HIV and multiple (concurrent) partnerships

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There’s a big to-and-fro in the latest issue of the Lancet about role of “multiple concurrent partnerships” versus “multiple partnerships” in the spread of HIV: four comments on an article published last week which argues (to simplify horribly) that there is no evidence that *concurrent* multiple sexual partnerships play more of a role than *sequential* multiple ones.  The four comments and the response from the authors of the original study response are here (scroll down).

It’s all quite interesting methodologically and epidemiologically speaking… in fact it is a debate that has been going on for some time.  But what strikes me most about the debate is the conclusions that a lot of the protagonists draw about what their findings mean for programmes.  Again, to simplify rather a lot, some of them (the ones that believe concurrency is a major factor) are saying “therefore we need messaging on limiting numbers of partners including concurrent partners”, whereas the others (the ones who dismiss concurrency) are saying “therefore we need messaging on limiting numbers of partners”.

And here’s the issue: there’s actually not a whole lot of evidence for the effects of either of these interventions. There’s certainly no evidence to show that either intervention is particularly more effective or more harmful or more costly than the other.  So the whole debate seems somewhat theoretical.

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And now, the Global Fund and human rights conditions

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If only I had noticed this article yesterday, I could have saved myself writing another blogpost.  But so it goes.

The article, from Uganda’s New Vision newspaper, reports that Dr Zainab Akol, the AIDS control manager, has accused sexual minority rights groups of “derailing” the fight against HIV.  Her specific complaint is that the Global Fund to Fight AIDS, Tuberculosis and Malaria has turned down Uganda’s application for US $270 on the grounds that the country’s policies on sexual minority rights are too harsh.  Keep in mind that Uganda is the country that is considering passing legislation to further criminalise homosexuality: at one stage sponsors of the bill wanted to include the death penalty as a punishment for “aggravated homosexuality”.  Keep in mind also Uganda’s dismissive response to David Cameron’s suggestion that the UK would withhold aid to countries that do not guarantee the rights of sexual minorities.

Here is what Dr Akol is quoted as saying:

The article was published on Novermber 15th 2011.  But the decision that Dr Akol is talking about is not a recent one.  She is referring to Uganda’s Round 10 application, submitted during 2010 and over which the Global Fund took a decision the same year, during its December 2010 Board Meeting.  As has always been the case, the Board accepted the recommendations of the Fund’s Technical Review Panel (TRP) when deciding which grant applications to approve. Uganda’s Round 10 application for HIV was an interesting case since part of the US$270m application was for “Health systems strengthening” (HSS) and the rest was for HIV programmes.  The TRP took the decision of recommending the HSS component (worth about US$25m) for funding but not the remainder.  They cited four major weaknesses and two minor weaknesses in the HIV-specific component, and stated that if these weaknesses were to be resolved the proposal could be resubmitted in the next round and considered for funding once again.  Any one of the major weaknesses would have been sufficient grounds to turn the proposal down.  

The list of weaknesses would suggest that “gay rights” were not the only reason the proposal was turned down.  In fact, the first reason mentioned was that only 11.6% of Uganda’s previous grant had been disbursed, suggesting that the current portfolio contains a considerable underspend that could be allocated to activities in the Round 10 proposal.  Next, the budget for the Round 10 proposal was described by the TRP is “questionable”, and if there is one thing that the Global Fund doesn’t like it is a questionable budget.  The third major weakness was to do with human rights:

The section on enhancing social and gender equity… do[es] not adequately address human rights of most-at-risk populations.  Moreover the proposal does not contain a statement on equitable access to… treatment for all Uganda citizens, including the most-at-risk groups in the society.  Such statements and references are of utmost importance at a time when the human rights of most-at-risk populations in Ugandan [sic] are at stake.

So, there is a recognition of the current febrile situation in Uganda but the concerns seem to be mainly around ensuring access to services.  A fourth major concern from the TRP states that the design of the proposal is not sound since it is based on weak situation assessments and poorly targeted.

Given this background, the New Vision article’s interpretation starts to look pretty weak.  By all accounts Uganda probably does have some of the money it needs to expand its treatment programme.  And the part of the proposal that was turned down had all sorts of weaknesses.

More worrying, it looks like another example of the whole debate about human rights conditionality being used to further stigmatise marginalised groups.  As if LGBT rights activists in Uganda weren’t getting enough of a hard time already, now they are being accused of compromising access to healthcare for hundreds of thousands of Ugandans.

It is hard to know what the Global Fund should do about human rights.  As I argued a few months ago, I’m skeptical about suggestions that the Fund should put in place even more controls to ensure programmes are respectful of human rights because I’m just not sure a Geneva-based organisation is going to be able to adequately measure the issues, and because I’m certain the Fund’s secretariat doesn’t need even more power.  On the other hand, the TRP’s attitude to Uganda’s Round 10 application is interesting since it showed that it is possible to fund some parts of an application and not others.  Maybe that’s the way things need to go: try to fund as much as possible of what is acceptable.  And at the same time, try to find alternative ways of supporting human rights and justice movements rather than doing anything that might further undermine them.  If the Global Fund is to effectively tackle things like sexual minority rights, maybe it is time it started making more money more easily available for organisations representing marginalised groups, so that they can act as effective counterweights to the mainstream.

— Update (17.18 GMT, 16th November) —

The Global Fund press office has emailed me the following brief statement in response to the New Vision article:

A report in the Ugandan media contains inaccuracies as to the reasons why the Global Fund rejected a recent application for HIV funding.

In 2010, Uganda submitted a Round 10 application to the Global Fund asking for $217 million for HIV and $25 million for health systems strengthening.

The application was examined, along with all grant proposals, by an independent panel of international experts on health and development to evaluate  soundness, effectiveness and viability. Based on the panel’s recommendations, the Global Fund Board approved the $25 million proposal for health systems strengthening but rejected the HIV proposal.

The panel of experts turned down the proposal mainly because significant funds from an earlier HIV grant are still  unspent, raising doubts about Uganda’s ability to take on a much larger HIV grant before it had effectively invested the resources it already has available. The HIV proposal also failed to adequately address equitable access of services particularly with respect to particularly vulnerable populations. Following an appeal by Uganda, the Global Fund’s Independent Appeals Panel upheld the decision not to fund the HIV proposal.

UK aid and human rights: what is the policy?

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During the recent Commonwealth Heads of Government Meeting, David Cameron said that countries that do not “adhere to proper human rights” risked losing their aid from the UK.  Making specific reference to the persecution of homosexuals, he stated that “This is an issue where we are pushing for movement, we are prepared to put some money behind what we believe“.  

This isn’t the first time the government has spoken out on this question – a few weeks earlier, the International Development secretary Andrew Mitchell, spoke along similar lines.

But is cutting aid the best way of promoting human rights?  Many African LGBTI activists don’t think so, especially as far as gay rights are concerned.  Various statements from activists made clear that they did not welcome the policy, stating that it would only add strength to those in Africa who argue that gay rights is a western concept.  The dismissive response from the Ugandan government, which accused the UK of a bullying and colonialist attitude, suggest the activists have got it right.  In any case, important as sexual rights are (and I believe they are very important), the suggestion that protecting them should be a condition for aid misunderstands the very purpose of aid.  A lot of aid is given to improve health care and education, to provide security, and to reduce poverty, and all of these things also help to further human rights. Singling out civil and political rights, as Cameron does, shows that we’re still quite a long way from understanding civil, political, economic, social and cultural rights as equally valuable, interdependent and indivisible – something that the human rights community has affirmed for some time.  

Out of curiosity I asked DFID – on Twitter – what the policy actually was.  They referred me to this page, which says “we only provide aid directly to governments once we are satisfied, based on robust assessments that… they share our own commitment to… respecting human rights… including Lesbian, Gay, Bisexual and Transgender [rights] and other international treaty obligations”.

This is more clear: the policy is not about any money going to a country, but about direct support to government.  Nonetheless it is still quite rigid since it suggests that no country discriminating against LGBT people – or failing to protect their rights – will receive direct aid.  This sets the bar pretty high: again, if countries need aid, one of the reasons is often that, economically speaking, they are struggling to fulfil international treaty obligations.  Many direct aid recipients fail this test. I don’t necessarily think they should lose aid as a result but they should certainly not be supported in any area of policy that compromises any human rights, and donors such as DFID should, as activists have demanded, find ways of providing additional support (not via the government) to human rights organisations who are campaigning for change.  It would be nice to see the UK government outlining a more nuanced policy reflecting all of these issues rather than resorting to the simplistic, unworkable soundbites we’ve been hearing.

In an additional twist, in the past week Minister for Africa Harry Bellingham, when confronted about the issue on a trip to the continent, said the UK would not be tying aid to gay rights, and went on to say the UK would “always be sensitive to local traditions”.  So presumably, if homophobia or other human rights violations are traditional, they are OK?  Is this the same as the cultural norms trap I discussed in my last post?  Weren’t these things traditional in the UK not so long ago?  Probably so, since most of the anti-sodomy laws that currently exist in Commonwealth countries were inherited from the British empire’s statute book anyway.

With thanks to @katesheill for pointing me to many of the quoted links & issues in this debate.

Pesky cultural norms

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In many countries, cultural norms contribute to stigmatization of sex workers, limiting their ability to seek or obtain care. PEPFAR is working with governments to ensure that access to health care and social services is not denied because an individual is a sex worker.

This is what PEPFAR, the US Government’s global HIV and AIDS programme, says about working with sex workers in its 2009-2013 strategy.  The use of the term “sex worker” is progress, as is the commitment to doing anything at all (after years of scaring implementers away from even discussing sex work).

However, having just sat through a week of sex workers reporting on the myriad abuses they face – violence and rape from law enforcement officers and security guards; either being turned away or abused in health care facilities; being systematically stigmatised in their communities, right down to pastors refusing to baptise their children (to list a few examples) – I really struggle with the label “cultural norms”.  To use this term seems like a miserly concession… maybe, just maybe, there are some situations where sex workers are treated differently and well, maybe programmes can try and get round these situations in the interests of making sure sex workers can get HIV tests and treatment…

The thing is, these “cultural norms” (or systematic abuses of human rights, if you prefer), do a whole lot more than stop sex workers in many developing countries getting HIV services.  They force them to work in riskier situations, and to live in fear; they don’t just stop them getting HIV services, but all manner of health and social services.  The idea that you can fix or tweak the situation just enough to hit your HIV programming targets fails to recognise how complex and entrenched the discrimination against sex workers is.  It also fails to recognise that the programme managers and outreach workers who are running programmes with sex workers often partial to a bit of prejudice and discrimination themselves.  And expecting people to stick to a treatment programme when all this other stuff is going on is at best naive and at worst insulting.

But what gets me most is the description of the problem as “cultural”.  In the world of aid and development, human rights are something you challenge, but culture is something you’ve got to respect. I guess the problem is that if it was called human rights, that would involve considering sex workers to be human.

Although PEPFAR still don’t get it, they don’t have the monopoly on this… the text from the PEPFAR strategy reminds me of the Lancet editorial from last year which suggested that where the rights sex workers are concerned, AIDS programmes merely need to find ways round criminalisation and systematic abuse in order to get them onto treatment programmes. It isn’t unusual to hear similar language from UN agencies.  There’s a long way to go.