AIDS, Religion and Development

Via Travis Kavulla's Twitter feed I see that he has a long and worthwhile essay in the New Atlantis touching on one of my favorite talking points, the necessity of recognizing the role of religious beliefs, systems and structures when engaged in development work on the African continent:

The Western public-health lobby, bred in a culture that preaches unconstrained freedom of the individual in the realm of sexual relations, is put off by talk of moralizing policies, or of any policy that de-emphasizes condoms. But it needs a dose of its own advice. It must stop imposing its own agenda on Africa. It must realize that HIV has a social dimension that must be addressed, that Africans are naturally wont to view this disease, which perversely inverts the life-giving act of sex, as a moral calamity. The sooner the donor community realizes this, and reorients its policies to fit African realities, the better.

There is much more to engage with there than I have the time to do at the moment so please give it a read.

That's What She Said: Pope Edition

William Easterly has already said everything that I wanted to say about the Pope's comments on condom usage in Africa.  However, here are a few semi-anecdotal asides:

1.  While living in Botswana, my base of operations, Francistown, had the highest HIV infection rate of 15-25 year olds in the world.  There was no shortage of condoms.  Nor was there a shortage of groups advocating for an A-B approach only (that's "abstain" and "be faithful" minus the C, "condom" for those not familiar with the infamous triad).  There was a shortage of groups offering real alternatives and solutions to the 15-25 year olds looking to avoid a positive diagnosis in the midst of rapidly changing cultural and social norms that had the deck stacked against them.  In a culture where women have few if any sexual rights how do you ask a man to put on a condom?  What's worse - the beating that is sure to follow such a request or the possibility of a disease somewhere down the road?

2.  Regardless of where you land on the condom argument the sad truth is that the Pope's statement probably hurt women and other sexually marginalized populations the most as they are the only ones who probably could have benefitted from a more nuanced message from the pontiff.

3.  Somewhere I have a photo I took of a group of boys playing soccer with a ball made entirely of condoms (thrown out by a clinic after they "expired").  Did I mention there were a lot of condoms around?

4.  The problem in my little slice of the world at that time was not condom usage.  It was a lot of things - a healthcare infrastructure scrambling to play catch up with relatively limited resources, finding an effective medium through which to educate a culture that never publicly discussed sexuality about the dangers of sexual intercourse, replacing the traditional sexual initiation/education model that rapid urbanization was demolishing, the necessity of economic transience, etc., etc., etc. -  and none of them were very effectively solved by the simple math of "do I or do I not use this piece of latex."

5.  Balloons.  You see a lot of condom balloons knocking about as well.

6.  To quote the Pope, HIV/AIDS is "a tragedy that cannot be overcome by money alone, that cannot be overcome through the distribution of condoms, which even aggravates the problems." Nor can it be overcome by the church alone, which even aggravates the problem.  One of the greatest tragedies of my time in Botswana was seeing how unwilling churches and secular NGO's were to work together and realizing how many instances there were where they could have been incredibly effective partners.  The lack of imagination and basic trust from both sides in the face of an unfolding epidemic was depressing to see.  In many places on the continent that has changed some, but not enough.

7.  Am I the only one that thinks the above sentence from the Pope would have been a good time for someone in the crowd to shout "That's what she said."  And if so, does that make me a bad person?

"AIDS in America is a black disease"

More info on the state of AIDS in America.  I posted earlier on how new infections have shifted to the rural south and now this report from the Black AIDS Institute fleshes out more carefully how new infections are affecting the African-American population.  From CNN:

The AIDS epidemic among African-Americans in some parts of the United States is as severe as in parts of Africa, according to a report out Tuesday.

"Left Behind - Black America: A Neglected Priority in the Global AIDS" is intended to raise awareness and remind the public that the "AIDS epidemic is not over in America, especially not in Black America," says the report, published by the Black AIDS Institute, an HIV/AIDS think tank focused exclusively on African-Americans.

"AIDS in America today is a black disease," says Phill Wilson, founder and CEO of the institute and himself HIV-positive for 20 years. "2006 CDC data tell us that about half of the just over 1 million Americans living with HIV or AIDS are black."

Although black people represent only about one in eight Americans, one in every two people living with HIV in the United States is black, the report notes.

. . . . .

According to this report, if black Americans made up their own country, it would rank above Ethiopia (420,000 to 1,300,000) and below Ivory Coast (750,000) in HIV population. Both Ethiopia and the Ivory Coast are among the 15 nations receiving funds from the President's Emergency Plan For Aids Relief. The United States has given about $15 billion to PEPFAR nations in the past five years. 

The Black AIDS Institute says it's not criticizing the federal government for helping poorer countries cope with the AIDS epidemic. Rather, it's saying the "AIDS epidemic [in the U.S.] is not getting the kind attention that it merits."

"We understand the needs of black folk in Johannesburg (South Africa)," Wilson says. "Why can't we understand the needs of them in Jackson, Mississippi? We understand the needs in Nigeria or Botswana, why not understand the needs of Los Angeles or Oakland?"

For some reason I haven't been able to find a copy of the actual report online yet, let me know if you do.

HIV/AIDS: A Rural/Southern Epidemic?

UPDATE: The Daily Dish points to another map reflecting disparities in US health/life expectancy, this one ranked by congressional district.  Not surprisingly, the bottom five contains two districts from Mississippi and two from Louisiana - I assume that the bottom of the bottom is an Appalachian district, and that the top of the top is peopled by congressional aides.  Here's the source.



This is one of several emerging trends that reflect a decline of the overall health of those living in rural portions of the deep South:

"Rising infection rates, coupled with inadequate funding, resources and infrastructure have resulted in a catastrophic situation in our public health care systems in the South," the report says.

Kathy Hiers, chief executive officer of AIDS Alabama and co-author of the report, told The Birmingham News that HIV/AIDS is taking hold in isolated parts of the South.

"The ruralness of the epidemic is what's becoming painfully clear," Hiers told the paper.

The report says the number of deaths from AIDS dropped in the rest of the nation between 2001 and 2005 but continued to increase in the South.

Health authorities have known for years that the 16-state Southern region was leading the country in the number of new infections. But, Hiers said, they thought the increase was concentrated in big cities in Florida, not spread across the region.

Experts have now focused in on the Deep South - Alabama, Georgia, Louisiana, Mississippi, North Carolina and South Carolina. They have found HIV infections rising in rural areas populated by blacks with financial, health and social problems.

Gary A. Puckrein is the president and CEO of National Minority Quality Forum in Washington. He said the shift in HIV infections has to be highlighted.

"Certainly one of the big misconceptions is it is big cities on the West Coast and East Coast that are really driving the disease, and it's not so," Puckrein said. "It's moved both in terms of geography and demography. It's really important for people in Southern states to know that because they're not getting their fair share of support."

This image is from the much reported story earlier in the year on declining life expectancy in the South, especially among women:

AIDS Profiteering

There is a lot of frustration brewing in the world of HIV/AIDS prevention these days and it's coming from all directions.  This piece from the Washington Post is from Sam Ruteikara, co-chair of Uganda's National AIDS Prevention Committee:

The President's Emergency Plan for HIV-AIDS Relief (PEPFAR) has been mired in the Senate for months. Last week finally brought signs that a vote, and passage, could be near. The program would cost $50 billion -- that's $165 from each American to fight AIDS, or $1.3 billion from New York City alone. But will the money allocated for AIDS stop the spread of the virus in sub-Saharan Africa, where 76 percent of the world's HIV-AIDS deaths occurred last year?

Not if the dark dealings I've witnessed in Africa continue unchecked. In the fight against AIDS, profiteering has trumped prevention. AIDS is no longer simply a disease; it has become a multibillion-dollar industry.

In the late 1980s, before international experts arrived to tell us we had it all "wrong," we in Uganda devised a practical campaign to prevent the spread of HIV. We recognized that population-wide AIDS epidemics in Africa were driven by people having sex with more than one regular partner. Therefore, we urged people to be faithful. Our campaign was called ABC (Abstain, or Be Faithful, or use Condoms), but our main message was: Stick to one partner. We promoted condoms only as a last resort.

Because we knew what to do in our country, we succeeded. The proportion of Ugandans infected with HIV plunged from 21 percent in 1991 to 6 percent in 2002. But international AIDS experts who came to Uganda said we were wrong to try to limit people's sexual freedom. Worse, they had the financial power to force their casual-sex agendas upon us.

There's more food for thought in the middle, but he closes with this:

We, the poor of Africa, remain silenced in the global dialogue. Our wisdom about our own culture is ignored.

Telling men and women to keep sex sacred -- to save sex for marriage and then remain faithful -- is telling them to love one another deeply with their whole hearts. Most HIV infections in Africa are spread by sex outside of marriage: casual sex and infidelity. The solution is faithful love.

So hear my plea, HIV-AIDS profiteers. Let my people go. We understand that casual sex is dear to you, but staying alive is dear to us. Listen to African wisdom, and we will show you how to prevent AIDS.

There are some harsh indictments in there and if it weren't so late I might have something to say in that regard, maybe tomorrow.

Towards Universal Access

I haven't had a chance to look at it yet but the WHO, UNAIDS, and UNICEF released their joint report on the state of the global HIV/AIDS pandemic today.  It's entitled Towards Universal Access: Scaling up Priority HIV/AIDS Interventions in the Health Sector.

Implications of the Lazarus Effect

Pomeroy has some good insights/analysis on the earlier linked Prospect article.  

More on Boredom and AIDS

Ok, not exactly boredom, more like success induced complacency, but certainly related to an earlier post on boring prevention ads leading to a rise in HIV infection rates in Utah.  This article in The Prospect does a good, sobering job of sketching out the impact that successful antiretroviral treatment is having on rising infection rates among gay men - and if you've ever perused a British tabloid you know that this can't be blamed on tame PSA's.  Here's a quote:

Well-monitored antiretroviral treatment can now bring HIV in body fluids down below levels that are associated with heterosexual transmission. There was much excitement about this in the late 1990s—mathematical modelling showed that if behaviour stayed the same and infected people got treated, HIV transmission would trickle to a halt. But the models didn't factor in the possibility that you need less virus to get infected in the more dangerous act of anal sex. They also forgot that humans don't behave like mathematical models. Gay men who have lived for 15 years in the shadow of a fearsome and disfiguring plague are especially unlikely to behave like mathematical models. In fact, gay men breathed a collective sigh of relief, hit the dancefloor and threw their condoms to the winds. Well, not to the winds exactly—48 per cent of gay men in Britain still use condoms all the time, which is more than can be said for straight men. But in 1996, just like everywhere in the world where HIV treatment became available, the proportion using condoms started falling. And so our hopes that getting everyone on treatment would squash viral load and slash new infections have been dashed. Viral load may be lower, but risk is higher, so new infections are motoring along nicely. And because so few people are dying, the number of people with HIV is climbing. In the last decade, the number of gay men living with HIV in Britain has more than doubled, from around 14,400 in 1998 to over 31,000 today.

Pomeroy has talked about this before but I'm still perplexed as to how to understand it.  Are we really heading for a world in which HIV is a slightly more lethal asthma - a pain to deal with but with proper treatment it won't affect your life all that much?

Boring Ads Lead to Rise in HIV Rates?

That is the claim of the Utah AIDS Foundation in this article from the Salt Lake Tribune.  Their current ad campaign was partially funded by state and federal money and thus had to focus on the mandated message of testing rather than a more blunt message aimed at prevention and condom use.  One question I have is how effective ads are in either case?  Are explicit ads more effective in changing behavior?   Another is why they aren't making ads that target the contributing factors acknowledged in their sidebar - effective use of retrovirals "taking the risk" out of risky behavior and rising drug use (their second cause - an Africa only problem - I would say is essentially an extension of the first)?  Pomeroy?

World Bank committed, the Senate . . . not so much

The World Bank released their new agenda for action on HIV/AIDS in Africa today.  Entitled "Our Commitment: World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011" it does pretty much what it says - lays out the World Bank's plan of action for dealing with HIV/AIDS in Africa over the next four years. I've only perused it so far, you can download it here, but it attempts to make the case for how the World Bank is going to move their focus from emergency relief mode to long-term, sustainable development mode by integrating their HIV/AIDS response into broader development efforts that take into account the changing dynamics of the epidemic.  With new infections still on the rise in Africa it will be interesting to see how these efforts play out on the ground and in what areas of the pandemic it is actually feasible to shift from relief to development.  It also acknowledges the World Bank's shift from the role of major funder for HIV/AIDS programs to that of "development partner and complementary funder."  In that new role it lays out these goals for the agenda:

• Strengthen the long-term prioritized sustainable response through incorporating HIV/AIDS more explicitly into national development agendas, focusing the response, articulating realistic strategies built on solid evidence generated by good M&E, and integrating HIV/AIDS efforts with those of other diseases.

• Intensify and accelerate a targeted multisectoral response by interventions in
education, transport, agriculture, and health; and by working with the private sector, CSOs, and local governments.

• Build stronger national systems to manage the response effectively and efficiently in health service delivery, financial management and procurement, supply chain management, human resources, and social services.

• Strengthen donor coordination by maintaining the commitment to the Three Ones and working effectively to rationalize the global aid architecture for health.

Ironically enough one of the funding sources that has supplanted the World Bank as a major donor for HIV/AIDS programs in Africa, PEPFAR, also found itself in the news today but for much less laudatory reasons.  Sadly this type of behavior is nothing new, although, as I mentioned previously, I still think President Bush is going to see this as a legacy issue (what other options does he have?) and go to bat for it in the end.

HIV/AIDS Animation/Video Resources

This is a pretty good animation of the replication of the HIV virus - the voice over is a little medical lingo heavy but if you combo it with a more layman's explanation it could be useful (you can download it from the creators website here).  This, however, is still my favorite video to use with groups - its designed to use with kids/youth but its honestly about the right level of science talk for most adults and the format provides something a little lighthearted in the midst of a heavy discussion.  While we're on it this short Doctors Without Borders advert is another animation I use to intro discussions on the wide sweeping cultural, social and familial destruction HIV/AIDS is wrecking across most of sub-Saharan Africa.

Mmmm, I had tracked down a higher res downloadable version somewhere but I can't seem to find it . . . . I'll keep looking.

PEPFAR: Makin' it rain?

Via the FP Passport blog (by the by, if you aren't reading a general global news blog already, the folks at FP do as good a job as anybody out there with equal measures of humor and insight) - it appears that congress is looking at both expanding and amending PEPFAR - increases of funds to $50 billion and loosening of some of those cumbersome abstinence requirements, which as the article points out were never as ennobled as their supporters liked to claim or as restrictive as their detractors liked to bemoan.  Like most projects of its ilk, PEPFAR has an equal number of proponents and detractors and there are all kinds of ways to splice the numbers as to how much "aid" is actually getting where and whether or not its actually an increase, etc., etc., etc. - I won't go into that here.  Point being, Bush is obviously thinking legacy and looking everywhere except Iraq, and if that means he starts pushing the HIV/AIDS agenda then who am I to complain - I know a number of individuals and organizations that have directly benefitted from PEPFAR, by which I mean they have been able to keep the lights on and the doors open as they minister to those suffering with HIV/AIDS so hopefully this will push through.  This, however, will probably still be true.