the Universal Declaration of Human Rights but “Taking into consideration the virtues of [African States's] historical tradition and the values of African civilization which should inspire and characterize their reflection on the concept of human and peoples’ rights”. The charter includes the following articles:

Article 2

Every individual shall be entitled to the enjoyment of the rights and freedoms recognized and guaranteed in the present Charter without distinction of any kind such as race, ethnic group, color, sex, language, religion, political or any other opinion, national and social origin, fortune, birth or other status.

Article 4

Human beings are inviolable. Every human being shall be entitled to respect for his life and the integrity of his person. No one may be arbitrarily deprived of this right.

Article 10

Every individual shall have the right to free association provided that he abides by the law.

Unless the “African civilization” has a very different concept of “human and peoples’ rights”, African governments have a lot of work to do for these articles to be more than empty words.

Once in Africa, an HIV Story (Pt. 2)

This is the second part of a true story told through a friend, a first person account of the life of Nhlanhla , a nurse in a Sub-Saharan country afflicted by HIV and AIDS (read part 1 here). Names, places and minor details have been changed to protect people’s privacy. It is a story of fear, stigma, discrimination but also of hope, the everyday story of a young woman whose life, on revealing to her family that she is HIV positive, spirals into hell and despair.

“A few days later I visited Nhlanhla at home. She had found a nice little home for her family, and I tried to say what an achievement that had been. But the house is a very long way off the main road and with no services around at all. There is no electricity or running water. They have to buy water and coal – but when I was there they had very little water and no money for coal so were cooking with wood. Her mum is a lot sicker than she had led me to believe and can hardly move – she sat vacant on a mat the entire time I was there. Her children were there when I visited but have since gone to two different relatives in order to access school – and I have no idea how Nhlanhla has managed the school fees for both but am guessing this is why she is so broke. Her sister is younger than her and obviously very submissive, and after meeting her I could better understand how the second suicide attempt happened at home as she really is not in a position to intervene (this is difficult to explain but she is like the house keeper who is completely financed by her older sister, so is not suppose to challenge her older sister, if that makes sense). I also met Nhlanhla’s aunty who lives elsewhere. Nhlanhla has only disclosed her HIV status to this auntie’s husband but he recommended her not to tell any of the other family members! This aunty is her late father’s sister – and it is her blood line relatives who threw her mother, sister and children out of the paternal homestead on accusations of witchcraft and threatened to burn them to break the spell – hence leading to the house in this area. So basically Nhlanhla really does not have any other family to go to and has no contact with any of her mothers kin at all.

When I was there Nhlanhla told me she had not taken her anti-depressants that day as she felt ‘too tired’. I again expressed the need to take them every day and each day I have spoken to her since she confirmed she had taken them. She went to a GP in town for pains in her back (not her own GP as she couldn’t get an appointment) and he gave her pain killers and sleeping tablets (she assured me she told him about the anti-depressants).

She had agreed to go to her own GP about starting ART treatment, and she did visit him. The back pain was still there so she had an X-ray which apparently identified a lung infection but she couldn’t tell me what type – so she is now on antibiotics as well. The GP wanted to admit her to hospital but she refused. The GP wanted to do another CD4 count before he started her on treatment (her last count was 167). Apparently her main concern about ARVs is a common side effect here of extended breasts and stomach. I have spoken to a friend of mine about this who works in the Department of Health services. He says this is mainly related to D4T in the first line regiment. She is completely refusing to go to the government services as she feels everyone knows her there. So we have advised her to speak to the GP about swapping D4T for AZT. In this way if her private health insurance through work runs out and she transfers to the DoH services then they will continue her on AZT and this will reduce the chance of the side effect she is most concerned about.

Nhlanhla is due to go back to the GP and I have asked one of our doctors to speak to her and offer to accompany her. She is officially back at work and her direct line manager at the clinic was the person who eventually found her after the first suicide attempt so knows about her situation – but she still refuses to disclose her status to her manager. She wants to be back at work to take her mind off other things and keep her busy. Her manager will keep a close eye on her at the clinic and I am hoping this will support our efforts to get her into regular psychological sessions.

As you can see this is not a simply case – she is obviously seriously depressed and the psychologist does not think that she is out of risk yet in terms of being about to make stable and rational decisions. I am also worried about her declining CD4 count – she had a number of quite extended illnesses. I really hope that she does start ARV treatment soon.

It is funny that in writing this down it almost feels like we are all too involved – but unfortunately this is the reality of this area in terms of the support that people need. It is all very time consuming and emotionally draining for all involved – but hopefully we will get her through! As usual the main people are offering all their support despite having their own challenges.

I am always reminded how lucky I was to just happen to be born in the UK!”

Nhlanhla’s mother died a few months ago.

Once in Africa, an HIV Story (Pt. 1)

This is a true story told through a friend, a first person account of the life of Nhlanhla, a nurse in a Sub-Saharan country afflicted by HIV and AIDS. Names, places and minor details have been changed to protect people’s privacy. It is a story of fear, stigma, discrimination but also of hope, the everyday story of a young woman whose life, on revealing to her family that she is HIV positive, spirals into hell and despair.

“Over the year, Nhlanhla has faced many challenges in finding out she was HIV positive, receiving a terrible response from her church members when she tried to disclose her status, so withdrawing again, getting herself in terrible debt with shop cards on the basis that she expected to die, her family being chased away from their home by her late fathers relatives on the accusation of witchcraft, her mum ending up in hospital seriously ill, and her holding the sole responsibility for supporting her mother, sister and her own children. This was confounded when we identified that her CD4 count had dropped below 200 and she was ready for treatment. Given the experience of the previous year the doctors and I knew that this would be a difficult step for her to take.

Then, Nhlanhla attempted suicide. Thankfully we had been reading the signs and as soon as we got an indication that she had committed to the attempt we were able to intervene. It was a very stressful time for all the staff involved who were frantically trying to find her after she had taken the overdose. After a few days in hospital she was discharged but unfortunately tried again the following day.”

In preparation of her being discharged a second time “the team had really pulled together to try to support Nhlanhla and we have had amazing support from a psychologist. He had established a support structure for her that includes her family, her team members involved with the case, a doctor at the hospital and himself.

Nhlanhla was discharged from hospital and collected by one of our staff. The plan was for her to be taken directly to the psychologists private practice in town who, as a favour to me, had offered to provide a planning session with Nhlanhla and her sister. Nhlanhla waited until the psychologist came out and then she left. Unfortunately the psychologist had to return to his office and by the time he came back out to the waiting room Nhlanhla had left on her own claiming she was too tired and had to go home. Even in the psychologists office she did not even introduce her sister and neither was she greeted by her. In my book these are all really bad signs that Nhlanhla is not acknowledging that she has ongoing psychological problems she needs to deal with, and she certainly does not appear to have the support from her sister.

Nhlanhla obviously has a number of problems that need to be addressed, but a very clear stress trigger for her is that when her family were chased away from their home, she was forced to buy a basic home in this area for her family. She has managed to clear a lot of the cost of the house, but she still owes quite a lot of money. She is now overdue on her payment since a few month and the landlord is threatening eviction.”

A collection was organised amongst friends as officially giving loans to staff was not allowed. No return was expected “but the reality of people’s lives is such that it is impossible to ignore the hardship. I just thought that instead of us all waiting for someone to die before we contribute, this time our contributions may actually reduce the risk of her attempting suicide again and hopefully give us more time to encourage her to start treatment.”

To be continued…