Paper on comprehensive HIV programmes

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This is a quick one, and no doubt for a very small audience. Anyone currently working on “strengthening community systems” within HIV, TB and Malaria programmes – particularly in the context of the current round of funding recently launched by the Global Fund to fight AIDS, Tuberculosis and Malaria, may be interested. While the paper started off as an investigation of the problems in strengthening HIV prevention in the era of HIV treatment – a major issue faced by HIV programmes in recent years – it became clear that the problems in “linking” different areas of programming  are not only about different objectives but also about the problems in linking services that are provided in clinical facilities and those provided in communities.  And this is why I think some of this paper will be relevant to those working on community systems now.

Please feel free to circulate. Many thanks to the International Council of AIDS Service Organizations (ICASO) who commissioned the report, for agreeing to me posting it before editing and formal publication.  As noted in the attached file, ICASO should be credited in citations of the report.

Leadership, AIDS, human rights

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The recent events surrounding the conviction and subsequent presidential pardon of a Malawian couple for “gross indecency and unnatural acts” have got me thinking about one of the big mantras of AIDS programming: the need for the response to HIV and AIDS to be underpinned by strong national leadership.  When President Bingu wa Mutharika ordered the release of Steven Monjeza and Tiwonge Chambalanga, he was praised as courageous by the UN Secretary General; and in a joint statement the Executive Director of the Joint UN programme on HIV and AIDS, and the Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria said “we applaud this decision. It is particularly important that it comes in Malawi, a country so dedicated to the AIDS response[1].  Meanwhile, the President warned journalists to stop talking about the “satanic gays”, conceded that the only reason for issuing the pardon was to avoid aid being cut, and stated that in all aspects of reasoning, in all aspects of human understanding, these two gay boys were wrong – totally wrong”.  And in case there was any further doubt about where the Malawian government stands on homosexuality, the Minister of Health made it clear that Malawi would not be reconsidering its legislation and that the couple would be rearrested if they reoffended, appealing to sovereignty and the constitution of Malawi.  

And there’s the rub.  Ever since President Museveni of Uganda showed remarkable commitment to speaking openly about HIV and AIDS and how to prevent it in the early 1990s, and with Uganda’s subsequent status as a success story in the fight against AIDS, the global community fighting AIDS has wanted to see this leadership replicated in other countries.  But it’s never really been clear what is meant by strong leadership.  For certain, during the 1990s the mere fact of talking openly about HIV and AIDS was seen as a brave political move, since there was still a great deal of denial about the problem, and huge stigma against those affected.  Museveni’s decision to speak out may have been aided by the fact that in the early 1990s Uganda was probably the most highly affected country in the world, and denial was scarcely possible. 

Having presidents talk about HIV and AIDS and support the development of national programmes has probably been helpful in breaking the silence around HIV and AIDS.  Many countries set up national AIDS commissions chaired by the president, presidents regularly mentioned HIV in speeches and took HIV tests on World AIDS Day.  Considerable efforts were put into informing people about HIV – and remarkable success has been achieved in putting people onto treatment that a few years before was being branded as unsustainable by donors.  Although it is hard to say whether stigma against people affected by HIV and AIDS has really decreased, it is clear that people affected are far more able to access services and to influence policies today than they were some years ago.  The hallmark of a good government – as far as the response to HIV and AIDS is concerned – has become the extent to which the president engages with the issue.  President Bingu wa Mutharika is himself held up as a dedicated AIDS leader, as the quotation above and his enlistment as head of the campaign to get more AIDS funding from the G8 show.

However, it is also true that the idea of big national responses to AIDS probably got in the way of evidence-based programming that focussed on the issues and the people most affected.  One of the big failures of HIV prevention programmes today is that they are still very poorly integrated with other health programmes, in particular those related to sexual and reproductive health.  And yet the synergies are clear both in terms of prevention and in terms of delivery of care and treatment.  High maternal mortality, one of the biggest scandals in global health, could and should be significantly reduced by effective HIV programming.

At the same time countries around the world, even those with relatively high HIV prevalence, are starting to recognise that HIV and AIDS are concentrated in certain groups.  And those groups are often groups that are criminalised, marginalised and stigmatised by society such as men who have sex with men, transgender people and sex workers, or disenfranchised from proper access to sex education and health services such as young people and women. 

This is where leadership has failed.  Many leaders have spoken out about HIV and AIDS.  But how many have spoken courageously about the things that need to be done to prevent HIV and to improve the health of populations in general and of women and young people in particular?  Specifically, the evidence-based but often politically unpopular approaches to tackling these determinants: respecting and protecting the human rights of criminalised, marginalised and stigmatised people, and promoting sexual health and healthy sexuality for all, in particular for women and young people.  Leadership means breaking the silence not just about HIV but also… about sex and sexuality.  And not in a way that condemns sex, or that reinforces norms or moralities or prescribes behaviours that do not reflect the realities of most people.  It means challenging those norms, recognising difference, and protecting rather than persecuting people’s sexual rights.  The links between human rights and AIDS have long been recognised from an analytical perspective, but progress in dealing with them has been too slow.

Instead, the most reliable leaders – and again their role in strengthening some aspects of their country AIDS responses can’t be denied – often endorse the opposite view.  President wa Mutharika’s statements on Monjeza and Chimbalanga exemplify this.  Back in Uganda, President Museveni’s government may still go ahead with the adoption of harsh criminal laws against homosexuality, and only a few years ago his wife called for a virginity census of girls as a means to fight HIV and AIDS.  It seems clear that Uganda’s response is far less robust than it used to be.  Throughout the continent, comprehensive health programming for marginalised groups, comprehensive sexuality education for young people, and access to comprehensive reproductive and sexual health services for women, are far from the reality.  For the sake of balance it should also be acknowledged that the outgoing Labour government in the UK also failed to make bold changes on access to sex education.

The problem is that “leadership” means being in charge but it doesn’t necessarily mean doing or saying the right thing.  There’s little acknowledgement of the tension between saying some good stuff about HIV treatment while trampling all over human rights of minorities.  As we move to an era where HIV and AIDS programming will probably increasingly become aligned with general health programming, it’s going to become even more important to make it clear what that leadership means, and the continued importance of talking about the most difficult subjects.

Addition:
On the day I wrote this entry, the UN Special Rapporteur on the Right to Health presented his report to the UN Human Rights Council.  The first part of the debate between UN member states is recorded in this webcast and is an interesting insight into the positions of UN member states on some of these issues.
Addition 2:
Since the release of the couple, they have been interviewed by the Malawian press.  In the interview they renounce what they did and express gratitude to the president.  It is worth reading this blog post to understand what may have been at play here.  If it is true that they were manipulated – and my personal view is that this is quite plausible – it goes to show how much more work is needed.  However, a further report suggests that the TV interview was conducted before the trial.

[1] The Malawian president, the press, and UN press statements have consistently referred to them as a “gay” couple, and indeed their conviction was based on an understanding that they were both male.  However, it is clear that Tiwonge identifies as a woman and is often referred to in the Malawian press as “Aunt Tiwo”.  On the other hand Stephen Monjeza is reported as referring to Chimbalanga as “he”.  This story then is not just about sexuality but also about sexual identity.  Misunderstanding and denial of transgender idenities is perhaps an even bigger issue than homophobia.  This blog post explores the issues more thoroughly.