Opinion

PEPFAR and Africa

The President of the U.S. President Donald Trump Jr. had plans to withdraw from that Global HIV Mechanism called Global Fund in which PEPFAR has been so pivotal. However, if it is reinstated in full, African countries must show cause they are willing to enshrine value for money best practices. 

Africa relies on development partners for a robust health system. She needs to involve all her institutions in entrenching judicious use of her vast mineral and human resources. Africa can use the mineral resources to invest in research and development. In the case of HIV Cure, she can set aside sums of money for ARV research. Research in the ARV medicines will enable Africa commit resources which can eventually lead her to have critical cure technologies and resources on the continent. Normally saying!!! But, the reality is that Uganda and many countries in Africa will rely on International Development Finance (IDF) for a long time. Why? Because, let us be honest with all the disadvantages and cumbersome conditions IDF comes with conditions of scrutiny. Which may not be the case of self generated incomes which mostly go to serve and consolidate military, repression and such goals in which the notion of "inclusivity" is considered an anti-government in power sentiment!

35 million out of seven and a half billion people in the world are infected with HIV/AIDS. When left out of control, AIDS weakens individuals and makes them more susceptible to other infectious diseases, such as TB. In addition, the economic burden of AIDS consumes entire public health systems in developing countries. Considering these factors, focusing on the AIDS epidemic can help to reduce the threat of global pandemics, and free up funding and space for other diseases to receive the attention and support they need.

Sub-Saharan Africa has been the hardest hit by the epidemic. In 1993, 9 million (out of a worldwide 14 million infections) were in Sub-Saharan Africa. Today, 22.5 million (out of a global 35 million infections) are from Sub-Saharan Africa. To put things in perspective, Haiti is the country with the highest prevalence rate outside of Sub-Saharan Africa, with a prevalence rate of only 2.2%. In terms of treatment, Sub-Saharan Africa uses almost four times the ARVs of the rest of the world combined.

However, the current system of treatment for HIV/AIDs is still insufficient. According to the WHO/UNAID/UNICEF 2009 progress report “Towards Universal Access,” 66% of people who need ARVs in Sub-Saharan Africa (around 6,700,000 people), are still not receiving treatment (why?). Not to mention the 2,925,000 people who have already begun treatment, will need to continue receiving ARVs for the rest of their lives. There is still a gap between what Donor organizations are able to provide and what is needed on the ground. The burden continues to expand as new people need treatment and old patients need to switch to even more expensive second-line drugs. Moreover, international donor funds have recently been more constrained, leaving African countries to find new resources to solve the demand for ARVs.

NB. PEPFAR in full is U.S. President’s Emergency Plan For AIDS Relief. The U.S. has committed $ 75 billion to-date. If the U.S. stays, it will commit another $ 4.3 billion to the Global Fund (GF). In Africa alone, this will keep 300,000 on ARVs from dying. It will also help avert 7.9 million additional HIV infections between 2017-2030. 

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Strategic Litigation  Versus Strategic Gender expansive Projects; Influencers of LGBTIQQ integration in Africa

Elvis is a 23 year old Transwoman. The pronouns preferred are she/her/they and the Trans name is Tiara. To come to this point Elvis had to undergo self-discovery through the sessions we offered at our resource center. We had dance, diet, dress and dignity affirming  mini-fairs. Elvis (Tiara) and 72 others were able to be who they felt they were. The good side is that at the resource center we had other ongoing activities some of which we encouraged Transgender persons to participate in as facilitators. There was a per diem at the end of day and this catered for transport. For those who preferred to stay, the money was saved to purchase consumables, cosmetics and other facilities which affirmed who they were.

Jovan Ssentamu 35 years, has been with our volunteer mobile home visit services. Through this mechanism we were able to look after a big number of LGBTIQQ living with HIV. We made sure our volunteers had airtime, planned home visit schedules and at all times were able to reach out to members in their marked out zones during an emergence. We had zoned out catchment areas and each area had focal persons. We ran on a shoelace budget which was supplemented by the founders' salaries, money from two video shacks, 5 boda-boda transport bikes, a quick food stall in Bwaise and three hair grooming salons. We even had started a credit extension service to improve LGBTIQQ corporate skills.  Every month we used  an average of Ugx. 3,000,000.00 and this meant paying rent, utilities, food and overhead costs. This was from 2007-2009. After 2009, we added extra costs of bailing out persons and burial arrangements. Up to 2012, we got 23 cases of home evictions, family rejection due to being outed as LGBTIQQ. We had to house or find shelter, food and other consumables. We attended 4 burial events where we had to be involved in burial arrangements. We worked on 13 events in which LGBTIQQ were in conflict with the police. Our average monthly costs were Ugx. 4,000,000.00. We never lasted beyond 2012. We failed to pay our bail for being "chief homosexual" recruiter organization and were eventually closed. Our founders had to flee the country for some time because they feared for their lives. Later, we re-organized and are hosted by another organization. 

The question is were we useful to the larger LGBTIQQ Community?

Were we a necessary organization?

In the story of the zebra and the lion it is also good to look at other angles besides the normalized one beyond the one of the lion as a predator and the zebra the prey that we are used to. We are so normalized by status quo. There LGBTIQQ-friendly models that work. We can use models like "Rights-based" "Gay-rights" and "human rights based approaches". These models are hinged in the people, participation and programing (PPP) principle. But, in the heat of the moment, this principle was missed. Even, sadly,  up to now it is still missed.  

At one time, during a general meeting the author asked lawyers who were facilitating a marginalized groups' movement consolidation gathering whether it was not prudent to first do needs assessment before we went into forming a full scale coalition. The issue raised was not addressed, it was not a majority question. The logic was that the coalition would take on the needs assessment as their first task. The author's raised issue was to promote a two track approach. That is, the human or Anthropological (sexuality, gender and cultural oriented) and the Structural (governance, policy and legal) needs. At that meeting it was a democracy and therefore the LGBTIQQ Community decided to take up one track and drop the other. So, all funding was earmarked for strategic litigation and not for organizations working in the gender expansive areas. 

There is a collective that argues that strategic litigation and all attendant activities have helped with the visibility of LGBTIQQ in Uganda. To them I would answer that this article is about the need to address the human or Anthropological e.g. sexuality, gender and cultural issues of the LGBTIQQ. That is why even when court cases are won (an example of policy institution), one will hear of statements in which, say, Transgender persons need space in which to grow and develop fully including hormonal therapy. These confessions continue to show us of the expansive role social-cultural institutions play in the life of LGBTIQQ. 

After 2008, funding that went into organizations which addressed structural litigation put them at a very good start. This is was the time when the HIV funding was supporting religious organizations to preach against demographic groups considered unacceptable. So, even within the LGBTIQQ Community some organizations were boosted while others were not. We should have provided opportunity for both tracks to be addressed with funding to all organizations involved. Funding is important because it facilitates activism as well as visibility. Funding ties any organization into the larger international yarn. Funding provides both motive force and inertia. It is the wind beneath wings. It is no wonder that some well funded LGBTIQQ CSOs are perceived as the be the face for LGBTIQQ in Uganda which is not the case. Funding catapults organizations and the lack of it is an episode of anaemia for others. This is what happened to our organization. We survived but could not do the full scale services we hoped to do. At one point we even failed to fully hospitalize a tortured founder and almost failed to post bail. It is no wonder that the same organizations that have continued getting funding are accumulating achievements. 

Unmet LGBTIQQ anthropological needs as well as not providing funding for organizations equipped to address these does not build the critical professionalism which also necessitates: safer spaces, confidentiality, separation of roles e.g. legal persons or assistants should stick to legal issues; social and health workers should be empowered to do the holistic social and cultural work. This addresses division of labour and does not burden workers with over and above burn out levels.  It also increases the number of critical and effective leaders in the LGBTIQQ Community. One of the reasons we are seeing a higher rise in deaths due to HIV in the LGBTIQQ Community is because the organizations have role disparities and incongruency. Organizations may have funding earmarked for renting an office space and a training in bookkeeping. But, they may have no funds for say, calls to attend to 12 bedridden persons whose issues may include support group membership,  nutrition, housing and hospitalization. 

Funding strategic litigation is enables the LGBTIQQ build a critical number of legally articulate individuals. However, there is need for funding projects addressing emotional health because it impacts the quality of life of the entire LGBTIQQ community.  

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Food, exercise, financials, regular check ups and social activities (like community meetings or spiritual gatherings) are fundamentals in keeping People Living with HIV stronger as well as enabling them survive for longer years.

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HIV and Your Foods

We want to keep it simple and practical

As a person living with HIV, you may experience chronic fatigue and most of this should not be blamed on activity. Some can be blamed on the food you eat and how this food is broken down.

Remember to have a diet which has Protein/Energy/Fruits/Vegetables and water.

Studies point toward having more fruits and vegetables that is, in larger portions than protein and carbohydrates. The idea is that one is getting more to ingest foods that are easily broken down in bigger numbers and less of the foods that are broken down only to be stored as fat.

We shall bring you more tips in future!

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In Africa, a Glimpse of Hope for Beating H.I.V.

Tina Rosenberg SEPT. 19, 2017

A couple of years ago, European researchers began studying more than a thousand couples, gay and straight, in which one member had been infected with H.I.V. and the other hadn’t. These couples weren’t using condoms. But the infected partner was taking antiretrovirals successfully; the virus was suppressed, undetectable in the blood. The researchers published their results in July 2016 in the Journal of the American Medical Association.

Can you guess how many times, over the course of more than a year, an infected partner gave an uninfected partner H.I.V.?

A. 928

B. 0

C. 503

D. 17

The answer is B. Zero. And in that fact lies hope.

How do you stop AIDS? Not just treating H.I.V., but ending the epidemic. Even when there’s no vaccine and no cure.

Part of the answer can be witnessed in a white trailer on the grounds of a polyclinic in Hatcliffe, a dusty town in the northern part of greater Harare, Zimbabwe. Even before the trailer opens each day, the benches outside are full of people waiting for a checkup or a fresh supply of medicine for H.I.V. or the diseases that pounce on weakened immune systems.

Hatcliffe’s clinic, like all public clinics in Harare, charges $5 for visits that don’t involve either H.I.V. or tuberculosis. That may seem like a bargain to Americans. But Zimbabwe is in an economic crisis, making millions of people struggle just to buy their staples of cornmeal, sugar and cooking oil.

The clinic is supposed to offer medicines free, but has run out of many, said Sheila Chiedza, the nurse who runs it. (A doctor visits on Wednesdays.) The clinic must send patients to a pharmacy to purchase what they need. “If we don’t have it here, we are not sure if they can get it,” Chiedza said.

For most Zimbabweans, then, medical care at the public clinic is a financial hardship. But H.I.V. and tuberculosis care are different: Drugs are free, each clinic visit costs just one dollar, and most patients come four times a year.

When I visited in August, the trailer’s back office was crowded with staff members entering data. I asked how well patients did on their AIDS meds. “Ninety percent undetectable,” said a young man who gave his name as Mr. Edwards.

This seemed unbelievably high. In the United States, the figure is about 81 percent.

But the clinic may not have been exaggerating. Zimbabwe is one of the world’s worst-governed countries and has suffered a staggering economic decline. But it’s doing right by people with H.I.V. — a lot better than the United States.

Every epidemic has a tipping point. When the transmission rate drops below that point, it begins to recede. For H.I.V., reaching the tipping point requires three things: that 90 percent of people with the virus know they have it, that 90 percent of that group are taking antiretroviral medicines to keep the epidemic in check, and that 90 percent of those taking medicine control the virus to the point where it is undetectable and therefore cannot be transmitted.

So having the world at 90-90-90 is the goal of Unaids by 2020. If you reach 90-90-90, you end up with 73 percent of people with H.I.V. being noncontagious. That 73 percent is the tipping point, at which the epidemic starts to burn out.

Achieving 73 percent is hard. In the United States, the figure is only 30 percent. A recent survey in which researchers went door to door testing people’s blood found that Zimbabwe is much closer, at 60.4 percent. Between 2003 and 2015, the rate of new infections there declined by two-thirds.

Surveys have been completed in three other countries. Malawi and Zambia are close to the tipping point. Swaziland, the country with the highest H.I.V. prevalence in the world, has just become the first that we know of to have achieved the target of 73 percent. These results are even more remarkable because across Africa an unusually large group of young people have been reaching the most dangerous age.

A large part of this success is due to George W. Bush, whose administration established the President’s Emergency Plan for AIDS Relief, or Pepfar, in 2004. Its impact is now evident in the trailer in the yard of Hatcliffe Polyclinic and just about every such trailer in countries with a large H.I.V. burden.

Of course, Bush’s initiative wasn’t alone. Pepfar programs are dwarfed by the Global Fund to Fight AIDS, Malaria and Tuberculosis, which began working around the world in 2002. Most governments take H.I.V. seriously, and campaigns by a global network of people living with H.I.V. and their supporters achieved those victories.

Pepfar began work in seven African countries in 2004, and also contributed to the Global Fund. Now it works in 22 African countries, along with some in Asia and Latin America.

In the past three and a half years, Pepfar has doubled the number of people for whom it provides treatment. It has added a million children in the past two years. On Tuesday, several organizations are releasing household surveys from two more countries — Lesotho, which is near a tipping point, and Uganda, which has stabilized its epidemic.

“Zimbabwe has made great strides,” said Martha Tholanah, a prominent campaigner there for the rights of H.I.V.-infected and gay people. Everyone I spoke with agrees.

This is all the more remarkable given the economic catastrophe of the past 10 years (in 2009, the central bank issued a 100 trillion Zimbabwean dollar bank note that was worth about $30 in U.S. currency) and given Zimbabwe’s repression. Gay male sex is illegal, and Robert Mugabe, Zimbabwe’s dictator, is scorching in his denunciations of homosexuality. “There is probably still fear of the health system,” said Ben Cheng, who researches diagnostic tools for H.I.V. at the London School of Hygiene and Tropical Medicine, and spends a lot of time in Zimbabwe. Gay men there, he says, “are probably not coming in to be tested.”

Still, here’s what Zimbabwe has done right:

It put its own money into fighting H.I.V. In 1999, the country instituted a 3 percent tax on income and corporate profits to fund AIDS programs. That continues, although the totals collected have suffered in synchrony with a failing economy. But few other poor countries have tried to do as much to pay for fighting the disease.

Some of the country’s leaders on H.I.V. are serious and competent, including Tsitsi Apollo, who directs the country’s response.

Deborah Birx, the United States’ global AIDS coordinator and head of Pepfar, said that the biggest global challenge is the first 90 in the 90-90-90 formula: getting people tested so that they know their H.I.V. status. It’s especially difficult to reach young people, so Pepfar focuses on them. “More than half of men under 35 and almost a third of women under 25” who have H.I.V. don’t know they’re infected, Birx said. “So they’re unintentionally passing it on.”

These groups are a priority in Zimbabwe as well. The country has a widely praised program to help adolescents stay on treatment, employing H.I.V.-positive teens as front-line workers.

And if men won’t come to the health clinic, the clinic goes to them. Mobile testing and even circumcision teams go in the afternoon and evenings to shopping centers, bars and other place where men congregate. (Male circumcision offers some protection against H.I.V.) “Men can now get circumcised at night at their favorite watering holes!” the Hatcliffe Polyclinic advertised.

But there’s a lot Zimbabwe still must do. “When we sit in committees with the National AIDS Council, it seems that everything is in place,” Tholanah said. “But in the communities, you find out there are such a lot of things communities lack.”

She said that clinics don’t talk to patients about managing the side effects of medicines. Labs frequently lose blood tests, and when the tests do come back, it’s with absurd delays. The results from one of her blood tests, taken in April, arrived in August, she said.

Perhaps most important, money is so short that needed drugs are not always acquired. One is fluconazole, an important drug that treats thrush and other fungal diseases in AIDS patients. Cheng visited a number of health centers and found that almost none had the drug. “They’re doing a much better job managing antiretrovirals,” he said. “But with drugs for opportunistic infections, stock-outs are still a common occurrence.”

Tholanah said that even some antiretrovirals are now going missing. “When things are O.K., people go every three months,” she said. “But of late, they’re not O.K.” She said that for some second-line drugs, clinics are giving out only a week’s supply, and that she had heard of people getting only three days’ worth.

So they have to go back to the clinic over and over, which means paying for transportation, paying that dollar and enduring a long wait. Patients have started sharing drugs, she said. “And yesterday I heard that even for first-line drugs, they’re now giving a one-month supply,” she said. “That’s a red flag.”

The budget President Trump submitted to Congress would have thrown this progress into reverse. He proposed a cut of $2.5 billion to America’s global health budget — $1 billion less for Pepfar and $225 million less for the Global Fund. Millions of people would have lost their treatment, and the epidemic would have once again picked up steam.

Both the House and Senate appropriations committees ignored him, approving funding at the same level as last year’s. When Sen. Patrick Leahy, a Democrat from Vermont, proposed adding $500 million, however, that was voted down, along party lines.

Until recently, funding H.I.V. medicines worldwide looked like a noble, necessary — and never-ending — project. Now we know that treatment is prevention. Do it wide and well enough, and AIDS could be defeated. “This program started as a humanitarian outreach effort to demonstrate the compassion of the American people,” Birx said of Pepfar. “Now it’s translated into a program controlling the epidemic.”

People waiting to be tested for H.I.V. in Harare, Zimbabwe, in 2012. Tsvangirayi Mukwazhi/Associated Press